Diagnostic and Diagnostic and emergency care for life-emergency care for life-threatening respiratory threatening respiratory

system injuriessystem injuries

Prepared by:Prepared by:C.m.s., assistant professor C.m.s., assistant professor

of outpatient therapy of outpatient therapy and emergency medical and emergency medical

emergency KSMUemergency KSMUA.R. AlpyssovaA.R. Alpyssova

The purpose of lectureThe purpose of lecture

► After completing the lecture, students After completing the lecture, students

should focus on issues of diagnosis and emergency should focus on issues of diagnosis and emergency

treatment for life-threatening respiratory treatment for life-threatening respiratory

system lesions in the amount of the first system lesions in the amount of the first

medical care (doctor's line crews), and medical care (doctor's line crews), and

depending on the patient - in the amount depending on the patient - in the amount

of specialized care (intensive care team, intensive of specialized care (intensive care team, intensive

care team) .care team) .

► Acute respiratory failure (ARF) - violation of the gas Acute respiratory failure (ARF) - violation of the gas exchange between ambient air and circulating blood to exchange between ambient air and circulating blood to the presence of hypoxemia and / or hypercapnia that the presence of hypoxemia and / or hypercapnia that develops in time from several minutes to several days.develops in time from several minutes to several days.

► SGL - a pathological condition in which SGL - a pathological condition in which the respiratory system does not provide normal blood the respiratory system does not provide normal blood gases, or it only provides increased work of gases, or it only provides increased work of breathing, dyspnea manifested.breathing, dyspnea manifested.

► In a wider sense the concept of "respiratory failure" In a wider sense the concept of "respiratory failure" brings together all kinds of disorders of gas brings together all kinds of disorders of gas exchange between the organism and the exchange between the organism and the environment, including hypoxia caused by low partial environment, including hypoxia caused by low partial pressure of oxygen in the atmosphere (hypobaric pressure of oxygen in the atmosphere (hypobaric type), breach of transport of gases between the type), breach of transport of gases between the lungs and body cells due to cardiac or vascular disease lungs and body cells due to cardiac or vascular disease (circulatory type), or changes in the concentration of (circulatory type), or changes in the concentration of hemoglobin in the blood or its properties hemoglobin in the blood or its properties (type hemic), blockade of the enzymes of tissue (type hemic), blockade of the enzymes of tissue respiration at the cellular level (gistotoksical type).respiration at the cellular level (gistotoksical type).

The etiology and pathogenesis, classificationThe etiology and pathogenesis, classification

On the pathogenesis On the pathogenesis of acute respiratory of acute respiratory failure are divided into:failure are divided into:

► hypoxic (low oxygen) - occurs in the event hypoxic (low oxygen) - occurs in the event of ventilation-perfusion relationships and of ventilation-perfusion relationships and shunting of blood to the lungs;shunting of blood to the lungs;

► hypercapnic (excess of carbon dioxide) - develops hypercapnic (excess of carbon dioxide) - develops when body's inability to provide when body's inability to provide adequate ventilation;adequate ventilation;

► mixed - a violation of both ventilation-mixed - a violation of both ventilation-perfusion relationships and ventilation in lung perfusion relationships and ventilation in lung function.function.

Depending on the pathogenesis:Depending on the pathogenesis:► ventilationventilation► diffusionaldiffusional► due to a violation of ventilation-due to a violation of ventilation-

perfusion relationships in pulmonaryperfusion relationships in pulmonary► In view of the causes of respiratory In view of the causes of respiratory

problems (B. E. Votchal, 1972):problems (B. E. Votchal, 1972):► tsentrogennaya (due to dysfunction of the tsentrogennaya (due to dysfunction of the

respiratory center)respiratory center)► neuromuscular (associated with damage to the neuromuscular (associated with damage to the

respiratory muscles or nervous system)respiratory muscles or nervous system)► torakodiafragmal (with changes in shape and torakodiafragmal (with changes in shape and

volume of the thoracic cavity, the rigidity of the volume of the thoracic cavity, the rigidity of the chest, severely chest, severely restricting her movements because of pain, such restricting her movements because of pain, such as trauma, disfunction of the diaphragm)as trauma, disfunction of the diaphragm)

► bronchopulmonary:bronchopulmonary: - Obstructive, ie associated with the violation - Obstructive, ie associated with the violation

of bronchial patencyof bronchial patency - Restrictive (restrictive)- Restrictive (restrictive) - diffusion- diffusion

Adrift NAM:Adrift NAM:► AcuteAcute► chronicchronic

On the severity of gas exchange disturbances:On the severity of gas exchange disturbances:► latent latent D. n. D. n. when increased work of breathing is when increased work of breathing is

still able to provide normal blood gasstill able to provide normal blood gas► partialpartial D. n. D. n. characterized by hypoxemia,  characterized by hypoxemia,

ie, decrease in arterial pO2 (up to ie, decrease in arterial pO2 (up to 80mm Hg. and below) and the concentration 80mm Hg. and below) and the concentration of oxygenated hemoglobin (up to 95% and below)of oxygenated hemoglobin (up to 95% and below)

► Global Global D.n.D.n. in which, apart  in which, apart from hypoxemia, hypercapnia, and notes - from hypoxemia, hypercapnia, and notes - increasingpCO2 in arterial blood, up to increasingpCO2 in arterial blood, up to 45 mm Hg. and above45 mm Hg. and above

► The severity of ODN establish the degree of reduction The severity of ODN establish the degree of reduction of pO2 and pCO2 increase blood pH changes.of pO2 and pCO2 increase blood pH changes.Moderate level (pO2 -79-65 mm Hg., PCO2 - 46-55)Moderate level (pO2 -79-65 mm Hg., PCO2 - 46-55)Severe (pO2 - 64-55 mm Hg., PCO2 - 56-69Severe (pO2 - 64-55 mm Hg., PCO2 - 56-69Prohibitive (pO2 - 54-45 mm Hg., PCO2 - 70-Prohibitive (pO2 - 54-45 mm Hg., PCO2 - 70-85 mm Hg.)85 mm Hg.)Respiratory coma (pO2 below Respiratory coma (pO2 below 45 mm Hg. PCO2 and higher than 85 mm Hg. Cent.)45 mm Hg. PCO2 and higher than 85 mm Hg. Cent.)

► Most common in clinical practice was proposed Most common in clinical practice was proposed by A. Dembo (1957) allocation of three degrees of by A. Dembo (1957) allocation of three degrees of severity of chronicseverity of chronic D.n. D.n. in depending on  in depending on the exercise, in which patients with shortness of the exercise, in which patients with shortness of breath says:breath says:- I degree - shortness of breath occurs - I degree - shortness of breath occurs only under unusual for a patient load increased;only under unusual for a patient load increased;- II degree - with the usual loads;- II degree - with the usual loads;- III degree - in peace.- III degree - in peace.

►

Etiology.Etiology.Distinguish pulmonary and extrapulmonary causes of ODN.Distinguish pulmonary and extrapulmonary causes of ODN.

