artificial respiration, artificial ventilation of the lungs

From Big Medical Encyclopedia

ARTIFICIAL RESPIRATION (claim. breath) (synonym: artificial ventilation of the lungs, the managed ventilation of the lungs, controlled ventilation of the lungs, the managed breath) - the alternating or continuous replacement of air in lungs by artificial methods at the termination or insufficiency of natural ventilation. There is an opinion that the claim. breath and artificial ventilation of the lungs — two various concepts. Artificial ventilation of the lungs replaces only one stage of process of breath — ventilation, influencing the others — alveolocapillary diffusion of gases, a pulmonary blood stream, fabric gas exchange — only indirectly. To the claim. to breath carry ways of management of oxidation-reduction metabolism of extra pulmonary ways: parapulmonic oxygenation (enteral, arterial), administration of the enzymes and power substances improving fabric oxidation, suppression of metabolism by a hypothermia, hibernation, etc.

In this article the claim is given traditionally developed statement of a concept. breath as process of exchange of gas between an alveolar air and atmospheric.

Claim. breath is carried out by the alternating administration of air in lungs and removal it that is reached by two various groups of methods: inflation (insufflation) of air in respiratory tracts (the claim. breath by the principle of inflation) or change of a form and volume of a thorax (outside, external methods the claim. breath). That and other group of methods can be applied both with use of tools and devices, and without them. Special form claim. breath so-called diffusion breath is, at Krom oxygen continuously comes to respiratory tracts against the background of an apnoea, unlike alternating (a breath — an exhalation) the claim. breath.

Use claim. breath it is required at the sudden or gradual termination of natural (spontaneous) ventilation because of an injury, diseases, a wedge, death, and also at planned switching off of ventilation during the general anesthesia or an intensive care.

HISTORY

In the history of use the claim. breath it is possible to allocate two essentially various periods. The first — from an extreme antiquity to the middle of 20 century, when the claim. breath was applied only to revival or maintenance of life at the sudden termination of breath. Claim. breath was rather widely used for revival of newborns, during the drowning and other accidents and sudden diseases. During this period claim. breath was applied only according to urgent indications and for short term. From the second half of 20 century the claim. breath began to be applied not only at accident or a sudden disease, but also in a planned order — to switching off of spontaneous ventilation at various operative measures and methods of anesthesia, to a multi-day intensive care of various terminal states and to months-long replacement therapy at some diseases of nervous and muscular system. New requirements led to modernization old and to emergence of new methods the claim. breath.

Historically earlier and more widely applied for the claim. breath methods of inflation of air in lungs (expiratory methods) are: recovering blows the air exhaled by him into respiratory tracts of the patient. Such method was widely applied in obstetrics to revival of newborns in 17 century. For the first time in medical literature the claim in detail described successful use of this method. breath the English surgeon W. Tossah in 1732. The equipment of a method is described in 1766 by S. G. Zybelin. In 1796 Herkholt and Rafn (J. D. Herholdt, Page G. Rafn) investigated this method in a wedge, and fiziol, aspects and recommended it for broad use. A big role in development of expiratory and other methods the claim. breath played about-va the rescue of the drowned created in 17 — 19 centuries in various countries.

From the middle 19 to the 50th 20 century expiratory methods the claim. breath were forced out by the so-called manual methods based on change of volume of a thorax by application of external effort. Elam (J. The lake of Elam, 1965) believes that the main cause of failure from expiratory methods the claim. breath from a mouth in a mouth and from a mouth in Nov there were esthetic reasons. For the first time manual methods of compression of a thorax and stomach for the claim. breath Leroy D'Etoilles applied in France in 1829. In the subsequent in medical practice the manual ways which are repeatedly replacing each other the claim were widely adopted. Hall's breath (M. of Hall, 1856), Silvestra (N. of Silvester, 1858), Schaefer (E. A. Schafer, 1904), Nielsen (N. of Nielsen, 1932) and their numerous modifications having only historical value.

In the 50th 20 century use of manual methods the claim. breath it was sharply reduced for many reasons. First, they did not provide passability of upper respiratory tracts. Secondly, efficiency of these methods, i.e. volumes of the ventilation provided with them, was small. The comparison which is carried out in 1946. Macintosh and Mashin (R. R. Macintosh, W. W. Mushin), showed that an expiratory method the claim. breath gives at least twice large volumes of ventilation, than ways of swing of Schaefer, Sylvester. Safar (P. Safar, 1958) reported that during the use of various manual methods the claim. breath from 14 to 50% of specially trained people whereas during the use of expiratory methods the same volume of ventilation 89 — 100% even could give the people who did not have training could provide to the patient the respiratory volume of 500 ml. Detailed comparative assessment of merits and demerits of various manual ways claim. breath G. A. Stepansky (1960) who believes that the majority of manual ways the claim carried out. breath it is tiresome (the third reason, on a cut these methods were left). Fourthly, ways manual claim. breath at which the victim lies not on spin do not allow along with the claim. to carry out by breath a cardiac massage. Only one fact of existence more than 120 manual ways claim. breath confirms their insufficient efficiency.

Small efficiency of manual ways claim. breath and damage of a chest wall and bodies of a stomach, quite often accompanying them, led to recovery in medical practice of expiratory methods. Starting with the message of Elam et al. (1954) there were numerous researches rehabilitating unfairly the forgotten expiratory methods the claim. breath that led to almost full replacement from daily practice of manual ways. The last apply only at impossibility to use expiratory methods and lack of any devices and tools if it is necessary to carry out the claim. breath at infectious diseases, poisonings with the gaseous fighting poisoning and fighting radioactive materials.

Both for methods of inflation, and for external methods the claim. breath used various tools and devices for a long time. For simplification of an expiratory method the claim. breath in 18 century applied special air ducts and masks. T. Paracelsus used for inflation in lungs of air chimney bellows, and A. Vezaly used the similar device both to inflation, and to active deaerating from lungs. J. Gunter in 1776 offered for the claim. breath double fur with the valve, and Goodwin (Goodwyn, 1788) recommended for the same purposes oxygen instead of air.

Since the beginning of 19 century automatic respirators appear; the first of them was let out by Dreger in Germany (1911). Epidemics of poliomyelitis in 30 — 50 - x 20 century promoted development of numerous methods and creation of devices for outside the claim. breath. In 1929 Mr. of Drinkeri Sho (Ph. Drinker, L.A.Shaw) offered box (tank, «iron lungs») a respirator, in Krom around a body of the patient the alternating depression and the positive pressure providing a breath and an exhalation was created. In 1937 there was a first kirasny respirator creating pressure differences only around a thorax and a stomach of the patient. These devices repeatedly were improved and changed. In 1932. Willows (F. Page of Eve) «the shaking respirator» offered, in Krom the body of the patient was shaken around a horizontal axis: at a raising of the head end on 20 — 30 ° the diaphragm was displaced towards a stomach — there was a breath, during the lowering — an exhalation. The way of swing of Yves is practically not applied because of bulkiness, adverse influence on a hemodynamics and frequent passive flowing of gastric contents in a nasopharynx with the subsequent aspiration. Gradually outside (next-to-skin, external) respirators were forced out by respirators of inflation which provided more effective ventilation, were less bulky and did not complicate access to the patient for carrying out various manipulations.

In the 50th 20 century S. J. Sarnoff et al. (1950) entered into practice an elektrofrenichesky method the claim. breath — rhythmical electrostimulation) phrenic nerves or a diaphragm, reduction the cut provides a breath. Improvement of an elektrofrenichesky method in parameters of current (frequency, duration, a form and amplitude of an impulse), reliability of electrostimulators and electrodes continues. However the method was not widely adopted hl. obr. because of rather quickly arising «fatigue» of a nerve or a neuromuscular synapse and instability in this regard the mode the claim. breath.

