Coping an attack of bronchial asthma

Emergency therapy

The mechanism of action of drugs used to stop the attack of bronchial asthma is described in the article " treatment of bronchial asthma."

Non-selective adrenomimetics

Non-selective adrenomimetics have a stimulating effect on beta1-beta2 and alpha-adrenergic receptors.

Adrenaline - is the drug of choice for relief of an attack of bronchial asthma due to the rapid stopping effect of the drug.

In adult patients at the time of an attack of bronchial asthma, subcutaneous injection of epinephrine in a dose of 0.25 mg (ie 0.25 ml of 0.1% solution) is characterized by the following features: the onset of action - after 15 minutes; the maximum of action is 45 minutes; duration of action - about 2.5 hours; the maximum air expiratory flow rate (MSSV) is increased by 20%; no changes in heart rate; the systemic diastolic blood pressure decreases slightly.

Injection of 0.5 mg of epinephrine leads to the same effect, but with the following peculiarities: the duration of action increases to 3 hours or more; The MSWR increases by 40%; slightly increases heart rate.

S.A. San (1986) for relief of an attack of bronchial asthma recommends adrenaline to be administered subcutaneously in the following doses depending on the body weight of the patient:

• less than 60 kg - 0.3 ml 0.1% solution (0.3 mg);
• 60-80 kg- 0.4 ml of 0.1% solution (0.4 mg);
• more than 80 kg - 0.5 ml 0.1% solution (0.5 mg).

In the absence of effect, adrenaline administration in the same dose is repeated after 20 minutes, it is again possible to inject epinephrine no more than 3 times.

Subcutaneous injection of epinephrine is a means of choice for initial therapy of patients at the time of an attack of bronchial asthma.

The administration of epinephrine is not recommended for elderly patients with IHD, hypertension, Parkinsonism, toxic goitre due to a possible increase in blood pressure, tachycardia, increased tremor, agitation, and sometimes worsening of myocardial ischemia.

Ephedrine - can also be used to stop an attack of bronchial asthma, but its effect is less pronounced, begins in 30-40 minutes, but lasts a little longer, up to 3-4 hours. To stop bronchial asthma, 0.5-1.0 ml of 5% solution.

Ephedrine should not be used in those patients who are contraindicated in adrenaline.

Selective or partially selective beta2-adrenostimulants

Preparations of this subgroup selectively stimulate beta2-adrenergic receptors and cause bronchial relaxation, do not stimulate or almost do not stimulate beta 1-adrenoreceptor myocardial receptors (when used in acceptable optimal doses).

Alupent (astmopent, orciprenaline) - is applied in the form of a dosed aerosol (1-2 deep breaths). The action begins in 1-2 minutes, complete relief of the attack occurs after 15-20 minutes, the duration of action is about 3 hours. When the attack is resumed, the same dose is inhaled. During the day you can use Alupen 3-4 times. To stop the attack of bronchial asthma, you can also use subcutaneous or intramuscular injection of 1 ml of 0.05% alupent solution, and possibly intravenous drip (1 ml of 0.05% solution in 300 ml of 5% glucose solution at a rate of 30 cap / min).

Alupent is a partially selective beta2-adrenostimulator, therefore, with frequent inhalations of the drug, palpitation, extrasystole, is possible.

Salbutamol (ventolin) - is used to stop an attack of bronchial asthma, using a metered aerosol - 1-2 breaths. In severe cases, in the absence of effect after 5 minutes, 1-2 breaths can be made. Admissible daily dose - 6-10 single inhalation doses.

The bronchodilator effect of the drug begins in 1-5 minutes. The maximum effect comes in 30 minutes, the duration of the action is 2-3 hours.

Terbutaline (bricanil) is a selective beta2-adrenostimulator used to stop an attack of bronchial asthma in the form of a metered aerosol (1-2 breaths). Bronchodilating effect is observed after 1-5 minutes, maximum after 45 minutes (according to some data after 60 minutes), the duration of action is not less than 5 hours.

There is no significant change in heart rate and systolic blood pressure after inhalation of terbutaline. To stop the attack of bronchial asthma can also be used intramuscularly - 0.5 ml of 0.05% solution up to 4 times a day.

