BRONCHOSPASM (bronchospasmus; bronchial tube[s] + spasm; synonym bronkhiolospazm) — narrowing of a gleam of small bronchial tubes and bronchioles; can arise at various diseases of a respiratory organs as manifestation of allergic reactions or at defeat by their toxic agents and also as an independent complication at surgical and bronchoscopic interventions.
the Great value in B.'s development is attached to mechanical irritation of fibers of the wandering and phrenic nerves, effect of the drugs having parasympathomimetic and antikholinesterazny activity, to accumulation in an organism of biogenic amines (a histamine, serotonin) and their release from fabric depots.
B.'s development at bronchial asthma and other diseases of bronchopulmonary system is promoted by infectious and allergic factors, directly and reflex influencing cholinergic structures of respiratory tracts. The attempt of an intubation or extubation of a trachea at active vagal reflexes, the insufficient depth of anesthesia, the Hypercapnia and a hypoxia in time or after an anesthesia can provoke B.
the Clinical picture
Depending on prevalence and extents of narrowing of bronchial tubes and bronchioles distinguish two types of B.: partial and total. At partial B. sites of normally functioning pulmonary fabric remain. At total B. there is a full spasm of bronchioles and small bronchial tubes.
The first symptoms of partial B. are: the complicated breath with the extended exhalation, increase in a tone of respiratory muscles, emergence of dry and wet rattles in lungs, moderate arterial hypertension against the background of relative bradycardia, an easy Crocq's disease and cyanosis of mucous membranes. With B.'s progressing cyanosis and sweating amplifies, dry and wet rattles accrue, breath becomes whistling, arterial hypertension is replaced by hypotension, and bradycardia — tachycardia. At partial B.'s emergence during the thoracic operations which are followed by surgical pheumothorax it is possible to see the reinflated lung with sites of an atelectasis which finish during creation of supertension on a breath in system of the narcotic device. Upon partial B.'s transition in total breath on a breath and an exhalation is at a loss, respiratory noise and rattles in lungs cease to be listened. Total B., in essence, represents «an acute stop of lungs» (V. P. Smolnikov) and is characterized by total absence of breath and heavy disturbances of gas exchange. After the end of operation and an anesthesia there can be B. which is combined with a partial laryngospasm. Find in Such patients the complicated exhalation and the forced breath, the phenomena of a hypercapnia, a hypoxia and respiratory acidosis.
total B.'s Diagnosis is not difficult whereas partial B.'s identification, especially its latent forms, presents the known difficulties; in these cases B.'s symptomatology can be very scanty. Along with slight cyanosis, moderate arterial hypertension note the increased resistance to an artificial breath and insufficient fall of a lung on an exhalation at direct vision in the conditions of a thoracotomy. The resistant respiratory acidosis at vigorous artificial ventilation of the lungs confirms existence of the latent form partial B.
Easy degree of B. can remain not distinguished during operation, and to be shown in the postoperative period.
In differential diagnosis of B. first of all it is necessary to exclude mechanical obturation of bronchial tubes a foreign body (see. Foreign bodys , bronchial tubes), an excess of an endotracheal tube, overlapping of its gleam the reinflated cuff, and also excessively deep introduction to a bronchial tube of an endotracheal tube with switching off from ventilation of intact departments of lungs (see. Intubation , at an anesthesia). It is often necessary to differentiate B. with fluid lungs (see) as it can be also an end-stage of B.: B.'s development is followed by bradycardia in combination with arterial hypertension and small pulse pressure owing to increase in diastolic arterial pressure in the beginning; at a fluid lungs tachycardia against the background of arterial hypertension develops, it is frequent with increase in pulse pressure owing to increase in systolic arterial pressure. Against the background of considerable tachycardia the hypoxia of a myocardium develops that can lead to gastric fibrillation and a cardiac standstill.
At B. the viscous, viscous «vitreous» phlegm owing to hypersecretion of tracheobronchial glands is allocated; at a fluid lungs the foamy bloody phlegm which is formed from penetration into alveoluses of the transudate which is mixing up with air is allocated.
It is necessary to differentiate B. with the atelectasis which sharply arose during an anesthesia, with the spastic state accompanying Mendelssohn's syndrome in the next postoperative period (see. Anaesthesia , complications).
B. as symptom bronchial asthma (see) and some other diseases of a respiratory organs usually does not constitute danger of death, but at emergence in the course of operation or in the postoperative period it can lead to the death of the patient if the emergency resuscitation measures are not taken. At total B. and prolonged partial B. the heavy asphyxia leading to a terminal fluid lungs and a cardiac standstill is possible.
