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Treatment of ARF

I. Support of free patency of respiratory tracts.

1. Triple method: the head is tilted back, the lower jaw is advanced forward
and the mouth is to be open. This method is contraindicated in the trauma and
pathology of the cervical part of spinal column and Down's syndrome.

2. Introduction of the airway tube. It impedes a tongue retraction. Oropharyngeal variant of the airway tube introduction is indicated in complete or partial obstruction of the upper respiratory tracts, coma, need in sanitation of the stomatopharynx. It is contraindicated in case of fracture of jaws and teeth. Nasopharyngeal variant is indicated in traumas of teeth and stomatopharynx. It is contraindicated in occlusion of nasal cavity, rhinoliquorrhea (a danger of ascending infection).

3. Sanitation of tracheobronchial tree is used in case of cough reflex inhibition, aspiration syndrome. In so doing, it is necessary to observe the following conditions:

a) patient's intubation;

b) use only sterile catheters and tips with smooth edges that do not traumatize a mucous membrane;

c) put on the gloves and use forceps in order to retain a proximal end of the catheter;

d) turn on a vacuum only after the end of the catheter is brought to the place of suction;

e) a diameter of the catheter must not be more than Vi of the tracheostomic or intubation tube lumen;

f) duration of the procedure is no more than 15 seconds;

g) before and after sanitation 0₂ inhalation is carried out.

4. Postural drainage (Trendelenburg's position for 40-60 min every 6-8 hours); turning the patient on his side every 2-3 hours; vibratory massage of the chest; artificial cough (press against the trachea in the region of jugular notch, microtracheostoma); humidifying and heating of the inhaled air.

5. Therapeutic bronchoscopy and lavage of the tracheobronchial tree.

6. Conicotomy is indicated in stomatofacial trauma, laryngospasm, laryngeal edema, unsuccessful endobronchial intubation; tracheostomy is indicated in the same cases as a conicotomy, as well as in the case of need in prolonged APV and sanitation of the tracheobronchial tree (grave craniocerebral trauma). Tracheal intubation is one of the most reliable methods to maintain a free patency of respiratory tracts. For intubation it is necessary to prepare a laryngoscope, sterile intubation tubes of three sizes: one — is appropriate o age and two — by one size larger and by one size lesser. Orotracheal intubation, under control of direct laryngoscopy, is indicated if it is impossible to maintain a patency of respiratory tracts by means of other methods: a threat of respiratory standstill (coma), ARF in the patients with mental disorder, hypercapnia with

Pa CO, more than 60 mm Hg, respiratory rate less than 8 and more than 35-40 per minute, maintenance of hypoxemia irrespective of carrying out oxy­genotherapy, grave craniocerebral trauma, risk of aspiration syndrome development.

Nasotracheal intubation is indicated in the traumas of cervical part of the backbone, severe injury of facial skeleton with hemorrhage, performing surgeries on the oral cavity.

II. Elimination of hypoxemia and hypoventilation is achieved by carrying out oxygenotherapy, HBO. The adequate ventilation is achieved by the fulfilment of the assisted artificial pulmonary ventilation (AAPV) and APV.

Main indication for carrying out oxygenotherapy is a decrease of oxygen tension in arterial blood lower than 90 mm Hg. Oxygen inhalation for the patient is carried out by means of nasal cannulae, catheters, mask or oxygen tent. Compulsory rules of oxygenotherapy are:

1) supply of only humidified oxygen;

2) gradual increase of oxygen concentration (to start from 3 1/min, this provides for 30 vol% and to increase up to 4-6 1/min — because of the danger of depression of respiration in fast increase of concentration);

3) monitoring of external respiration, prevention of its inhibition and in case of its inhibition — APV or AAPV;

4) to try not to supply oxygen in the concentration of more than 40 vol%.
Oxygenotherapy is effective under all conditions contributing to the

development of turbulence, — obstructive syndrome. Owing to a high diffusion ability and low solubility helium easily penetrates the atelectatic areas of the lung and exerts its antiatelectatic effect.