     For     For extrapulmonary causes  extrapulmonary causes include:include:► Disorders of central regulation of respiration: a) Disorders of central regulation of respiration: a)

acute vascular disorders (cerebral embolism in blood acute vascular disorders (cerebral embolism in blood vessels, stroke, cerebral edema), b) brain injury, and vessels, stroke, cerebral edema), b) brain injury, and c) toxicity of drugs acting on the respiratory c) toxicity of drugs acting on the respiratory center (narcotic drugs, barbiturates, etc.) d) infectious, center (narcotic drugs, barbiturates, etc.) d) infectious, inflammatory and neoplastic processes that lead to the inflammatory and neoplastic processes that lead to the defeat of the brain stem, and e) coma, leading to cerebral defeat of the brain stem, and e) coma, leading to cerebral hypoxia.hypoxia.

► The defeat of the musculoskeletal frame of the The defeat of the musculoskeletal frame of the chest and the pleura: a) peripheralchest and the pleura: a) peripheral and central paralysis of and central paralysis of respiratory muscles, and b) spontaneous pneumothorax, respiratory muscles, and b) spontaneous pneumothorax, and c) degenerative dystrophy-s change in respiratory and c) degenerative dystrophy-s change in respiratory muscle, r), polio, tetanus, and e) spinal cord injury; e) the muscle, r), polio, tetanus, and e) spinal cord injury; e) the effects the impact of FOS and muscle relaxants.effects the impact of FOS and muscle relaxants.

► ODN in violation O2 transport in large blood ODN in violation O2 transport in large blood loss, acute circulatory failure andloss, acute circulatory failure and poisoning "blood poisons«poisoning "blood poisons« medhemiglobinform.medhemiglobinform.

Pulmonary causes of ODN:Pulmonary causes of ODN:► Obstructive disorders: a) airway obstruction by foreign Obstructive disorders: a) airway obstruction by foreign

bodies andbodies and mucus, vomit, amniotic fluid, and mucus, vomit, amniotic fluid, and b) mechanical obstruction of air in the compression from b) mechanical obstruction of air in the compression from the outside (hanging, strangulation), c) allergicthe outside (hanging, strangulation), c) allergic bronchopulmonary and laryngeal spasm, and d) tumor bronchopulmonary and laryngeal spasm, and d) tumor processes the respiratory tract, and e ) violation of the act processes the respiratory tract, and e ) violation of the act of swallowing, paralysis of the tongue of swallowing, paralysis of the tongue with its retraction e) edema and inflammatory diseases with its retraction e) edema and inflammatory diseases of the bronchial tree, g) increase in the tone of smooth of the bronchial tree, g) increase in the tone of smooth muscles of the bronchi, the violation of the muscles of the bronchi, the violation of the supporting structures of the small bronchi, lower the tone supporting structures of the small bronchi, lower the tone of the large bronchi.of the large bronchi.

► The defeat of respiratory structures: a) infiltration, The defeat of respiratory structures: a) infiltration, destruction, degeneration of lung tissue, and destruction, degeneration of lung tissue, and b) pneumosclerosis.b) pneumosclerosis.

► Reduced functioning lung parenchyma: a) Reduced functioning lung parenchyma: a) the underdevelopment ofthe lungs, and the underdevelopment ofthe lungs, and b) compression and atelectasis of the lung; in) a b) compression and atelectasis of the lung; in) a largeamount of fluid in the pleural cavity, and largeamount of fluid in the pleural cavity, and d) pulmonary embolism.d) pulmonary embolism.

Pathogenesis of ODN. The main clinicalPathogenesis of ODN. The main clinical syndromessyndromes

► Pathogenesis of ARF caused by the Pathogenesis of ARF caused by the development of oxygen starvation of the development of oxygen starvation of the organism as a result of violations of the alveolar organism as a result of violations of the alveolar ventilation, diffusion of gases through ventilation, diffusion of gases through the alveolar membrane and thethe alveolar membrane and the uniformity of the uniformity of the distribution of oxygen to organs and systems.distribution of oxygen to organs and systems. Clinically, it manifests the major syndromes Clinically, it manifests the major syndromes of ARI (Acute respiratory insufficiency):of ARI (Acute respiratory insufficiency):

► HypoxiaHypoxia► HypoxemiaHypoxemia► HypercapniaHypercapnia► In addition, great importance in the pathogenesis In addition, great importance in the pathogenesis

of ARI is a significant increase in energy of ARI is a significant increase in energy expenditure for the implementation of breath.expenditure for the implementation of breath.

► 1. HYPOXIA defined as a condition that 1. HYPOXIA defined as a condition that develops at low tissue oxygenation.develops at low tissue oxygenation. Given  Given the etiological factors, hypoxic conditions are the etiological factors, hypoxic conditions are divided into 2 groups.divided into 2 groups.

► a) Hypoxia due to the decrease of partial a) Hypoxia due to the decrease of partial pressure of inspired pressure of inspired oxygen (hypoxia exogenous), oxygen (hypoxia exogenous), such such as in mountainous conditions, accidents on as in mountainous conditions, accidents on submarines, etc.submarines, etc.

► b) Hypoxia in pathological processes that b) Hypoxia in pathological processes that violate the oxygen violate the oxygen supply or its normal partial supply or its normal partial pressure of inspired air. These include the pressure of inspired air. These include the following types of hypoxia: following types of hypoxia: respiratory (breathing), circulatory, tissue, respiratory (breathing), circulatory, tissue, hemic.hemic.

► The The basis of respiratory hypoxia is alveolar hypoventilatibasis of respiratory hypoxia is alveolar hypoventilation. It can be caused by obstructions of the upper on. It can be caused by obstructions of the upper respiratory tract, reducing the respiratory surface respiratory tract, reducing the respiratory surface of the lung, chest injuries, respiratory depression of of the lung, chest injuries, respiratory depression of central genesis, inflammation, or pulmonary edema.central genesis, inflammation, or pulmonary edema.

► Circulatory hypoxia occurs against a background of Circulatory hypoxia occurs against a background of acute or chronic heart failure.acute or chronic heart failure.

► Tissue hypoxia is caused by Tissue hypoxia is caused by specific poisons (eg cyanide), which leads to specific poisons (eg cyanide), which leads to a violation of Theological processes of assimilation of a violation of Theological processes of assimilation of O2 at the tissue level.O2 at the tissue level.

► Any hypoxia leads to circulatory failure. Without Any hypoxia leads to circulatory failure. Without the immediate removal of the causes the immediate removal of the causes of severe hypoxia for a few minutes causes a of severe hypoxia for a few minutes causes a patient to death. Integral indicator of patient to death. Integral indicator of the assessment of the severity of hypoxia is to the assessment of the severity of hypoxia is to determine the partial pressure of oxygen in arterial determine the partial pressure of oxygen in arterial blood.blood.

