Mechanical Ventilation Of Lungs Research Articles

Patients of risk groups in the perioperative period: the review of modern guidelines

Background. According to the Decree of the Ministry of Health of Ukraine № 275 issued on 11.09.2018, there is a list of measures to ensure surgical safety and patient’s safety. These measures can be divided into those that should be performed 1) before anesthesia; 2) before skin dissection; 3) before the patient leaves the operating room. Perioperative medicine (POM) is a patient-centered and interdisciplinary perioperative care for surgical patients.
 Objective. To describe the current recommendations for POM.
 Materials and methods. Review of available guidance documents.
 Results and discussion. The pathophysiology of postoperative complications (infectious processes, intestinal paralysis, respiratory failure, kidney damage, etc.) includes the following factors: triggers (anxiety, pain, surgical trauma), patient factors (age, comorbid conditions), the consequences of general operative stress (autonomous system imbalance, inflammation, coagulopathy, metabolic imbalance). Clinical evaluation or biomarkers should be used to identify high-risk patients in the perioperative period. Measures to improve postoperative rehabilitation should be carried out in the pre-, intra- and postoperative period. Thus, in the preoperative period it is necessary to examine the patient, to provide the carbohydrate load 2 hours before the intervention, to conduct antibiotic prophylaxis, to correct or stabilize the comorbid diseases (especially cardiovascular and renal diseases, diabetes, anemia). In the intraoperative period it is necessary to maintain normovolemia and normothermia, to use protective mechanical lung ventilation, to limit the use of opioids, to perform extubation immediately after the intervention. In the postoperative period early activation, early enteral nutrition and early removal of drainages and catheters should be used. The key components of POM include the identification of low-risk patients in order to save resources, the identification of high-risk patients with the possible use of alternative management strategies, and the frequent risk reassessment. The main components of the success of anesthesia include preoperative assessment of the patient’s somatic status and risk, use of controlled hypnotics and effective and predictable muscle relaxant, use of analgesics that break down quickly and have no ability to accumulate, control of the hemodynamics stability, blood gases and acid-base balance. To prevent the perioperative myocardial ischemia, it is advisable to use esmolol – a cardioselective β-blocker of ultrashort action. Preoperative anxiety, intubation and extubation, surgical manipulations lead to the excessive adrenergic response, which justifies the use of β-blockers. The pharmacological effects of esmolol (Biblok, “Yuria-Pharm”) include the reduction of myocardial oxygen consumption, increase of the diastole duration, limitation of the free radicals’ production, control of the activity of metalloproteinases, and the reduction of inflammation around atherosclerotic plaques. In addition, esmolol (Biblok) is able to reduce intra- and postoperative use of opioids, and therefore its use as a component of multimodal total intravenous anesthesia has been proposed. Preoperative administration of esmolol may also be an effective and safe method of myocardial protection in patients undergoing cardiac surgery. β-blockers are well tolerated in patients with acute hypovolaemia during anesthesia, however, episodes of hypercapnia should be avoided during their use.
 Conclusions. 1. For the optimal POM, the individual risk of perioperative complications should be determined. 2. POM includes a number of pre-, intra- and postoperative measures. 3. The use of ultrashort-acting β-blocker esmolol prevents intraoperative myocardial ischemia, has antioxidant and anti-inflammatory effects, reduces the need for opioids.

