It is well known that in the early postoperative period all patients have acute respiratory failure. Therefore, already in the first hours after the recovery of consciousness and muscle tone in a patient, it is always necessary to achieve adequate breathing, effective cough and early motor activity. For this, it is extremely important to provide complete anesthesia. The pain not only reduces the depth of breathing and the force of cough tremors, but also seriously disrupts the central mechanisms of regulation of respiration, inhibits the patient’s psyche, and prevents his active participation in the treatment process. Excessive sympathetic stimulation suppresses parasympathetic activity, preventing the restoration of the tone of the stomach and intestines, which sharply limits the excursion of the diaphragm. In addition, pain changes the rheological properties of blood,contributing to the blockage of pulmonary capillaries with cell aggregates and increasing the intensity of non-respiratory functions of the lungs. For effective postoperative analgesia, a combination of conductive (epidural or subpleural) blockade with a central analgesia drugs that do not depress respiration (non-narcotic analgesics, tramal, norfin, etc.). The latter are administered in combination with antihistamines (diphenhydramine, suprastin) and an antipsychotic drug (droperidol 0.25% —1 ml) 3 times a day.
An important component of the treatment of respiratory failure is to ensure the patency and drainage function of the respiratory tract. To liquefy sputum and restore the function of the wall of the respiratory tract, 2 — times a day, steam-oxygen inhalations are carried out with healing traps (chamomile, sage, thyme, eucalyptus leaves). If vapor-oxygen inhalation is not enough, combine them with aerosol inhalation: mucolytics (acetylcysteine 5 ml of a 20% solution, himopsin 10— mg per 5 ml of a 0.5% solution of novocaine), moisturizers (1 g of hydrocarbonate
sodium), bronchodilators (Novodrin, Solutan, Euspiran 5-10 drops in 5 ml of water), glucocorticoids, local anesthetics and other drugs.
Sputum removal is promoted by postural drainage, percussion, vibratory and vacuum massages, cough stimulation, therapeutic bronchoscopy. Effective dressing, as a rule, allows the majority of patients, either alone or under the supervision of a physical therapy specialist, to do breathing exercises, breathe deeply and cough up sputum. In rest patients, percussion or vibratory massages are used, changing the position of the patient in bed for a minute, followed by a minute pause, during which the patient must take a deep breath and clear his throat. With a clear ineffectiveness of these measures, as well as with massive atelectases associated with impaired bronchial drainage function, therapeutic bronchoscopy is performed.
A highly effective way to prevent postoperative pneumonia is breathing with constant positive pressure during expiration. Self-breathing sessions under pressure of 15— cm of water column. carry out for 15 – min. 3 – times a day through a mask of the narcotic device (Polinarkon-2) with the injector, creating a stream of a mixture of air and oxygen in a ratio of 1: 1 with a gas flow 15—
l / min We emphasize that the systematic use of this complex is relatively
simple but very important measures for the prevention and treatment of postoperative respiratory failure is mandatory in all patients operated on the lungs. It is extremely important and holding a long, throughout the acute period of inhalation of humidified oxygen through a nasal catheter or mask.
In addition to the measures taken, 5 to 2.4 ml of euffilin solution are injected intravenously 2 to 2 times a day, and from 2 days after the operation, if stable hemostasis is administered, heparin 5 thousand units after 6 hours subcutaneously. In patients with critical disorders of gas exchange, heparin is best administered by intravenous drip, maintaining the coagulation time according to Lee-White within 10— min. It is possible to improve the rheological properties of blood entering the lung using pentoxifylline (trental), which increases the deformability of red blood cells, reduces blood viscosity and inhibits platelet aggregation. As a result of its use, the blood supply to respiron improves, oxygenation of mixed venous blood is normalized.
With the most severe forms of postoperative respiratory failure and, above all, with single lung pneumonia, a more intensive complex effect on the blood is required, including detoxification, rheological and immunological correction. These tasks are strictly differentiated and can be solved in a timely manner using extracorporeal perfusion procedures. As our experience shows, the inclusion of efferent therapy methods in the complex of intensive therapy of postoperative respiratory failure is often a turning point in the course of the disease. First of all, it concerns the extracorporeal metabolic support of the aching lung. As known, oxygen supply to the lung parenchyma is carried out mainly on the residual principle. With the development of venous hypoxemia, ischemia of the lung tissue occurs, which leads to the progression of respiratory failure and insolvency of the respiratory system. In this situation, plasma exchange with hemo-oxygenation (as a preliminary detoxification option) is most effective, followed by a transition to long-term venovenous auxiliary hemoxygenation with a perfusion rate of 150–200 ml / min. This metabolic support of the lung tissue improves the condition of the alveolar
capillary membrane, facilitates the smoothing of the lung and increases its diffusion capacity (Belsky AN, 1994).