Inolin - selective beta2-adrenostimulant, is used to stop the attack of bronchial asthma in the form of metered aerosols (1-2 breaths), as well as subcutaneously - 1 ml (0.1 mg).

Ipradol is a selective beta2-adrenostimulator used to stop an attack of bronchial asthma in the form of a metered aerosol (1-2 breaths) or intravenously drip 2 ml of a 1% solution.

Berotek (fenoterol) - partially selective beta2-adrenostimulant, is used to stop an attack of bronchial asthma in the form of a metered aerosol (1-2 breaths). The beginning of bronchodilator action is observed after 1-5 min, the maximum of action is 45 minutes, the duration of action is 5-6 hours (even up to 7-8 hours).

Yu.B.Belousov (1993) considers berotek as a drug of choice in connection with a sufficient duration of action.

Combined beta2-adrenergic stimulants

Berodual is a combination of beta2-adrenostimulator of fenoterol (beroteka) and cholinolytics of iprapropium bromide, which is an atropine derivative. Produced in the form of a dosed aerosol, it is used to stop an attack of bronchial asthma (1-2 breaths), if necessary, the drug can be inhaled up to 3-4 times a day. The drug has a pronounced bronchodilator effect.

Ditek - a combined metered aerosol, consisting of fenoterol (beroteka) and the stabilizer of mast cells - intala. With the help of the diet it is possible to stop attacks of bronchial asthma of mild and moderate severity (1-2 breaths of aerosol), in the absence of effect, inhalation can be repeated after 5 minutes in the same dose.

The use of beta1, beta2-adrenergic stimulants

Isodrine (isoproterenol, novorrin) - stimulates beta1 and beta2-adrenoreceptors and thus dilates the bronchi and increases the frequency of cardiac contractions. For relief of an attack of bronchial asthma is used in the form of metered aerosols at 125 and 75 μg in a single dose (1-2 breaths), the maximum daily dose is 1-4 inhalations 4 times a day. In some cases, it is possible to increase the number of receptions up to 6-8 times a day.

It should be remembered that in the case of an overdose of the drug, the development of severe arrhythmias is possible. It is inappropriate to use the drug in IHD, as well as with severe chronic circulatory failure.

Treatment with euphyllin

If after 15-30 minutes after using epinephrine or other stimulants of beta2-adrenergic receptors, an attack of bronchial asthma does not stop, then intravenous administration of euphyllin should be started.

As M. E. Gershwin points out, eufillin plays a central role in the therapy of reversible bronchospasm.

Eufillin is released in ampoules of 10 ml of 2.4% solution, i.e. In 1 ml of the solution contains 24 mg of euphyllin.

Eufillin is administered intravenously initially at a dose of 3 mg / kg, and then an intravenous infusion of a maintenance dose at a rate of 0.6 mg / kg / h is made.

According to SA Sana (1986), euphyllin should be administered intravenously drip:

• in a dose of 0.6 ml / kg in 1 h patients who received earlier theophylline;
• in a dose of 3-5 mg / kg for 20 min to persons who did not receive theophylline, and then switched to a maintenance dose (0.6 mg / kg per hour).

Intravenously, euphyllin is administered drastically until the condition improves, but the concentration of theophylline in the blood is controlled. The therapeutic concentration of theophylline in the blood should be in the range of 10-20 μg / ml.

Unfortunately, in practice it is not always possible to determine the content of theophylline in the blood. Therefore, it should be remembered that the maximum daily dose of euphyllin is 1.5-2 g (ie 62-83 ml of 2.4% euphyllin solution).

To stop the attack of bronchial asthma is not always necessary to enter this daily dose of euphyllin, this need arises with the development of asthmatic status.

If there is no possibility to determine the concentration of theophylline in the blood and the absence of automated systems - pumps that regulate the administration of the drug at a given rate, you can proceed as follows.

Example.

An attack of bronchial asthma in a patient weighing 70 kg, who did not receive theophylline.

First, we inject intravenously with euphyllin in a dose of 3 mg / kg, i.e. 3x70 = 210 mg (approximately 10 ml of 2.4% euphyllin solution) in 10-20 ml isotonic sodium chloride solution very slowly for 5-7 minutes or intravenously drip for 20 minutes.