Sedation in obstetrics and gynecology

Background. Sedation is a controlled medical depression of consciousness with the preservation of protective reflexes, independent effective breathing and response to physical stimulation and verbal commands. Requirements for sedation include rapid onset of effect, short action, minimal impact on the cardiorespiratory system, lack of delirium and emetic effect. The goals of sedation include patient comfort, minimization of pain and discomfort, anxiolysis, amnesia, control of patient behavior, rapid recovery.
 Objective. To describe the features of sedation in obstetrics and gynecology.
 Materials and methods. Analysis of literature data on this topic; own research. The study included 64 women with gynecological diseases who underwent elective surgery under regional anesthesia. Longocaine and Longocaine Heavy (“Yuria-Pharm”) were used as local anesthetics. Sedation by dexmedetomidine ("Yuria-Pharm") was used in group 1, and by propofol in group 2.
 Results and discussion. Cesarean section is characterized by high levels of stress. The main requirements for sedation during caesarean section include the preservation of consciousness, self-breathing and protective reflexes of the respiratory tract, minimal impact on hemodynamics, short duration of action of drugs. Subjective methods (different scales, verbal contact with the patient, assessment of pupil dilation, pulse, respiratory rate, blood pressure) and objective methods (electroencephalography, BIS spectral index) are used to determine the degree of sedation. Mandatory monitoring during sedation includes non-invasive blood pressure measurement, pulse oximetry, electrocardiography, capnography, BIS monitoring. Capnography is the most effective type of monitoring. For the safety of procedure carefully trained personnel, the device for mechanical lung ventilation, a set for ensuring passability of respiratory tracts, a defibrillator, and drugs for emergency medical care are necessary. For procedural sedation, drugs such as propofol, barbiturates, benzodiazepines, dexmedetomidine, ketamine, and inhalation anesthetics are used. The advantages of benzodiazepines are rapid effect and amnestic action, the disadvantages include the promotion of delirium and respiratory depression, no analgesic effect. The last two effects are also typical for propofol, which also causes pain in the vein during administration and the propofol infusion syndrome. The advantages of propofol include rapid onset of effect and rapid awakening, ease of titration, amnestic and antiemetic action. Ketamine also provides a rapid onset of effect and rapid awakening, and has an analgesic effect, however, causes hallucinations and hypersalivation, increased motor activity. Dexmedetomidine is an analgesic, has a sedative effect and a minimal effect on respiratory status. Disadvantages of dexmedetomidine include slow onset of effect and dose-dependent decrease in blood pressure. A number of scientific studies indicate the absence of adverse effects of dexmedetomidine during cesarean section under regional anesthesia. According to our own study, sedation with dexmedetomidine caused hypotension 26.5 % less often than sedation with propofol. Targeted sedation with dexmedetomidine caused almost no respiratory depression, whereas sedation with propofol led to moderate hypoxemia in 21 % of patients and severe hypoxemia in 35.9 % of patients. Dexmedetomidine contributed to a more pronounced reduction in pain, which can be explained by its own analgesic effect.
 Conclusions. 1. The goals of sedation include patient comfort, minimization of pain and discomfort, anxiolysis, amnesia, control of patient behavior, rapid recovery. 2. The main requirements for sedation during caesarean section include the preservation of consciousness, independent breathing and protective reflexes of the respiratory tract, minimal impact on hemodynamics, short duration of action of drugs. 3. Capnography is the most effective type of monitoring during sedation. 4. Sedation with dexmedetomidine caused hypotension 26.5 % less often than sedation with propofol. 5. Targeted sedation with dexmedetomidine caused almost no respiratory depression. 6. Dexmedetomidine contributed to a more pronounced reduction in pain than propofol.

Mechanical ventilation of the healthy lungs: lessons learned from recent trials.

Although there is clear evidence for benefit of protective ventilation settings [including low tidal volume and higher positive end-expiratory pressure (PEEP)] in patients with acute respiratory distress syndrome (ARDS), it is less clear what the optimal mechanical ventilation settings are for patients with healthy lungs. Use of low tidal volume during operative ventilation decreases postoperative pulmonary complications (PPC). In the critically ill patients with healthy lungs, use of low tidal volume is as effective as intermediate tidal volume. Use of higher PEEP during operative ventilation does not decrease PPCs, whereas hypotension occurred more often compared with use of lower PEEP. In the critically ill patients with healthy lungs, there are conflicting data regarding the use of a higher PEEP, which may depend on recruitability of lung parts. There are limited data suggesting that higher driving pressures because of higher PEEP contribute to PPCs. Lastly, use of hyperoxia does not consistently decrease postoperative infections, whereas it seems to increase PPCs compared with conservative oxygen strategies. In patients with healthy lungs, data indicate that low tidal volume but not higher PEEP is beneficial. Thereby, ventilation strategies differ from those in ARDS patients.

What Open-Lung Biopsy Teaches Us about ARDS in COVID-19 Patients: Mechanisms, Pathology, and Therapeutic Implications.

Difficulties have risen while managing Acute Respiratory Distress Syndrome (ARDS) caused by COVID-19, although it meets the Berlin definition. Severe hypoxemia with near-normal compliance was noted along with coagulopathy. Understanding the precise pathophysiology of this atypical ARDS will assist researchers and physicians in improving their therapeutic approach. Previous work is limited to postmortem studies, while our report addresses patients under protective lung mechanical ventilation. An open-lung minithoracotomy was performed in 3 patients who developed ARDS related to COVID-19 and were admitted to the intensive care unit to carry out a pathological and microbiological analysis on lung tissue biopsy. Diffused alveolar damage with hyaline membranes was found, as well as plurifocal fibrin microthrombi and vascular congestion in all patients' specimens. Microbiological cultures were negative, whereas qualitative Reversed Transcriptase Polymerase Chain Reaction (RT-PCR) detected SARS-CoV-2 in the pulmonary parenchyma and pleural fluid in two patients. COVID-19 causes progressive ARDS with onset of severe hypoxemia, underlying a dual mechanism: shunt effect through diffused alveolar damage and dead space effect through thrombotic injuries in microvascular beds. It seems reasonable to manage this ventilation-perfusion ratio mismatch using a high dose of anticoagulant combined with glucocorticoids.

