After the onset of a stroke, it is necessary to carry out urgent rehabilitation measures aimed at combating complications. The result of internal hemorrhage is the development of serious pathological changes in the functioning of the brain: impairment of motor, respiratory and psycho-emotional functions. Breathing problems after a stroke are observed when a special center responsible for the functioning of a person’s lungs is affected.

Why is it difficult to breathe after a stroke?

Respiratory failure during stroke is a consequence of damage to the body's self-regulation and defense mechanisms. Pathophysiological disorders include:

Complications may subside as basic brain functions are restored. Deterioration in health leads to the inability to breathe independently and requires connection to an artificial lung ventilation device (ALV).

Mechanical ventilation after stroke

Mechanical ventilation for stroke is a standard measure aimed at combating possible complications after hemorrhagic or ischemic lesion. The method itself is not new. Ventilation is used in case of acute disorder respiratory function.

Indications for mechanical ventilation for stroke

The use of an artificial respiration apparatus for stroke is a common rehabilitation measure. Connection to a ventilator is required for the following indications:

Difficulty breathing is observed in almost every case of an ischemic or hemorrhagic attack and is not a direct indication for the use of mechanical ventilation, especially in view of the existing risks of the procedure. Inability to breathe independently, weakened respiratory function - observing these signs, the neurologist decides on the advisability of connecting to the device.

Transfer to artificial respiration is necessary in order to create the prerequisites for restoring lost brain functions. The primary task of the treating staff is to provide nerve cells sufficient quantity oxygen.

What are the benefits of mechanical ventilation for stroke?

Artificial ventilation is needed to maintain the patient’s life, as well as recovery necessary functions brain The decision on the advisability of connecting to the device is made by the resuscitator, based on general condition patient.

Gasping breathing indicates the need to check the condition and clear the oxygen supply pathways. If mechanical reasons there are no dysfunctions, MRI or CT diagnostics are prescribed to determine the location of bleeding.

In case of a stroke, a ventilator is connected for a period of several days to 1-2 weeks. Usually this is enough for the acute period of the disease to pass and the swelling of the brain to begin to decrease. Transfer to independent breathing is carried out as early as possible. The longer the connection to mechanical ventilation lasts, the worse the prognosis for the patient will be.

Initially, breathing becomes difficult due to damage to certain areas of the brain. To normalize the functioning of the body, the patient is connected to a ventilator. Forced ventilation, continuous for a long time, leads to infectious damage to the respiratory tract, as well as the development of congestive pneumonia.

How to restore the respiratory system after a stroke

The number of days on mechanical ventilation after a stroke depends on the severity of the brain damage. A tracheostomy is installed to supply oxygen. Artificial oxygen supply is required all the time until the absence of spontaneous breathing is diagnosed. The task of the rehabilitation team is to return the patient to normal vital signs as quickly as possible.

During therapy, it is taken into account that prolonged connection to a ventilator leads to serious complications: inflammation of the upper respiratory tract, the development of pneumonia and acute inflammatory processes that worsen the patient’s condition.

Rehabilitation includes the prescription of drug therapy, as well as the prescription of a set of breathing exercises for stroke.

Drug therapy to strengthen breathing

Spontaneous breathing is restored when brain activity comes back to normal. This usually occurs after tissue swelling has decreased. Undamaged areas of the brain gradually take over the lost functions. While the patient is connected to a ventilator, negative changes occur in the respiratory system.

When prescribing drug therapy, possible complications must be taken into account.

• Removing viscous sputum - mucus is aspirated. Inhalations of acetylcysteine ​​and bronchodilators are prescribed.
• Shortness of breath after a stroke, caused by disruption of the bronchi, requires the prescription of corticosteroids and bronchodilators.
• Paralysis of the respiratory muscles - leads to heavy rapid breathing, subsequently to its complete cessation. Injections of atropine and neostigmine are prescribed.

At the same time, a course of therapy is prescribed to combat the consequences of the stroke. The patient takes neoprotectors, antihistamines and other drugs.

How to breathe properly after a stroke

Restoration of respiratory function occurs gradually. As the patient recovers, he is recommended to undergo exercise therapy for breathing, and is also given recommendations related to daily habits.

There are several basic rules:

• Breathing should be smooth and deep.
• Intermittent and frequent breaths, which leads to re-development of stroke, as well as hyperventilation.

It is believed that the most beneficial is abdominal breathing, which contributes to the maximum enrichment of the patient’s blood with oxygen.

