Acute bronchial obstruction

Obstructive disorders in the lower respiratory tract arise as a result of obstruction of the movement of air in the trachea at the level of the keel of the trachea, large and medium bronchi.

Pathological conditions and diseases accompanied by bronchoobstructive syndrome:

• bronchial asthma;
• acute or recurrent obstructive bronchitis;
• bronchiolitis;
• heart failure;
• chronic obstructive bronchitis;
• pneumonia;
• poisoning with phosphor-etching agents;
• tumor lesions of the tracheobronchial tree.

In some cases (bronchial asthma, obstructive bronchitis), violations of bronchial patency prevail in the clinical picture of the disease, in others (pneumonia) - occur secretly, but exerting a significant influence on the course of the underlying disease and causing the occurrence of complications.

Pathogenetic mechanisms of bronchial obstruction:

• spasm of smooth muscles of the bronchi;
• edema of the mucous membrane of the bronchial tree with possible transudation of edematous fluid into the lumen of the bronchi;
• hypersecretion of mucus;
• purulent crusts covering the lumen of the bronchi;
• collapse of bronchioles due to pressure on them from the outside by swollen alveoli;
• bronchial dyskinesia.

In most cases, the formation of violations of bronchial patency is due to all mechanisms, however, in each individual patient their specific weight is different, which explains the variety of the clinical picture.

Hypercnia prevails in children of the first three years of life, in the children of older age - the bronchospastic component.

The development of obstruction at the bronchioles level is manifested by expiratory dyspnea, wheezing of a high timbre against a background of local weakening of breathing, a pronounced violation of the gas composition of the blood.

Obstructive bronchitis and bronchiolitis

In most cases, obstructive bronchitis and bronchiolitis causes a viral infection in combination with an allergic component. Isolate the respiratory syncytial virus, parainfluenza, rhinovirus. Recently, the role of chlamydia and mycoplasmal infections has increased. Unlike obstructive bronchitis, bronchiolitis is affected by small bronchi and bronchioles. Bronchioles infiltrated; patency is severely disrupted, as with an attack of bronchial asthma.

Obstruktivy bronchitis is typical for young children, bronchiolitis - mainly for children in the first months of life.

The disease begins suddenly and is manifested by hyperthermia, dyspnea, anxiety.

When viewed in the act of breathing, auxiliary musculature participates.

With percussion of the lungs, the boxed sound; at auscultation listen a large number of moist, mostly small bubbling rales.

The natural consequence of bronchiolitis is hypoxia (55-60 mm Hg), metabolic and respiratory acidosis. The severity of respiratory failure in bronchiolitis is determined by the Fletcher scale.

Scale of severity of acute bronchiolitis

Criterion	0 points	1 point	2 points	3 points
BHD in 1 min	Less than 40	40-50	51-60	More than 60
Labored breathing	No	Slightly	Only with exhalation	With exhalation and inspiration McCSS (1
The ratio of the time of inspiration and expiration	2.5: 1	1.3: 1	1: 1	Less than 1: 1
Participation of auxiliary respiratory muscles	No	Doubtfully	Moderate	Expressed

First aid for the treatment of acute bronchial obstruction syndrome - inhalation of salbutamol (2-6 years - 100-200 μg, 6-12 years - 200 μg, over 12 years - 200-400 μg) or ipratropium bromide (2-6 years - 20 mcg, 6-12 years - 40 mcg, over 12 years - 80 mcg) with a metered aerosol inhaler or nebulizer. Possible use of combined bronchospasmolytic - ipratropium bromide + fenoterol (up to 6 years - 10 cap, 6-12 years - 20 caps over 12 years - 20-40 cap). For inhalation of young children use a spacer, an air chambers. With increasing acute respiratory failure, hormones (prednisolone 2-5 mg / kg intramuscularly or intravenously) are administered and repeated inhalations of bronchospasmolytic (ipratropium bromide + fenoterol, ipratropium bromide) are performed. With the restriction of inhalation, 2.4% 4 mg / kg of aminophylline was injected slowly intravenously slowly for 10-15 minutes on isotonic sodium chloride solution. Obligatory oxygen therapy 40-60% oxygen, infusion therapy. With severe acute respiratory failure and ineffective breathing, intubation of the trachea, auxiliary ventilation with 100% oxygen.

Acute attack of bronchial asthma

Acute attack of bronchial asthma - acute or progressively worsening expiratory suffocation. Clinical manifestations: dyspnea, spastic cough, wheezing or wheezing. For exacerbation of bronchial asthma, a decrease in the expiratory flow rate, manifested by a decrease in FEV1 (the volume of forced expiration in the first second) and a peak expiratory flow rate during spirometry is characteristic.

