Examination of the respiratory function of the nose

A person suffering from a violation of nasal breathing can be identified at the first glance at him. If this deficiency accompanies him from an early childhood (chronic adenoiditis), then signs of respiratory failure of the nose are detected with a single cursory examination of the face: a slightly open mouth, an incorrectly developed skeleton of the facial part of the skull ( protuberance and underdevelopment of the lower jaw), anomalies in the development of teeth and the pyramid of the nose, the smoothness of the nasolabial folds, closed nasal (difficulties in pronouncing the sonorous sounds "en", "en", "he", etc.) - because of the disturbance of the resonator function of the nose. There may also be a Woqueza syndrome that occurs with a youthful deforming recurrent polyposis of the nose, which is manifested by vivid signs of obstruction of the nasal passages, thickening and widening of the back of the nose. These signs of nasal breathing are confirmed in its objective causes, which are revealed during anterior and posterior (indirect) rinoscopy or with the help of modern rhinoscopes equipped with special optics. As a rule, there are "physical" obstacles in the nasal cavity or in the nasopharynx that disrupt the normal functioning of the aerodynamic system of the nose (polyps, hypertrophic nasal concha, curvature of the septum, tumors, etc.).

There are many simple ways to assess the state of nasal breathing, allowing you to obtain the necessary data without resorting to complex and costly methods, such as computer rhinomanometry. For example, the patient breathes only through the nose, the doctor watches him. With difficulty in nasal breathing, the frequency and depth of breathing change, characteristic noises appear in the nose, movements of the nose wings synchronizing with the respiratory phases are observed; with a sharp obstruction of nasal breathing, the patient passes to the mouth type of respiration with characteristic signs of dyspnea after a few seconds.

Disruption of nasal breathing of each half of the nose can be established in very simple ways: by attaching a small mirror, a frontal reflector or a handle of a metal spatula to the nostrils (estimate the degree of fogging of the surface of the object brought to the nose). The principle of studying the respiratory function of the nose with the definition of the magnitude of the condensate spot on a polished metal plate was proposed at the end of the 19th century. R.Glatzel (R.Glatzel). In 1908, E.Escat proposed his original device, which, thanks to concentric circles placed on the mirror, allowed to estimate the amount of exhaled air indirectly through each half of the nose according to the size of the misted area.

The disadvantage of methods with fogging is that they allow you to evaluate only the quality of exhalation, while the inspiratory phase is not recorded. Meanwhile, nasal breathing, as a rule, is disturbed in both directions and less often in only one single phase, for example, as a result of a "valve mechanism" with a movable polyp of the nasal cavity.

Objectification of the respiratory function of the nose is necessary for a number of reasons. The first of them is the evaluation of the effectiveness of the treatment. In some cases, patients after treatment continue to make complaints about the difficulty of nasal breathing, explaining this by the fact that they sleep with their mouth open, they dry out in the mouth, etc. In this case, it may be the habit of the patient to sleep with his mouth open, and not about unsuccessful treatment. The objective data convince the patient that the nasal breathing in him after the treatment is quite sufficient and it is only a matter of the need to restructure the breathing on the nasal type.

In some cases, with osteoporosis or severe atrophy of the endonasal structures, when the nasal passages are extremely wide, patients still complain of difficulty in nasal breathing, although the magnitude of the condensation spots on the mirror surface indicates good patency of the nasal passages. As more in-depth studies show, in particular with the use of the method of rhinomanometry, the complaints of these patients are due to extremely low air pressure in the broad nasal passages, the absence of "physiological" turbulent movements and atrophy of the receptor apparatus of the nasal mucosa, which together leads to a loss of patients feeling the passage of air stream through the nasal cavity and to a subjective impression of the absence of nasal breathing.

Speaking about simple methods for assessing nasal breathing, we can not fail to mention the "test with fluff" by V.Voyachek, which visually demonstrates to the doctor and the patient what the degree of patency of the nasal passages. Two fluffs 1-1.5 cm long made of cotton wool fibers are simultaneously brought to the nostrils. With good nasal breathing, fluff excursions, driven by a flow of inhaled and exhaled air, are significant. With insufficient nasal breathing, fluff movements are flaccid, small amplitude or none at all.

To determine the disturbance of nasal breathing caused by an obstruction in the run-up to the nose (the so-called front bow valve), the Cottle test is used. With calm breathing carried out through the nose, pull soft tissues of the cheek out at the level and near the wing of the nose, side from the septum of the nose. If the nasal breathing becomes more free, the Cottle test is evaluated as positive and the function of the front nasal valve is considered to be impaired. If this technique does not significantly improve nasal breathing in the presence of objective insufficiency, the cause of disturbance of the respiratory function of the nose should be sought in deeper parts. Reception Kottle can be replaced by reception of Kohl at which on the threshold of a nose enter a wooden chips or the probe by means of which a wing of a nose move aside outside.

Rinomanometry

During the XX century. Many devices have been proposed for carrying out objective rhinomanometry with the registration of various physical parameters of the air flow passing through the nasal passages. In recent years, the method of computer rhinomanometry has been increasingly used, which makes it possible to obtain various numerical indicators of the state of nasal breathing and its reserve.