Breathing exercises during the recovery period

Breathing exercises after a stroke are useful even for those patients who were not connected to a ventilator. Immediately after the patient’s condition is normalized and stabilized, they begin to restore lost motor and other functions.

Breathing exercises during rehabilitation after a stroke help achieve the following improvements:

• Enrichment of blood with oxygen - dynamic breathing exercises have a particularly beneficial effect on the functioning of the blood supply system, improving tissue metabolism and enriching them with nutrients necessary for recovery.
• Gradual restoration of muscle activity. It has been observed that static breathing exercises while lying down lead to an improvement in tone muscular system and have a beneficial effect on the functioning of internal organs.

There are many techniques that help normalize lung function and restore normal blood supply. After a stroke you can use breathing exercises according to Strelnikova, exercises taken from oriental gymnastics (yoga and wushu). Pick up best option a rehabilitator will help.

Strelnikova’s set of breathing exercises is aimed not only at eliminating the consequences of a stroke, but also at improving the health of the body as a whole. Proper implementation of exercise therapy improves well-being, elevates mood and promotes a positive attitude in the patient.

Traditional recipes for difficulty breathing

Folk remedies for the treatment of shortness of breath are used only during the period of non-exacerbation of the disease, strictly according to indications related to the patient’s health:

Traditional recipes do not replace a professional examination by a doctor. Therefore, if a stroke victim becomes worse, severe shortness of breath occurs, you should see a neurologist as soon as possible.