It is very important for patients who have undergone partial resection of the lung to overcome respiratory disorders and prevent pleural empyema to achieve the earliest rectification of the remaining part of the lung parenchyma. Monitoring the effectiveness of the expansion of the lung is constantly performed using auscultation and daily x-ray. In patients undergoing pneumonectomy, daily radiological monitoring for 7–10 days after surgery is also necessary and necessary to determine the position of the mediastinum, the dynamics of accumulation of exudate and the selection of the most optimal point for puncture the pleural cavity. We will write that the excessive accumulation of exudate, air or blood in the pleural cavity is often manifested only by hemodynamic impairments — the growth of tachycardia,hypotension or the development of a sudden episode of atrial fibrillation. Of course, in such a situation, therapeutic measures generally accepted in cardiology and resuscitation (an increase in the rate of infusions, the use of depolarizing mixtures, glycosides, antiarrhythmic drugs) will be ineffective and will lead at best only to a loss of time, so necessary for the rapid stabilization of the patient’s general condition. Therefore, all patients with acute circulatory disorders after operations on the lungs, it is advisable to include in the complex of diagnostic measuresso necessary for the rapid stabilization of the general condition of the patient. Therefore, all patients with acute circulatory disorders after operations on the lungs, it is advisable to include in the complex of diagnostic measuresso necessary for the rapid stabilization of the general condition of the patient. Therefore, all patients with acute circulatory disorders after operations on the lungs, it is advisable to include in the complex of diagnostic measures urgent X-ray examination, and if necessary, and diagnostic puncture of the pleural cavity.
During intensive therapy, it is important to regularly monitor the tension of oxygen and carbon dioxide in arterial and mixed venous blood. Accounting of the obtained data allows objectively, in dynamics to evaluate the effectiveness of the chosen tactics and to make appropriate changes in a timely manner. In addition, there is the possibility of early detection and even forecasting decomposition of pulmonary gas exchange, the threat of which shows the use of artificial respiration.
It is important to emphasize that the transfer of the patient on mechanical ventilation with obvious clinical signs of respiratory failure (impaired consciousness, cyanosis, participation in the act of breathing of the auxiliary muscles, tachypnea more than 35 / min, tachy- or bradycardia) and sharp changes in pH (less than 7.2), RaO 2 (less than 65 mm of mercury.), PaCO 2 (more than 55 mm Hg) is often doomed to failure. In this case, it is necessary to treat not only the primary disorders, but also their consequences, which alter the functionality of vital organs. Therefore, in cases where less intensive treatment measures do not eliminate impaired gas exchange, hypoxemia that is not blocked by oxygen intake increases, and detectable radiographically diffuse tissue infiltration persists or progresses, early preventive use of assisted or artificial respiration is warranted. The prolonged after the operation of the ventilator helps to prevent the decompensation of vital functions. After extended and combined pulmonary resections, it is certainly indicated for patients with critical weight loss,as well as if surgical intervention was accompanied by massive (more than 40%) blood loss, prolonged episodes of hypotension or hypoxia. In such patients, mechanical ventilation is carried out in a controlled mechanical ventilation mode with periodic swelling of the lungs in double volume. This mode has less side effects on blood circulation than long-term mechanical ventilation with a positive end of expiration or constant positive pressure. The subsequent transfer of the patient from mechanical ventilation to assisted ventilation or independent breathing is carried out after stabilization of the condition under the following conditions: the presence of clear
consciousness, full recovery of muscle tone, absence of pain, hypovolemia, hypothermia, hypotension, tachycardia (pulse rate not more than 110 beats / min), arrhythmias (with a negative hemodynamic effect), oxygen pressure in arterial blood more than 60 mm Hg. with FiO 2 less than 0.4 and a heart index of at least 3.0 l / min * m2.
We emphasize the important prognostic value of hemodynamic parameters, noted also in other types of surgical pathology (Levshankov AI, 1993). This situation is obvious, it is determined by the interdependence of the processes of respiration and blood circulation, united by a common goal – to ensure compliance with the delivery of oxygen to the tissues of their metabolic needs. Violation of pulmonary gas exchange is always accompanied by an increase in the load on the next stage of oxygen transport — its blood transport. However, during pulmonary operations, the circulatory system is also subjected to strong and multidirectional effects. Significant, often critical reduction of the pulmonary circulation, blood and plasma loss, inadequate anesthesia, direct mechanical and adverse pharmacological effects, hypoxia,hypercatecholaminemia and other numerous factors of operative trauma significantly limit or change the adaptive capabilities of the circulatory system. Equally important are the initial condition of the patient, comorbidities, age-related changes, homeostatic disorders caused by the disease. As a result of all these reasons, at any stage of treatment, there may be a mismatch between the increased requirements for the circulatory system and its capabilities. It is possible to prevent the development of such a dangerous situation for the patient by carrying out a certain set of therapeutic measures.caused by the disease. As a result of all these reasons, at any stage of treatment, there may be a mismatch between the increased requirements for the circulatory system and its capabilities. It is possible to prevent the development of such a dangerous situation for the patient by carrying out a certain set of therapeutic measures.caused by the disease. As a result of all these reasons, at any stage of treatment, there may be a mismatch between the increased requirements for the circulatory system and its capabilities. It is possible to prevent the development of such a dangerous situation for the patient by carrying out a certain set of therapeutic measures.