Vitamin D for prevention of sternotomy healing complications: REINFORCE-D trial

BackgroundMost cardiac surgery patients undergo median sternotomy during open heart surgery. Sternotomy healing is an arduous, very complex, and multifactorial process dependent on many independent factors affecting the sternum and the surrounding soft tissues. Complication rates for median sternotomy range from 0.5 to 5%; however, mortality rates from complications are very variable at 7–80%. Low calcidiol concentration below 80 nmol/L results in calcium absorptive impairment and carries a risk of bone loss, which is considered as a risk factor in the sternotomy healing process. The primary objective of this clinical trial is to compare the incidence of all postoperative sternotomy healing complications in two parallel patient groups administered cholecalciferol or placebo. The secondary objectives are focused on general patient recovery process: sternal bone healing grade at the end of the trial, length of hospitalization, number of days spent in the ICU, number of days spent on mechanical lung ventilation, and number of hospital readmissions for sternotomy complications.MethodsThis clinical trial is conducted as monocentric, randomized, double-blind, placebo-controlled, with planned enrollment of 600 patients over 4 years, approximately 300 in the placebo arm and 300 in the treatment arm. Males and females from 18 to 95 years of age who fulfill the indication criteria for undergoing cardiac surgery with median sternotomy can be included in this clinical trial, if they meet the eligibility criteria.DiscussionREINFORCE-D is the first monocentric trial dividing patients into groups based on serum calcidiol levels, and with dosing based on serum calcidiol levels. This trial may help to open up a wider range of postoperative healing issues.Trial registrationEU Clinical Trials Register, EUDRA CT No: 2016-002606-39. Registered on September 8, 2016.

Hidden Microatelectases Increase Vulnerability to Ventilation-Induced Lung Injury.

Mechanical ventilation of lungs suffering from microatelectases may trigger the development of acute lung injury (ALI). Direct lung injury by bleomycin results in surfactant dysfunction and microatelectases at day 1 while tissue elastance and oxygenation remain normal. Computational simulations of alveolar micromechanics 1-day post-bleomycin predict persisting microatelectases throughout the respiratory cycle and increased alveolar strain during low positive end-expiratory pressure (PEEP) ventilation. As such, we hypothesize that mechanical ventilation in presence of microatelectases, which occur at low but not at higher PEEP, aggravates and unmasks ALI in the bleomycin injury model. Rats were randomized and challenged with bleomycin (B) or not (H = healthy). One day after bleomycin instillation the animals were ventilated for 3 h with PEEP 1 (PEEP1) or 5 cmH2O (PEEP5) and a tidal volume of 10 ml/kg bodyweight. Tissue elastance was repetitively measured after a recruitment maneuver to investigate the degree of distal airspace instability. The right lung was subjected to bronchoalveolar lavage (BAL), the left lung was fixed for design-based stereology at light- and electron microscopic level. Prior to mechanical ventilation, lung tissue elastance did not differ. During mechanical ventilation tissue elastance increased in bleomycin-injured lungs ventilated with PEEP = 1 cmH2O but remained stable in all other groups. Measurements at the conclusion of ventilation showed the largest time-dependent increase in tissue elastance after recruitment in B/PEEP1, indicating increased instability of distal airspaces. These lung mechanical findings correlated with BAL measurements including elevated BAL neutrophilic granulocytes as well as BAL protein and albumin in B/PEEP1. Moreover, the increased septal wall thickness and volume of peri-bronchiolar-vascular connective tissue in B/PEEP1 suggested aggravation of interstitial edema by ventilation in presence of microatelectases. At the electron microscopic level, the largest surface area of injured alveolar epithelial was observed in bleomycin-challenged lungs after PEEP = 1 cmH2O ventilation. After bleomycin treatment cellular markers of endoplasmic reticulum stress (p-Perk and p-EIF-2α) were positive within the septal wall and ventilation with PEEP = 1 cmH2O ventilation increased the surface area stained positively for p-EIF-2α. In conclusion, hidden microatelectases are linked with an increased pulmonary vulnerability for mechanical ventilation characterized by an aggravation of epithelial injury.