The amount of therapy depends on the severity of the exacerbation.

Criteria for assessing the severity of an attack of bronchial asthma in children

Symptoms	Light attack	Severe attack	Severe attack	Threat of stopping breathing (Stofus asthmaticus)
Physical activity	Saved	Restricted	Forced position	Absent
Speaking	Saved	Limited; individual phrases	Speech is difficult	Absent
The sphere of consciousness	Sometimes arousal	Excitation	Excitement, fright, panic "	Confusion, hypoxic or hypox-hypercapnia coma
Breathing rate	Breathing quickened	Expressive Expiratory Dyspnea	Strongly expressed Expiratory Dyspnea	Tachypnea or bradypnea
Participation of auxiliary muscles, retraction of the pit	Unexpectedly expressed	Expressed	Strongly expressed	Paradoxical thoraco-abdominal breathing
Wheezing	Usually at the end of exhalation	Expressed	Strongly expressed	Mute lung ", absence of respiratory noises
Heart Rate	Increased	Increased	Sharply increased	Decreased
FEV1, PEFb% ot the norm or the best values of the patient	> 80%	50-80%	<50% of the norm	<33% of the norm
PO2	N	> 60 mm Hg	<60 mmHg	<60 mmHg
PaCO2	<45 mmHg	<45 mmHg	> 45 mmHg.	> 45 mmHg.

Algorithm for the therapy of an easy attack of bronchial asthma

Inhalation of a bronchodilator with a metered aerosol inhaler or nebulizer.

Used drugs

Salbutamol (beta ₂ -adrenomimetik short-acting); single dose through the inhaler 100-200 mcg, nebulizer - 1.25-2.5 mg (1 / 2-1 nebulas).

Ipratropium bromide (M-anticholinergic); single dose through the DAI 20-40 mcg (1-2 doses), 0.4-1 ml through the nebulizer.

Combined preparation of ipratropium bromide + fenoterol; a single dose of 0.5-1 ml through nebulizer, 1-2 doses with the help of DAD (50 μg fenoterola + 20 μg ipratropium bromide).

After 20 minutes, assess the patient's condition. Criteria for the effectiveness of the treatment being administered are a reduction in dyspnea, a number of dry wheezes in the lungs and an increase in the peak expiratory flow rate. With poorly expressed positive dynamics, a repeated dose of bronchodilator is prescribed; absence of effect - reassess the severity of an attack of bronchial asthma and, in accordance with the condition, correct the therapy.

Algorithm for the treatment of a moderate attack of bronchial asthma

Produce 1-2 inhalation of bronchodilator drugs through an inhaler or nebulizer: salbutamol 2.5 mg (2.5 ml), ipratropium bromide + fenoterol 0.5 ml (10 cap) in children under 6 years and 1 ml (20 caps) in children over 6 years old within 5-10 minutes. Inhaled glucocorticosteroids are used: 0.5-1 mg budesonide in nebulas, parenterally 1-2 mg / kg prednisolone. Therapy is evaluated after 20 minutes. Unsatisfactory effect - a repeated dose of a bronchodilator, a glucocorticoid. In the absence of a metered aerosol inhaler or nebulizer, aminophylline 4-5 mg / kg is injected intravenously slowly for 10-15 minutes with isotonic sodium chloride solution. After elimination of an easy or moderate attack, it is necessary to continue treatment with beta ₂ -adrenomimetics every 4 to 6 hours for 24-48 hours, with an average attack it is possible to transfer to prolonged bronchodilators (beta ₂ -adrenomimetics, methylxanthines) to normalize clinical and functional parameters. It is necessary to prescribe or correct a basic anti-inflammatory therapy.

Algorithm for the treatment of a severe attack of bronchial asthma

Use (beta ₂ -adrenomimetics in 20 minutes for 1 hour, then every 1-4 hours or spend a long nebulization.

Preferably the use of a nebulizer: salbutamol 2.5 mg or ipratropium bromide + fenoterol 0.5-1 ml, budesonide 0.5-1 mg, systemic glucocorticosteroids - 60-120 mg prednisolone intravenously or 2 mg / kg orally. If the patient can not create a peak flow on the exhalation, prescribe epinephrine subcutaneously at a dose of 0.01 ml / kg or 1 mg / ml, a maximum dose of 0.3 ml. In the absence of inhalation equipment (nebulizer and metered-dose inhaler are unavailable), or with insufficient effect, 2.4% aminophylline is injected slowly intravenously for 20-30 minutes, then (if necessary) intravenously drip for 6-8 hours. A satisfactory result (improvement in condition, growth of peak exhalation rate, S _a 0 ₂ ) is used by the nebulizer every 4-6 h for 24-48 h, systemic glucocorticosteroids 1-2 mg / kg every 6 hours; (increase in symptoms, absence of growth in peak exhalation rate, S _a 0 ₂ ) - repeated administration of systemic glucocorticosteroids: 2 mg / kg intravenously, intramuscularly (up to 10 mg / kilogram daily) or per os for children 1-2 mg / kgsut), 1-5 years - 20 mg / day, over 5 years -20-60 mg / day; aminophylline - intravenously continuously or fractionally every 4-5 hours under the control of theophylline concentration in the blood.