Treatment is carried out taking into account etiol. and pathogenetic factors and features of pulmonary pathology. At the developing partial B. intravenously enter cholinolytic substances (atropine, Methacinum), antispasmodics (an Euphyllinum, Aminophyllinum, Halidorum), antihistaminic substances (Pipolphenum, Suprastinum, Dimedrol), corticosteroid hormones (a hydrocortisone, Prednisolonum). Bronchodilatory means, in particular adrenaline and derivatives of an izopropilnoradrenalin (Isadrinum, Novodrinum, Isuprelum, alupent), apply about care as these β-adrenergic substances along with broncholitic action exert the stimulating impact on heart and can sharply aggravate a hypoxia of a myocardium.
The begun B. can be stopped by Ftorotanum or ether through a mask of the narcotic device or intravenous administration of hydroxybutyrate of sodium in a dose of 70 — 100 mg on 1 kg of weight. At heavy attacks of bronchial asthma when pathogenetic and symptomatic therapy does not render effect and B. it is not stopped, threatening to pass into total B. with an asystolia or a terminal fluid lungs, carrying out artificial or assisted ventilation of lungs is recommended (see. Artificial respiration ). At the prolonged B. accompanying bronchial asthma and which is combined with obturation of bronchial tubes it is necessary to apply the means liquefying a phlegm (bisolvon, chymotrypsin, Acetylcysteinum), to carry out an intensive bronchial lavage soda or fiziol, solution with furaginy or with proteolytic enzymes via the bronchoscope or an endotracheal tube. For elimination of obturation of bronchial tubes a viscous viscous phlegm bronchial lavage via the bronchoscope in the conditions of an anesthesia with artificial injection ventilation of the lungs is effective. If partial B. arose in the conditions of operation under the general anesthesia, then it is necessary to deepen an anesthesia Ftorotanum or ether before achievement of a narcotic dream, to enter a muscle relaxant of the depolarizing action, to aspirate a phlegm, to strengthen ventilation of the lungs by giperoksichesky mix. Easy this patients should carry out artificial and assisted ventilation until the phenomena B remain. For the purpose of prevention of a fluid lungs it is reasonable to begin dehydrational therapy — intravenous administration of 2% of solution of lasixum (see. Furosemide ), hypertonic salt solutions of glucose; introduction of ganglioblokator (an arfonad or Pentaminum), and for elimination of a metabolic acidosis — sodium bicarbonate. Also vagosympathetic blockade is shown. At total B. it is necessary to apply direct massage of lungs in the manual or hardware way. At the same time carry out hormonal therapy and dehydration for the purpose of the prevention of a fluid lungs. At the total B. which is followed by sharp bradycardia or an asystolia urgently apply direct massage of a lung and a cardiac massage after left-side a thoracotomy. Direct massage of a lung is combined in the manual way with forcing in easy for gas mixture from the narcotic device. At the same time the breath is carried out by fur of the narcotic device, and exhaled — squeezing of a lung hands. The indirect massage of lungs combining artificial ventilation of the lungs with squeezing of a thorax is less effective. At the total B. arising during an attack of bronchial asthma, a bronkhoskopiya or the operations which are not connected with opening of a pleural cavity the device Η can be used. F. Mistakopulo designed for vozdushnokislorodny massage of lungs. Device (fig.) provides a forced breath and an exhalation by serial forcing of air-oxygen mix through an endotracheal tube in lungs and through the rubber tubes which are connected to a trocar in both pleural cavities.
For the purpose of the prevention of development of B. in the course of operation it is necessary to conduct in the preoperative period a course of the desensibilizing therapy by antihistaminic drugs and corticosteroid hormones and a course of an aerosoltherapy with bronchodilators. In the prenarcotic period use of tranquilizers and cholinolytic means before drugs of morphine and its analogs since the last strengthen bronkhospastichesky effect is more preferable. From barbiturates it is safer to apply hexenal to an introduction anesthesia. The general anesthesia of sufficient depth with the adequate lung ventilation providing normal gas exchange is necessary. Optimal conditions of an anesthesia are created during the use of Ftorotanum and muscle relaxants of the depolarizing type.
Bibliography: Votchal B. E. Sketches of clinical pharmacology, M., 1965; Kessler G. and d river. Resuscitation, the prevention and treatment of sudden complications, the lane from Czeches., page 66, Prague, 1968; To au g and B. B N. The main questions of treatment of bronchial asthma, Rubbed. arkh., t. 28, No. 8, page 30, 1956; Sarkisov D. S., etc. Postoperative pulmonary complications, page 54, M., 1969; With mo l of ni-k of V. P. and Mistakopulo Η F. Bronkhospazm and massage of lungs, M., 1969-Wylie W. D. ampere-second of h u of of s h i 1 1-D a v i-d s o n H. C. A practice of anesthesia, L. 1960.
BB. H. Jaline.