Page 29 of 43

A patient needs mechanical ventilation only as long as his spontaneous breathing is insufficient or is accompanied by too much energy consumption. Unjustified prolongation of artificial respiration can bring nothing but harm. However, deciding on the timeliness of stopping mechanical ventilation, especially long-term ventilation, is not always easy. Perhaps the second most common mistake when performing mechanical ventilation in practice intensive care is premature shutdown of the respirator. This can easily cause re-development hypoxia and nullify all previous efforts. Here is an observation.
A 41-year-old patient underwent surgery for a tumor of the middle lobe of the right lung. During the lobectomy, massive bleeding occurred and clinical death occurred. Cardiac activity was restored by direct cardiac massage after 4-5 minutes. After the end of the operation, transfusion of 1500 ml of blood and 1750 ml of plasma substitutes, the patient with stable hemodynamics was transferred to the postoperative intensive care unit, where mechanical ventilation was continued. After 7 hours, consciousness was restored, a reaction to the endotracheal tube appeared, and therefore mechanical ventilation was stopped and the trachea was extubated. Respiratory functions were not determined by gas analysis and blood CBS was not performed.
4 hours after extubation, the patient stopped answering questions and responded poorly to calls. On examination, the pulse is 132 per minute, blood pressure is 140/60 mmHg. Art., PO2 capillary blood 60 mmHg Art., РсО2 38 mm Hg. Art. The trachea was re-intubated and mechanical ventilation was resumed. The condition has improved somewhat, the tachycardia has decreased, however full recovery consciousness did not occur.
After 2 days, the patient follows simple instructions, fixes his gaze, sometimes shows signs of understanding speech addressed to him and recognizes those around him. Hemodynamics are stable, breathing in the lungs on the right is weakened, and the X-ray shows signs of incipient right-sided lower lobe pneumonia. When the respirator is turned off, spontaneous breathing is rhythmic, 18 per minute, “medium depth” (?). During mechanical ventilation with (FiO2 = 0.6) PO2 of capillary blood is 95 mm Hg, 15 minutes after switching off - 70 mm Hg. Art. Under these conditions, the trachea was extubated again. After 2 hours, the medical history noted: “Spontaneous breathing is adequate.” However, all signs of consciousness gradually disappeared, which was regarded as cerebral edema. Dehydration therapy (mannitol, Lasix) did not improve the condition. 11 hours after repeated cessation of mechanical ventilation, a tracheostomy was performed and artificial respiration was resumed. It was not possible to achieve an improvement in the condition. On the 12th day after the operation, the patient died.
Pathological examination: edema and swelling of the brain, bilateral focal bronchopneumonia, fibrinous pleurisy on the right.
When deciding on the possibility of transferring a patient to spontaneous breathing, many authors consider monitoring clinical symptoms and blood gases to be the main thing. There is an opinion that if the respiratory rate does not exceed 30 per minute, and PaO2 for 1 hour does not exceed 35-40 mm Hg. Art., then mechanical ventilation can be stopped. However, a number of researchers believe that after switching off the respirator, post-hyperventilation hypoxia may be observed and, in general, PaO2 in the first hours after stopping mechanical ventilation is too inconsistent and variable to serve as a reliable criterion for the adequacy of spontaneous breathing. According to E.V. Vikhrov (1983), the absence of hypercapnia during spontaneous breathing cannot serve as a basis for complete cessation of mechanical ventilation.
We consider it necessary to emphasize that stopping mechanical ventilation is a very important moment. After prolonged artificial respiration, turning off the respirator can cause adverse changes in hemodynamics - a decrease cardiac output, increased vascular resistance in the pulmonary circulation and increased right-to-left shunting in the lungs. During the transition to independent breathing, the patient needs not less, but perhaps even more attention and care.
Ventilation can be stopped only if there is significant regression of the underlying pathological process that caused breathing problems. It is necessary to eliminate hypovolemia and gross metabolic disorders.
If the duration of mechanical ventilation is no more than 24 hours, then it can most often be stopped immediately. The main conditions under which you can try to turn off the respirator are:
restoration of clear consciousness;
stable hemodynamics for at least 2 hours, pulse less than 120 per minute, urine output rate at least 50 ml/h without the use of diuretics;
absence of severe anemia (hemoglobin content not less than 90 g/l), hypokalemia (plasma potassium not less than 3.5 mmol/l) metabolic acidosis (BE not less than -4 mmol/l).
Before turning off the respirator, you must once again count the pulse, measure blood pressure, determine gases and blood oxygen levels. Immediately after stopping mechanical ventilation, after 5, 10 and 20 minutes of spontaneous breathing, the pulse and number of respirations should be determined again, blood pressure, MOD and vital capacity should be measured. Increasing tachycardia and arterial hypertension, a progressive increase in MOD, respiration more than 30 per minute, vital capacity below 15 cm3/kg are contraindications to continued spontaneous breathing. If the condition remains stable, does not worsen, and vital capacity exceeds 15 cm3/kg, observation should be continued. After 30 and 60 minutes, it is necessary to repeat the analysis of gases and blood CBS. Capillary blood PO2 is below 75 mmHg. Art. (under conditions of oxygen inhalation) and a progressive decrease in РсO2, as well as an increasing metabolic acidosis serve as indications for resumption of mechanical ventilation. Re-monitoring of blood gases and CBS, external respiration indicators is mandatory after 3; 6 and 9 hours after tracheal extubation. After stopping mechanical ventilation, it is useful to allow the patient to breathe oxygen for 11/2-2 hours with an exhalation resistance of 5-8 cm of water. Art. using a special mask or some other device. We must not forget that the appearance of well-being on the part of breathing does not necessarily mean the absence of respiratory failure and hidden hypoxia.
When mechanical ventilation lasts for several days, stopping it immediately is most often impractical. The conditions under which the transition to spontaneous breathing can begin, along with those listed above, are:
absence of inflammatory changes in the lungs (or their significant regression), septic complications, hyperthermia;
absence of hypercoagulation syndrome;
good tolerance by patients to short-term cessation of mechanical ventilation (when changing body position, suction, changing the tracheostomy cannula);
PaO2 not lower than 80 mm Hg. Art. at Fi0, no more than 0.3 during the day;
restoration of the cough reflex and cough impulse.
A valuable method for judging the adequacy of spontaneous breathing after cessation of mechanical ventilation is electroencephalography. G.V. Alekseeva (1984) found that if the respirator is turned off prematurely, despite the patient’s clear consciousness and the absence of clinical signs of respiratory failure, a flattening of the alpha rhythm begins to be recorded on the EEG after 10-15 minutes, and beta activity may appear. If mechanical ventilation is not resumed, then after 40-60 minutes PaO2 decreases and signs of respiratory failure develop. In the most severe cases, immediately after the flattening of the alpha rhythm, slow waves appear in the theta rhythm range. Following this, a disturbance of consciousness may occur, leading to coma. When mechanical ventilation is resumed, consciousness and the alpha rhythm on the EEG are quickly restored. The appearance of a delta rhythm should be considered especially unfavorable, which is a harbinger of rapidly occurring respiratory decompensation and loss of consciousness. Thus, it can be considered that changes in the EEG are an early indicator of tension and exhaustion compensatory mechanisms, discrepancies between the patient’s capabilities and the increased work of breathing.
Before termination long-term mechanical ventilation Fi02 should be gradually reduced and the patient should be psychologically prepared. During the period of cessation of artificial respiration, the patient’s condition is monitored as described above, but along with the listed tests great importance purchase D(A-a)O2 studies: it should be no more than 350 mm Hg. Art. when breathing 100% oxygen and Vd/Vt no more than 0.5. When trying to inhale from a confined space, the patient must create a vacuum of at least -30 cm of water column. (Table 9).
Even with good clinical and instrumental indicators, the first period of spontaneous breathing should not exceed 1.5-2 hours, after which mechanical ventilation should be resumed for 4-5 hours and a break taken again. You can start turning off the respirator only in the morning and afternoon hours. At night, mechanical ventilation should be resumed, and the next day it should be interrupted again under the control described above.