CHANGES IN OXYGENATION IN CHILDREN WITH RESPIRATORY FAILURE

Acute respiratory failure is a component of the multiorgan dysfunction syndrome and a common cause of death among the children treated in intensive care units. Readiness to wean a patient from a mechanical ventilation is determined by a set of indices, including the data on the level of hypoxemia and its ability to regress under the influence of oxygen therapy. The indices such as the paO2/FiO2 and SpO2/FiO2 ratios are valid for determining the severity of hypoxemia. In order to study the dynamics of changes in SpO2/FiO2, paO2/FiO2, oxygenation index and the one of frequent shallow breathing in the children with acute respiratory failure as well as to substantiate the criteria for their readiness to wean from pulmonary ventilation, a prospective, observational cohort investigation in patients aged from 1 month to 18 years was performed. The patients of group I received pulmonary−protective strategy of mechanical lung ventilation, II − in addition to it received the diaphragm−protective strategy. The ratios of SpO2/FiO2 and paO2/FiO2, oxygenation index and frequent shallow respiration index were calculated. Weaning was considered successful if the patient did not require a respiratory therapy after extubation for the next 48 hours. The primary endpoint of the assessment was the duration of weaning from mechanical ventilation, the secondary ones were the SpO2 / FiO2, paO2 / FiO2, oxygenation index, the one of frequent shallow breathing. Significant differences in SpO2 / FiO2 and paO2 / FiO2 indices were found on days 5 and 9 of the study. It was found that at paO2 / FiO2 values less than 200 and SpO2 / FiO2 less than 265 the prognosis of weaning is unfavorable. Key words: children, oxygenation, mechanical ventilation.

Synchronized Inflations Generate Greater Gravity-Dependent Lung Ventilation in Neonates

To describe the regional distribution patterns of tidal ventilation within the lung during mechanical ventilation that is synchronous or asynchronous with an infant's own breathing effort. Intubated infants receiving synchronized mechanical ventilation at The Royal Children's Hospital neonatal intensive care unit were studied. During four 10-minute periods of routine care, regional distribution of tidal volume (VT; electrical impedance tomography), delivered pressure, and airway flow (Florian Respiratory Monitor) were measured for every inflation. Post hoc, each inflation was then classified as synchronous or asynchronous from video data of the ventilator screen, and the distribution of absolute VT and delivered ventilation characteristics determined. In total, 2749 inflations (2462 synchronous) were analyzed in 19 infants; mean (SD) age 28 (30) days, gestational age 35 (5) weeks. Synchronous inflations were associated with a shorter respiratory cycle (P=.004) and more homogenous VT (center of ventilation) along the right (0%) to left (100%) lung plane; 45.3 (8.6)% vs 48.8 (9.4)% (uniform ventilation 46%). The gravity-dependent center of ventilation was a mean (95% CI) 2.1 (-0.5, 4.6)% toward the dependent lung during synchronous inflations. Tidal ventilation relative to anatomical lung size was more homogenous during synchronized inflations in the dependent lung. Synchronous mechanical ventilator lung inflations generate more gravity-dependent lung ventilation and more uniform right-to-left ventilation than asynchronous inflations.

Clinical features and prognostic factors of parainfluenza virus infections in adult patients

