RESPIRATORY INSUFFICIENCY — the morbid condition caused by disturbance of exchange of gases between an organism and the environment. The term is offered by A. Wintrich in 1854. In the resolution XV of the All-Union congress of therapists (1962) D. of N it is defined as a condition of an organism, at Krom or maintenance of normal gas composition of blood is not provided, or the last is reached due to the abnormal operation of the device of external respiration leading to decrease in functionality of an organism.
At D. of N normal gas composition of blood the long time can be provided with tension of compensatory mechanisms: increase in minute volume of breath at the expense of depth and at the expense of its frequency, the increase of cordial reductions, increase in cordial emission and rate of volume flow of a blood-groove strengthened by removal of the connected carbonic acid and nedookislenny products of exchange of kidneys, increase in oxygen capacity of blood (increase in a hemoglobin content and number of erythrocytes), etc.
Classifications Of N are offered by A. G. Dembo (1957), Stid and Mack-Doneld (W. W. Stead, F. M of MacDonald, 1959), etc. Rossye (R. of H. Rossier, 1956) suggested to divide D. of N on latent (at rest the patient has no disturbances of gas composition of blood), partial (there is an anoxemia without hypercapnia) and global (an anoxemia in combination with a hypercapnia). Of N divide also on primary, connected with defeat directly of the device of external respiration, and secondary, a cut are the cornerstone of a disease and injuries of other bodies and systems.
In 1972 B. E. V otchat offered classification, according to a cut distinguish tsentrogenny, neuromuscular, torakodiafragmalny, or parietal, and bronchopulmonary D. of N; and in bronchopulmonary D. N allocate the obstructive form caused by disturbance of bronchial passability restrictive (restrictive) and diffusion.
D.'s Tsentrogennaya of N can be caused by disturbance of functions of a respiratory center, napr, at defeat of a trunk of a brain (a disease or an injury), and also at oppression of the central regulation of breath as a result of poisoning with depressants of breath (drugs, barbiturates, etc.). Neuromuscular D. of N can arise owing to disorder of activity of respiratory muscles at injury of a spinal cord (an injury, poliomyelitis, etc.), motor nerves (polyneuritis) and neuromuscular synapses (botulism, a myasthenia, a hypopotassemia, poisoning with kurarepodobny drugs) etc. D.'s Torakodiafragmalnaya of N can be caused by frustration of biomechanics of breath owing to pathology of a thorax (a fracture of edges, a kyphoscoliosis, Bekhterev's disease), high standing of a diaphragm (paresis of a stomach and intestines, ascites, obesity), widespread pleural unions. etiol, a factor the prelum of a lung an exudate, and also blood and air can be important at haemo - or pheumothorax.
patol, processes in lungs and airways (fig.) are the most frequent reason of bronchopulmonary D. of N. Damage of airways, as a rule, is followed by partial or their full obstruction (an obstructive form); it can be caused by a foreign body, hypostasis or a prelum a tumor, a bronchospasm, allergic, inflammatory or congestive hypostasis of a mucous membrane of bronchial tubes. Obstruction of respiratory tracts a secret of bronchial glands is observed at patients with the broken expectoration, napr, at coma, sharp weakness with restriction of function of muscles of an exhalation, nesmykaniya of a glottis. One of important etiol, mechanisms is change of activity surfactant (see) — the factor reducing liquid tension, covering an inner surface of alveoluses; insufficient activity of surfactant promotes fall of alveoluses and development of atelectases (see. Atelectasis ). The restrictive form of bronchopulmonary D. of N can be caused acute or hron, pneumonia, emphysema, a pneumosclerosis, an extensive resection of lungs, tuberculosis, an actinomycosis, syphilis, a tumor, etc.
The pneumoconiosis, a pneumosclerosis, Hammen's syndrome — Rich are diffusion D.'s reasons of N (see. Hammena-Rich syndrome ); however in «a pure look» this form D. of N occurs at adults rather seldom. Along with it as an accessory factor in D.'s development by N, disturbance of diffusion can take place in a stage of an aggravation hron, pneumonia, at an acute pneumonia, a toxic fluid lungs. Diffusion D. of N is significantly aggravated if circulatory disturbances and ratio distortion ventilation — a blood stream in lungs are at the same time observed that takes place at a thromboembolism of a pulmonary artery, a sclerosis of a pulmonary trunk (see. Ayersa syndrome ), primary hypertensia of a small circle of blood circulation (see), heart diseases (see), an acute left ventricular failure (see. Heart failure ), hypotensions of a small circle at blood loss, etc.