After this, we pass to the intravenous infusion of a maintenance dose of 0.6 mg / kg / h, i.е. 0.6 mg χ 70 = 42 mg / h, or approximately 2 ml 2.4% solution per hour (4 ml 2.4% solution in 240 ml isotonic sodium chloride solution at a rate of 40 drops per minute).

Treatment of glucocorticoids

In the absence of the effect of euphyllin for 1-2 hours from the onset of administration of the above-mentioned maintenance dose, treatment with glucocorticoids is initiated. Intravenously injected 100 mg of water-soluble hydrocortisone (hemisuccinate or phosphate) or 30-60 mg of prednisolone, sometimes 2-3 hours later, they must be re-introduced.

In the absence of effect after the introduction of prednisolone, you can again enter eufillin, apply beta2-adrenostimulants in inhalations. The effectiveness of these drugs after the use of glucocorticoids often increases.

Inhalation of oxygen

Inhalations of oxygen contribute to arresting an attack of bronchial asthma. Humidified oxygen is inhaled through the nasal catheters at a rate of 2-6 l / min.

Chest massage

Vibration chest massage and acupressure can be used in the complex therapy of asthma attack to get a faster effect from other activities.

General scheme of treatment

SA San (1986) recommends the following activities:

1. Inhalation of oxygen through the nasal catheter at 2-6 l / min (oxygen can be given and through the mask).
2. The appointment of one of the beta-adrenergic drugs:
   • epinephrine subcutaneously;
   • terbutaline sulphate subcutaneously;
   • inhalation of orciprenaline.
3. If after 15-30 minutes there is no improvement, repeat the introduction of beta-adrenergic substances.
4. If after another 15-30 minutes there is no improvement, intravenous drip infusion of euphyllin is established.
5. The lack of improvement within 1-2 hours after initiation of the administration of euphyllin requires additional administration of atropine or atrovent in inhalations (patients with mild cough) or intravenous corticosteroids {100 mg hydrocortisone or equivalent amount of another drug).
6. Continue inhalation of beta-adrenergic substances and intravenous injection of euphyllin.

Treatment of asthma status

Asthmatic status (AS) is a syndrome of acute respiratory failure, which develops due to pronounced bronchial obstruction, resistant to standard therapy.

A generally accepted definition of asthmatic status does not exist. Most often, asthmatic status develops with bronchial asthma, obstructive bronchitis. Given the etiology and conducted before the development of the asthmatic status of therapeutic measures, it is possible to give other definitions of asthmatic status.

According to SA San (1986), asthmatic status is defined as an acute asthma attack, in which treatment with beta-adrenergic agents, infusion of fluids and euphyllin is ineffective. The development of asthmatic status also requires the use of other treatments due to the immediate and serious threat to life.

According to Hitlari Don (1984), asthmatic status is defined as a pronounced, potentially life-threatening deterioration in the patient's condition with bronchial asthma that does not respond to conventional therapy. This therapy should include three subcutaneous injections of epinephrine with 15-minute intervals.

Depending on the pathogenetic features of asthmatic status, there are three variants of it:

1. Slowly developing asthmatic status due to increasing inflammatory bronchial obstruction, swelling, thickening of sputum, deep blockade of beta2-adrenergic receptors and a pronounced deficiency of glucocorticoids, which aggravates the blockade of beta2-adrenergic receptors.
2. Immediately developing asthmatic status (anaphylactic), caused by the development of a hyperergic anaphylactic reaction of immediate type with the release of mediators of allergy and inflammation, which leads to total bronchospasm and asphyxia at the time of contact with the allergen.
3. Anaphylactoid asthmatic status due to reflex cholinergic bronchospasm in response to irritation of respiratory tract receptors by various irrigants; the release of histamine from mast cells under the influence of nonspecific stimuli (without the participation of immunological mechanisms); primary hyperreactivity of the bronchi.

All patients with asthmatic status should be immediately hospitalized in the intensive care unit and intensive care unit.

Treatment of a slowly developing asthmatic status

I stage is the stage of the formed resistance to sympathomimetics, or the stage of relative compensation

Treatment of glucocorticoids

The use of glucocorticoids is mandatory in the treatment of asthmatic status as soon as a diagnosis of this life-threatening condition is diagnosed.