Objective: To explore the clinical features and prognostic factors of parainfluenza viral lower respiratory tract infections in adults. Methods: A total of 70 patients withpositive nucleic acid of parainfluenza virus (PIV) admitted to China-Japan Friendship Hospital between August 2016 and November 2019 were enrolled. Multiplex real-time polymerase chain reaction (RT-PCR) assays for viral detection were implemented to specimens (nasopharynx swab, sputum or bronchoalveolar lavage) obtained from all the patients, which was consistent with the diagnosis of lower respiratory tract infection. Patients were divided into two groups depending on the status of immune function (immunocompromised group, n=26; immunocompetent group, n=44), and patients were divided into PIV infection group (n=43) and mixed infection group (n=27) according to whether there was mixed infection. Characteristics including age, gender, underlying diseases, symptoms, disease severity, imaging manifestations, etiology, respiratory failure, mechanical ventilation, vasoactive drug, antimicrobial drug and 30-day mortality between the groups were compared, and the prognostic factors of PIV infections were investigated using Cox regression. Results: The peak incidence of PIV infection time was in May, August, September and December, accounting for 58.6% of all cases. The enrolled 70 cases included 43 cases with pneumonia, 16 cases with interstitial lung disease and infection, 7 cases with bronchiectasis and infection, and 4 cases with acute exacerbation of chronic obstructive pulmonary disease. Eight patients (11.4%) had no underlying diseases, 21 patients (30.0%) had respiratory failure, 18 patients (25.7%) were treated with mechanical ventilation, 15 patients (21.4%) died within 30 days after admission. The pneumonia severity index score, percentage of patients with ground-glass opacity according CT scan, with honeycomb or reticular pattern, with mechanical ventilation, with respiratory failure, with ICU admission, and 30-day mortality in immunocompromised group were higher than those of immunocompetent group [(91.5 vs 84.0), (60.0% vs 34.1%), (44.0% vs 11.4%), (42.3% vs 15.9%), (50.0% vs 18.2%), (38.5% vs 22.7%), (34.6% vs 13.6%)] (all P<0.05). There were 27 cases (38.6%) with mixed infection, including 17 viruses (24.3%), 19 bacteria (27.1%), 14 (20.0%) fungi (PCP, aspergillus) and 1 (1.4%) Mycobacterium intracellulare. Sixteen patients (59.3%) in the mixed infection group were immunocompromised patients and 21 patients (77.8%) had chronic lung disease. Cox regression analysis showed that mechanical ventilation and interstitial lung disease were independent predictors of prognosis in all patients, and mechanical ventilation was an independent predictor of prognosis in PIV infection group. Conclusions: Most of the patients with PIV lower respiratory tract infection in adults are complicated with underlying diseases and mixed infection, with a high 30-day mortality. Interstitial lung disease and mechanical ventilation indicate poor prognosis in these patients.

Experience in the use of dexmedetomidine for sedation in patients with pneumonia in the intensive care unit

The experience of using dexmedetomedine for sedation with respiratory disorders of varying severity has been known for a long time. This article examined two clinical cases in which dexmedetomedine was used for connection and adaptation of patients to mechanical ventilation of lungs. The purpose of the work is evaluation of the effectiveness and depth of sedation with varying degrees of respiratory failure, as well as the effect of dexmedetomedine on respiration.

Dynamics of Serum Cytokines During Resection Surgery for Malignant Neoplasms in the Lungs

Purpose— to carry out a comparative assessment of inflammation based on evaluation of intraoperative and early postoperative dynamics of blood serum cytokines in pulmonary malignant neoplasm patients in different anesthesia and analgesia settings.Material and methods.24 patients of 45 to 50 years of age divided into 2 groups were examined. All patients suffered from verified new onset malignant neoplasms without true signs of metastases. Tumor differentiation by morphology was not undertaken since that was beyond the study design. Patients did not receive radio- or chemotherapy. In Group I (the main group,n=12), a multimodal combined anesthesia [1] followed by extended postoperative epidural analgesia was applied. In Group II (the comparison group,n=12), a combined general anesthesia including mechanical lung ventilation followed by morphine analgesia was used. 4 study points were determined: prior to induction, and one, 12, and 24 hours post-surgery.Results.12 hours after surgery completion, the concentration of TNFα in the main group was lesser by 57.1% vs. the comparison group; by the end of the first 24 hours, it fell down by 64.3%. Within the same period, in both groups IL-6 turned out to be significantly higher than the upper reference limit. By the end of the first 24 hours, IL-6 tend to decrease in both groups; however, in the comparison group, this parameter was 15% higher than in the main group. Serum IL-10 was within the reference range in both groups. One hour after surgery, concentrationof IL-10 was exponentially growing in both groups and exceeded multifold the upper reference limit, whereas the content of IL-10 in the main group remained reliably higher: the difference amounted to 35.6% percent.Conclusion.During the postoperative period, patients undergone lung resection displayed significant changes in cytokines concentrations demonstrating an inflammation reaction. Inflammation was significant in patients who received epidural analgesia as evidenced by an altered content of anti-inflammatory cytokines.

Spontaneous ventilation versus mechanical ventilation during video-assisted thoracoscopic surgery for spontaneous pneumothorax: a study protocol for multicenter randomized controlled trial.