► 2. Hypoxemia. 2. Hypoxemia. At the heart At the heart of anoxemical syndrome is a violation of the of anoxemical syndrome is a violation of the processes of oxygenation of arterial blood in the processes of oxygenation of arterial blood in the lungs. This syndrome can occur as a result lungs. This syndrome can occur as a result of alveolar hypoventilation any of alveolar hypoventilation any etiology (eg, asphyxia), changes in ventilation-etiology (eg, asphyxia), changes in ventilation-perfusion relationships in the lungs (for example, perfusion relationships in the lungs (for example, the prevalence of blood in the the prevalence of blood in the lungs of ventilated with airway lungs of ventilated with airway obstruction), shunting of obstruction), shunting of blood to diffuse power and violations of blood to diffuse power and violations of the alveolar-capillary membrane (eg, respiratory the alveolar-capillary membrane (eg, respiratory distress syndrome). Integral indicator distress syndrome). Integral indicator anoxemical syndrome is the determination anoxemical syndrome is the determination of partial oxygen tension in arterial blood.of partial oxygen tension in arterial blood.

► 3. Hypercapnia.3. Hypercapnia. Hypercapnia is a  Hypercapnia is a pathological syndrome characterized by elevated pathological syndrome characterized by elevated levels of carbon dioxide in the blood or the end of levels of carbon dioxide in the blood or the end of the exit of exhaled air.the exit of exhaled air.

► At the heart of hypercapnic syndrome is a At the heart of hypercapnic syndrome is a mismatch between the mismatch between the alveolar vetilation and excessive accumulation alveolar vetilation and excessive accumulation of CO2 in the blood and tissues.of CO2 in the blood and tissues.

► This syndrome can occur in obstructive This syndrome can occur in obstructive and restrictive respiratory disorders, disorders and restrictive respiratory disorders, disorders of breathing control of central genesis, of breathing control of central genesis, pathological decrease in tone of respiratory pathological decrease in tone of respiratory muscles of the chest, etc.muscles of the chest, etc.

► Integral indicator of the level Integral indicator of the level of hypercapnic syndrome is the partial carbon of hypercapnic syndrome is the partial carbon dioxide tension in arterial blood.dioxide tension in arterial blood.

► SGL form, in which arterial blood SGL form, in which arterial blood is not sufficiently oxygened its called anoxemical.is not sufficiently oxygened its called anoxemical.

► If DIR is characterized by increased CO2 content If DIR is characterized by increased CO2 content in blood and tissues, it is called hypercapnia.in blood and tissues, it is called hypercapnia.

Clinical manifestations Clinical manifestations depend on the underlying depend on the underlying causes that led to the development of DIR, but you causes that led to the development of DIR, but you can highlight the main clinical syndromes and can highlight the main clinical syndromes and symptoms observed in all types of ODN.symptoms observed in all types of ODN.

► Shortness of breath, impaired breathing Shortness of breath, impaired breathing rhythmrhythm: tachypnea, accompanied by a feeling : tachypnea, accompanied by a feeling of shortness of breath with an auxiliary muscles in the of shortness of breath with an auxiliary muscles in the act of breathing, respiratory depression may be, act of breathing, respiratory depression may be, indicating that the growth of hypoxia, breathing Cheyne-indicating that the growth of hypoxia, breathing Cheyne-Stokes equations, Biota, with the development Stokes equations, Biota, with the development of acidosis - Kussmaul breathing.of acidosis - Kussmaul breathing.

► Cyanosis: Cyanosis: the early manifest acrocyanosis against the early manifest acrocyanosis against the pale skin and normal the pale skin and normal humidity, then cyanosis increases and becomes diffuse, humidity, then cyanosis increases and becomes diffuse, with with accession hypercapnia may be "red" cyanosis, excessive accession hypercapnia may be "red" cyanosis, excessive sweating on the background and the final stages sweating on the background and the final stages of ARI has been "marbling of the of ARI has been "marbling of the skin," spotted "cyanosed.skin," spotted "cyanosed.

The severity of the ODN (NR Paleev, VA Ilchenko, The severity of the ODN (NR Paleev, VA Ilchenko, EG Shuganov, BVGordienko, 1995, as amended)EG Shuganov, BVGordienko, 1995, as amended)

► The The clinic dedicatclinic dedicated 5 degrees ed 5 degrees of ARI.of ARI.

► Diagnosis is Diagnosis is based on an based on an assessment assessment of respiration,of respiration, circulation,  circulation, consciousnesconsciousness and the s and the definition definition of partial tensof partial tension of ion of O2 and CO2 iO2 and CO2 in the blood.n the blood.

The severity of the ARI

Ventilation ARF paCO2 mm

Parenchymal  ARFpaO2 mmHg

ModerateSevereHeavyhypercapnic ComaHypocapniccoma

rate

<50<50

50-7050-70

>70>70

90-13090-130

35-4535-45

>70>70

70-5070-50

<50<50

39-3039-30

80-10080-100

► ARF I stage.ARF I stage. The patient is conscious, restless, can  The patient is conscious, restless, can be euphoric. Complaints of feeling short of breath. Pale skin, be euphoric. Complaints of feeling short of breath. Pale skin, easy acrocyanosis.BH-25-30 in 1 min., HR-100-110 in 1 min., easy acrocyanosis.BH-25-30 in 1 min., HR-100-110 in 1 min., Blood pressure within several scroll-N or to increased, Blood pressure within several scroll-N or to increased, paO2 reduced to 70 mmHg, paCO2reduced to 35 mmHgpaO2 reduced to 70 mmHg, paCO2reduced to 35 mmHg

► ARF  II stage. ARF  II stage. Consciousness is impaired, it is often agitated. Consciousness is impaired, it is often agitated. Complaints about the strongest asthma. Possible loss of Complaints about the strongest asthma. Possible loss of consciousness, delirium, consciousness, delirium, hallucinations. Cyanotic skin, sometimes in hallucinations. Cyanotic skin, sometimes in combination with flushing, profuse perspiration. FB - 30-combination with flushing, profuse perspiration. FB - 30-40 in 1 min., Heart rate - 120-140 in 1 40 in 1 min., Heart rate - 120-140 in 1 min., Marked hypertension. paO2 reduced to 60 mm Hg, min., Marked hypertension. paO2 reduced to 60 mm Hg, paCO2 increased to 50 mmHg.paCO2 increased to 50 mmHg.

► ARF  III stage.ARF  III stage. Consciousness is absent. Clonic-tonic  Consciousness is absent. Clonic-tonic convulsions, dilated pupils with their lack of reaction to light, convulsions, dilated pupils with their lack of reaction to light, patchy cyanosis. Often there is a rapid patchy cyanosis. Often there is a rapid transition tachypnea (FB 40 and over) in bradypnea (FB - 8-transition tachypnea (FB 40 and over) in bradypnea (FB - 8-10 in 1 min.). The fall in blood pressure. FHSH 140in 1 10 in 1 min.). The fall in blood pressure. FHSH 140in 1 min. May experience atrial fibrillation. paO2 reduced to 50 min. May experience atrial fibrillation. paO2 reduced to 50 mmHg and below, paCO2 increases to 80-90 mm  mmHg and below, paCO2 increases to 80-90 mm  Hg and above.Hg and above.

Features of respiratory failure in childrenFeatures of respiratory failure in children

► In children, the NAM most often cited:In children, the NAM most often cited:► acute and chronic respiratory diseases,acute and chronic respiratory diseases,► genetically caused by chronic lung disease (cystic genetically caused by chronic lung disease (cystic

fibrosis, Kartagener's syndrome)fibrosis, Kartagener's syndrome)► malformations of the respiratorymalformations of the respiratory► result in aspiration of foreign bodiesresult in aspiration of foreign bodies► violation of the central regulation of respiration violation of the central regulation of respiration

during neurotoxicosis, poisoning, head injury, during neurotoxicosis, poisoning, head injury, with injuries of the chest.with injuries of the chest.