PHYSIOLOGICAL INFLUENCE

In addition to the changes arising in an organism as a result of adequate or inadequate exchange of air in lungs, the claim. breath directly or indirectly influences various functions of an organism of hl. obr. thanks to mechanical effect and the related reflex reactions.

Fig. 1. The diagrammatic representation of lungs at an artificial respiration by the principle of inflation with various, depending on techniques, ratios of ventilation and a blood-groove: 1 — natural breath (it is given for comparison); 2 — 4 — an artificial respiration (2 — with a passive exhalation, 3 — with an active exhalation, with negative pressure at the end of an exhalation, 4 — an artificial respiration with positive pressure at the end of an exhalation); and — the site of a lung with a normal ratio of ventilation and a blood-groove of lungs (effective alveolar volume); — the site of a lung with dominance of ventilation over a blood-groove (alveolar «dead» space); in — the site of a lung with dominance of a blood-groove over ventilation (the alveolar shunt).

Changes in system of breath

the Mechanics of breath changes depending on a method and the mode the claim. breath. At the claim. breath by the principle of inflation the breath is carried out thanks to forced forcing of air in lungs during which inflating the thorax whereas at spontaneous ventilation expansion of a thorax with increase in depression in a pleural cavity is primary thanks to what air comes to lungs extends. The characteristic of the processes happening in lungs at different types the claim. breath by the principle of inflation, it is presented in the figure 1. Intra pulmonary pressure at the end of a breath happens at the claim. breath +15, +20 cm w.g., and at spontaneous ventilation 0 — 1 cm w.g. Intrapleural pressure at the same moment equally in respectively +3 and — 10 cm w.g. At the end of an exhalation as at the claim. breath with a passive exhalation, and at spontaneous ventilation intra pulmonary pressure happens 0, +1 cm w.g., and intrapleural — 5 cm w.g. At the claim. breath with an active exhalation, i.e. at suction of air from lungs, intra pulmonary and intrapleural pressure at the end of an artificial exhalation differs from indicators at spontaneous ventilation. Thanks to these distinctions transpulmonic pressure (a difference between intra pulmonary and intrapleural pressure) at the claim. breath and spontaneous ventilation variously, namely transpulmonic pressure is motive power of ventilation. Closer to natural dynamics intra pulmonary and intrapleural pressure during a respiratory cycle arises during the use of external methods the claim. breath, napr, kirasny and box respirators, and also elektrofrenichesky method. However and here absolutely similar sizes because artificial and natural expansion of a thorax are not equivalent are not observed: under natural conditions ventilation of separate pulmonary zones and, respectively, pleural pressure have accurate regional distinctions. Besides, kirasny and box respirators break natural dynamics of intra pulmonary and intrapleural pressure because of a bigger pliability of an abdominal wall in comparison with a thorax.

Thanks to distinction of absolute values and dynamics of transpulmonic pressure at the claim. breath and spontaneous ventilation of the mechanic of a breath and an exhalation changes: it belongs also to distensibility of lungs — a thorax (elastic resistance), and to the aerodynamic resistance of respiratory tracts, and to the deformation (fabric) resistance of lungs and a thorax. Only the fourth type of the general respiratory resistance — inertial — both at spontaneous ventilation, and at the claim. breath equally depends on the mass of moving bodies and the arising accelerations (respiration rate). It is known that at long the claim. breath distensibility of lungs gradually decreases. It happens because of an atelektazirovaniye of various zones of lungs in connection with disturbance of drainage function, patol, a ventilating and perfused ratio, destruction surfactant (see), and also because of a lymphostasis and a frequent overhydratation.

Drainage function of lungs at the claim. breath it is broken almost always. It is connected with an exception of the tussive mechanism of cleaning, with disturbance of work of a ciliate epithelium because of insufficient (is more rare excessive) moistening, with narrowing of bronchioles because of a lymphostasis and hypostasis. A part is played probably also by decrease in production of surfactant at long the claim. breath thanks to what development of atelectases is facilitated and the stretching effect of alveoluses decreases by small respiratory tracts. The begun delay of a phlegm closes openings in interalveolar partitions (Kohn's time) and other ways of collateral ventilation: distalny obstructions air cannot get thanks to what surface tension forces complicate otkhozhdeny phlegms from walls of alveoluses and respiratory tracts. Disturbance of drainage function of lungs leads to growth of aerodynamic and elastic resistance to breath, distensibility of lungs decreases thanks to what ventilation is broken even more.

Fig. 2. The diagrammatic representation of a ratio of intra pulmonary pressure at a natural and artificial respiration (b) in upper (1), average (2) and the lower (3) zones of lungs: Ra — arterial pressure; RA — alveolar pressure; Pv — venous pressure. In an upper zone of lungs at natural breath arterial pressure is less alveolar, but it is more venous that corresponds to the nature of distribution of pressure in this zone and at an artificial respiration; in an average zone of lungs at natural breath alveolar pressure is lower arterial, but it is more venous while at an artificial respiration a ratio of Ra, PA and Pv remains same, as well as in an upper zone; in the lower zone of a lung at natural breath arterial pressure is more venous which in turn is more alveolar, at an artificial respiration alveolar pressure is less arterial, but it is more than venous.

Gas exchange and distribution of ventilating and perfused ratios. In most cases claim. breath is carried out in the mode of a hyperventilation causing respiratory alkalosis (see) and related disturbances of the central regulation breath (see), hemodynamics (see), electrolytic structure and fabric gas exchange. The hyper ventilating mode — the compulsory measure connected with nefiziol. a ratio of ventilation and a blood-groove in lungs during an artificial breath and an exhalation: at an artificial breath, unlike natural, in lungs air volume increases and the volume of blood decreases, at an exhalation — on the contrary. Other reason of inadequacy claim. breath in comparison with spontaneous ventilation of the same volume — nefiziol. intra pulmonary distribution of air, blood and ventilating and perfused ratio. Not physiology of such distribution is connected with various reasons: 1) a peculiar mechanics of breath at the claim. breath causes regional distribution of ventilation, other than natural breath; 2) as at the claim. breath air is forced in lungs under pressure, the pulmonary blood stream during an artificial breath is reduced; thanks to it the general ratio ventilation — a blood stream in lungs changes that is expressed in change fiziol, respiratory «dead» space, the alveolar shunt and other components of the total pulmonary amount; 3) change of alveolar pressure and the change of a pulmonary capillary blood-groove connected with it changes regional distribution of ventilating and perfused ratios since this distribution depends on a ratio of the alveolar, arterial and venous pulmonary pressure (fig. 2). It is shown that at the claim. breath by the principle of inflation it is impossible to find the mode of ventilation providing strictly fiziol, distribution of ventilating and perfused ratios.

Alveolocapillary diffusion at the claim. breath it can be broken because of a thickening of an alveolocapillary membrane in connection with the lymphostasis and hypostasis connected with high intrathoracic pressure.

Influence claim. breath on fabric gas exchange depends on adequacy of ventilation to a metabolic rate. As at the majority of methods and modes the claim. breath is less physiologic, than spontaneous ventilation, it is hard to pick up its adequate volume. Arising because of it hypercapnia (see), hypocapny (see) and the anoxemia is more rare (see. Hypoxia ) influence a curve of dissociation of oxyhemoglobin and break fabric gas exchange.

Regulation of breath

Claim. breath breaks regulation of breath and quite often prevents recovery of spontaneous ventilation. There is it not only because of frequent reduction of content of carbonic acid in blood. More often at the claim. breath the perversion of effect of stretch receptors of the lungs and a chest wall sending information to a respiratory center is observed.