BackgroundWith the evolution and adoption of video-assisted thoracoscopic surgery (VATS), options for anesthesia control have also seen major developments. Intubated anesthesia with single lung mechanical ventilation VATS (MV-VATS) is considered the standard of care in VATS. However, this type of ventilation strategy has been associated with several adverse effects, which can trigger complications and increase the overall surgical risk. In order to avoid intubated anesthesia related adverse effects, non-intubated spontaneous ventilation VATS (SV-VATS) strategies have been proposed in recent years and widely applied.MethodsWe established a two-arm parallel multicenter randomized controlled trial for comparative analysis of the outcomes of patients undergoing either SV-VATS or MV-VATS for spontaneous pneumothorax. Outcomes of interest include safety during operation, total analgesic dose, recovery time, postoperative complication rates, postoperative pain score, length of hospitalization, inflammation index, medical cost, etc. The recruitment target is 316 patients. Patients will be eligible if their chest CT is diagnosed with “localized lung bullae” and need VATS resection. Patients will be randomized into the SV-VATS (test group) or MV-VATS (control group) after signing informed consent and surgical anesthesia evaluation.DiscussionThis protocol has been approved by the Research Ethics Committee of the First Affiliated Hospital of Guangzhou Medical university. Results will be presented at national and international meetings and conferences and published in peer-reviewed journals. We will also disseminate the main results to all participants in a letter. Non-intubated SV-VATS offered a more individual choice of anesthetics and surgical method for spontaneous pneumothorax patients.Trial registrationNCT03016858; pre-results.

Proportional assist ventilation

The idea of proportional assist ventilation, in which the patient himself sets the respiratory pattern — the frequency and depth of breathing — was suggested in 1992, but has not yet found widespread practical application. One of the possible reasons for this is the complex algorithm of regime adjustment on first-generation respiratory devices. Over time, the accumulated body of information on the early damage of the diaphragm because of its atrophy in patients on respiratory support formed the basis of the awareness of the importance of maintaining the physiological state of the diaphragm during artificial lung ventilation and led to the emergence of the term “myotrauma”.At the turn the 21st century, the idea of the maximum possible preservation of spontaneous breathing of the patient during mechanical lung ventilation realized in the formation of the concept of “diaphragm-protective ventilation”. The need for further development of assisted lung ventilation technologies designed to reduce the risk of diaphragm damage, the frequency of asynchrony in the pair “respirator-patient”, and to facilitate the process of weaning of the patient from the artificial lung ventilation became apparent. This article, based on scientific literature and own clinical experience of using proportional ventilation, describes the peculiarities of regime adjustment on different respirators, places the accents necessary for successful practical use of proportional lung ventilation. Describes key conditions for its use, advantages and limitations.

Smart Mode of Mechanical Lung Ventilation During Early Activation of Cardiosurgical Patients

Purpose of the study: a comparative assessment of safety and quality of respiratory support carried out using the ASV mode vs. conventional protocol, in which ventilation parameters are set by an ICU physician during early postoperative period in cardiosurgical patients.Materials and methods. The modes of a respiratory support included automated ASV ventilation (40 patients) versus conventional ventilation (38 patients) managed by 8 ICU physicians were compared in a cohort of cardiosurgical patients in a randomized controlled study.The comparison included ventilation parameters, all efforts of physicians to adjust ventilator settings and time it took, duration of respiratory support in ICU, incidence of adverse events in the course of weaning, total time in ICU and hospital, postoperative complications and mortality.Results. There was no reliable difference in the duration of postoperative trachea intubation, which was equal to 267±76 minutes (the ASV group) and 271±80 minutes (the control group).The number of manual adjustments, which was 2 vs. 4 (P&lt;0.00001), and the time spent by a clinical physician near a ventilator, which was 99±35 seconds vs. 166±70 seconds, were reliably lower in the ASV group (P=0.00001).The time between restoration of patient’s own respiratory activity and transfer to the assisted breathing mode was longer in the control group and amounted to 30 (0–90) min. while in the smart mode, the transfer took place immediately after restoration (P=0.004969).When ASV was used, the driving pressure was reliably lower during all phases of respiratory support: ΔP 7.2±1.6 vs. 9.3±2.1 cm H2O, (P=0.000001); there was no reliable difference in the tidal volume: 7.0 (6–8.5) (ASV) vs. 7 (6–10) ml/kg/ideal body mass (the control group).Conclusion. ASV represents a lung-protective ventilation that reduces physician’s time cost and medical staff efforts in ALV management without compromising patient’s safety and respiratory support quality.