Glucocorticoids in this case have the following effect:

• restore the sensitivity of beta2-adrenergic receptors;
• strengthen the bronchodilating effect of endogenous catecholamines;
• eliminate allergic edema, reduce inflammatory obstruction of the bronchi;
• reduce the hyperreactivity of mast cells, basophils and, thus, inhibit the release of histamine and other mediators of allergy and inflammation;
• eliminate the threat of acute adrenal insufficiency due to hypoxia.

Glucocorticoids are administered intravenously calve or struino every 3-4 hours.

NV Putova recommends the use of prednisone 60 mg every 4 hours before withdrawal from asthmatic status (daily dose can reach 10 μg / kg body weight of the patient).

According to the recommendations of TA Sorokina (1987), the initial dose of prednisolone is 60 mg; if within the next 2-3 hours the condition does not improve, a single dose increases to 90 mg, or hydrocortisone hemisuccinate or phosphate is added intravenously to prednisolone 125 mg every 6-8 hours.

If the patient's condition improves with treatment, continue to administer prednisolone 30 mg every 3 hours, then the intervals are extended.

In recent years, along with parenteral administration of prednisolone, it is prescribed by mouth 30-40 mg per day.

After withdrawal from the status, the daily dose of prednisolone is reduced by 20-25% daily.

In 1987, the method of treatment of the asthmatic status of Yu. V. Anshelevich was published. The initial dose of prednisolone intravenously is 250-300 mg, after that the injection of the drug is continued every 2 hours for 250 mg or continuously drip until a dose of 900-1000 mg is given within 6 hours. If the asthmatic status persists, continue the administration of prednisolone 250 mg every 3 -4 h in a total dose of 2000-3500 mg for 1-2 days before reaching a stopping effect. After arresting asthmatic status, the dose of prednisolone is reduced every day by 25-50% with respect to the initial dose.

Treatment with euphyllin

Eufillin is the most important drug for removing a patient from asthmatic status. Against the background of the introduction of glycocorticoids, the bronchodilating effect of euphyllinum increases. Euphyllinum, in addition to bronchodilating effect, reduces pressure in the small circle of blood circulation, reduces the partial pressure of carbon dioxide in the blood and reduces platelet aggregation.

Euphyllin is administered intravenously at an initial dose of 5-6 mg / kg (ie approximately 15 ml of a 2.4% solution for a person weighing 70 kg), the injection is very slow for 10-15 minutes, after which the drug is injected intravenously at a rate 0.9 mg / kg per hour (ie approximately 2.5 mL of 2.4% solution per hour) until the condition improves, and then the same dose for 6-8 hours (maintenance dose).

Intravenous drip infusion of euphyllin with the above-mentioned speed is most conveniently performed with an automatic dosing device. If it is absent, you can simply "puncture" the system every hour with approximately 2.5 ml of a 2.4% solution of euphyllin or adjust the intravenous drip of euphyllin 10 ml of 2.4% euphyllin in 480-500 ml of isotonic sodium chloride solution at a rate of 40 drops per minute, in this case the rate the infusion of euphyllin will approach 0.9 μg / kg per hour.

When helping a patient in a state of asthmatic status, 1.5-2 g of euphyllin per day (62-83 ml of 2.4% solution) is allowed.

Instead of euphyllin, you can introduce similar drugs - diaphylline and aminophylline.

Infusion therapy

It is carried out for the purpose of hydration, improvement of microcirculation. This therapy replenishes the deficit of bcc and extracellular fluid, eliminates hemoconcentration, facilitates the spitting and liquefaction of sputum.

Infusion therapy is performed by intravenous drip infusion of 5% glucose, Ringer's solution, isotonic sodium chloride solution. With pronounced hypovolemia, low arterial pressure, it is advisable to administer reopoly glen. The total volume of infusion therapy is about 3-3.5 l in the first day, in the following days - about 1.6 l / m ^{2 of} the body surface, i.е. About 2.5-2.8 liters per day. The solutions are heparinized (2,500 units of heparin per 500 ml of liquid).