► Babies - When pneumopathies, such Babies - When pneumopathies, such as hyaline membrane disease of the as hyaline membrane disease of the newbornnewborn (respiratory distress  (respiratory distress syndrome births),syndrome births), pneumonia, bronchiolitis,  pneumonia, bronchiolitis, with intracranial birth trauma, intestinal paresis, with intracranial birth trauma, intestinal paresis, diaphragmatic hernia, diaphragm paresis, diaphragmatic hernia, diaphragm paresis, congenital heart defects, malformations of congenital heart defects, malformations of respiratory tract infections.respiratory tract infections.

► In children, J. N. growing more rapidly than adults in similar In children, J. N. growing more rapidly than adults in similar situations. This is due to the narrowness of the bronchi, with a situations. This is due to the narrowness of the bronchi, with a tendency to more pronounced swelling of the bronchial walls and tendency to more pronounced swelling of the bronchial walls and exudation, leading to the rapid emergence of an obstructive exudation, leading to the rapid emergence of an obstructive syndrome in inflammatory and allergic diseases. In young children syndrome in inflammatory and allergic diseases. In young children and especially infants, during intoxication manifested arrhythmia and especially infants, during intoxication manifested arrhythmia breathing. The weakness of the respiratorybreathing. The weakness of the respiratory  muscularly, high muscularly, high standing of the diaphragm, lack of development of elastic standing of the diaphragm, lack of development of elastic fibers in the lung tissue and bronchial walls in infants and preschool fibers in the lung tissue and bronchial walls in infants and preschool children are responsible for a relatively smaller compared with children are responsible for a relatively smaller compared with older deep breath, inhaling and exhaling reserve.older deep breath, inhaling and exhaling reserve. Therefore, increased ventilation is achieved not only by increasing Therefore, increased ventilation is achieved not only by increasing the depth of respiration, as by increasing its frequency. The need the depth of respiration, as by increasing its frequency. The need forO2 in children is higher than in adults, is associated with more forO2 in children is higher than in adults, is associated with more intense metabolism. Therefore, at various acidosis when intense metabolism. Therefore, at various acidosis when further increases the need for O2, the children develop DN. further increases the need for O2, the children develop DN. Hypoxemia in children quickly leads to disruption of tissue Hypoxemia in children quickly leads to disruption of tissue respiration, shot,function of many organs and systems, in Phase respiration, shot,function of many organs and systems, in Phase I, CNS and cardiovascular. Quickly develop and decompensated I, CNS and cardiovascular. Quickly develop and decompensated respiratory and metabolic respiratory and metabolic acidosis.acidosis.

►

► To assess the severity of the NAM in the pediatric To assess the severity of the NAM in the pediatric population, as adults, it is classified by the degree population, as adults, it is classified by the degree of breathlessness:of breathlessness:

► Grade I (mild) - shortness of breath comes with Grade I (mild) - shortness of breath comes with little physical exertionlittle physical exertion

► Grade II (moderate) - aloneGrade II (moderate) - alone► Grade III (severe) - alone and with the Grade III (severe) - alone and with the

participation of auxiliary muscles.participation of auxiliary muscles.► Grade IV (severe) - hypoxic comaGrade IV (severe) - hypoxic coma

     The severity of the RF (Respiratory      The severity of the RF (Respiratory Failure) more accurately determine the voltage Failure) more accurately determine the voltage variations on arterial blood gases (pO2 and variations on arterial blood gases (pO2 and pCO2) and energy cost per unit of pCO2) and energy cost per unit of ventilation. If there are ventilation. If there are deviations spirography indicators, peak deviations spirography indicators, peak flow, but blood gases and energy flow, but blood gases and energy costs remain the norm, we should talk about costs remain the norm, we should talk about the abuse of respiratory the abuse of respiratory function without respiratory failure.function without respiratory failure.

Clinical manifestations of DN in childrenClinical manifestations of DN in children determined  determined by the degree of its severity.by the degree of its severity.

► At RF I even a small degree of physical activity leads At RF I even a small degree of physical activity leads to shortness of breath, tachycardia, cyanosis nasolabial to shortness of breath, tachycardia, cyanosis nasolabial triangle, the voltage of the wings of the nose, blood triangle, the voltage of the wings of the nose, blood pressure is normal, pO2 decreased to 80-65 mm Hg.pressure is normal, pO2 decreased to 80-65 mm Hg.

► When the degree of  RF When the degree of  RF  II marked dyspnea and tachycardia at rest(ratio  II marked dyspnea and tachycardia at rest(ratio of respiration to heart of respiration to heart rate - 1:2.5), and cyanosis acrocyanosis nasolabial rate - 1:2.5), and cyanosis acrocyanosis nasolabial triangle, pale skin, increased blood pressure, there triangle, pale skin, increased blood pressure, there iseuphoria, anxiety, can iseuphoria, anxiety, can be lethargy, weakness, muscle hypotonia .Minute be lethargy, weakness, muscle hypotonia .Minute volume of respiration is increased to 150-160% of volume of respiration is increased to 150-160% of normal. Breathing reserve is reduced by 30%, pO2 - up normal. Breathing reserve is reduced by 30%, pO2 - up to 64-51 mm Hg., pCO2 is normal or slightly elevated (up to 64-51 mm Hg., pCO2 is normal or slightly elevated (up to 46-50 mm Hg.), the pH is to 46-50 mm Hg.), the pH is normal or slightly reduced. When inhaled 40% oxygen normal or slightly reduced. When inhaled 40% oxygen condition significantly improved, the partial pressure of condition significantly improved, the partial pressure of blood gases normalized.blood gases normalized.

► Respiratory failure is characterized by Respiratory failure is characterized by severe degree III dyspnea. In an severe degree III dyspnea. In an auxiliary breathing muscles involved. Marked resauxiliary breathing muscles involved. Marked respiratoryarrhythmia, tachycardia, respiratory piratoryarrhythmia, tachycardia, respiratory rate ratio for heart rate - 1:2,blood rate ratio for heart rate - 1:2,blood pressure decreased. Arrhythmia and respiratory apressure decreased. Arrhythmia and respiratory apnea leads to a reduction pnea leads to a reduction in frequency. Observed pallor, cyanosis acrocyanin frequency. Observed pallor, cyanosis acrocyanosisor total skin and mucous osisor total skin and mucous membranes, skin marbling. Appear membranes, skin marbling. Appear lethargy, listlessness, weakness, pO2 decreased lethargy, listlessness, weakness, pO2 decreased to 50 mm Hg. art.,pCO2 rises to 75-100 mm Hg., to 50 mm Hg. art.,pCO2 rises to 75-100 mm Hg., the pH decreased to 7,25-7,20.Inhalation of 40% the pH decreased to 7,25-7,20.Inhalation of 40% oxygen does not give a positive effect.oxygen does not give a positive effect.