After the elimination of the attack, bronchodilators are prescribed every 4 hours: beta ₂ -agonists of short action 3-5 days, transfer to prolonged bronchodilators (beta ₂ -adrenomimetics, methylxanthines); systemic corticosteroids intravenously, intramuscularly or per os 3-5 days 1-2 mgDkgsut) before cupping of bronchial obstruction. Correction of basic therapy with corticosteroids with increasing dose 1.5-2 times.

Algorithm for the treatment of asthmatic status

Obligatory oxygen therapy is 100% oxygen, blood pressure monitoring, respiratory rate, heart rate, pulse oximetry. Prednisolone 2-5 mg / kg or dexamethasone 0.3-0.5 mg / kg intravenously; epinephrine 0.01 ml / kg subcutaneously or 1 mg / ml (the maximum dose to 0.3 ml). If there is no effect, 2.4% 4-6 mg / kg of aminophylline intravenously is used for 20-30 min, followed by a dose of 0.6-0.8 mg Dkgxh), using isotonic sodium chloride solution and 5% glucose solution (1 :1). Increasing hypoxia requires intubation, ventilation, infusion therapy with glucose-salt solutions at a dose of 30-50 ml / kg at a rate of 10-15 drops per minute.

Foreign bodies of the respiratory tract and aspiration syndrome

The foreign body can partially or completely disrupt airway patency.

Clinical signs of obstruction:

• ineffective cough;
• inspiratory dyspnoea with the involvement of an auxiliary musculature; participation in the breathing of the wings of the nose;
• wheezing in exhalation;
• stridor;
• cyanosis of the skin and mucous membranes.

Balloting foreign bodies

Most of all aspirated foreign bodies get into the bronchi, and only 10-15% remain at the level of the larynx or oral cavity and can be removed upon examination. A constantly acting negative factor is the time elapsed since the aspiration. Balloting foreign bodies in connection with the great danger to life and the peculiarity of the clinic are singled out as a separate group. Most of these bodies have a smooth surface (seeds of watermelon, sunflower, corn, peas). When coughing, laughing, restless, they easily move in the tracheobronchial tree, air streams toss them to the glottis, irritating the true vocal cords that close instantly. At this moment, the sound of the slamming of the foreign body is heard (even at a distance) about closed ligaments. Sometimes the ballot body sticks in the glottis and causes an attack of suffocation. The insidiousness of the balloting bodies lies in the fact that at the time of aspiration the patient experiences, in most cases, a short-term attack of suffocation, then for a while his condition improves. With prolonged spasm of the vocal cords, a fatal outcome is possible.

Fixed foreign bodies

The condition of patients with foreign bodies fixed in the trachea can be severe. Suddenly there is a cough, breathing is quickened and difficult, there is an entrainment of the compliant places of the chest, acrocyanosis is expressed. The child tries to take a position that facilitates breathing. The voice is not changed. With percussion, box sound over the entire surface of the lungs; at auscultation, the breathing is weakened equally from both sides. Foreign bodies, fixed in the region of tracheal bifurcation, are of great danger. When breathing, they can move in one direction or another and close the entrance to the main bronchus, causing its complete closure with the development of lung atelectasis. The condition of the patient in this case worsens, shortness of breath and cyanosis increase.

Aspiration of emetic masses often occurs in children who are in a coma, during anesthesia, with poisoning or CNS depression caused by other causes, i.e. In those cases when the mechanism of coughing is broken. Aspiration of food is observed mainly in children of the first 2-3 months of life. When food masses enter the respiratory tract, the reactive edema of the mucous membrane develops, while aspirating acidic gastric juice, a toxic edema of the respiratory tract (Mendelssohn syndrome) is added to the local reactive edema. Clinical manifestations are rapidly increasing asphyxia, cyanosis, severe laryngo- and bronchospasm, and a drop in blood pressure.

Despite the vivid clinical picture that indicates the likelihood of aspiration of a foreign body, diagnosis is difficult, since with most balloting foreign bodies, the physical data are minimal.