Application of citrate dialysis in the treatment of puerperal sepsis

Aim. To describe the results of applying citrate dialysis in the complex therapy of a patient with postpartum sepsis.Materials and methods. This paper presents an analysis of a case of the successful treatment of patient P. with the diagnosis “Childbirth 3 urgent. Pfannenstiel laparotomy. Caesarean section in the lower uterine segment. Hypotonic bleeding. Relaparotomy: ligation of the internal iliac arteries, hemostasis. Relaparotomy: additional hemostasis, pelvic tamponade, abdominal cavity tamponade. Hemorrhagic shock of fourth category. Extirpation of the uterus with tubes. Sepsis. Septic shock. DIC syndrome”. Citrate dialysis was included as part of intensive care therapy.Results. Citrate dialysis allowed the patient with multiple organ failure, against the background of complex intensive care therapy, to restore kidney function after 28 sessions of renal replacement therapy. Diuresis was completely restored on day 42. Biochemical parameters, such as urea and creatinine, were normalized on day 45. The duration of treatment in the anesthesiology and resuscitation departments was 47 days, out of which lung mechanical ventilation lasted for 17 days. The total duration of treatment in the hospital was 54 bed days. The patient was discharged in satisfactory condition.Conclusion. The methods of extracorporeal detoxifi cation can signifi cantly improve treatment outcomes in this category of patients and reduce maternal mortality rates.

COMPARATIVE EFFECTIVENESS OF RADIOFREQUENCY PULMONARY VEIN ISOLATION PLUS AMIODARONE THERAPY IN PREVENTING POST-CORONARY ARTERY BYPASS GRAFTING ATRIAL FIBRILLATION

Objective. To evaluate the effectiveness of epicardial bipolar radiofrequency ablation (RFA) of pulmonary vein ostia (PV) in comparison with its being combined with amiodarone administration for post-CABG atrial fibrillation (AF) prevention.Methods. A single-centre, prospective randomized study (PULVAB), including 96 CAD patients with no history of AF, was conducted between January 2015 and December 2018. Group 1 (control; n=34) had standard CABG alone. Group 2 (n=29) received RFA of PV as an adjunct to CABG for prevention of postoperative AF (POAF). Group 3 patients (n=33) had RFA at the time of CABG and were given amiodarone. Allocation was concealed using sequentiallynumbered opaque envelopes. The efficacy and safety of RFA concomitant with CABG were assessed, as both performed independently and combined with amiodarone administration, as well as intra-and postoperative course.Results. No differences were seen in operation length (p=0.937), cardiopulmonary bypass (CPB) or the aorta clamping times (р=0.377 and p=0.072, respectively). The study groups (CABG, CABG-RFA, CABG-RFA-amiodarone) did not differ statistically in the number of shunts placed - 3.17±0.61, 3.10±0.51 and 2.94±0,6 (p=0,121). No significant difference was noted in RFA duration between Groups 2 and 3 - 11.7±3.7 and 11.4±6.3 min, respectively (p=0,834).AF was found to occur most commonly at postoperative days two or four. The isolated CABG surgery group patients developed POAF most often of all (32,4%). The incidence of POAF was lower after RFA concomitant to CABG - 20.7% (р=0,29). A significant difference was identified in POAF incidence between Groups 1 and 3- 32.4% and 6.1%, respectively (p = 0.0065). Differences between Groups 2 and 3 proved not to be statistically significant (р= 0,086). Sinus rhythm in most of those who had developed arrhythmias was restored by pharmacological cardioversion except for three patients (one in each group). At discharge, 97.1% , 96.7% and 97% of the subjects in Groups 1, 2 and 3, respectively, exhibited sinus rhythm (p&gt;0,05).There was no in-hospital mortality in any of the groups. Neither were there any wound complications, reoperations, perioperative myocardial infarction or cerebral circulatory disorders observed. No difference was revealed in the severity and frequency of renal or respiratory failure. The mechanical lung ventilation time and duration of stay in the ICU in the isolated CABG group were shown to be increased as compared with the CABG-RFA and CABG-RFA-amiodarone groups (p&lt;0.05).Conclusion. The evidence from the pilot study (PULVAB) suggests that bipolar ablation of PV does not significantly complicate CABG, while being combined with amiodarone administration for prevention of rhythm disorders it significantly reduces the incidence of POAF. The in-hospital incidence of POAF tended to decrease, which was not statistically significant, though. Evaluating the efficacy of RFA concomitant with CABG, as performed independently, invites further investigation with more data analysis.

Механизмы взаимодействия сердечно-сосудистой и дыхательной систем

In this review we discuss the mechanisms of cardio-pulmonary interaction during spontaneous respiration and mechanical lung ventilation. We noted the interrelations between the changes of the intrathoracic pressure, venous return and cardiac output; the changes of the intrathoracic pressure and pulmonary hemodynamics; the values of the intrathoracic pressure and right and left ventricular myocardial contractility; the changing of respiratory phases and heart rate; the changes of respiratory muscles contraction and circulatory system. The phasic changes of the venous flow (it increases during respiration and decreases during expiration) are caused by the changes of both the intrathoracic and transdiaphragmatic pressures. However, the sucking thoracic effect is practically absent to the mean values of the venous return. During phasic respiratory changes the shifts of the venous return and pulmonary artery flow are opposite to the changes of the cardiac output and arterial pressure as a result of the changes of capacitance and resistance of the pulmonary vessels. In case of positive end expiratory pressure ventilation the changes of the cardiac output are dependent from the interrelations of the venous return, right ventricular myocardial contractility, pulmonary veins outflow and left ventricular myocardial contractility. The reflectory neurogenic influences on the heart and vessels from the pulmonary and respiratory muscles receptors are important during the cardio-pulmonary interaction.