► When RF grade IV (hypoxic coma) there is When RF grade IV (hypoxic coma) there is no consciousness, earth-colored skin, no consciousness, earth-colored skin, lips and face cyanotic, the limbs and body bluish lips and face cyanotic, the limbs and body bluish or bluish-purple spots. Convulsive breathing, mouth or bluish-purple spots. Convulsive breathing, mouth open (the child lacks the air by mouth). Respiration open (the child lacks the air by mouth). Respiration rate decreases and becomes rate decreases and becomes almost normal or even reduced to 8-10 in 1 minute due almost normal or even reduced to 8-10 in 1 minute due to prolonged apnea. Tachycardia or bradycardia, the to prolonged apnea. Tachycardia or bradycardia, the pulse was thready, BP dramatically reduced or not pulse was thready, BP dramatically reduced or not detected, pO2 below 50 mm Hg.,pCO2 greater than 100 detected, pO2 below 50 mm Hg.,pCO2 greater than 100 mm Hg., pH decreased to 7.15 or below. mm Hg., pH decreased to 7.15 or below. V case of hypocapnia (pCO2 below 35 mmHg. cent.) due V case of hypocapnia (pCO2 below 35 mmHg. cent.) due to hyperventilation, which occurs in children more than to hyperventilation, which occurs in children more than adults, marked lethargy, drowsiness, pallor, dry skin, adults, marked lethargy, drowsiness, pallor, dry skin, hypotension muscles, tachy - or hypotension muscles, tachy - or bradycardia. alkalosis (pH above 7.45), alkaline urine. Wbradycardia. alkalosis (pH above 7.45), alkaline urine. With an increase ith an increase in hypocapnia possible fainting, marked hypocalcemia, in hypocapnia possible fainting, marked hypocalcemia, leading to seizures.leading to seizures.

► ARF ARF of any cause and at any ageof any cause and at any age is an  is an indication for hospitalization of the child.indication for hospitalization of the child.

► Prehospital IV degree at RF doctor Prehospital IV degree at RF doctor renders emergency care -mouth to renders emergency care -mouth to mouth breathing, the ambulance surgeon - a mouth breathing, the ambulance surgeon - a broad emergency treatment.broad emergency treatment.

► In chronic respiratory failure I and II degree child In chronic respiratory failure I and II degree child can be treated at home, hospitalization is can be treated at home, hospitalization is required when the condition was.required when the condition was.

Emergency aid for ARFEmergency aid for ARFThe nature and sequence of therapeutic measures The nature and sequence of therapeutic measures

in ARF depends on the severity and causes of this in ARF depends on the severity and causes of this syndrome.syndrome.

In any case, therapeutic measures should be In any case, therapeutic measures should be implemented in the following order:implemented in the following order:

► 1. Restore airway throughout their length.1. Restore airway throughout their length.► 2. Normalize the general and 2. Normalize the general and

local disturbances in alveolar ventilation.local disturbances in alveolar ventilation.► 3. Eliminate the associated disorders of 3. Eliminate the associated disorders of

central hemodynamics.central hemodynamics.► 4. For relief of ARF I degree it is sufficient 4. For relief of ARF I degree it is sufficient

to conduct the patient oxygen to conduct the patient oxygen therapy. therapy. Main purpose - oxygen therapy - to Main purpose - oxygen therapy - to improve tissue oxygenation.improve tissue oxygenation.

► Oxygenation can be performed through the Oxygenation can be performed through the nasal catheter, ventimaski, pass oxygen through the nasal catheter, ventimaski, pass oxygen through the apparatus of Bobrov. The use of oxygen bags is apparatus of Bobrov. The use of oxygen bags is ineffective remedy. You can spend hyperbaric ineffective remedy. You can spend hyperbaric oxygenation under pressure 1.6 - 2 atm. 1 - 3 oxygenation under pressure 1.6 - 2 atm. 1 - 3 sessions a day for 40 -60 min. It is advisable sessions a day for 40 -60 min. It is advisable to combine with oxygen therapy introduction anti to combine with oxygen therapy introduction anti hypoxants - hydroxybuty rate sodium - 50-100 mg / hypoxants - hydroxybuty rate sodium - 50-100 mg / kg / infusion in200 ml 5% glucose, cytochrome "C" kg / infusion in200 ml 5% glucose, cytochrome "C" - to 30-80 mg per 200 ml of 5% glucose over 6-8 - to 30-80 mg per 200 ml of 5% glucose over 6-8 hours .hours .

► When ARF I degree eliminated against When ARF I degree eliminated against the obstruction of the airways and in the absence the obstruction of the airways and in the absence of the duct to prevent the tongue the patient should of the duct to prevent the tongue the patient should be given a steady lateral position. The presence be given a steady lateral position. The presence of ARF II-III century. is an indication for the transfer of of ARF II-III century. is an indication for the transfer of the patient on mechanical ventilation. In an extreme the patient on mechanical ventilation. In an extreme situation, with rapid growth characteristics ARF is situation, with rapid growth characteristics ARF is shown holding konikotomii, or puncturing shown holding konikotomii, or puncturing the trachea with thick needles. Performing in an the trachea with thick needles. Performing in an emergency tracheotomy is not carried out because of emergency tracheotomy is not carried out because of the duration of the surgery.the duration of the surgery.

► 5. Therapy of the underlying disease.5. Therapy of the underlying disease.► Heparin: 20000 ED under skin, distributed on 4 Heparin: 20000 ED under skin, distributed on 4

injections (with PE is supported injections (with PE is supported by state by state gipokoaguliationgipokoaguliation).).

► Reucing the pressure in the pulmonary circulation:Reucing the pressure in the pulmonary circulation:     - Papaverine and No-Spa 2.0 ml  intravenously      - Papaverine and No-Spa 2.0 ml  intravenously every 4 hours;every 4 hours;     - Aminophylline 2.4% - 10.0 intravenously every      - Aminophylline 2.4% - 10.0 intravenously every 5-6 hours;5-6 hours;     - Nitroglycerin  intravenously, drip 10 mg / min.     - Nitroglycerin  intravenously, drip 10 mg / min.

► Symptomatic therapy:Symptomatic therapy: - KSCHR correction,- KSCHR correction, - anesthesia,- anesthesia, - infusion therapy,- infusion therapy, - stimulation of respiration, etc.- stimulation of respiration, etc.

Absolute indications for mechanical ventilationAbsolute indications for mechanical ventilation

► 1. Gipocsechemical ARF (PaO2 less than 1. Gipocsechemical ARF (PaO2 less than 50 mmHg.).50 mmHg.).

► 2. Hypercapnic ARF  (raSO2 more than 60mm 2. Hypercapnic ARF  (raSO2 more than 60mm Hg.)Hg.)

► 3. Critical decrease in respiratory reserve (the 3. Critical decrease in respiratory reserve (the ratio of: tidal volume in ml / kg ratio of: tidal volume in ml / kg of patient weight - is less than 5 ml / kg).of patient weight - is less than 5 ml / kg).

► 4. Ineffectiveness of breath (a condition 4. Ineffectiveness of breath (a condition where the MOU with more than 15 l / where the MOU with more than 15 l / min. And with normal or slightly min. And with normal or slightly elevated raSO2 not achieved adequate saturation elevated raSO2 not achieved adequate saturation of arterial blood oxygen).of arterial blood oxygen).