Criterion	In conditions of mechanical ventilation	After disconnecting the respirator
Clinical signs	Clear consciousness, stable blood pressure, pulse less than 100 per minute, diuresis of at least 50 ml/h, absence of pneumonia, sepsis, hyperthermia, restoration of coughing	Respiratory rate no more than 30 per minute, no progressive tachycardia, arterial hypertension and complaints of lack of air
Laboratory data		PO2 of capillary blood is not lower than 75 mm Hg. Art., РсО2 does not tend to decrease, metabolic acidosis does not increase
Functions of respiration and gas exchange		MOP does not increase, vital capacity is more than 15 cm3/kg, forced expiratory volume is more than 10 cm3/kg, vacuum when inhaling from a confined space is more than -30 cm of water. Art., Vp/Vx less than 0.5, D(A-a)o.. at Fi0 = 1.0 no more than 300 mm Hg. Art.

By increasing and increasing the periods of spontaneous breathing, we achieve cessation of mechanical ventilation for all daytime, and then for the whole day. After prolonged mechanical ventilation (more than 6-7 days), the period of transition to independent breathing usually lasts 2-4 days.
The transition to spontaneous breathing can be facilitated by using the intermittent mandatory ventilation (IPPV) technique described in Chapter III. PPVL is especially indicated for patients who have undergone long-term mechanical ventilation in the PEEP mode.
When using a RO-6 respirator for PPVL, it is recommended to start with a forced breath rate of about 20 per minute (key “2c”). Then, every 20-30 minutes, forceful breaths are reduced to 3-4 per minute, all the time maintaining a positive pressure of at least 5 cm of water in the respiratory tract. Art. Such sessions of PPVL with a constant decrease in instrumental inhalations usually take 3-31/2 hours; they can be repeated 2-3 times a day.
As studies have shown [Vikhrov E.V., Kassil V.L., 1984], PPVL facilitates the patient’s adaptation to independent breathing and prevents the development of decompensation. During the transition from mechanical ventilation to PPVL, PasO2 increases to subnormal values, good oxygenation of arterial blood is maintained without increasing energy costs. Similar data were obtained by R. G. Hooper and M. Browning (1985). As a rule, patients prepared to stop mechanical ventilation subjectively tolerate PPV sessions well. After carrying out PPVL with the most infrequent mode of forced breaths for 1 - 11/2 hours, you can completely turn off the respirator under the control described above. The next day, it is also advisable to begin the next cessation of mechanical ventilation with a PPV session, but forced breaths can be reduced much faster - every 10-15 minutes. If PPVL is accompanied by a deterioration in the patient’s condition and reducing the frequency of forced breaths is impossible, then the patient is not ready to stop mechanical ventilation.
In the first 2-3 days, some patients do not tolerate prolongation of periods when the respirator is turned off by more than 30-40 minutes, not because of a deterioration in their condition, but for purely subjective reasons. In such cases, we do not recommend immediately extending mechanical ventilation breaks. It is better to increase their frequency up to 8-10 times a day, and then gradually and unnoticed by the patient to increase the time of spontaneous breathing.
After prolonged mechanical ventilation (more than 4-6 weeks), some patients become accustomed not so much to hypocapnia as to constant mechanical stretching of the lungs. In this regard, a decrease in tidal volume causes them to feel a lack of air even at a relatively low Raso, and the cessation of mechanical ventilation leads to debilitating hyperventilation. In such situations, L. M. Popova (1983), K. Suwa and N. N. Bendixen (1968) recommend increasing the dead space of the respirator. Indeed, by gradually increasing it from 50 to 200 cm3, it is possible to achieve an increase in PaO2 to 35-38 mm Hg. Art., after which patients switch to independent breathing much more easily. An increase in the dead space of the device is achieved by connecting additional sections of hose of increasing length, and therefore volume, between the tee connecting the inhalation and exhalation hoses and the tracheostomy cannula adapter.