The basic methods of correction and replacement of functions of external respiration are APV and AAPV. The main task of these methods is the normalization of lost and weakened volume of ventilation of pulmonary alveoli. Besides, APV has a certain effect on the intracranial pressure and decreases the operation of respiration. Indications for APV are: apnea, respiration rate is more than 35 per min.; respiratory volume (RV) is less than 5 ml/kg, Pa0₂ is below 70 mm Hg, PaC0₂ is more than 55 mm Hg, pH — below 7.2.

There are the following methods of APV:

1. Expiratory method without equipment and instruments. It includes mouth-to-mouth or mouth-to-nose respiration that stipulates the performance of the triple technique. At first, 3-5 deep inspirations are made in succession, then one should stick to the following rhythm: 1 inspiration in 5 seconds, i.e. 12 inspirations per min., and in children — 24-30 inspirations per min. The air volume necessary for an adequate APV by means of expiratory method is the following: for adults — 1.0-1.5 1, for new-borns — 0.05-0.08 1. A mouth-to-nose artificial respiration is indicated in the injury of lips, lower jaw, tongue, when it is impossible to open the mouth.

2. Expiratory method with instruments. This method is easier to carry out using a facial mask of the apparatus for general anesthesia or S-shaped airway tube.

3. APV with the use of manual apparatuses (ADR, Ambou's bag). They allow to introduce an oxygen-air mixture into the patient's lungs.

4. APV with automatic respirators that are divided, according to the principle of change-over the apparatuses for APV from inspiration to expiration, into 3 main groups:

a) by pressure (DP-2, RD-1). Here, changing-over from inspiration to expiration occurs after the designed pressure in the respiratory circuit;

b) by volume (RO). Changing-over from inspiration to expiration occurs after the end of supply of the preset volume of gas by the apparatus;

c) by time (Phasa-5, DP-8, AND-2). Changing-over occurs when the preset time interval is elapsed.

Main units of APV apparatuses are: 1) a source of gas supplied to the patient (generator of inspiration); 2) distributing device presetting the required direction of gas movement in inspiration and expiration; 3) control mechanism for gas distribution; 4) instrumentation with warning devices of dangerous states; 5) humidifiers.

To carry out a rational APV a proper choice of the main parameters of APV is necessary such as: minute ventilation, respiratory volume, pressure at the inspiration and expiration, relation of inspiration length to expiration. The calculation of RV, RMV and RR is made using the following formulae: RV= 10-15 ml per kg of body mass; RMV = RV x RR.

III. Pathogenetic therapy is directed to a decrease or elimination of pathologic effect caused ARF.

1. Correction of obstructive syndrome (berotec, salbutamol, euphilline, conduction blocks, prednisolon).

2. Restoration of the activity of myoneural synapses (proserinum, galantamine, calcium chloride).

3. Analgesia (analgetics, regional anesthesia).

4. Antibacterial therapy.

5. Puncture and drainage of pleural cavity in accumulation of gas or fluid.

6. Application of respiration stimulating agents (doxapram in patients with the postoperative depression of respiration and with the alveolar hypoventilation syndrome; naloxone in overdosage of narcotic analgetics; progesterone in obese patients with hypoventilation syndrome).

IV Maintenance therapy.

1. Increase of resistance to hypoxia: hypothermia, antihypoxants, metabolic therapy.

2. Stabilization of hemodynamics.

3. Detoxication therapy.

4. Antihistamine agents.

V. Improvement of nonrespiratory pulmonary functions.

1. Improvement of rheologic properties of blood (trental, heparin,
rheopoliglucin, aspirin).

2. Activation of immunity (decaris, thymalinum, thymogenum).

3. Correction of water-electrolyte exchange and AAB.

Having considered general provisions of ARF, i.e. the principles of treatment and clinical signs that are encountered in different combinations dependent on the cause of ARF, it is necessary to dwell on the particular variants of ARF.

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