Changes in the blood circulatory system. Influences the blood circulatory system connected about the claim. breath elimination or, on the contrary, emergence of an anoxemia, respiratory acidosis or alkalosis. Besides, claim. breath makes direct mechanical impact on the blood circulatory system, a cut was considered so expressed that Waters (R. The m of Waters, 1921) recommended the claim. breath as the mechanical engine of blood for recovery of blood circulation. At the claim. breath by the principle of inflation the prisasyvayushchy action of a thorax providing return of a considerable part of a venous blood at a natural breath is broken. In this regard venous return is at a loss, and though various compensatory mechanisms provide adequate blood circulation for many hours, days and even months, at the accompanying pathology of the blood circulatory system the claim. breath with unsuccessfully picked up mode can cause life-threatening hemodynamic frustration.

As pressure is equal in pulmonary capillaries to 10 — 12 mm of mercury., claim. breath with more high pressure of a breath inevitably breaks a pulmonary blood stream. Replacement from easy blood in the left auricle during an artificial breath and counteraction to emission of a right ventricle bring an imbalance in work of the right and left half of heart. Less expressed imbalance is available also at spontaneous ventilation, however ratios of a hemodynamics of the right and left heart during a natural breath and an exhalation are opposite observed at the claim. breath.

Changes in water exchange

At long the claim. breath there can be intersticial hypostases (see), fiziol. which mechanism is diverse. First, high intra pulmonary pressure breaks return of a lymph through a chest channel in a venous bed, and the lymphostasis promotes development of hypostases. Secondly, disturbance of venous return and high peripheral venous pressure can also promote developing of hypostases. Thirdly, change of filling of cameras of heart and large intrathoracic vessels can through system volyumoretseptor — a hypothalamus — a hypophysis — antidiuretic hormone (ADG) — Aldosteronum to increase a reabsorption of water in kidneys and to lead to an overhydratation. It is established that than average intrathoracic pressure in time the claim is higher. breath, that the ADG levels of plasma and subjects smaller are big there is a diuresis. And, at last, at long the claim. breath the hyponutrient against the background of a high catabolism of proteins can cause a hypoproteinemia, low oncotic pressure of blood and, therefore, hypostases.

Despite listed negative fiziol, effects, the claim. breath provides the main thing — gas exchange function of lungs, i.e. is means of resuscitation and an intensive care for patients with acute respiratory insufficiency.

INDICATIONS AND CONTRAINDICATIONS

Use claim. breath it is shown in all cases when the volume of spontaneous ventilation is insufficient for ensuring adequate gas exchange. It is required at many urgent and planned a wedge, situations: 1) disorders of the central regulation of breath in connection with a wedge, death, disturbance of cerebral circulation, hypostasis, an inflammation, an injury or a tumor of a brain, medicamentous and other types of poisonings; 2) defeat of nerve pathways and a neuromuscular synapse — an injury of cervical department of a brain, poliomyelitis and other viral infections, polyneurites, a myasthenia, botulism, tetanus, toxic effect of antibiotics, poisoning with Pachycarpinum, organophosphorous connections and other cholinergic poisons, use of muscle relaxants at anesthesia and an intensive care; 3) diseases and injuries of respiratory muscles and a chest wall — polymiosites, myodystrophies, polyarthritis with damage of costovertebral joints, open pheumothorax (including operational), multiple fractures of edges and a breast; 4) restrictive and obstructive damages of lungs — intersticial hypostasis, pneumonia and a pneumonitis, a bronkhoastmatichesky state, a bronchiolitis, etc., followed by hard work of the respiratory muscles absorbing the most part of oxygen and giving surplus of nedookislenny products; high respiratory «dead» space at some pulmonary diseases.

About need the claim. breath judge on a combination a wedge, symptoms and these functional methods of a research. Existence of excitement or a coma, cyanosis, the increased perspiration, takhi-and bradisistoliya, change of size of pupils, active participation in breath of auxiliary muscles against the background of dispnoe and hypoventilations demand use the claim. breath. If to judge according to data of gasometry and other functional researches, then use the claim. breath it is shown when breath becomes frequent twice in comparison with norm, the vital capacity of lungs decreases by 40 — 50% and the volume of spontaneous ventilation does not allow to receive in an arterial blood saturation of hemoglobin oxygen more than 70 — 80%, pO 2 it is higher than 60 mm of mercury., pCO 2 it is lower than 50 — 60 mm of mercury., and pH higher than 7,2. But even in that a wedge, situations when these indicators at spontaneous ventilation it is slightly better, but are reached by excess work of respiratory muscles, and also at danger of a decompensation because of the accompanying pathology transition to the claim is shown. breath.

When not hypoventilation, but other mechanisms of pathology of lungs (e.g., disturbance of alveolocapillary diffusion, the big alveolar shunt of a venous blood, etc.), the claim is the reason of an anoxemia. breath, almost without increasing intake of oxygen from lungs in blood, reduces its consumption by respiratory muscles and, therefore, increases amount of the oxygen coming to vitals.

In most cases claim. breath is only an auxiliary method which is not substituting the intensive care directed to the main fiziol, the mechanism of pathology.

Use claim. breath it is necessary when spontaneous ventilation is switched off by means of the muscle relaxants entered in to lay down. purposes: anesthesia during operation, an intensive care of a convulsive and hyper thermal syndrome, etc.

Absolute contraindications to the claim. to breath is not present, there are only contraindications to use of various methods and modes the claim. breath. So, at difficulty of venous return of blood the modes the claim are contraindicated. breath, even more breaking it, at an injury of a lung methods the claim can be contraindicated. breath by the principle of inflation with the high pressure of a breath, etc.

METHODS

apply methods the claim More often. breath, the inflations based on the principle. Expiratory methods (from a mouth in a mouth, in Nov, in an endotracheal tube or an air duct), hardware methods with a hand gear concern to them (Ambu's bag, RPA, RDA, a respiratory bag or fur of the narcotic device, etc.) and hardware methods with the automatic drive (automatic respirators of RO-2, RO-5, ROA-2, DP-8, AND-2, LADA, RD-1, RD-2, RD-4, etc.), Smaller distribution have external methods the claim. breath with use of box and kirasny respirators.

Technique and equipment claim. breath has the general for all methods and lines, specific to everyone. Treat the general requirements: 1) ensuring passability of respiratory tracts with special position of a body of the patient, introduction of an air duct, endotracheal tube, imposing of a tracheostoma; 2) careful control of adequacy claim. breath, carried out on the basis of external signs or special researches; 3) providing a drainage of respiratory tracts by means of moistening of respiratory mix, aerosol inhalations, a toilet of a trachea and bronchial tubes, etc.; 4) prevention of possible complications and adverse effects claim. breath on various functions of an organism.

In time claim. breath consider necessary to spend each 30 — 40 min. inflation to lungs of the trebled respiratory volume. It is necessary for prevention of atelectases as at the claim. breath drainage function of respiratory tracts is broken, ventilating and perfused ratios, food of alveolar fabric, etc. are abnormal. Automatic inflating of lungs by the increased volume of a breath is provided each 20 — 40 min. in some respirators (RO-5, RO-6).

Necessary condition long claim. breath — moistening of respiratory mix. At spontaneous ventilation respiratory mix, passing in Nov and a nasopharynx, it is warmed, cleared and humidified. At the claim. breath gas mixture gets directly into a trachea: drying up a mucous membrane of respiratory tracts, it deprives of it antibacterial barrier properties, breaks drainage function of bronchial tubes and promotes emergence of obstructive and inflammatory complications. For a normality of a mucous membrane of respiratory tracts the inhaled gas shall be completely moistened. Full saturation of respiratory mix water vapors at t ° 37 ° happens with a pressure of 47 mm of mercury., for what it is required apprx. 50 mg of water on 1 l of air. The relative 100% air humidity at the room temperature (20 °) decrease to 36% when air gets into a trachea where temperature 37 °. It proves need of use of humidifiers at the claim. breath.