Nevertheless, the patient’s complaints of fatigue and a feeling of lack of air should be treated carefully and the process of stopping mechanical ventilation should not be forced.
If a decrease in Pco and a moderate decrease in Po of capillary blood during the first shutdown of the respirator are not accompanied by any clinical signs of deterioration of the patient’s condition, then we recommend not to rush into resuming mechanical ventilation, but to repeat the study after 1* /2-2 hours. Often during this time adaptation to new living conditions occurs and external respiration functions improve. But if at feeling good Vital vital capacity decreases, then it is necessary to resume mechanical ventilation.
It should be borne in mind that turning off a respirator with a humidifier and a warmer of inhaled air can dry out and cool the mucous membrane of the respiratory tract and impair their patency. During spontaneous breathing, it is recommended to supply oxygen to the opening of the tracheostomy cannula through steam inhaler or humidifier UDS-1P. Decannulation should also not be over-delayed. The question about it can be raised after the patient has spent a day (including the night) without mechanical ventilation. A prerequisite for decannulation is restoration of the act of swallowing1. Before removing the cannula from the trachea, the patient should be examined by an otolaryngologist.
*T. V. Geironimus (1975) recommends giving the patient water colored with methylene blue, and then checking the contents of the trachea for the presence of dye.
If mechanical ventilation lasted more than 5 days, then it is advisable to carry out decannulation in several stages: 1) replace the cannula with an inflatable cuff with a plastic one without a cuff and of a smaller diameter; 2) if the patient’s condition has not worsened, then the next day replace this tube with a cannula of minimal diameter; 3) on the 2nd day, remove the cannula and tighten the skin wound with an adhesive plaster. The patch must be changed at least 3-4 times a day.
During the process of replacing cannulas and after decannulation, the patient should also be under the supervision of an otolaryngologist. After complete removal tubes from the trachea, the patient should be taught to talk and cough, pressing the bandage with a finger. The wound after tracheostomy quickly heals by secondary intention.
The doctor’s desire to stop mechanical ventilation as soon as possible is understandable, but not always justified. This issue should be resolved on the basis of objective tests, which are quite accessible in a modern intensive care unit. To avoid premature shutdown of the respirator with all its dangerous consequences, it is necessary to take into account a set of parameters and their dynamics. The more severe the patient’s condition before the start of mechanical ventilation and the longer the period of hypoxia, the slower the body’s adaptation to independent breathing occurs. Sometimes stopping mechanical ventilation takes significantly longer than continuous respiratory therapy. The following observation illustrates this point well.
A 50-year-old patient was admitted to the intensive care unit on October 17, 1974 with a diagnosis of diffuse pneumosclerosis with the development of bronchiectasis, cor pulmonale. He has suffered from bronchial asthma for many years. On admission: consciousness is preserved, complains of lack of air. Severe cyanosis of the skin, acrocyanosis. Breathing 40 per minute, shallow. Blood pressure 160/110 mm Hg, pulse 130 per minute. In the lungs, breathing is weakened in all parts, there is a lot of dry and wet rales. The radiograph shows pulmonary emphysema, pneumosclerosis, congestive pulmonary pattern, residual effects of pulmonary edema Pco, capillary blood 71.5-68.9 mm Hg. Art.
On the 2nd day from the moment of admission, despite intensive therapy, the condition worsened: severe lethargy appeared, blood pressure increased to 190/110 mm Hg. Art., РсО2 135 mm Hg. Art. A tracheostomy was performed and mechanical ventilation was started. After a few hours, consciousness began to recover, blood pressure dropped to 140/80 mm Hg, PcO2 68 mm Hg. Over the next 5 days, the condition gradually improved significantly. РсО2 decreased to 34-47 mm Hg. Art. Fi0 was reduced from 1.0 to 0.4. On
On the first day, a trial shutdown of the respirator was performed. After 20 minutes, the patient began to complain of a feeling of lack of air, the pulse increased from 76 to 108 per minute, blood pressure increased from 140/70 to 165/100 mm Hg. Art. Ventilation was resumed and the attempt was repeated the next day. However, after 30 minutes, tachycardia developed again, breathing increased to 34 per minute, Pco7 decreased from 39 to 30 mm Hg. Art. Starting from the 9th day after the start of mechanical ventilation, the patient was allowed to breathe on his own for 30-40 minutes 3-4 times a day. Only on the 20th day were the periods of spontaneous breathing able to be extended to 1 1/2-2 hours. The period of stopping mechanical ventilation took 26 days. The patient was discharged on February 16, 1975.
This observation once again shows that stopping mechanical ventilation is difficult process, requiring patience and exceptional attention to the patient from the doctor and nursing staff. We consider it necessary to remind about this, because by the time mechanical ventilation is stopped, the patient’s condition improves significantly compared to the moment mechanical ventilation began. It is easy to feel unjustifiably confident that nothing will happen. However, this is true: deterioration during the period of stopping mechanical ventilation can negate the multi-day efforts of the entire team and cause a number of life-threatening complications for the patient.