Relative (differential) statement Relative (differential) statement for mechanical ventilation for mechanical ventilation

► SBT (Skull brain trauma)SBT (Skull brain trauma) with signs of ARF of with signs of ARF of varying severity.varying severity.

► Poisoning drugs and sedatives.Poisoning drugs and sedatives.► Chest injuries.Chest injuries.► St. astmaticus II class.St. astmaticus II class.► Hypoventilational syndrome of central origin, a Hypoventilational syndrome of central origin, a

violation of neuromuscular transmission.violation of neuromuscular transmission.► Pathological conditions Pathological conditions

requiring treatment for a muscle relaxation requiring treatment for a muscle relaxation epistatus, tetanus, convulsions.epistatus, tetanus, convulsions.

Asthma: determination, classification, risk factors, Asthma: determination, classification, risk factors, first aidfirst aid

► Bronchial asthma (BA) Bronchial asthma (BA) - a chronic respiratory - a chronic respiratory disease, the major pathogenetic mechanism disease, the major pathogenetic mechanism of bronchial hyperreactivity which is caused of bronchial hyperreactivity which is caused by inflammation, a major by inflammation, a major clinical manifestation - asthma(predominantly expiratoclinical manifestation - asthma(predominantly expiratory character) as a result of bronchospasm, ry character) as a result of bronchospasm, hypersecretion and swelling of the mucous membrane hypersecretion and swelling of the mucous membrane of the bronchi.of the bronchi.

► ClassificationClassification of asthma based on a joint of asthma based on a joint assessment of symptoms and the clinical picture assessment of symptoms and the clinical picture of lung function:of lung function:

1. Acc.to Etiology:1. Acc.to Etiology:► atopic (exogenous);atopic (exogenous);► unatopic (endogenous);unatopic (endogenous);► mixedmixed

► 2. On the severity of the disease (1):2. On the severity of the disease (1):► episodic asthma, when short-episodic asthma, when short-

term acute asthma episodes daily and occasionalterm acute asthma episodes daily and occasional nocturnal attacks of breathlessness (usually only 2-4 nocturnal attacks of breathlessness (usually only 2-4 weeks and 1 per year, for example. asthma caused by pollen weeks and 1 per year, for example. asthma caused by pollen from plants), without deterioration  from plants), without deterioration  ОФВ1  or or PEF (peak expiratory flow rate)PEF (peak expiratory flow rate) > 80% of > 80% of normal and scatter parameters  normal and scatter parameters  PEF PEF  less than 20%; less than 20%;

► asthma continuously recurrent mild when the number asthma continuously recurrent mild when the number of symptoms by day 1 orof symptoms by day 1 or more times a week and every day, more times a week and every day, night symptoms more than 2 times a month,night symptoms more than 2 times a month, without without exacerbation of exacerbation of ОФВ1 or  or  PEF PEF over 80% of over 80% of normal variation and indicators of  normal variation and indicators of  PEF PEF from 20 to 30% , the from 20 to 30% , the exacerbation of asthma may interfere with physical exacerbation of asthma may interfere with physical activity and sleep;activity and sleep;

► continuously recurrent asthma of moderate severity, when continuously recurrent asthma of moderate severity, when symptoms daily, nightsymptoms daily, night symptoms more than 1 time per week, symptoms more than 1 time per week, regardless of regardless of ОФВ1 or or PEF PEF episodes from 60 to 80% of episodes from 60 to 80% of normal variation and indicators of  normal variation and indicators of  PEF PEF  greater than  greater than 30%,exacerbation of asthma violate physical activity and 30%,exacerbation of asthma violate physical activity and sleep;sleep;

► severe recurrent asthma continuously when severe recurrent asthma continuously when symptoms are persistent, day and night, symptoms are persistent, day and night, frequent exacerbations,  frequent exacerbations,  ОФВ1 or PEF less than 60% of or PEF less than 60% of normal, the dispersion indices over 30% of  PEF , normal, the dispersion indices over 30% of  PEF , physical activity is limited by the patient;physical activity is limited by the patient;

► severe recurrent hormone-continuous asthmasevere recurrent hormone-continuous asthma► status asthmaticus - a prolonged severe attack status asthmaticus - a prolonged severe attack

of asthma, characterized by acute progressive of asthma, characterized by acute progressive respiratory insufficiency due to bronchial respiratory insufficiency due to bronchial obstruction and the development of resistance to obstruction and the development of resistance to the patient's therapy.the patient's therapy.

► On the severity of the disease (2)On the severity of the disease (2) are distinguished: are distinguished:► - stage I (mild intermittent): number of symptoms during - stage I (mild intermittent): number of symptoms during

the day. 2 times per week, and the absence of normal the day. 2 times per week, and the absence of normal levels PEF (peak expiratory flow rate) between levels PEF (peak expiratory flow rate) between exacerbations, number of symptoms but whose. 2 times a exacerbations, number of symptoms but whose. 2 times a month;  month;  ОФВ1 or PEF 80% rate, the spread rates PEF  less or PEF 80% rate, the spread rates PEF  less than 20%than 20%

► - stage II (mild persistent), the number of symptoms by - stage II (mild persistent), the number of symptoms by day> 1 per week but <1 time per day, the day> 1 per week but <1 time per day, the attacks violate activity, nocturnal symptoms> 2 times per attacks violate activity, nocturnal symptoms> 2 times per month; month; ОФВ1 or PEF. 80% rate, the spread rates PEF 20% - or PEF. 80% rate, the spread rates PEF 20% -30%.30%.

► - stage III (persistent, moderate), daily symptoms, - stage III (persistent, moderate), daily symptoms, seizures violate activity, nocturnal symptoms> 1 time per seizures violate activity, nocturnal symptoms> 1 time per week,  week,  ОФВ1  or PEF - 60 - 80% of normal, range of  or PEF - 60 - 80% of normal, range of indicators PEF> 30%.indicators PEF> 30%.

► - stage IV (severe persistent) symptoms - stage IV (severe persistent) symptoms of persistent, limited physical activity, frequent night of persistent, limited physical activity, frequent night time symptoms,  time symptoms,  ОФВ1 or PEF <60% of normal, range of or PEF <60% of normal, range of indicators PEF > 30%.indicators PEF > 30%.

► 3. Phase flow:3. Phase flow: sharpening, unstable remission, remission,  sharpening, unstable remission, remission, stable remission (more than 2 years).stable remission (more than 2 years).

► Risk Factors:Risk Factors: mite allergen, house  mite allergen, house dust (eg small, that are invisible to the naked eye), dust (eg small, that are invisible to the naked eye), smoking tobacco (smoking or whether the smoking tobacco (smoking or whether the patient inhales the smoke it when others are patient inhales the smoke it when others are smoking), animal allergens, covered with hair, smoking), animal allergens, covered with hair, allergens of cockroaches, pollens and allergens of cockroaches, pollens and molds outdoors , fungi, indoor physical molds outdoors , fungi, indoor physical activity, medications.activity, medications.