Supersonic generators of aerosols are most effective, humidifiers of other types are less productive. At ventilation of 12 l/min water temperature in the evaporator falls on 13 ° below surrounding, therefore, the evaporator shall have heating. Danger of infection at humidifiers of this kind is more. H. Bendixen et al. (1965) believes that at the claim. breath of 10 l/min it is necessary to add 650 ml of water a day to the inhaled mix.

Excess moistening constitutes not smaller danger as distensibility of lungs worsens, excess water is soaked up in lungs, quite often leading to an overhydratation.

Fig. 3. Diagrammatic representation of a humidifier and heater of air («artificial Nov»): above — in a mouth at the patient; below — a habit view of «an artificial nose».

Important measure of maintenance of normal moistening of a mucous membrane of respiratory tracts — use of «an artificial nose the» (fig. 3) representing capacity with the corrugated foil supporting close to laminar a flow of air and condensing on themselves moisture thanks to what its losses decrease. This device can be connected to an endotracheal or tracheostomy tube. The sensors which are controlling the level of humidity and including an aerosol generator at a lack of moisture are provided in some modern respirators.

Adaptation of the patient to a respirator (synchronization with own respiratory movements) is reached by several methods. The suggestive method («breath — an exhalation» team) is applicable at the patients who are in consciousness and is effective at a moderate hyperventilation. The expressed hyperventilation (30 — 40% over due size) also allows to synchronize the respiratory movements of the patient with a respirator. Narcotic and the sedatives suppressing own respiratory attempts apply at inefficiency of the previous methods.

Muscle relaxants of short action use the claim at the beginning. breath; Muscle relaxants of long action should be applied to adaptation to a respirator only in the absence of effect of other methods or in need of suppression of a convulsive syndrome. Desynchronization of respiratory movements of the patient and a respirator arises most often at disturbance of tightness of a rebreathing system and at hypoventilation.

Fig. 4. Diagrammatic representation of expiratory methods of an artificial respiration. 1 — 3 — position of the head of the patient and the condition of a gleam of upper respiratory tracts corresponding to it (it is shown on dummies on the right): 1 — the wrong position of the head of the victim — respiratory tracts are impassable (it is specified by an arrow), 2 — the head is unbent in a vertebral and occipital joint — respiratory tracts are passable (it is specified by an arrow), 3 — the mandible is put forward kpered — respiratory tracts are expanded; 4 — 6 — an artificial respiration using air ducts (in drawings the provision of air ducts is shown on the right): 4 - the S-shaped air duct is entered into an oral cavity for a root of language, 5 — the corrugated hose with the irreversive valve is applied, 6 — the endotracheal tube with a pear is applied to inflating of a cuff, occlusive a trachea; 7 and 8 — an artificial respiration without use of tools: 7 — breath from a mouth in a mouth, 8 — breath from a mouth in a nose.

Expiratory methods are applied only in urgent situations — at the sudden termination of breath and impossibility to apply hardware methods. To provide passability of upper airways, the head of the victim lying on spin as much as possible unbend in a vertebral and occipital joint, pushing a mandible forward and up so that the chin held the most sublime position (fig. 4). Ensuring passability of respiratory tracts is facilitated by introduction of a S-shaped air duct or endotracheal tube. Recovering blows into a mouth or Nov of the victim the air exhaled by him after the previous deep breath.

At inflation in a mouth of a nostril of the victim shall be clamped by fingers or a cheek recovering though in some cases this measure is excessive as the soft palate carries out a role of the valve and does not pass the blown air in a nasal cavity. At inflation in Nov the mouth of the victim which should be opened at an exhalation shall be closed if the soft palate does not pass air in Nov.


Main criterion of efficiency of expiratory methods claim. breath — expansion of a thorax at inflation of air and its fall at a passive exhalation. Frequency of inflations depends on the speed of passive exhalation of air and for the adult the volume of the blown air every time — 0,5 — 1,0 l fluctuates within 10 — 20 in 1 min., and. As with a pressure of St. 20 cm w.g. air can get into a stomach, causing regurgitation of gastric contents and other complications, it is necessary that pressure of a breath did not exceed this size. At good passability of respiratory tracts pressure of a breath is 12 — 15 cm w.g. there is enough to blow necessary air volume into lungs of the victim.

When claim. breath is combined with closed cardiac massage (see), do one inflation through 4 — 5 compression of a thorax. If one recovering carries out the claim. breath and the closed cardiac massage, is recommended two inflations in a row, and then 10 — 12 compression of a thorax.

In spite of the fact that expired air which is blown to the victim contains only 15 — 17% of oxygen and 2 — 4% of carbonic acid, expiratory methods are highly effective in maintenance of necessary gas exchange for tens of minutes and even hours.

However these methods not only are tiresome for recovering, but thanks to a hyperventilation inevitably lead to emergence at it a respiratory alkalosis, to vasodepression and other frustration. Therefore expiratory methods apply in case of emergency.

Fig. 5. The diagrammatic representation of artificial ventilation of the lungs by a manual respirator like Ambu's bag (and — position of the head of the patient, hands of the medic and a respirator during the carrying out manipulation; — the mode of a breath; in — the mode of an exhalation): 1 — a mask; 2 — the irreversive valve like Ruben; 3 — an elastic wall of a bag; 4 — the suction valve; shooters specify flow direction of air (oxygen); dotted shooters — the direction of forces operating on a wall of a bag (elastic properties of a wall of a bag allow it during an exhalation instantly to take the initial form).

Manual respirators, as well as expiratory methods claim. breath, hl are applied. obr. in urgent cases. A special case of planned use of manual respirators is the claim. breath by periodic compression of a respiratory bag (fig. 5) or fur of the narcotic device during the carrying out anesthesia with muscle relaxation.

Fig. 6. VNIIMP automatic irreversive valve: and — outward (1 — a branch pipe of connection with the device, 2 — a branch pipe of connection with the patient, 3 — a branch pipe of an exhalation); and in — the schematic diagram (— an inspiratory phase, in — an expiratory phase), 1 — the small lamellar valve, 2 — an opening for a breath, 3 — a membrane, 4 — an opening for an exhalation; shooters specify the direction of the movement of gas-narcotic mix.

At the claim. breath by manual respirators it is necessary as well as at expiratory methods to provide passability of upper respiratory tracts with their cleaning, special position of a body, introduction of an air duct or endotracheal tube. Indispensable condition claim. breath manual respirators of any type (Ambu, RDA-1, RPA-2, etc.) is existence between respiratory tracts of the patient and a respirator of the irreversive valve (like Ruben, VNIIMP, etc.) providing division of the blown and passively expired air (fig. 6). Volume, frequency, pressure and control of efficiency claim. breath by manual respirators same, as at expiratory methods the claim. breath. However, unlike the last, the claim. breath by manual respirators allows to add oxygen to inhaled air or even to carry out the claim. breath of 100% oxygen.

Automatic respirators are applied as for short-term the claim. breath in the conditions of ambulance (DP-7, GS-8, RD-1, etc.), and for long (from several hours to several years) the claim. breath in a hospital (RO-2, RO-3, RO-5, DI-8, AND-2, LADA, etc.), If the claim. breath is expected several hours, it is carried out through an endotracheal tube. For multidaily and longer claim. breath the Tracheostomy is required, as a rule.