Emergency care - the fastest removal of a foreign body, the elimination of bronchial spasm and bronchioles. In children under 1 year, 5-8 strokes are applied on the back (the child is placed on the adult's hand with the stomach down, the head is below the trunk), then turn the child and make several shocks in the chest (at the level of the lower third of the sternum one finger below the nipples). Children older than 1 year perform Heimlich's reception (up to 5 times), while sitting behind a seated or standing child. If the foreign body is visible, it is extracted with carcane, tweezers, Migill forceps; vomit, remnants of food are removed from the oropharynx by sucking. After releasing the respiratory tract, 100% oxygen is supplied with a mask or a respiratory bag.

Immediate intervention is not indicated for partial airway obstruction (with normal color of the skin and cough reflex). Finger research and removal of a foreign body blindly in children is contraindicated due to the fact that it is possible to move the foreign body inwards with the development of complete obstruction.

During the emergency, the patient is given a draining position by lowering the head end of the bed. As soon as possible, tracheal intubation and aspiration of the contents of the trachea and bronchi are performed to eliminate obstruction. The inflatable cuff on the endotracheal tube protects the airways from repeated vomiting. In the absence of effective spontaneous breathing, ventilation is performed. Through the tube, 50 ml of isotonic sodium chloride solution is introduced into the respiratory tract followed by evacuation by suction. The procedure is repeated several times until the airway is completely cleansed. With the restriction of intubation, a conicotomy, a puncture of the cryothyroid ligament, a large-caliber catheter, or a puncture of the trachea with 2-3 needles of large diameter are performed. Oxygenotherapy with 100% oxygen.

Hospitalization is mandatory even with the removal of a foreign body, transportation is always in a sitting position.

Pulmonary edema

Edema of the lungs is a pathological increase in the volume of extravascular fluid in the lungs, which develops as a result of increased hydrostatic pressure in the pulmonary vessels, a reduction in the oncotic pressure of the blood plasma; increase the permeability of the vascular wall, intrathoracic pressure and redistribution of blood from the large to the small circle of blood circulation.

Types of pulmonary edema:

• cardiogenic;
• non-cardiogenic.

In children, non-cardiogenic pulmonary edema occurs more often, due to a sharp increase in negative pressure in the chest with unresolved airway obstruction, resumption of spontaneous breathing after it stops and prolonged cardiopulmonary resuscitation, aspiration, severe hypoxia (increased capillary permeability), drowning. Cardiogenic edema in children develops with left ventricular failure due to mitral valve defects, arrhythmias, myocarditis, hyperhydration due to excessive infusion therapy.

Clinical signs: shortness of breath, cough with bloody sputum.

When auscultation - wet rale, sometimes bubbling breath. Tachycardia becomes a tachyarrhythmia, a violation of the heart rhythm; Shortness of breath with retraction of compliant places of the chest. When examined, they reveal edema on the legs, widening the boundaries of the heart.

An important indicator is the increase in CVP (15-18 cm of water).

Develops respiratory and metabolic acidosis.

Treatment of pulmonary edema begins with giving the elevated position to the patient (the head end of the bed is raised). Enter furosemide in a dose of 1-2 mg / kg intravenously, in the absence of effect, repeat the introduction after 15-20 minutes; prednisolone 5-10 mg / kg. Obligatory oxygen therapy 40-60% oxygen, passed through 33% alcohol; independent breathing in positive pressure mode at the end of expiration. In case of ineffectiveness of the conducted measures - transfer to artificial ventilation in the mode of positive pressure at the end of exhalation; Children over 2 years of age are given intramuscularly or intravenously 1% trimeperidine (0.1 ml / year of life). Hospitalization in the intensive care unit.

Syndrome of acute intrapleural tension

Sharp tension in the pleural cavity develops as a result of spontaneous or traumatic stress pneumothorax, incorrect medical manipulations. Spontaneous pneumothorax can occur in an apparently healthy child, with bronchial asthma, pneumonia, cystic fibrosis, bronchiectasis.

Pneumothorax characterizes sudden, rapidly increasing dyspnea and cyanosis, pain in the chest, pronounced tachycardia with a paradoxical pulse, arterial hypotension, a shift of the mediastinum to a healthy side. Death occurs within a few minutes of acute hypoxia, electromechanical dissociation.

Emergency care begins with oxygen therapy with 100% oxygen. The main activity with intense pneumothorax is puncture of the pleural cavity in the position of the "half-asleep" body under anesthesia (1-2 ml of 0.5% novocaine) in the second intercostal space along the anterior or middle axillary line along the upper edge of the underlying rib. To remove fluid (blood, pus), puncture is performed in the fifth intercostal space along the middle axillary line. If the patient is unconscious, then anesthesia is not performed. When removing the needle, the skin around the puncture is compressed with fingers and treated with a glue.

Treatment measures for valve pneumothorax - passive drainage according to Bylau.

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