One of the reasons of D. of N connected with disturbance of pulmonary blood circulation and diffusion of gases is the so-called shock lung. It can develop at the patients who transferred heavy disturbance of a hemodynamics (shock, blood loss, a temporary cardiac standstill, burns, etc.). At a shock lung as a result of deep disturbances of peripheral microcirculation units of uniform elements of blood which cause a microembolism of spazmirovanny pulmonary capillaries are formed. Further hypostasis of an alveolocapillary membrane with the subsequent proliferation of cellular elements develops in an alveolus and formation of hyaline membranes.
Distinguish three types of mechanisms of disturbance external breath (see), the N conducting to D.: disturbance of alveolar ventilation, disturbance of the ventilating and perfused relations and disturbance of diffusion of gases through an alveolocapillary membrane (fig).
The most frequent mechanism of development of disturbance of ventilation of alveoluses is obstruction of respiratory tracts. The movement of air on bronchial tubes submits to Gagen's law — Poiseuille:
where: ΔF — a volumetric gain; r — the radius of respiratory tracts; l — their length; P1 and P2 — pressure at the beginning and the end of respiratory tracts; Δt — a time term and μ — coefficient of friction of gas. The investigation follows from this law that resistance to a gas flow (R) in inverse proportion to a square of cross-sectional area of respiratory tracts, i.e.
Therefore even small reduction of a gleam of bronchial tubes causes considerable difficulty of breath. First of all at the same time the expiratory phase since at an exhalation in general there is a nek-swarm a narrowing of bronchial tubes is broken, and during the forced exhalation their almost full fall because at a considerable flow rate of gas pressure in pneumatic ways becomes lower than intrapleural can be observed. Acceleration of an exhalation due to reduction of expiratory muscles increases resistance even more, a cut increases according to a square of a flow rate of gas. As a result sharply work of breath increases that is followed by the strengthened oxygen consumption respiratory muscles; if at the healthy person on it 1 — 3% of the oxygen coming to an organism leaves, then at obstructive D. of N, according to O. A. Dolina (1965) and Grenvik (A. Grenvik, 1966), for work of breath it is spent to 35 — 50% of the consumed oxygen.
The large role in D.'s pathogeny of N is played by ratio distortion ventilation — perfusion (blood supply) of lungs. Emergence ventilated can be one of the reasons of respiratory frustration in these cases, but not perfusing alveoluses that leads to increase fiziol, dead space and to increase in its relation to respiratory volume, a cut at the healthy person does not exceed 0,3. Perfusion of not ventilated sites is other cause of infringement of breath that increases impurity of the venous, not oxygenated blood to arterial (normal such impurity does not exceed 3% of volume of cordial emission) and leads to developing of a hypoxia. The hypercapnia at the same time, as a rule, does not develop in connection with the strengthened elimination of carbonic acid in the hyper ventilated sites easy. Intake of oxygen in blood practically does not increase even in sites with the strengthened ventilation and an adequate blood-groove since the oxygen capacity of blood is limited and in these sites blood already at normal ventilation is almost most oxygenated.
Disturbances of diffusion of gases through an alveolocapillary membrane usually are not followed by a hypercapnia owing to big diffusion capacity of carbonic acid and, as a rule, cause an anoxemia.
The diffusion factor of D. of N meets quite seldom. Some researchers in general throw doubt upon a role of disturbances of diffusion in development of Dative, however formation of hyaline membranes in lungs (see. Hyaline and membrane disease of newborns ) it is capable to break process of diffusion significantly. The same phenomenon is observed in various degree and at a thickening of an alveolocapillary membrane as a result of intersticial inflammatory process in lungs.
Clinical manifestations of D. of N in many respects depend on the nature of the disease which caused disturbance of breath, however separate symptoms develop irrespective of D.'s etiology of N. Their expressiveness is defined by sharpness of development patol, process. Distinguish hron. Of N, at a cut disturbance of gas exchange and strengthening of compensatory processes come gradually and life activity of an organism is supported for a long time, and acute D. by N, edges develops quickly, and the maximum tension of compensatory systems is often not capable to provide normal gas composition of blood; at acute D. of N disturbances of oxygenation quickly accrue and acid-base equilibrium (see) in blood and in body tissues.