The MODES

In a wedge, practice apply hl. obr. three modes claim. breath, differing from each other in character of an exhalation: with the alternating positive pressure of breath of +15, + 20 cm w.g. at a passive exhalation (PPD, IPPV of English authors), at an active exhalation with negative pressure — 3 — 5 cm w.g. (PPOD, IPNPV) and at preservation of the positive pressure +3, +8 cm w.g. by the end of an exhalation (Ppdvyd, PEEPV).

In addition to the basic characteristic of an exhalation, mode claim. breath select for the minute and respiratory volume of ventilation, a respiration rate, peak size and the pressure curve of a breath and exhalation, duration and a phase ratio of a breath, an exhalation and a pause. Does not allow to regulate all listed parameters independently from each other any of the existing respirators; therefore, selecting one or two parameters the claim. breath, change the others in the necessary direction.

Minute volume claim. breath choose on one of special nomograms (see), napr, Radford's nomogram, Engstrem's nomogram — the Duke, made taking into account a sex, age, weight, a body surface of the patient and sometimes other indicators. Such choice, however, is only approximate and demands amending still before the claim. breath as it is provided also by authors of nomograms. The size received according to the nomogram is increased or reduced by 10 — 20% depending on existence hron, respiratory insufficiency, morfol, changes of lungs, a deviation of body temperature from normal, character of anesthesia and operation, introduction of an endotracheal or tracheostomy tube, extensible (corrugated) or rigid connecting hoses, etc.

Considering so numerous amendments, volume the claim. breath, chosen according to the nomogram, korrigirut according to changes of some functions of an organism in time the claim. breath. The main criteria for correction are the partial pressure of oxygen and carbon dioxide (pO 2 and pCO 2 ) arterial blood, central venous pressure and other indicators of blood circulation, and also public wedge, indicators (color and humidity of integuments, etc.).

Considering nefiziol. influence claim. breath by the principle of inflation on ventilating and perfused ratios in lungs, safer for patients consider a moderate hyperventilation, at a cut of pCO 2 arterial blood (PaCO 2 ) equally to 30 — 35 mm of mercury., than hypoventilation. However the expressed hyperventilation can break a hemodynamics because of mechanical effect on the intrathoracic volume of blood and because of a hypocapny. At the same time the level of the general anesthesia without addition of anesthetic can go deep, be broken fabric gas exchange. Increase in respiratory volume with simultaneous addition of tool «dead» space is perspective. Then big alveolar ventilation straightens lungs better, and the increased respiratory «dead» space prevents emergence of a hypocapny.

Choice of the mode claim. breath depends on its purpose (the claim. breath at anesthesia, at pathology of lungs or the muscular device of breath, sudden an apnoea, etc.), from a condition of the patient (age, the nature of the main and accompanying pathology, volume of an operative measure, etc.)? from opportunities to lay down. institutions and situations. During the claim. breath the mode can repeatedly change depending on caused the claim. breath salutary or patol. effects.

The mode with the alternating pressure of a breath and exhalation. The most widespread mode is the claim. breath with the positive pressure of a breath at a passive exhalation. The mode with the negative pressure of an exhalation is applied by hl. obr., for decrease in an adverse effect the claim. breath on a hemodynamics. However at this mode distribution of a ventilating and perfused ratio happens more broken in connection with deepening of abnormal effect of intra pulmonary pressure upon ventilation and a blood stream (at a breath in lungs there is a lot of air and not enough blood, at an exhalation — on the contrary). Besides, mode claim. breath with the negative pressure of an exhalation promotes more expressed expiratory closing of respiratory tracts in this connection shunting of a venous blood through lungs grows. For this reason use of such mode the claim. the breath useful at the high resistivity of respiratory tracts or an endotracheal tube, is not recommended at patients where the leading mechanism of the increased resistance is expiratory closing of respiratory tracts (obstructive emphysema of lungs, an asthmatic bronchitis, etc.). Mode claim. breath with an active exhalation it is contraindicated also at a fluid lungs, atelectases, multiple fractures of edges.

Mode claim. breath with preservation of positive pressure by the end of an exhalation it is recommended for decrease in intra pulmonary volume of blood, napr, at a fluid lungs, including intersticial, for reduction of expiratory closing of respiratory tracts in the postoperative period, at obstructive emphysema of lungs, etc.

the Bradipnoichesky mode (frequency of inflations 4 — 6 in 1 min. at increase in respiratory volume by 2 — 4 times) is applied to decrease in intrathoracic pressure, and also to providing rather motionless surgery field at operative measures on a diaphragm, a mediastinum, lungs.

V. A. Gologorsky (1971) finds that bradipnoichesky the claim. breath provides adequate gas exchange though influence it on other functions of an organism demands further specification.

The Takhipnoichesky mode is carried out in two options: at increase in frequency of inflations to 30 — 40 in 1 min. with a deliberate hyperventilation [Gray (T. S. Gray), 1960] or with a frequency up to 80 — 110 of 1 min. with a normoventilyation [A. Jonson et al., 1971, 1973]. At takhipnoichesky claim. breath respiratory volume is reduced, pressure of a breath is equal to from +5 to +10 cm w.g., an exhalation from 0 to — 5 cm w.g. Average intra pulmonary and low intrathoracic pressure, disturbances of a hemodynamics are minimum, gas exchange is, as a rule, adequate if the size of respiratory «dead» space is considered. To reach the frequency of inflations 100 — 110 in 1 min., respirators with the special electronic valve breaker are required.

The asynchronous mode is applied seldom, hl. obr. for decrease in average intrathoracic pressure; essence — serial ventilation of the right and left lung when inflation of gas mixture in one lung is combined with an exhalation in other lung. For carrying out asynchronous the claim. breath use on one respirator on each lung or a special respirator of AR-1.

Autoreguliruyemy mode. The claim is truly automatic. breath, parameters to-rogo are regulated by the principle of a feed-back according to functional changes of an organism. The method autoreguliruyemy the claim is most widespread. breath, the mode to-rogo is controlled the size pCO 2 alveolar gas (T. M. Darbinyan et al., 1970). There is a method autoreguliruyemy the claim. the breath managed by biocurrents of a phrenic nerve and a diaphragm.

FEATURES of the ARTIFICIAL RESPIRATION IN VARIOUS CONDITIONS

in the conditions of anesthesia and operation

For carrying out anesthesia with an artificial mioplegiya use a respiratory bag or fur of the narcotic device (the claim. breath with a hand gear), automatic respirators with a narcotic block (RO-5, RO-6, AND-2, etc.) or narcotic devices with respirators prefixes (RD-2, «Assistor» of Dreger, etc.). At manual claim. breath the anesthesiologist shall adapt to «feeling» of a bag, a cut it consists of the inflated volume, distensibility of lungs, resistance of respiratory tracts, etc.

To keep necessary gas composition of insuffliruyemy anesthetics during the use of respirators, use only devices with fur (RO-3, RD-2, etc.) or with the large volume of injection (RD-1). At intrathoracic operations, in particular at lung operations, it is necessary to carry out sometimes one-pulmonary the claim. breath for what use bronchus blockers or a separate intubation of bronchial tubes. In some cases use bradipnoichesky the claim. breath, diffusion breath.

The injection method for the first time offered in 1967 by R. D. Sanders and developed in the USSR by G. I. Lukomsky et al. (1971) is applied at leakage of a rebreathing system; e.g., at some endobronchial manipulations (a biopsy, removal of foreign bodys, lavage of respiratory tracts, etc.). At an injection method claim. breath oxygen under pressure in several atmospheres moves through an injection needle in a tube of the bronchoscope which carries out a role of the diffuser. During a breath free air podsasyvatsya via the bronchoscope in a lung, the exhalation is carried out passively at the termination of inflation of oxygen through a needle. Regulating pressure in a needle and duration of injection, it is possible to receive the necessary duration, pressure, volume and rate of volume flow of a breath. There are special automatic respirators for an injection method the claim. breath.