Anesthesiology and resuscitation: lecture notes Marina Aleksandrovna Kolesnikova

Lecture No. 15. Artificial ventilation

Artificial pulmonary ventilation (ALV) provides gas exchange between the surrounding air (or a certain mixture of gases) and the alveoli of the lungs, is used as a means of resuscitation in case of sudden cessation of breathing, as a component of anesthesia and as a means of intensive therapy for acute respiratory failure, as well as some diseases of the nervous and muscular system. systems

Modern methods of artificial pulmonary ventilation (ALV) can be divided into simple and hardware. A simple mechanical ventilation method is usually used in emergency situations(apnea, with a pathological rhythm, agonal breathing, with increasing hypoxemia and (or) hypercapnia and gross metabolic disorders). The simplest are expiratory methods of mechanical ventilation (artificial respiration) from mouth to mouth and from mouth to nose. Hardware methods are used when long-term mechanical ventilation is necessary (from one hour to several months and even years). The Phase-50 respirator has great capabilities. The Vita-1 device is produced for pediatric practice. The respirator is connected to the patient's respiratory tract through an endotracheal tube or tracheostomy cannula. Hardware ventilation is carried out in normal frequency mode, which ranges from 12 to 20 cycles per minute. In practice, there are high-frequency ventilations (more than 60 cycles per minute), in which tidal volume is significantly reduced (to 150 ml or less), positive pressure in the lungs at the end of inspiration is reduced, as well as intrathoracic pressure, and blood flow to the heart is improved. Also, with the high-frequency mode, the patient’s adaptation (adaptation) to the respirator is facilitated.

There are three methods of high-frequency mechanical ventilation: volumetric, oscillatory and jet. Volumetric ventilation is usually carried out with a respiratory rate of 80-100 per 1 min, oscillatory ventilation - 600-3600 per 1 min, which provides vibration of a continuous or intermittent gas flow. The most widely used jet high-frequency ventilation with a respiratory rate of 100–300 per minute, at which Airways Using a needle or catheter with a diameter of 1–2 mm, a stream of oxygen is injected under a pressure of 2–4 atm.

Jet ventilation is carried out through an endotracheal tube or tracheostomy (at the same time, atmospheric air is sucked into the respiratory tract) and through a catheter, which is inserted into the trachea through the nasal passage or percutaneously (puncture). The latter is important in situations where there are no conditions for tracheal intubation. Artificial ventilation can be performed in automatic mode, but this is acceptable in cases where the patient’s spontaneous breathing is completely absent or suppressed pharmacological drugs(muscle relaxants).

Auxiliary ventilation is also carried out, but in this case the patient’s spontaneous breathing is maintained. Gas is supplied after the patient makes a weak attempt to inhale, or the patient is synchronized to an individually selected mode of operation of the device. There is also a mode of intermittent mandatory ventilation (PPVL), which is used in the process of gradual transition from artificial ventilation to spontaneous breathing. In this case, the patient breathes on his own, but additionally a continuous flow of gas mixture is supplied into the respiratory tract. Against this background, with a set frequency (from 10 to 1 time per minute), the device performs artificial inhalation, coinciding (synchronized PPVL) or not coinciding (unsynchronized PPVL) with the patient’s spontaneous inhalation. A gradual reduction in artificial breaths prepares the patient for independent breathing. Breathing circuits are shown in Table 10.

Table 10

Breathing circuits

Manual ventilation with a bag or mask is readily available and is often sufficient to adequately inflate the lungs. Its success, as a rule, is determined correct selection the size of the mask and the experience of the operator, and not the severity of the lung pathology.

Indications

1. Resuscitation and preparation of the patient in a short period of time for subsequent intubation.

2. Periodic ventilation with a bag and mask to prevent post-extubation atelectasis.

3. Restrictions on mechanical ventilation with a bag and mask.

Equipment

A conventional breathing bag and mask with a pressure vacuum gauge installed or a self-inflating breathing bag with an oxygen chamber are used.

Technique

1. It is necessary to place the mask tightly on the patient’s face, placing the patient’s head in a medial position and fixing the chin with a finger. The mask should not lie on your eyes.