The most often precursory symptoms of chronic respiratory insufficiency are an asthma, weakness at considerable, and then and small physical. loadings, restriction of activity and working capacity. On expressiveness of an asthma B. E. Votchal divides hron. Of N on four degrees: the 1st degree — an asthma at unusual loadings (short run, bystry rise on a ladder), earlier well transferable; the 2nd degree — an asthma at usual loadings of everyday life; the 3rd degree — an asthma at small loadings (clothing, washing); the 4th degree — an asthma at rest. Further there is a feeling of shortage of air, a headache, loss of appetite, sleeplessness, perspiration. Diffusion cyanosis, change of indicators of function of external respiration is noted (respiration rates, the minute volume of breath, a reserve of breath, etc.).
Depending on a form D. of N features are possible some wedge. So, at an obstructive form of D N an asthma is changeable, often arises in the form of attacks of expiratory character (the exhalation is complicated). Breath in the beginning urezheno, respiratory volume is increased; cyanosis can develop only during episodes of suffocation. In lungs the dry whistling rattles are listened; pliable sites of a thorax are involved at a breath and eminate at an exhalation; gradually the thorax gets a barrel-shaped form. The volume of the forced exhalation decreases, the functional residual capacity of lungs and coefficient of resistance of respiratory tracts increases. Vital capacity of lungs (see) changes a little, Tiffno's index decreases (see. Votchala — Tiffno test ).
At restrictive and diffusion forms D. of N which are quite often combined an asthma can carry inspiratory (the breath is complicated) or the mixed character, increases gradually and keeps constantly; existence of constant cyanosis is characteristic. Breath is speeded up; auskultativno — weakening of breath, in some zones of lungs it is not listened. Decrease the vital capacity of lungs at a normal index of Tiffno, the functional residual and total capacity of lungs; distensibility of lungs decreases.
Arising at hron. Of N an anoxemia is quite often combined with hypercapnia (see), develops polycythemia (see), viscosity of blood increases, the hypertrophy of a right ventricle accrues, especially at an obstructive form D. of N (see. Pulmonary heart ), hypostases develop. Venous and likvorny pressure is increased. Hypoxemic defeat of parenchymatous bodies, generally a liver and kidneys develops.
Bystry increase of symptoms, the early emergence of disturbances of mentality (hypoxemic encephalopathy) connected with quickly developing hypoxia is characteristic of acute respiratory insufficiency (see. Hypoxia, brain ), in the form of sleeplessness, euphoria, nonsense, hallucinations that can lead to diagnosis of a mental disease; development of a coma is possible. Skin is hyperemic, with a cyanochroic shade, wet, cyanosis sharply amplifies at slightest physical. to loading.
In acute D.'s development by N sometimes it is possible to reveal three stages. The initial stage is characterized by concern, euphoria, sometimes drowsiness, block; there can be a hyperemia and cyanosis of integuments, a Crocq's disease, plentiful sweat. Breath is speeded usually up, wings of a nose are inflated; tachycardia is quite often observed, the ABP it is moderately raised. Tension of oxygen in an arterial blood (RUSSIAN JOINT STOCK COMPANY 2 ) 80 — 60 mm of mercury., HbO 2 arterial blood of 89 — 85%. Stage of a deep hypoxia: patients are sharply uneasy, excited; diffusion cyanosis, breath with participation of auxiliary muscles, sharp tachycardia and arterial hypertension is noted; sometimes there are spasms, an involuntary urination and defecation; PaO 2 60 — 45 mm of mercury., HbO 2 arterial blood of 85 — 75%. Stage of a hypoxemic coma: consciousness is absent, an areflexia, a mydriasis; skin sharply tsianotichna; The ABP critically falls, pulse arrhythmic; breath quite often gets expressed patol, character up to terminal (agonal) forms. Soon there comes the stop of cordial activity and death. Speed of development and increase wedge, acute D.'s symptoms and. depends on the reason which caused it; e.g., at mechanical asphyxia (see) death can come in 4 — 5 min.; bystry development of symptomatology, extremely heavy current, a deep hypoxia, refractory to oxygen therapy is characteristic of a shock lung. Acute D. of N always demands active and urgent therapy since it poses a threat of life of the patient.