► Cupping: Cupping: an inhaled an inhaled β2-β2-agonists, short-agonists, short-acting (salbutamol, fenoterol); acting (salbutamol, fenoterol); β2-β2-agonists, long-agonists, long-acting with rapid onset of action (salmeterol, acting with rapid onset of action (salmeterol, formoterol), inhaled anticholinergics (ipratropium formoterol), inhaled anticholinergics (ipratropium bromide), combined drugs, including anticholinergics bromide), combined drugs, including anticholinergics and and β2-β2-agonists, short-agonists, short-acting methylxanthines (aminophylline), systemiccortiacting methylxanthines (aminophylline), systemiccorticosteroids (prednisone).costeroids (prednisone).

► Criteria for transfer to the next stage of Criteria for transfer to the next stage of treatment. treatment. In efficiency of bronchodilator In efficiency of bronchodilator therapy in asthma not cropped for 6-8 hours, an therapy in asthma not cropped for 6-8 hours, an increase of respiratory failure, “silent lung".increase of respiratory failure, “silent lung".

► Asthmatic condition -Asthmatic condition - not cropped attack of  not cropped attack of asthma lasting 6 hours or more with the development of asthma lasting 6 hours or more with the development of resistance to the sympathomimetic-m drug, a violation resistance to the sympathomimetic-m drug, a violation of the drainage function of bronchi and the occurrence of the drainage function of bronchi and the occurrence of hypoxemia and hypercapnia.of hypoxemia and hypercapnia.

► Classification of asthma status (AS)Classification of asthma status (AS)     Forms of asthma status:     Forms of asthma status:

► 1. Anaphylactic form (immediately developing a 1. Anaphylactic form (immediately developing a form of AS)form of AS) is characterized by apredominance no  is characterized by apredominance no immunological or pseudoallergic reactions to the release immunological or pseudoallergic reactions to the release of many mediators of allergic reactions. In this form of many mediators of allergic reactions. In this form of hypoxia may progressively increase, of hypoxia may progressively increase, and therefore all clinical and therefore all clinical symptoms develop rapidly and violently, quickly one after symptoms develop rapidly and violently, quickly one after another. The emergence of coma state is preceded by an another. The emergence of coma state is preceded by an acute and severe attack of breathlessness.acute and severe attack of breathlessness.

► 2. 2. Metobolic form (slowly developed form of AC) Metobolic form (slowly developed form of AC) –– the main place is plays functional blockade of the main place is plays functional blockade of β-β- adrenergic receptors. This form of asthmatics condition is adrenergic receptors. This form of asthmatics condition is form under, sometimes during several days and ever form under, sometimes during several days and ever weeks. Sicks can save in particularly volume the motor weeks. Sicks can save in particularly volume the motor activity (through room, toilet), however it difficulty and activity (through room, toilet), however it difficulty and always accompanied sharp breath and deterioration of always accompanied sharp breath and deterioration of general condition.general condition.

►On the severity of color phase ACOn the severity of color phase AC::► stage I - phase of relative compensation - a long, no stage I - phase of relative compensation - a long, no

cropped bronchial asthma attack, resistant to cropped bronchial asthma attack, resistant to therapy and other sympathomimetic bronchodilator.therapy and other sympathomimetic bronchodilator.

Reveal the following Reveal the following clinical symptoms and syndromes:clinical symptoms and syndromes:► tachypnea with tachypnea with BHBH - 30 and above in the minutes. with a  - 30 and above in the minutes. with a

pronounced difficultypronounced difficulty inhaling and exhaling, inhaling and exhaling, remote wheezing;remote wheezing;

► forced the sitting position the patient with a fixed upper forced the sitting position the patient with a fixed upper shoulder girdle, part of the subsidiary of muscles;shoulder girdle, part of the subsidiary of muscles;

► common cyanosis of the skin and mucous membranes;common cyanosis of the skin and mucous membranes;► percussion - box sound;percussion - box sound;► auskult, but in the auskult, but in the

lower auscultated sharply attenuated vesicular lower auscultated sharply attenuated vesicular breathing, andbreathing, and upper parts - with a hard tone, diffuse dry upper parts - with a hard tone, diffuse dry rales;rales;

► TachycardiaTachycardia moderate;moderate;► Normal or raised blood pressure;Normal or raised blood pressure;► ECG - signs of overload of the right atrium and right ECG - signs of overload of the right atrium and right

ventricle;ventricle;► continued hyperventilation leads to an increase in the continued hyperventilation leads to an increase in the

viscosity of sputum, which is completely occlusive lumen viscosity of sputum, which is completely occlusive lumen of the bronchi, leading to an increase in hypercapnia of the bronchi, leading to an increase in hypercapnia and hypoxemia.and hypoxemia.

► II class. - The stage of decompensation or II class. - The stage of decompensation or "silent" light:"silent" light:

► discrepancy between the severity of wheezing distance discrepancy between the severity of wheezing distance and their lack ofand their lack of

► auscultation of lungs - "silent lung";auscultation of lungs - "silent lung";► this is seriously ill, which is very difficult to say, every this is seriously ill, which is very difficult to say, every

move is accompanied by a deterioration of general move is accompanied by a deterioration of general condition;condition;

► Patients typically sit, leaning his hands on the edge of the Patients typically sit, leaning his hands on the edge of the bed;bed;

► consciousness is kept, the disparity between the severity consciousness is kept, the disparity between the severity of wheezing and their distance lack at auscultation - of wheezing and their distance lack at auscultation - "silent lung";"silent lung";

► consciousness is kept, but sometimes there consciousness is kept, but sometimes there comes excitement alternating with apathy;comes excitement alternating with apathy;

► moist skin because of sweating, cyanosis, diffuse;moist skin because of sweating, cyanosis, diffuse;► emphysematous chest inflated, visit its almost not emphysematous chest inflated, visit its almost not

noticeable, lung sounds - a box;noticeable, lung sounds - a box;

► weakened breathing, wheezing are heard only in the weakened breathing, wheezing are heard only in the upper part, places the respiratory noise in general is upper part, places the respiratory noise in general is not listening, because of the complete obturation of not listening, because of the complete obturation of bronchi ("Silent Light");bronchi ("Silent Light");

► paradoxical pulse - reduced filling pulse on paradoxical pulse - reduced filling pulse on inspiration (pulsus paradozus) heart rate exceeds inspiration (pulsus paradozus) heart rate exceeds 120 per minute;120 per minute;

► ECG right heart overload, arrhythmias are possible;ECG right heart overload, arrhythmias are possible;► blood pressure is high;blood pressure is high;► increase in the right upper quadrant pain due increase in the right upper quadrant pain due

to stretching of the fibrous capsule of the liver;to stretching of the fibrous capsule of the liver;► changes in arterial blood gas changes in arterial blood gas

composition - pronounced hypoxia (Po 50-60 mm composition - pronounced hypoxia (Po 50-60 mm Hg) and hypercapnia (PCO2 50-70 mm Hg) is formed Hg) and hypercapnia (PCO2 50-70 mm Hg) is formed by respiratory acidosis or a mixed type.by respiratory acidosis or a mixed type.