The normal reserve of nasal breathing reserve is expressed as the ratio between the measured values of intranasal pressure and air flow in different phases of one respiratory cycle with normal nasal breathing. In this case, the examinee should be sitting in a comfortable position and remain at rest without any previous even the most minimal physical or emotional loads. The size of the reserve of nasal breathing is expressed as the resistance of the nasal valve to the air flow during nasal breathing and is measured in SI units as kilopascal per liter per second - kPa / (ls-s).

Modern rhinomanometers are complex electronic devices in the design of which special microsensors are used - converters of intranasal pressure and airflow velocity into digital information, as well as special programs of computer mathematical analysis with calculation of nasal breathing indices, graphical display facilities of the investigated parameters. The presented graphs show that with normal nasal breathing, the same amount of air (the ordinate axis) passes through the nasal passages in a shorter time with a twice-three times lower pressure of the air jet (abscissa axis).

The method of rhinomanometry provides three methods for measuring nasal breathing: anterior, posterior and retro-natal manometry.

The anterior rhinomanometry is that in one half of the nose a tube with a pressure sensor is inserted through its vestibule, with the help of a hermetically sealed obturator that this half of the nose is excluded from the act of breathing. With the corresponding "corrections" introduced by the computer program, it is possible to obtain sufficiently correct data with it. The drawbacks of the method include the fact that the output (the total nasal resistance) is calculated using Ohm's law for two parallel resistors (simulating the resistance of both open half of the nose), while in fact one of the halves is blocked by a pressure sensor. In addition, as noted by Ph.Cole (1989), the changes occurring in patients in the mucus system of the nose in the intervals between right-hand and left-sided studies reduce the accuracy of this method.

The posterior rhinomanometry involves placing a pressure sensor in the oropharynx through the mouth with tightly clamped lips, and the end of the tube must be placed between the tongue and the soft sky so that it does not touch the reflex zones and does not cause an unacceptable gag reflex for this procedure. To implement this method, the patient needs patience, habituation and lack of a high pharyngeal reflex. These conditions are especially important when examining children.

In retronasal or overgrazing rhinomanometry (according to F. Kohl 's method), which he uses in the children's department of respiratory diseases in a hospital in Toronto), a neonatal catheter (No. 8 Fr) with a lateral retraction near the tip is used as a pressure conductor, pressure to the sensor. The catheter, lubricated with lidocaine gel, is carried out 8 cm along the bottom of the nasal cavity to the nasopharynx. The child's slight irritation and anxiety disappear immediately, as soon as the catheter is fixed with a plaster adhesive to the upper lip. The differences in the indices of these three methods are insignificant and depend mainly on the volume of cavities and aerodynamic characteristics of the air flow at the location of the end of the tube.

Acoustic rhinomanometry. In recent years, the method of sound scanning of the nasal cavity has been increasingly used to determine certain metric parameters related to its volume and total surface area.

The pioneers of this method were two scientists from Copenhagen O.Hilberg and O.Peterson who in 1989 proposed a new method for examining the nasal cavity using the above principle. Later, SRElectronics (Denmark) created a serially produced acoustic rhinometer "RHIN 2000", intended for daily clinical observations and for scientific research. The installation consists of a measuring tube and a special nasal adapter attached to its end. The electronic sound transducer at the end of the tube sends a continuous wideband audio signal or a series of intermittent sound parcels and registers the sound reflected from the endonasal tissues returning to the tube. The measuring tube is connected to the electronic computer system for processing the reflected signal. Contact with the measuring object is carried out through the distal end of the tube by means of a special nasal adapter. One end of the adapter corresponds to the contour of the nostril; sealing of the contact to prevent the "leak" of the reflected sound signal is carried out with the help of medical Vaseline. It is important not to apply force to the tube, so as not to change the natural volume of the nasal cavity and the position of its wings. Adapters for the right and left half of the nose are removable and must be sterilized. The acoustic probe and the measuring system provide interference delay and issue only undistorted signals to the recording systems (monitor and built-in printer). The unit is equipped with a mini-computer with a standard 3.5-inch drive and a high-speed, nonvolatile permanent-storage disk. An additional disk is a permanent memory with a capacity of 100 MB. Graphic display of parameters of sound rhinometry is carried out continuously. The display in the stationary mode displays both single curves for each nasal cavity and a series of curves reflecting the dynamics of the changing parameters over time. In the latter case, the curve analysis program provides both the averaging of the curves and the mapping of probability curves with an accuracy of at least 90%.

The following parameters are evaluated (in graphic and digital display): the transverse area of the nasal passages, the volume of the nasal cavity, the difference in the areas and volumes between the right and left halves of the nose. To the possibility of RHIN 2000, an electronically controlled adapter and stimulator for olfactometry and an electronically controlled stimulant are expanded to conduct allergic provocative and histamine samples by injecting appropriate substances.

The value of this device is that it can accurately determine the quantitative spatial parameters of the nasal cavity, their documentation and research in dynamics. In addition, the facility provides ample opportunities for carrying out functional tests, determining the effectiveness of the drugs used and their individual selection. Database computer, color plotters, storing in memory received information with passport data surveyed, as well as a number of other possibilities allow attributing this method to very promising in both practical and scientific research.