N play an Important role in D.'s diagnosis a wedge, symptoms, and also rentgenol, and tool researches which along with data of the anamnesis allow to reveal a basic disease. At hron. Of N the next researches are of great importance: the spirography (the minute volume of breath, respiratory volume, a respiration rate, maximal ventilation of lungs, vital capacity of lungs, reserve volume of a breath and exhalation, volume of the forced exhalation for 1 sec.), a pnevmotakhografiya (distensibility of lungs, coefficient of resistance of respiratory tracts, work of breath), a nitrografiya (uniformity of ventilation of the lungs), a kapnografiya (CO 2 the exhaled and alveolar air), a miografiya (function of respiratory muscles, structure of the respiratory act) etc. The research of gas structure and acid-base equilibrium of arterial, venous and capillary blood is of great importance, especially at acute D. N. Complex use of several methods allows to specify D.'s pathogeny of N, to reveal a functional condition of the device of external respiration and to define to lay down. tactics (see. Acid-base equilibrium , Lung ventilation , Pneumography , Pnevmotakhografiya , Spirography ).
Differential diagnosis carry out with heart failure, at a cut in the anamnesis and at inspection usually it is possible to reveal a heart disease. Heart failure begins with a tachypnea, a cut is more accurately connected with physical. loading and it is stabler, is followed by feeling of heartbeat more often. Weakening of breath or dry rattles are more characteristic of an auskultativny picture D. of N, and at heart failure wet rattles in back and lower parts of lungs usually appear, and their localization changes depending on position of the patient. At heart failure there are signs of stagnation in system of a small and big circle of blood circulation earlier (a plethora of lungs, a liver, an edematous syndrome). The condition of patients with heart failure improves at use of cardiac glycosides and diuretic drugs. However respiratory and heart failure usually complicate one another, respectively making heavier a clinical picture and complicating diagnosis,
Lech. tactics at D. of N is various depending on D.'s type of N (acute or chronic). Lech. actions at hron. Of N shall be directed to treatment of the basic patol, the state which caused dysfunction of the device of external respiration. Along with it the important role belongs to symptomatic therapy, the cut first of all is the purpose maintenance of passability of respiratory tracts. For fluidifying of a secret of bronchial glands and simplification of expectoration appoint plentiful alkaline drink, expectorants (potassium iodide, Mucolyticums, etc.), aerosol therapy, use a drainage situation (a bed with the lowered head end, turns of the patient with a side sideways). At a dense secret, occlusive bronchial tubes, there can be indications to bronkhoskopiya (see) and to a bronchial lavage. For fight against an infection use antibiotics (under control of sensitivity of a bacterial flora), sulfanamide and nitrofuran drugs. Use of bronchial spasmolytics (an Euphyllinum, ephedrine, derivatives of Isoproterenolum, etc.), corticosteroids is of great importance. The important role belongs to physiotherapy exercises. At accession of heart failure (pulmonary heart) cardial therapy is necessary.
At patients with a combination of a hypoxia and a hypocapny oxygen therapy yields good results, oxygen can be appointed in any concentration (if higher than 75%, then for the term of no more than 4 — 5 hours because of danger of toxic effect of oxygen to lungs) by usual inhalations through catheters, a mask or under a tent. If there are disturbances of the central regulation of breath or a combination of a hypoxia and a hypercapnia, it is necessary to carry out oxygen therapy carefully, gradually increasing concentration of oxygen in the inhaled mix and not exceeding 50% of its contents because of danger of deepening of hypoventilation. At heavy degree of D. of N assisted ventilation of lungs is shown. Use of stimulators of breath (respiratory analeptics) at treatment hron. To of N it is limited; in case of the progressing hypercapnia they are applied during no more than 48 hours, most often use Cordiaminum, Corazolum, an Euphyllinum.
The intensive care and resuscitation are practically always shown at acute D.'s emergence to N and a decompensation of breath, and also at a shock lung. The deep hypoxia therefore resuscitation actions shall begin perhaps earlier, before development in c is characteristic of the terminal states caused by acute D. in N. N page and parenchymatous bodies of irreversible changes. Etiol, the moments at the same time often fade into the background.