► III Art. - The stage of hypoxic hypercapnic coma.III Art. - The stage of hypoxic hypercapnic coma.► If the resolution of the syndrome of "Silent Light" does not If the resolution of the syndrome of "Silent Light" does not

occur, it becomes hypoxic stimulation, the occur, it becomes hypoxic stimulation, the active refusal from intravenously injection:active refusal from intravenously injection:

► state B'sstate B's extremely heavy, dominated by the neuro- extremely heavy, dominated by the neuro-psychiatric disorders, loss of consciousness may be preceded psychiatric disorders, loss of consciousness may be preceded by convulsions;by convulsions;

► respiration irregular, rare, and the surface;respiration irregular, rare, and the surface;► diffuse gray cyanosis, sweating, salivation;diffuse gray cyanosis, sweating, salivation;► thready pulse, hypotension, collapse;thready pulse, hypotension, collapse;► in arterial blood - hypoxemia (PO2 40-50 mmHg), in arterial blood - hypoxemia (PO2 40-50 mmHg),

high hypercapnia (PCO2 80-90mm high hypercapnia (PCO2 80-90mm Hg). Significantly expressed in the Hg). Significantly expressed in the ventilation violations. There is a shift of ventilation violations. There is a shift of acid-foundedacid-founded the  the first state in the direction of metabolic alkalosis, and with an first state in the direction of metabolic alkalosis, and with an increase in the severity of the increase in the severity of the asthmatic condition develops metabolic acidosis;asthmatic condition develops metabolic acidosis;

► decline in the circulation of blood and extracellular fluiddecline in the circulation of blood and extracellular fluid► lack of bronchodilatory effect, lack of bronchodilatory effect,

or even increased bronchoconstriction ("reboundsyndrome") or even increased bronchoconstriction ("reboundsyndrome") in terms of multiple (up to 15-20 times a day) use of inhaledin terms of multiple (up to 15-20 times a day) use of inhaled sympathomimetic drugs and receiving purine series.sympathomimetic drugs and receiving purine series.

Indications for hospitalization:Indications for hospitalization: All patients with  All patients with AS are subject to immediateAS are subject to immediate admission to an admission to an intensive care unit.intensive care unit.

► List of main and additional diagnostic List of main and additional diagnostic measures:measures:

► 1. Assessment of general condition and vital 1. Assessment of general condition and vital signs: consciousness, breathing andsigns: consciousness, breathing and circulation.circulation.

► 2. An evaluation of the patient: the characteristic 2. An evaluation of the patient: the characteristic of orthopnea.of orthopnea.

► 3. Visual assessment of the presence of:3. Visual assessment of the presence of:- Barrel-shaped chest;- Barrel-shaped chest;- Participation in the act of - Participation in the act of breathing support muscles of the chest;breathing support muscles of the chest;- Extended exhalation;- Extended exhalation;- Cyanosis;- Cyanosis;- Swelling of the neck veins;- Swelling of the neck veins;- Hyperhidrosis.- Hyperhidrosis.

► 4. Counting the frequency 4. Counting the frequency of respiratory (tachypnea).of respiratory (tachypnea).

► 5. The study of the pulse 5. The study of the pulse (may be paradoxical), counting the heart rate (may be paradoxical), counting the heart rate (tachycardia, in severe cases can be bradycardia).(tachycardia, in severe cases can be bradycardia).

► 6. Measuring blood pressure (hypertension, in severe 6. Measuring blood pressure (hypertension, in severe cases may be hypotension).cases may be hypotension).

► 7. Percussion lungs box sound.7. Percussion lungs box sound.► 8. Auscultation of the lungs: a hard breath, different 8. Auscultation of the lungs: a hard breath, different

keys dry wheezing, primarily on the keys dry wheezing, primarily on the exhale, may hear mixed wet rales.exhale, may hear mixed wet rales.

► When the AU noted a sharp weakening When the AU noted a sharp weakening of breathing primarily in the lower regions of the of breathing primarily in the lower regions of the lungs, and in more severe cases - the complete lungs, and in more severe cases - the complete absence of bronchial conductance absence of bronchial conductance and wheezing ("silent lung").and wheezing ("silent lung").

Tactics of careTactics of care► Emergency care:Emergency care:► in the form of anaphylactic 0.3-0.5 ml 0.18% solution of in the form of anaphylactic 0.3-0.5 ml 0.18% solution of

epinephrine in 0.9%sodium chloride epinephrine in 0.9%sodium chloride solution intravenously;solution intravenously;

► humidified oxygen through a mask;humidified oxygen through a mask;► injected to intravenously of glucocorticoid injected to intravenously of glucocorticoid

hormones: prednisolone intravenous bolus 90-hormones: prednisolone intravenous bolus 90-150mg tively (300 mg), in terms of 120-180 150mg tively (300 mg), in terms of 120-180 mg methylprednisolone;mg methylprednisolone;

► inhalation inhalation β2-β2-agonists - salbutamol 100 mcg / agonists - salbutamol 100 mcg / dose nebulized over 5-10 minutes.When an dose nebulized over 5-10 minutes.When an unsatisfactory effect after 20 unsatisfactory effect after 20 minutes inhalation repeat; salmeterol orfluticasone spray minutes inhalation repeat; salmeterol orfluticasone spray + 25/50 mg, 25/125 mg, 25/250 mg or budesonide 10002+ 25/50 mg, 25/125 mg, 25/250 mg or budesonide 10002000mkg 000mkg 

nebulized over nebulized over 5-10 minutes5-10 minutes► aminophylline initial dose 5.6 mg / kg body weight (10-aminophylline initial dose 5.6 mg / kg body weight (10-

15 ml 2.4% solution intravenously slowly over 5-7 15 ml 2.4% solution intravenously slowly over 5-7 minutes), the maintenance dose - 2-3.5 ml fractional minutes), the maintenance dose - 2-3.5 ml fractional drip to improve the patient's clinical condition;drip to improve the patient's clinical condition;

► heparin intravenously 10000ED 5000;heparin intravenously 10000ED 5000;

► infusion therapy, in order to meet the shortfall in the infusion therapy, in order to meet the shortfall in the liquid, remove haemoconcentration, liquefaction of liquid, remove haemoconcentration, liquefaction of bronchial contents - in / injected 4% solution bronchial contents - in / injected 4% solution bicarbonate Na, 0,9% solution NaCl, 5% solution of bicarbonate Na, 0,9% solution NaCl, 5% solution of dextrose.dextrose.

► a progressive deterioration of a progressive deterioration of lung ventilation ventilator shownlung ventilation ventilator shown

At a coma:At a coma:► emergency intubation during spontaneous breathing;emergency intubation during spontaneous breathing;► Ventilation;Ventilation;► if necessary - cardiopulmonary resuscitation;if necessary - cardiopulmonary resuscitation;► drug therapydrug therapy► Indications for intubation and mechanical Indications for intubation and mechanical

ventilation:ventilation:► hypoxic and hypercapnic coma;hypoxic and hypercapnic coma;► cardiovascular collapse;cardiovascular collapse;► the number of breaths for more than 50 in 1 min.the number of breaths for more than 50 in 1 min.► Indications for emergency hospitalization: Indications for emergency hospitalization:

transportation to the hospital on the background of the transportation to the hospital on the background of the therapy.therapy.

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