Diffusion breath, or apnoyny oxygenation — insufflation of oxygen in a lung in the absence of respiratory movements. Oxygen is entered by various methods — through a mouth-nose mask, an endotracheal tube, the bronchoscope, catheters; it reaches alveoluses by gas diffusion, partially washing away carbonic acid. The method is used rather seldom, by hl. obr. because claim. breath with the alternating administration and removal of adequate volumes of gas is much more effective. Nevertheless claim. breath by a method of diffusion breath is capable to prevent development of an anoxemia within 10 — 20 min. though the hypercapnia at the same time can arise.

Fig. 7. The diagrammatic representation of lungs depending on influence of gas structure of an alveolar air on the volume of a pulmonary blood-groove (in white color the alveolar air, black color — the volume of a pulmonary blood-groove is designated): 1 — at natural ventilation; 2 — at introduction to the right lung of oxygen — 10 l/min (apnoyny oxygenation); 3 — at introduction to the right lung of oxygen — 10 l/min, and in left nitrogen — 10 l/min (an apnoyny nitrogenation).

Before diffusion breath it is necessary to carry out a denitrogenation of an organism by inhalation of 100% of oxygen. Adequacy claim. breath at a method of apnoyny oxygenation during the specified term it was proved by A. P. Zilber (1971) by means of a radio isotope research. Use of a method is shown at lung operations for creation of a motionless surgery field, at an injury of a lung when introduction of a pressured air is contraindicated. Apnoyny oxygenation not only provides sufficient ventilation of a lung, but also reduces the shunt of a venous blood which is inevitably arising in not ventilated easy (fig. 7). In this regard during the carrying out one-pulmonary the claim. breath on a healthy lung by PPD or PPOD method it is necessary to enter oxygen or nitrogen into a motionless sore lung by method of apnoyny oxygenation or an apnoyny nitrogenation — both receptions reduce the shunt of a venous blood.

Glossofaringealny breath — rather seldom applied method the claim. breath, offered in 1951 by G. W. Dail, it is used at patients with paralysis of respiratory muscles as a result of poliomyelitis and other neuroviral infections at preservation of consciousness at them. The essence of a method consists that after the special training of the patient, using a back and a root of language as the piston, and a nasopharynx as the camera for the piston, fractionally forces in lungs air — 6 — 8 «glotaniye» on 50 — 80 ml for a cycle. The exhalation is carried out passively. J. E. Affeldt et al. (1955) showed that glossofaringealny breath quite provides the adequate volume of ventilation of the lungs. Feature of this version claim. breath consists that the patient himself carries out the claim. breath, but it is capable to do it only in a condition of wakefulness and needs connection of a respirator for the period of a dream.

The Auxiliary Artificial Ventilation of the Lungs (AAVL) — artificial increase in ventilation at inadequacy of spontaneous ventilation. Distinguish adaptation VIV JI when insufficient spontaneous and artificial ventilation is synchronized by various methods, and «responding», or trigger when deepening of a breath is reached automatically in attempt of a natural breath.

At adaptation VIVL use any respirators, and apply suggestive methods, introduction of neuroleptics and depressants of breath to synchronization of VIVL with spontaneous ventilation. In the latter case VIVL actually turns into the claim. breath. For trigger VIVL use the respirators supplied with the responding device (RO-3, RO-5, RO-6, etc.) which is working at achievement of the certain depression arising in a respirator during an independent breath and including a respirator on the mode of an artificial breath. Actually trigger VIVL is a version autoreguliruyemy the claim. breath, when need in the claim. breath and its volume are defined by functional changes in an organism of the patient. In this option the autoregulyation is carried out on degree of rarefaction in lungs at a natural breath. VIVL is shown at «respiratory hronik», at hypoventilation in the postoperative period and can be applied even in out-patient conditions. V. M. Yurevich (1973) notes improvement of mechanics of breath, gas exchange, decrease in a metabolic cost and the cumulative salutary effect of VIVL at patients with hron, respiratory insufficiency.

At resuscitation of newborns the claim. breath is carried out by respirators with a hand gear and automatic. Feature claim. breath in such conditions the high frequency of breath is at the small volumes of a breath (15 — 20 ml). Moderate negative pressure at the end of an exhalation is necessary to overcome resistance of a narrow endotracheal tube. Claim. breath at newborns can be carried out also by the modified Eyre's system when lungs inflate closing of side withdrawal of the connector.

In the conditions of hyperbaric oxygenation. Due to a possibility of the fire in these conditions it is possible to use respirators only with the pneumatic drive (RD-1, LADA, etc.). Along with increase of pressure in a pressure chamber it is necessary to increase pressure of the gas moving to a respirator that conducts to the considerable deviations of minute ventilation demanding timely correction. Indicators of volyumetr in the conditions of hyperbaric oxygenation also differ from conditions of standard atmosphere pressure.

In field conditions. Acute respiratory insufficiency in field conditions arises at severe wounds and the closed brain injuries, maxillofacial area and a breast, and also at a serious poisoning.

Indications to the claim. to breath, as well as in peace time, are defined by extent of disturbance of breath, and opportunities and ways of carrying out depend on the number of persons in need and conditions of a situation.

In the battlefield and the advanced stages of evacuation for the purpose of recovery and maintenance of breath at tyazheloporazhenny the simplest methods are used, to-rymi saninstruktor and hospital attendants, and also all military personnel for rendering mutual assistance shall own. Breath from a mouth in a mouth, from a mouth in Nov and the claim belongs to such methods. breath by means of a S-shaped tube, edge is available in a dignity. bags. During the periods of emergence mass a dignity. losses and in the conditions of an adverse fighting situation the possibility of use and these methods can be very limited.

More favorable conditions for the claim. breath on the IFV where the paramedic can carry out the claim. breath through a S-shaped tube or through a mask of the portable manual respiratory device. Previously for the purpose of recovery of passability of upper respiratory tracts, except giving to the wounded of the relevant provision, the paramedic deletes slime and blood from an oral cavity and a nasopharynx by means of a portable suction, and if necessary enters an air duct.

On PMP an opportunity the claim. is much wider than breath, however and here it will be out only struck with that, the Crimea threatens asphyxia directly or during the forthcoming evacuation. In addition to manual respiratory devices, use portable respiratory automatic machines here. In some cases connection of the device is preceded by an intubation of a trachea or the Tracheostomy.

The possibility of implementation not only short-term, but also rather long the claim is provided in MSB and hospitals. breath by means of various devices. It can be carried out at the same time several struck and in most cases with the assistance of intensivists in the conditions of antishock chambers or operating rooms. Claim. breath — one of the most important elements of anesthesiology ensuring many operations. In this area for it there are no essential restrictions in comparison with conditions of peace time.

CONTROL of ADEQUACY

Fig. 8. The scheme of inclusion of the spirocount in a rebreathing system at an artificial respiration: and — the spirocount with a respirator like RO with separate bellows of a breath and exhalation; 1 — the spirocount; 2 — the rotameter; 3 — the evaporator; 4 — an adsorber; 5 — fur of a breath; 6 — fur of an exhalation; 7 — a connecting tube for administration of gas-narcotic (kislorodovozdushny) mix to the patient; — the spirocount with a respirator like RON with one fur: 1 — a connecting tube for administration of gas-narcotic (kislorodovozdushny) mix to the patient; 2 — the evaporator; 3 — an adsorber; 4 — the rotameter; 5 — the magnetic electric solenoid valve blocking the channel of a breath on reaching the set volume or pressure; in — the spirocount; 7 — a respirator.