One of the first tasks is recovery or maintenance of passability of respiratory tracts. In the presence of a foreign body in a trachea or bronchial tubes its urgent removal with the help is shown bronkhoskopiya (see). At obturation of a throat a large foreign body, a cut it is impossible to remove through an oral cavity, and also at acute hypostasis of a mucous membrane of a throat, a prelum her tumor or a hematoma urgent is necessary tracheotomy (see), edges it can be made also at a pre-hospital stage of treatment.
If D. of N is caused by obstruction of respiratory tracts a secret of bronchial glands, at impossibility of expectoration apply conservative and radical methods of treatment. Treat conservative: a postural drainage (a raising of the foot end of a bed to 30 degrees for a period of 30 min. to 2 hours), auxiliary cough (vigorous pressing on a thorax of the patient in his attempts of expectoration), aspiration of contents from respiratory tracts by means of the catheter entered through the nasal course. Also microtracheotomy — a puncture of a trachea through skin by a trocar or a needle and introduction to it of a polyethylene or teflon catheter for systematic instillations in respiratory tracts of 5 — 10 ml of isotonic solution of sodium chloride with antibiotics for the purpose of stimulation of cough and fluidifying of a phlegm is shown.
Radical methods are an intubation of a trachea (see. Intubation ) and tracheotomy using soft catheters which enter into a trachea and attach to vacuum venting, carrying out aspiration at slow extraction of a catheter; in the presence of a dense and viscous secret single-step introduction to a trachea of 10 — 15 ml of isotonic solution of sodium chloride or 1% of solution of hydrosodium carbonate, a furagin etc. is useful.
At oxygen therapy of D. of N it is necessary to consider that even the short-term termination of inhalation of oxygen is followed by change of gas composition of blood that at patients with reduced compensatory opportunities can lead to heavy complications; the oxygen content in inhalation mix shall not exceed 50 — 60%. At a fluid lungs good results are achieved insufflation of mix of oxygen and by 50% of alcohol. At patients with an obstructive form D. of N use of oxygen-helium mix (70 — 60% of helium and 30 — 40% of oxygen) is shown. It can be applied hyperbaric oxygenation (see).
At the sudden termination of breath, and also at an agony and a wedge, death the main condition of resuscitation actions (see. Resuscitation ) artificial ventilation of the lungs is. It allows to support life of the patient with deep and permanent disturbance of breath within many days, months, and sometimes and years; its efficiency in many respects depends on the timely beginning. A task at the same time is maintenance of oxygenation of blood, removal of carbonic acid, reduction of energy consumptions by work of respiratory muscles, improvement of oxygenation of vitals (see. Artificial respiration, artificial ventilation of the lungs ).
In emergency situations of emergence of acute D. of N, when there is no an opportunity to conduct full examination of the patient, the indication to artificial ventilation of the lungs is: 1) lack of independent breath; 2) gross violations of a rhythm or patol, respiratory rhythms; 3) increase of breath — more than 40 in 1 min. if it is not connected with anemia and a hyperthermia; 4) the wedge, symptoms of a hypoxia and a hypercapnia which are not disappearing after the conservative actions and tracheotomy.
At gradual increase of symptoms of acute D. of N artificial ventilation of the lungs, according to Norlander (O. of Norlander, 1968) and
V. A. Gologorsky (1972), is shown at undervoltage of oxygen in an arterial blood lower than 60 — 65 mm of mercury. and at increase in tension of carbonic acid 50 — 60 mm of mercury are higher. According to V. A. Negovsky (1971) and H. M. Ryabova (1973), it is necessary to begin artificial ventilation of the lungs at sharp increase in minute volume of breath and at decrease to 30% of vital capacity of lungs that speaks about the maximum tension of compensatory processes.
The method of artificial ventilation of the lungs at D. of N significantly differs from that at anesthesia. Adaptation of the patient with D. of N to hardware breath is carried out (preferably) moderate hyperventilation at maintenance of tension of carbonic acid in an arterial blood within 28 — 32 mm of mercury. Only in the absence of positive takes it is recommended to use a medicamentous depression respiratory center (see) way of use of drugs, neyroleptanalgetik, etc. At long artificial ventilation of the lungs special attention shall be paid on full moistening and warming of the inhaled gas mixture; for this purpose a number of authors considers the best the supersonic generator of aerosols.