2. Respiration rate – usually 30–50 per minute.

3. Inspiratory pressure is usually 20–30 cm of water. Art.

4. Higher pressure (30–60 cm of water column) is acceptable during primary resuscitation of a woman during labor.

Efficiency mark

1. Return of heart rate to normal values ​​and disappearance of central cyanosis.

2. Excursion chest should be good, breathing is carried out equally well on both sides.

3. Blood gas testing is usually required and performed during prolonged resuscitation.

Complications

1. Pneumothorax.

2. Bloating.

3. Hypoventilation syndrome or episodes of apnea.

4. Facial skin irritation.

5. Retinal detachment (when applying a mask to the eyes and creating a long-term high peak pressure).

6. Ventilation with a mask and bag may worsen the patient's condition if he actively resists the procedure.

Hardware ventilation

Indications

2. Coma in the acute period, even without signs of respiratory failure.

3. Convulsions that are not controlled by standard anticonvulsant therapy.

4. Shock of any etiology.

5. Increase in the dynamics of the CNS depression syndrome with hyperventilation syndrome.

6. In case of birth spinal injury in newborns, forced breathing and crepitating widespread wheezing appear against the background of shortness of breath.

7. PO 2 of capillary blood is less than 50 mm Hg. Art. when spontaneously breathing a mixture with FiO 2 0.6 or more.

8. PCO 2 of capillary blood more than 60 mm Hg. Art. or less than 35 mm Hg. Art. with spontaneous breathing.

Equipment: “PHASE-5”, “BP-2001”, “Infant-Star 100 or 200”, “Sechrist 100 or 200”, “Babylog 1”, “Stephan”, etc.

Principles of treatment

1. Oxygenation in stiff lungs can be achieved by increasing the inspired oxygen concentration, increasing inspiratory pressure, increasing PEEP, prolonging inspiratory time, increasing plateau pressure.

2. Ventilation (removal of CO 2) can be enhanced by increasing tidal volume, increasing frequency, and lengthening expiratory time.

3. The selection of mechanical ventilation parameters (frequency, inspiratory pressure, inspiratory plateau, inspiratory-expiratory ratio, PEEP) will vary depending on the nature of the underlying disease and the patient’s response to the therapy.

Goals performing mechanical ventilation

1. Oxygen: achieve pO 2 50-100 mm Hg. Art.

2. Keep pCO 2 within 35–45 mm Hg. Art.

3. Exceptions: in some situations, pO 2 and pCO 2 indicators may differ from the above:

1) in case of chronic pulmonary pathology more than high values pCO 2 tolerable;

2) with severe heart defects, smaller pO 2 numbers are tolerated;

3) depending on the therapeutic approach in case of pulmonary hypertension higher or lower pCO 2 numbers are tolerable.

4. Indications and parameters of mechanical ventilation should always be documented.

Technique

1. Initial parameters of mechanical ventilation: inspiratory pressure 20–24 cmH2O. Art.; PEER from 4–6 cm water. Art.; respiratory rate 16–24 per 1 min, inspiratory time 0.4–0.6 s, DO from 6 to 10 l/min, MOV (minute volume of ventilation) 450–600 ml/min.

2. Synchronization with a respirator. As a rule, patients are synchronous with the respirator. But excitement can impair synchronization, in such cases it may be necessary drug therapy(morphine, promedol, sodium hydroxybutyrate, muscle relaxants).

Survey

1. An important component of the examination is repeated blood gas tests.

2. Physical examination. Monitoring the adequacy of mechanical ventilation.

During emergency ventilation simple method It is enough to observe the color of the patient’s skin and chest movements. The chest wall should expand with each inhalation and fall with each exhalation, but if the epigastric region rises, then the blown air enters the esophagus and stomach. The cause is often the incorrect position of the patient's head.

When performing long-term mechanical ventilation, it is necessary to judge its adequacy. If the patient’s spontaneous breathing is not suppressed by pharmacological drugs, then one of the main signs of the adequacy of the mechanical ventilation is the patient’s good adaptation to the respirator. If there is a clear consciousness, the patient should not feel a lack of air or discomfort. Breath sounds in the lungs should be the same on both sides, and skin must have a normal color.

Complications

1. Most frequent complications mechanical ventilation are: rupture of the alveoli with the development of interstitial emphysema, pneumothorax and pneumomediastenitis.

2. Other complications may include: bacterial contamination and infection, endotracheal tube obstruction or extubation, one-pulmonary intubation, pneumopericarditis with cardiac tamponade, decreased venous return and decreased cardiac output, chronic pulmonary disease, tracheal stenosis and obstruction.