ПРОГНОСТИЧЕСКОЕ И ДИАГНОСТИЧЕСКОЕ ЗНАЧЕНИЕ УРОВНЯ БЕЛКА КЛЕТОК КЛАРА ПРИ БРОНХОЛЁГОЧНОЙ ДИСПЛАЗИИ У НЕДОНОШЕННЫХ НОВОРОЖДЕННЫХ

Background. Bronchopulmonary dysplasia (BPD) is a polyetiological chronic disease of morphologically immature lungs that develops in premature newborns receiving oxygen and undergoing mechanical lung ventilation (MLV). The study of the severity and outcomes of bronchopulmonary dysplasia is one of the significant fields of modern research studies in pediatrics. The aim of our research was to determine Clara cell protein (CCP) levels in tracheal aspirate and blood serum in mechanically ventilated premature newborns with features of respiratory failure, who were subsequently diagnosed with BPD. Material and methods. Under our supervision, there were 34 preterm infants with respiratory disorders, who have been on mechanical ventilation for more than 1 week. The object of the study was serum and tracheal aspirate, sampling was performed twice on the 1st-2nd days and on the 10th-12th days. Results. In children who developed BPD, a low level of CCP in tracheal aspirate was noted. The level of CCP positively correlated with the diagnosis of BPD and negatively with the severity of the disease. Conclusions. Children with bronchopulmonary dysplasia on the 1st-2nd and 10th-12th days of life in TA and blood serum showed a low concentration of CCP (p <0.01) compared with the group of children without BPD.

Minimum requirements for rescuit beds and respiratory equipment in institutions refined for treatment of the new coronavirus infection COVID-19. Article

The article discusses the need for resuscitation beds and mechanical ventilation devices in hospitals redeveloped for the treatment of patients with new coronavirus infection. According to the analysis of the work of the City Clinical Hospital No. 15 named after O.M. Filatov, in the context of re-profiling into an infectious diseases hospital, the need for beds in the intensive care unit amounted to at least 12 % of the total number of hospital beds. Provision of apparatus for mechanical ventilation of lungs (mechanical ventilation) should be at least 80 % of the total number of beds in the intensive care unit. In addition, it is necessary to provide for the possibility of expanding the bed capacity to 30 % of the number of regular beds.

Venous return and pulmonary hemodynamics under the positive end-expiratory pressure mechanical ventilation

In the review we have discussed the mechanisms of the changes of the venous return and pulmonary hemodynamics which take place in clinical cases of the mechanical lung ventilation with positive end-expiratory pressure. In these conditions the elevating of right atrial pressure does not cause the decreasing of the venous return, because the mean circulatory filling pressure also increases. Thus, the gradient for venous return remains relatively constant. In case of the mechanical lung ventilation with positive end-expiratory pressure the decreasing of the venous return is the result of the elevation of the venous resistance as consequence of the direct increasing of the intrathoracic and transdiaphragmatic pressures and activation of the reflectory neurogenic mechanisms. In the conditions, indicated above, the increased alveolar pressure leads to the improvement of the diffused lung capacity for oxygen, which decreases the manifestations of the hypoxic pulmonary vasoconstriction and thus diminishes pulmonary vascular resistance. The character of changes of the last one is determined by the reactions of the two types (alveolar and extraalveolar) intraparenchimal pulmonary vessels. This leads to the changes of the resistive and capacitive functions of the pulmonary vessels. In case of the high levels of the positive end-expiratory pressure (more than 30 cm of water column) the value of alveolar pressure is comparable or even more excessive than pulmonary artery pressure (1216 mm Hg), which can be the reason of the decreasing of the right ventricular contractility and the venous return. The increasing of the capillary filtration coefficient of pulmonary vessels in the conditions of the mechanical lung ventilation with positive end-expiratory pressure can be the result of the activation of the mechanosensitive transient receptor potential vanilloid-4 (TRPV4) channels and the increasing endothelial calcium entry.