The technique of artificial ventilation of the lungs depends on character patol, the process which caused D. of N. At dominance of obstructive processes the bradypnoea (16 — 18 in 1 min.) is shown by large respiratory volumes (800 — 850 ml) relatively. At restrictive D. the N should speed up breath to 26 — 28 in 1 min., reducing respiratory volume. Patients with the fluid lungs and diseases which are followed by the expressed shunting of a venous blood in poorly ventilated alveoluses need an artificial respiration with constant supertension that is reached by creation of resistance to an exhalation. The same method with success is used at Dative, the caused disease of hyaline membranes at newborns.
Artificial ventilation of the lungs can be stopped only at total disappearance of symptoms of D. of N, in the absence of a hypovolemia and gross violations of metabolism and if at shutdown of a respirator the number of dykhaniye does not exceed 30, there is no cyanosis, the hypocapny does not develop; it is necessary to stop it gradually, doing at first a break for 30 — 40 min. 1 — 2 time a day, then the periods of independent breath extend and speed up.
Resuscitation at D. of N shall be directed not only to elimination of disturbances of breath, but also to elimination of frustration of a hemodynamics, functions of a liver and kidneys and disturbances of exchange processes, i.e. to be complex.
Respiratory insufficiency at children
Due to anatomo-fiziol, features of a structure of respiratory system at children of early age of D. of N develops more sharply, proceeds heavier, than at adults. It is connected with bystry generalization of inflammatory processes in lungs and bystry development of obstruction of respiratory tracts owing to the small size of a throat and bronchial tubes. Besides, children are inclined to the meteorism complicating the movement of a diaphragm whereas at this age belly type of breath prevails. At children of the first month of life predisposition to the central respiratory depression is explained by immaturity of regulatory systems. Oppression of a respiratory center most often arises at a birth trauma, a hypoxia, intoxication. The neuromuscular device of breath can be broken at infections (e.g., it is typical at poliomyelitis), Giyen's syndrome — Barret and myasthenias. Restriction of mobility of a thorax and a diaphragm most often happens owing to a meteorism, and also at a fracture of edges, at a sclerema, during an epileptic attack; the prelum of lungs takes place at the big abscess of a lung, exudative pleurisy and a pyopneumothorax complicating staphylococcal pneumonia.
The inflammation of an epiglottis, a false croup, a virus laryngotracheobronchitis, a true croup can be the cause of obstruction of upper respiratory tracts at diphtheria, traumatic hypostasis of a throat, a foreign body, retraction of language at unconsciousness, an inborn stridor, an inborn laryngeal partition. The expressed obstruction of small bronchial tubes is observed at a virus bronchiolitis, an asthmatic syndrome, a mucoviscidosis, aspiration of emetic masses, a delay of a phlegm in the postoperative period. Heavy D. of N can arise at premature children (see. Distress syndrome ), and also at a hyaline and membrane disease of newborns (see), at a cut heavy disturbance of diffusion of gases through alveolocapillary membranes develops. Other reasons of D. the same N that at adults. Increase in shunting and difficulty of diffusion lead to an anoxemia, about a cut it is possible to speak at decrease in PaO 2 it is lower than 80 mm of mercury. Heavy disturbances of mechanics of breath are demonstrated by the expressed zatrudnennost of breath or, objectively, increase in St. 150% (from norm) works of breath. Work of breath at children of the first 5 years of life can be estimated a combination of methods pletizmografiya (see) and impedance pneumography (see), and at more advanced age by means of a pnevmotakhografiya.
Indicators of PaCO testify to hypoventilation at children of the first month of life 2 — it is higher than 50 mm of mercury., at children is more senior than one month — higher than 46 mm of mercury.; about a hyperventilation — it is lower than 35 mm of mercury. at children is younger than one month and lower than 30 mm of mercury. — at children is more senior than one month. At assessment of ventilation at D. the N needs to consider the stimulating influence of a metabolic acidosis and the oppressing action of an alkalosis. So, at the child is more senior than one month at primary metabolic acidosis (see) it is possible to speak about hypoventilation at PaCO 2 apprx. 45 mm of mercury. At primary metabolic alkalosis (see) increase in PaCO 2 on 3 — 5 mm the N
Klin, a picture of a malospetsifichn is a sign of compensatory hypoventilation without D. The anamnesis and complaints at children have small value. The first wedge, D.'s symptom of N — an asthma with retraction of pliable places of a thorax. Unlike adults, at an attack of asthma at children of younger age rare deep breath is atypical. The Zatrudnennost of breath on any site of respiratory tract involves excitement of the child and a forsirovannost of a breath and an exhalation therefore D. of N accrues and the condition of the patient worsens. More young than 5 — 6 years simplification of a stenotic asthma in a dream and under the influence of sedative therapy is especially peculiar to children. The second leading symptom of D. of N — cyanosis, arises at children at diseases of lungs. The third sign of D. of N is the hypercapnia, to-ruyu it is very difficult to diagnose for children without analysis of gas composition of blood. At PaCO 2 apprx. 50 mm of mercury. the general oppression can take place, excitement of the child is more rare; at PaCO 2 higher than 60 mm of mercury. there are symptoms of acute hypercapnias (see) up to coma. At younger age unconsciousness precedes a mydriasis and disturbance of cordial activity.