The duty of a respirator is controlled on the blown volume, absolute value and dynamics of pressure of a breath and an exhalation. Volyumetra (flowmeters of a flow) it is necessary to establish on the channel of an exhalation, it reduces probability of wrong indications in connection with leak. Special difficulties are presented by the spirography in conditions the claim. breath, especially in the presence of the narcotic device in the general rebreathing system. Option of inclusion of the spirocount with various respirators during the carrying out the claim. breath it is presented in the figure 8. At spirometry in these conditions the internal gas leak is possible. The scheme 6 is in this respect more reliable, however a possibility of carrying out spirometry at the claim. breath and creations of the corresponding models of devices it is studied. Pnevmotakhografiya who is seldom applied in daily a wedge, practice allows to control at the claim. breath not only volumes, but also rate of volume flow and dynamics of pressure of a breath and exhalation, and also other indicators of mechanics of breath. The sensor of the pneumotachograph should be installed before an endotracheal or tracheostomy tube and at the choice of volume of ventilation to consider additional tool «dead» space.

Almost in all respirators there are manometers allowing to control the peak pressure of a breath and exhalation. There are devices («Signal-1», etc.)? pressure signaling about a deviation from the set parameters and about depressurization of a contour.

Finally about adequacy the claim. breath judge by a condition of the vital functions of an organism, estimating blood gases, the central venous pressure and other indicators of a hemodynamics, a water and electrolytic and acid-base condition, color and humidity of integuments, participation in breath of auxiliary muscles, etc.

Transition to spontaneous ventilation

Ability of the patient to provide adequate ventilation, by data a wedge, and a functional research, allows to stop the claim. breath. Sometimes after long the claim. breath it should be done in several stages, gradually accustoming the patient to spontaneous ventilation or transferring it to assisted ventilation of lungs in the beginning. In the course of transition to spontaneous ventilation which can continue up to several days it is necessary to control carefully its volume, blood gases, to watch outward of the patient, to carry out respiratory gymnastics and to carry out sanitation of respiratory tracts.

PATIENT CARE

Patient care, especially being on long the claim. breath, includes, first of all, a toilet of respiratory tracts with use of the device of artificial cough, aspiration of a phlegm, aerosol inhalations of mucolytic and antibacterial drugs, use of a postural drainage. An important role in improvement of a drainage of respiratory tracts is played by effleurage on a thorax and vibration massage (concussion of a chest wall during an exhalation).

Good probe or parenteral nutrition, control of function of intestines, of a diuresis, prevention of an infection of uric ways and decubituses is of great importance.

The special psychological mode for the patients who are in consciousness is an important component of leaving at long the claim. breath. Systematic control of a hemodynamics, biochemical, a blood analysis, urine etc. is required. Results of researches, and also a duty of a respirator and additional actions which are held to the patient are registered in special cards.

COMPLICATIONS

Most often complications begin with system of breath. In addition to respiratory acidosis (see) and alkalosis (see), arising because of incorrectly chosen mode, long the claim. breath quite often leads to development atelectases (see) in connection with disturbance of drainage function of respiratory tracts, an abnormal ratio a ventilation/blood stream and decrease in products of surfactant. Microatelectases can form a basis for development pneumonia (see). Prevention of these complications — a careful toilet of respiratory tracts, periodic inflating of lungs. Long claim. breath of 100% oxygen can lead to developing of a pneumonitis in this connection concentration of oxygen shall not exceed 40 — 50%.

To complications the claim. breath belongs prolonged by an apnoea upon transition to spontaneous ventilation. Usually it is result of the abnormal irritation of receptors of lungs suppressing normal reflexes of Goering — B of yards-era and others fiziol, mechanisms of switching of a breath and exhalation. Elektromiografichesky control of recovery of neuromuscular conductivity allows to differentiate prolonged by an apnoea of a peripheral etiology (action of muscle relaxants, diseases of muscles and a neuromuscular synapse) from an apnoea in connection with disturbance of the central regulation of breath because of a respiratory alkalosis, damage of a respiratory center, etc.

Ruptures of alveoluses with emergence of a tension pneumothorax at the claim. breath arise at the abscessing pneumonia, especially at children more often. Sometimes this complication is connected with failure of a respirator, is frequent with desynchronization of own breath of the patient and the mode of a respirator. Pheumothorax demands immediate drainage of a pleural cavity.

In the blood circulatory system treat complications connected about the claim. breath disturbance of venous return and reduction of cordial emission. In such cases the claim is recommended to replace the mode. breath, in particular to use PPOD.

Disturbance of a hemodynamics at the claim is frequent. breath it is connected with a hypoxia, a respiratory alkalosis or acidosis, especially at sharp fluctuations of pO 2 and pCO 2 at the beginning and at the end claim. breath.

Disturbance of water exchange (an overhydratation, hypostases) is connected with many reasons. Sometimes at the beginning the claim. breath paresis of intestines and decrease in an intestinal vermicular movement is observed. Occasionally there are bleedings from went. - kish. a path, the reason and a pathogeny of these complications remain not quite clear.

Rather seldom at the patients who are on long the claim. breath, the nephrolithiasis as result of renal compensation of a respiratory alkalosis by decrease in a reabsorption of bicarbonates develops. Formation of stones is promoted by an infection of uric ways against the background of alkali reaction of urine.

To complications the claim. breath it is possible to carry and patol, the states connected with long stay in respiratory tracts of an endotracheal or tracheostomy tube — stenotic and fibrinous and necrotic laryngotracheobronchites, decubituses, bleedings from respiratory tracts.

DEVICES

Fig. 9. The device RD-1 with a pneumatic actuator.
Fig. 10. The device RD-2 with a pneumatic actuator.
Fig. 11. The device RO-2 with the electric drive.
Fig. 12. The device RO-6N with the electric drive of universal appointment.
Fig. 13. The device ADR-2 with a hand gear (with the elastic self-filled bag).
Fig. 14. The office of Vit-1 for children.
Fig. 15. Computer-controlled device ROA-2.
Fig. 16. Tube respiratory TD-1. 02: and — in assembled form; — in partially sorted look (1 — a mouthpiece with a goffering; 2 — the irreversive valve; 3 — a nagubnik; 4 — an air duct).
Fig. 17. Device respiratory manual ADR-2 (set) in unassembled form: 1 — a respiratory latex bag; 2 — the valve device; 3 — a mask; 4 — a caterpillar tube; 5 — air ducts; 6 — a branch pipe for oxygen; 7 — the mouth gag.

Distinguish devices for outside the claim. breath and the devices operating by the principle of inflation. The last are more effective, allow to manage easily the mode of ventilation and are simpler structurally.

An energy source for operation of the device the claim. breath there can be a compressed gas, electricity or muscular force. The device with the pneumatic drive (fig. 9 and 10) has the small sizes since cylinders with gas usually are not its part. Such device is more convenient during an inhalation anesthesia since it is less explosive. Devices claim. it is more breath with the electric drive (fig. 11 and 12) by the size, but it is much more convenient for long ventilation. From devices with a hand gear models with the elastic self-filled bag (fig. 13) are most widespread.

Devices claim. breath classify and to destination — for resuscitation, for an anesthesia, for use for children (fig. 14) etc.

In the USSR more than 15 various models of devices for the claim are produced. breath. For the first time in the world, in particular, the release of the devices which are automatically supporting minute ventilation of such size is made, edges are provided by the set content of carbonic acid in alveolar gas (fig. 15).

Main node of the device claim. breath the generator of a breath supplying during a breath gas in lungs of the patient is. In the pneumatic device the injector fed by the compressed oxygen under pressure of 4 kgfs/cm for this purpose is usually used 2 and podsasyvayushchy free air or other gas. The centrifugal blower or the pump working with the set respiration rate serves in devices with the electric drive the generator of a breath. If it is necessary to apply a half-closed rebreathing system, then include the dividing capacity, an elastic bag which enters a rebreathing system in structure of the device.