Intravenous drip infusions are carried out under the control of CVP, diuresis. The HPC should not exceed 120 mm of water. And the tempo diuresis should be at least 80 ml / hour without the use of diuretics.

When raising the CVP to 150 mm of water column, 40 mg of furosemide should be administered intravenously.

It is also necessary to control the content of electrolytes in the blood - sodium, potassium, calcium, chlorides and in case of a violation of their level, make correction. In particular, it is necessary to add potassium salts to the fluid to be administered, since asthmatic status often causes hypokalemia, especially when treated with glucocorticoids.

Fighting hypoxemia

Already in the first stage of asthmatic status, patients have mild arterial hypoxemia (PaO260-70 mmHg) and normo- or hypocapnia (PaCO2 in norm, ie 35-45 mmHg or less than 35 mmHg). St.).

Kupirovanie arterial hypoxemia is the most important part in the complex therapy of asthmatic status.

An oxygen-air mixture with an oxygen content of 35-40% is inhaled, humidified oxygen inhalation through the nasal catheters is made at a rate of 2-6 l / min.

Inhalation of oxygen is a substitution therapy for acute respiratory failure. It prevents the adverse effects of hypoxemia on the processes of tissue metabolism.

Very effective inhalation helio-oxygen mixture (75% helium + 25% oxygen) lasting 40-60 minutes 2-3 times a day. A mixture of helium and oxygen due to a lower density than air makes it easier to penetrate into poorly ventilated areas of the lungs, which significantly reduces hypoxemia.

Measures to improve sputum removal

The dominant pathological process with asthmatic status is bronchial obstruction viscous sputum. To improve sputum discharge, it is recommended:

• Infusion therapy, reducing dehydration and promoting liquefaction of sputum;
• intravenous injection of 10% sodium iodide solution - from 10 to 30 ml per day; T. Sorokina recommends administering it to 60 ml per day intravenously and also taking 3% solution inside 1 tablespoon every 2 hours 5-6 times a day; sodium iodide is one of the most effective mucolytic expectorants. Standing out of the blood through the mucous membrane of the bronchi, it causes their hyperemia, increased secretion and dilution of sputum, normalizes the tonus of bronchial muscles;
• additional humidification of the inhaled air, which contributes to the liquefaction of phlegm and its coughing up; humidification of the inhaled air is carried out by spraying the liquid; you can also inhale air moistened with warm steam;
• intravenous or intramuscular administration of vaccines (lasolvan) - 2-3 ampoules (15 mg in an ampoule) 2-3 times a day, and taking the drug 3 times a day for 1 tablet (30 mg). The drug stimulates the production of surfactant, normalizes bronchopulmonary secretion, reduces the viscosity of sputum, promotes its escape;
• methods of physiotherapy, including percussion and vibration massage of the chest.

Correction of acidosis

In the first stage of asthmatic status, acidosis is mild, compensated, so intravenous administration of soda is not always indicated. However, if the pH of the blood is less than 7.2, it is advisable to administer about 150-200 ml of a 4% sodium bicarbonate solution intravenously slowly.

It is necessary to regularly measure the pH of the blood in order to maintain it at 7.25.

The use of inhibitors of proteolytic enzymes

In some cases, it is advisable to include inhibitors of proteolysis enzymes in the complex therapy of asthmatic status. These drugs block the action of mediators of allergy and inflammation in the bronchopulmonary system, reduce edema of the bronchial wall. Intravenous drip is introduced kontrikal or trasilol at a rate of 1,000 units per 1 kg of body weight per day in 4 divided doses in 300 ml of 5% glucose.

Treatment with heparin

Heparin reduces the risk of thromboembolism (the threat of thromboembolism exists due to dehydration and thickening of blood in case of asthmatic status), has a desensitizing and anti-inflammatory effect, reduces platelet aggregation, improves microcirculation.

It is recommended to inject heparin (in the absence of contraindications) under the skin of the stomach at a daily dose of 20,000 units, distributing it to 4 injections.