At clarification of the reasons of D. of N at children results rentgenol, researches are of great importance. The role of a X-ray analysis is especially big in the presence of an atelectasis, abscess, exudative pleurisy, pheumothorax, a tumor of lungs and a mediastinum, share emphysema, phrenic hernia and other diseases of the bodies of a thorax demanding an operative measure.
At acute D.'s development by N in children the system of actions of an intensive care, including the resuscitation having a number of features is shown. At hypoventilation and disturbance of mechanics of breath at children paramount value has suction of slime from respiratory tracts through a catheter by means of a suction machine or a rubber pear. Fight against a meteorism is obligatory. In acute cases of D. of N sometimes resort to removal of gastric contents the probe. Usually it is easier for child to breathe in vertical position on hands at adults. For strengthening of an otkhozhdeniye of bronchial slime or a foreign body it is possible to turn the child on 10 — 15 sec. headfirst and in such situation to knock on a thorax; sometimes this reception possible to remove a foreign body from respiratory tracts quickly. At inefficiency of the listed actions it is shown bronkhoskopiya (see). Is less difficult, but also is less effective how to lay down. and diagnostic means straight line laringoskopiya (see). In case of emergency, at serious condition, to children of early age introduction of a catheter to a trachea without anesthesia for the purpose of aspiration of its contents is sometimes possible.
In an initial stage of a croup appoint high doses of sedative and neuroplegic means. During the progressing of a stenosis are shown an intubation by a thermoplastic tube and as a last resort — tracheotomy.
At pheumothorax and pleurisy it is necessary to reduce first of all intrathoracic tension by means of a puncture and a drainage; in some cases at children of early age the emergency operative measure is necessary.
At the children less sensitive to a hypoxia, than adults, artificial ventilation of the lungs is shown at undervoltage of oxygen in an arterial blood lower than 50 mm of mercury. Long artificial ventilation of the lungs at younger age yields considerably the worst results, than at more senior children. On the contrary, rather effectively independent breath with the complicated exhalation which is carried out usually by means of the plastic bag fixed on the head of the child to which give air-oxygen mix under pressure of 5 —-15 cm w.g.; the long inflating of lungs created this way is especially useful at D. for N against the background of a hyaline and membrane disease, aspiration pneumonia and the beginning fluid lungs.
The medicines applied at D. by N (antibiotics, bronchial spasmolytics, vitamins, hormones, enzymes, infusional solutions, etc.) dose depending on the weight of the child; approximate calculation for a dose of adults is reasonable: 10 years 1/2, 5 years — 1/4, 2 years — 1/8, till 1 year — 1/24 - 1/12 doses of the adult. Derivatives of morphine are very badly transferred and at younger age are shown only for the purpose of respiratory depression for synchronization with a respirator.
For an oxygenotherapy usually use the moistened mix 40 — 60% of oxygen and air; give it to a tent or by means of nasal catheters (see. Oxygen therapy ). Inhalation of oxygen practically never causes hypoventilations in children.
The child is younger, the it is more at D. than N of the general extra pulmonary manifestations — central, vegetative and exchange. In this regard paramount value is allocated for fortifying treatment. Very often D. of N manages to be liquidated only after correction of disturbances of activity of cardiovascular system and disturbances of water and electrolytic balance.
Forecast. Hron. Of N can last for years, the aggravation comes from the joined infection; gradually heart failure joins; patients can die at a decompensation of respiratory or cordial activity. The forecast at acute D. of N is better for those, than the intensive care and resuscitation actions are begun earlier.
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B. L. Kassil; M. I. Anokhin (ped.).