By a radical method of decrease in harmful effects claim. breath on a hemodynamics use of an active exhalation is that is provided with the generator of an exhalation similar on the device to the generator of a breath. Necessary switching of gas streams is carried out by the distribution mechanism switching from the provision of a breath in the provision of an exhalation and back after achievement of the values of volume of gas, a time term set by an operating controls or. pressure. Other operating controls determines productivity of the generator of a breath, the depression created by the generator of an exhalation and other parameters.

As a rule, in structure of the device the claim. breath the filter, a humidifier of the inhaled gas, measuring devices, and sometimes and signaling devices of dangerous situations enter. The last point to escaping of the set limits of pressure of the end of a breath, minute ventilation, pressure of the feeding gas or other parameters and, thus, are one of means of ensuring of reliable operation of the device the claim. breath that has paramount value for this type of the medical equipment.

Before each connection to the patient working capacity and tightness of the device is surely checked. For assessment of the last it is necessary to block outlet opening of the device and to be convinced of bystry increase of pressure not less than to 30 cm w.g. at installation of minute ventilation to 5 l/min. It is necessary to observe the frequency and volume of maintenance specified in the maintenance instruction, and also requirements of the accident prevention.

Before connection of the device claim. breath to the patient the rebreathing system of the device is disinfected. Metal removable parts autoclave, rubber and plastic details carefully wash out, and then keep in disinfecting solutions or wipe. Boiling of such details accelerates natural processes of their aging. Disinfection of internal lines of a rebreathing system can be carried out by vapors of formaldehyde, a high density aerosol of desinfectants. After disinfection the device shall be blown by a pure air for removal of traces of disinfecting drugs.

PO devices are intended for long the claim. breath. Thanks to full dissociation of a rebreathing system from the line of the drive they can ensure functioning on a half-closed rebreathing system during an anesthesia; the devices RO-5, RO-6N which part also the small-size device of an inhalation anesthesia is are most convenient in this case. All models of this type have ample opportunities, are completed with a humidifier, measuring devices and a set of accessories. The RO-5 and RO-6 models allow to carry out as managed, and assisted ventilation.

The devices RD-1 and RD-4 have the drive from the compressed oxygen under pressure of 4 kgfs/cm 2 also are executed on jet elements of pneumoautomatic equipment. RD-1 is intended for resuscitation and has ample opportunities, providing, in particular, assisted ventilation. The RD-4 model is a prefix to the universal device of an inhalation anesthesia Polynarcon-2 and has a folding rebreathing system that facilitates its disinfection.

The device Pnevmat-2 is used for short-term resuscitation. Existence of a cylinder in it with oxygen does this model completely autonomous.

The office of Vit-1 is intended for newborns and children under 3 years as it provides an opportunity to dose very small respiratory volumes and rather high frequencies of breath. For measurement of the actual values of ventilation the device is completed with a lung-tester.

The short characteristic of the most widespread domestic devices for the claim. breath it is provided in tab. 1.

During the rendering the first medical aid in field conditions apply a respiratory tube of TD-1.02, and at stages of medical evacuation — the portable manual devices DP-10.02, ADR-2 and the DP-9.02 submachine guns, devices the claim. breath on the Pnevmat-1 pneumoelements (with the fixed parameters of breath), on pneumoelements (USEPPA) of the HARMONY, devices the claim. breath Phase-1, Phase-2. They are convenient and reliable in work. Except a respiratory tube, all devices can be used in the infected atmosphere thanks to existence of device for a suction of air through a box of a gas mask. Laying metal, pylebryzgozashchishchayushchy (except TD-1.02). The main characteristics of manual devices are provided in tab. 2.

The respiratory tube of TD-1.02 consists from demountable a mouthpiece with a goffering, the irreversive valve, a nagubnik, an air duct (fig. 16). The devices DP-10.02, ADR-2 consist of a respiratory latex bag in a rubber bag, two irreversive valves and the valve pay-off of oxygen. Devices, a caterpillar tube, masks, branch pipes for oxygen, the mouth gag, tongue forceps, etc. are included in the packages (fig. 17).

Automatic devices for the claim. breath provide supply of kislorodovozdushny mix (35 — 40%), pure oxygen or a pressured air (from compressors). Depending on drives they are subdivided on pneumatic (DP-9.02, Pnevmat-1, LADA) and electric (the Phase-1, the Phase-2).

A gas rate on the drive of pneumatic devices to 4 l/min. Adjustment of parameters smooth (in Pnevmat-1 all parameters are fixed). Respirators can be connected to devices of an inhalation anesthesia. Main characteristics of devices claim. breath are provided in tab. 3.

Fig. 18. The device Pnevmat-1 on pneumoelements with the fixed parameters of breath.
Fig. 19. The device on the HARMONY pneumoelements: and — in laying; — in assembled form.

The device for the claim. breath of DP-9.02 consists of the product assembled with laying, oxygen cylinders, air ducts, masks, connecting elements, a rubber bag, a bridle, the mouth gag, tongue forceps, zaplechny belts, a set of the reserve tools, accessories (RT,A). The device for the claim. breath of Pnevmat-1 (fig. 18) it is intended for ventilation of the lungs in operating rooms, in antishock tents. It is included in the package of the device for an inhalation anesthesia of Narkon-2. Consists of a reducer, the pneumatic actuation device, an injector, the filter, the safety valve. The device, masks, a respiratory hose, the irreversive valve, a bridle, adapters, etc. the Device for the claim are included in the package. breath of the HARMONY (fig. 19) the claim is intended for automatic or manual auxiliary. breath at the kept breath of the patient, and also for a constant or the pulsing regulated inhalation of breathing gas. Represents pneumatic system with the elements of pneumoautomatic equipment on a pneumopayment which are carrying out analog and discrete logical operations. The devices Phase-1 and Phase-2 provide long automatic ventilation of the lungs with a pressured air or kislorodovozdushny mix (from a source of oxygen). They are highly effective for patients with partially or completely broken independent breath.

The device Phase-2 is counted on two patients; adjustment of all parameters autonomous. The ZIP consists of the power block (with an electric motor and the blower), electronic (turning on blocks and operating controls) the block, food, and also magnet valves and the distribution block, valves of a suction, caterpillar tubes, masks. Laying of devices is used as a basis support.

Table 1. The GENERAL CHARACTERISTIC of SOME DEVICES FOR the ARTIFICIAL RESPIRATION


Table 2. The CHARACTERISTIC of the DEVICES FOR the ARTIFICIAL RESPIRATION USED DURING the RENDERING the FIRST MEDICAL AND PRE-MEDICAL AID


Table 3. The CHARACTERISTIC of the DEVICES FOR the ARTIFICIAL RESPIRATION USED DURING the RENDERING the FIRST the MEDICAL, QUALIFIED AND SPECIALIZED MEDICAL CARE



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Devices — Belyaev V. L. and Belov V. A. Vozdukhovod for artificial ventilation of the lungs of «TD-1», Voyen. - medical zhurn., No. 11, page 78, 1974; B of e of l I am e in V. L., etc. The portable device for artificial ventilation of the lungs of «Pnevmat-1», in the same place, No. 6, page 68, 1974; To with and N d r the island and S. E. The manual device for artificial ventilation of the lungs of ADR-12, Is new. medical tekhn., No. 2, page 77, 1974; Shanin Yu. N., etc. Lada medical ventilator, Voyen. - medical zhurn., No. 8, page 82, 1976.


A. P. Zilber; I. F. Bogoyavlensky, Yu. Sh. Galperin (tekhn.), B. S. Uvarov (soldier.).

Яндекс.Метрика