Intravenous administration of sympathomimetics

As indicated above, asthmatic status is characterized by resistance to sympathomimetics. However, there is no unambiguous attitude to these drugs. NV Putov (1984) points out that the use of adrenomimetic drugs is sharply restricted or eliminated in the treatment of asthmatic conditions. GB Fedoseev and GP Khlopotova (1988) believe that as a bronchodilator, sympathomimetics can be used if there is no overdose.

SA San (1986) believes that the introduction of beta-adrenergic agents (eg, isadrine) should be given intravenously only in the most severe asthma attacks that do not respond to conventional therapies, including intravenous administration of euphyllin, atropine, and corticosteroids.

X. Don (1984) indicates that a progressive asthmatic status that does not respond to intravenous administration of aminophylline (euphyllin), inhalations of sympathomimetics, intravenous fluids of glucocorticoids, can be successfully treated with intravenous administration of Shadrin.

It should be noted that in the course of the above therapy in patients, sensitivity to sympathomimetics increases and, with observance of the rules for their use, a pronounced bronchodilator effect can be obtained.

Treatment with ipridine should be started with an intravenous dose of 0.1 μg / kg per minute. If no improvement is observed, the dose should gradually increase by 0.1 μg / kg / min every 15 minutes. It is advisable not to exceed the heart rate of 130 per minute. The lack of the effect of intravenous administration of isadrin is observed in about 15% of patients.

Treatment with isradine should be performed only in patients of young age without concomitant cardiac pathology.

The main complications are cardiac arrhythmias and toxic-necrotic changes in the myocardium.

During treatment with izadrin it is necessary to constantly monitor heart rate, arterial pressure, daily determine the blood level of myocardial enzymes, especially specific MB-CFA isoenzymes.

To treat asthmatic status, selective beta2-adrenergic stimulants can be used. Given their ability to selectively stimulate beta2-adrenergic receptors and have almost no effect on myocardial beta-1 adrenoceptors and thus do not stimulate excess myocardium, the use of these drugs is preferred over isadrin.

G. B. Fedoseev recommends the introduction of intravenous or intramuscularly 0.5 ml 0.5% solution of alupent (orciprenaline) - a drug with partial beta2-selectivity.

It is possible to use highly selective beta2-adrenostimulators - terbutaline (bricanil) - 0.5 ml of 0.05% solution intramuscularly 2-3 times a day; ipradol - 2 ml of 1% solution in 300-350 ml of 5% glucose solution intravenously drip, etc.

Thus, beta2-adrenoreceptor stimulants can be used in the treatment of progressive asthmatic status, but only against a background of complex therapy that restores the sensitivity of beta2-adrenergic receptors.

Long peridural blockade

In the complex therapy of AS, a high blockage of the epidural space between DIII-DIV can also be used. According to AS Borisko (1989), for a prolonged blockade in the epidural space in the region of DIII-DIV, a chlorovinyl catheter with a diameter of 0.8 mm is inserted through the needle. Using a catheter, 4-8 ml of a 2.5% solution of trimecaine is fractionally injected every 2-3 hours. Pervuralnaya blockade can last from several hours to six days.

Prolonged perivural blockade normalizes the tone of the smooth muscles of the bronchi, improves pulmonary blood flow, allows you to quickly remove the patient from the asthmatic state.

In bronchial asthma, especially with the development of asthmatic status, dysfunction of the central and autonomic nervous system develops according to the type of stasis pathological interoceptive reflexes that cause a spasm of sensitized bronchial muscles and increased secretion of viscous sputum with bronchial obstruction. A long peridural blockade blocks pathological interoceptive reflexes and thereby causes bronchodilation.

Fluorotanic anesthesia

C. X. Skoggin points out that ftoratan has a bronchodilator effect. Therefore, patients with asthmatic status can undergo general anesthesia. As a result, bronchospasm often stops and after the termination of the anesthesia no longer occurs. However, in some patients, after a withdrawal from anesthesia, a severe asthmatic condition develops again.

The use of droperidol

Droperidol is an alpha-adrenoreceptor and a neuroleptic. The drug reduces bronchospasm, relieves the toxic effects of sympathomimetics, agitation, reduces arterial hypertension. Given these effects of droperidol, in some cases it is advisable to include it in the complex therapy of asthmatic status under the control of arterial pressure (1 ml of 0.25% solution intramuscularly or intravenously 2-3 times a day).

II stage - the stage of decompensation (the stage of the "mute lung", the stage of progressive ventilation disorders)

In the II stage the patient's condition is extremely difficult, there is a pronounced degree of respiratory failure, although consciousness is still preserved.

Treatment of glucocorticoids

In comparison with the I stage of asthmatic status, a single dose of prednisolone is increased by 1.5-3 times and its administration is carried out every 1-1.5 hours or continuously intravenously drip. Introduce 90 mg of prednisolone intravenously every 1.5 hours, and in the absence of effect in the next 2 hours, a single dose is increased to 150 mg and simultaneously inject hydrocortisone hemisuccinate 125-150 mg every 4-6 hours. If the patient's condition improves with treatment, 60 mg, and then 30 mg of prednisolone every 3 hours.

The lack of effect within 1.5-3 h and the preservation of the picture of the "mute lung" indicates the need for bronchoscopy and segmental lavage of the bronchi.

Against the backdrop of glucocorticoid therapy, oxygen inhalation therapy, infusion therapy, intravenous administration of euphyllin, and measures to improve the drainage function of the bronchi continue.

Endotrocheal intubation and artificial ventilation of the lungs with sanation of the bronchial tree

If treatment with large doses of glucocorticoids and the rest of the above therapy does not eliminate the picture of "mute lung" for 1.5 h, endotracheal intubation should be performed and the patient transferred to artificial lung ventilation (IVL).

SA San and ME Gershwin formulate the indications for IVL as follows:

• deterioration of the patient's mental status with the development of excitement, irritability, confusion, and, finally, coma;
• increasing clinical deterioration, despite vigorous drug therapy;
• marked tension of the auxiliary muscles and retraction of the intercostal spaces, marked fatigue and danger of complete depletion of the patient's strength;
• cardiopulmonary failure;
• a progressive increase in the level of CO2 in the arterial blood, established by the determination of blood gases;
• decrease and absence of respiratory sounds on inspiration, as the respiratory volume decreases, which is accompanied by a decrease or disappearance of expiratory rales.

For introductory anesthesia, preion (viadryl) is used at the rate of 10-12 mg / kg in the form of a 5% solution. Before intubation, 100 mg of muscle relaxant deferentone is injected intravenously. Basis anesthesia is carried out with nitrous oxide and fluorotan. Nitrous oxide is used in a mixture with oxygen in a ratio of 1: 2.

Simultaneously with artificial ventilation, urgent medical bronchoscopy is performed with segmental lavage of the bronchi. The bronchial tree is washed with warmed up to 30-35 'with 1.4% sodium bicarbonate solution followed by sucking off the bronchial contents.

With intensive therapy of asthmatic status, AP Zilber recommends that the ventilator should be used in the positive end-expiratory pressure (PEEP) mode. However, in case of right ventricular failure, the PEEP mode can further disturb hemodynamics. This is especially dangerous when the ventilator begins against a background of epidural anesthesia with unresolved hypovolemia, which leads to a difficultly correctable collapse.

Against the backdrop of artificial ventilation, the therapy described in the section on the treatment of stage I asthmatic status, as well as the correction of acidosis (200 ml of 4% sodium hydrogen carbonate solution intravenously) under the control of blood pH, continues.

The ventilator stops after the stage II is stopped ("mute lung"), but bronchodilator therapy, treatment with glucocorticoids in decreasing doses, expectorants continue.

II stage - hypoxemic hypercapnic coma

In the III stage the following amount of medical measures is performed.

Artificial ventilation

The patient is immediately transferred to the artificial ventilation of the lungs. In the period of its carrying out every 4 hours, the blood pressure of oxygen, carbon dioxide, and blood pH is determined.

Bronchoscopic sanitation

Bronchoscopic sanation is also an obligatory medical measure, a segmental lavage of the bronchial tree is carried out.

Glucocorticoid therapy

Doses of prednisolone in stage III increase to 120 mg intravenously every hour.

Correction of acidosis

Correction of acidosis is made by intravenous infusion of 200-400 ml of a 4% solution of sodium bicarbonate under the control of blood pH, deficiency of buffer bases.

Extracorporeal membrane oxygenation of blood

In acute respiratory failure, ventilation does not always give a positive result even at high oxygen concentrations (up to 100%). Therefore, sometimes extracorporeal membrane oxygenation of the blood is used. It allows you to gain time and prolong the life of the patient, giving the possibility of acute respiratory failure to decline under the influence of therapy.

In addition to the above measures, treatment with zuffillin, rehydration, sputum excretion and other measures described in the section "Treatment in the first stage of asthmatic status" also continue.

Treatment of the anaphylactic variant of asthma status

1. Introduced intravenously 0.3-0.5 ml of 0.1% solution of adrenaline in 10-20 ml of isotonic sodium chloride solution. If there is no effect, after 15 minutes, intravenous drip infusion of 0.5 ml 0.1% solution of adrenaline in 250 ml of isotonic sodium chloride solution is adjusted. If there are difficulties with intravenous infusion of epinephrine into the qubital vein, adrenaline is injected into the sublingual region. Due to the abundant vascularization of this zone, adrenaline quickly enters the systemic circulation (0.3-0.5 ml of 0.1% adrenaline solution is administered) and simultaneously into the trachea by the protocol of the cricoid-thyroid membrane.

It is possible to administer intravenously drip Shadrin by 0.1-0.5 mcg / kg per minute.

Adrenaline or izadrin stimulate beta2-adrenoreceptors of the bronchi, reduce edema of the bronchi, stop bronchospasm, increase cardiac output, stimulating beta 1-adrenergic receptors.

2. Intensive glucocorticoid therapy is performed. Immediately intravenously, 200-400 mg of hydrocortisone hemisuccinate or phosphate or 120 mg of prednisolone is injected intravenously, followed by an intravenous drip infusion of the same dose into 250 ml of a 5% glucose solution at a rate of 40 drops per minute. If there is no effect, you can inject again 90-120 mg of prednisolone intravenously.
3. Intravenous 0.5-1 ml of 0.1% solution of atropine sulfate is injected into 10 ml of isotonic sodium chloride solution. The drug is peripheral M-holinolitikom, relaxes the bronchi, eliminates anaphylactic bronchospasm, reduces hypersecretion of sputum.
4. Intravenously slowly (within 3-5 minutes) 10 ml of 2.4% solution of euphyllin in 10-20 ml of isotonic sodium chloride solution.
5. Antihistamines (suprastin, tavegil, dimedrol) are administered intravenously 2-3 ml per 10 ml of isotonic sodium chloride solution.

Antihistamines block the H1-histamine receptors, help relax the bronchial muscles, reduce the swelling of bronchial mucosa.

6. In the absence of effect from the listed measures, fluorotanic anesthesia is performed and in the absence of the effect of it - IVL. Inhalation of 1.5-2% solution of ftorotanum as the narcosis deepens eliminates the phenomena of bronchospasm and facilitates the patient's condition.
7. Direct massage of the lungs is performed manually (inhaled by a bag of anesthesia apparatus, exhalation by squeezing the chest with hands). Direct massage of the lungs is performed with total bronchospasm with "stopping of the lungs" in the position of maximum inhalation and impossibility of exhalation.
8. Elimination of metabolic acidosis is carried out under the control of pH, deficiency of buffer bases by intravenous infusion of 200-300 ml of 4% sodium bicarbonate solution.
9. Improvement of the rheological properties of blood is effected by intravenous or intravenous heparin injection at a daily dose of 20,000-30,000 units (divided into 4 injections). Heparin reduces the aggregation of platelets and swelling of the bronchial mucosa.
10. To combat cerebral edema, 80-160 mg of lazix, 20-40 ml of hypertonic 40% glucose solution, is injected intravenously.
11. The use of alpha-adrenoblockers (droperidol) intravenously in a dose of 1-2 ml of 0.25% solution in 10 ml of isotonic sodium chloride solution under the control of arterial pressure reduces the activity of alpha-adrenoreceptors and promotes the arrest of bronchospasm.

Treatment of anaphylactoid variants of asthma status

The basic principles of excretion of the patient from anaphylactoid status are similar to those in the provision of emergency care for an anaphylactic variant of asthmatic status.

[1], [2], [3], [4], [5], [6], [7]