Against the background of mechanical ventilation, it is possible to use a number of analgesics, which should provide a sufficient level and depth of anesthesia in doses, the administration of which would be accompanied by hypoxemia under conditions of spontaneous breathing. By maintaining a good supply of oxygen to the blood, mechanical ventilation helps the body cope with surgical trauma. In many operations on the chest organs (lungs, esophagus), separate intubation of the bronchi is used, which allows surgical interventions turn off one lung from ventilation in order to facilitate the surgeon’s work. This intubation also prevents contents from the operated lung from leaking into the healthy lung.

During operations on the larynx and respiratory tract, transcatheter jet high-frequency ventilation is used, which facilitates inspection of the surgical field and allows maintaining adequate gas exchange when the trachea and bronchi are opened. In conditions general anesthesia and muscle relaxation, the patient is not able to respond to the resulting hypoxia and hypoventilation, therefore monitoring the content of the blood gas composition (continuous monitoring of partial pressure of oxygen and partial pressure of carbon dioxide) percutaneously using special sensors becomes important.

In case of clinical death or agony, mechanical ventilation is a mandatory component of resuscitation. You can stop performing mechanical ventilation only after consciousness is fully restored and spontaneous breathing is complete.

In the complex of intensive care, mechanical ventilation is the most effective method of treating acute respiratory failure. It is passed through a tube that is inserted into the trachea through the lower nasal passage or tracheostomy. Of particular importance is the care of the respiratory tract and its adequate drainage.

Assisted ventilation is used in sessions of 30–40 minutes to treat patients with chronic respiratory failure.

Mechanical ventilation is used in patients in a coma (trauma, brain surgery), as well as in cases of peripheral damage to the respiratory muscles (polyradiculoneuritis, spinal cord injury, amyotrophic lateral sclerosis). Mechanical ventilation is also widely used in the treatment of patients with chest trauma, various poisonings, cerebrovascular accidents, tetanus, and botulism.

From the book Anesthesiology and Reanimatology author Marina Aleksandrovna Kolesnikova

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Ventilation of the lungs and pulmonary volumes The amount of pulmonary ventilation is determined by the depth of breathing and the frequency of respiratory movements. A quantitative characteristic of pulmonary ventilation is the minute volume of breathing (MVR) - the volume of air passing through the lungs in 1 minute.

Tracheostomies are divided into non-infectious and infectious. Non-infectious complications include bleeding of varying severity and (or) hemoaspiration, emphysema of the mediastinum and subcutaneous tissue, bedsores with ulcerations of the tracheal mucosa from cannulas and endotracheal tube cuffs.

Infectious complications of tracheostomy - laryngitis, tracheobronchitis, pneumonia, phlegmon of paratracheal tissue, purulent thyroiditis.

Complications of artificial ventilation

Pulmonary resuscitation is carried out using artificial ventilation. During the process of mechanical ventilation, especially over a long period of time, a number of complications can develop, and some of them themselves turn out to be thanatogenetically significant. According to various authors, the frequency of these complications ranges from 21.3% to 100% (Kassil V.L., 1987).

According to the location and nature of the complication, V.L. Kassil (1981) divides mechanical ventilation into four groups:

1. complications from the respiratory tract (tracheobronchitis, bedsores of the tracheal mucosa, tracheoesophageal fistulas, tracheal stenosis);
2. pulmonary complications (pneumonia, atelectasis, pneumothorax);
3. complications from the cardiovascular system (bleeding from blood vessels, sudden cardiac arrest, decreased blood pressure);
4. complications due to technical errors in performing mechanical ventilation.

General complications of mechanical ventilation. Before considering the particular complications of mechanical ventilation, we will separately dwell on the unfavorable physiological changes and complications that artificial ventilation itself carries with it.

In this regard, it is appropriate to recall the philosophical remark of F. Engels (1975):

“Let us not, however, be too deluded by our victories over nature. For every such victory she takes revenge on us. Each of these victories, however, has, first of all, the consequences that we were counting on, but in the second and third place completely different, unforeseen consequences, which very often destroy the significance of the first ones.”

First of all, when using artificial respiration, the biomechanics and regulation of breathing changes, primarily due to the fact that there is a pronounced difference in intra-alveolar and intra-pleural pressure at the end of inspiration compared to spontaneous breathing. If during spontaneous breathing these indicators are respectively minus 1 - 0 mmHg. Art. and minus 10 cm water. Art., then with mechanical ventilation - respectively +15 - +20 mm Hg. Art. and +3 cm water. Art. In this regard, during mechanical ventilation, the distensibility of the airway wall increases and the ratio of anatomically dead space to transpulmonary pressure changes. With prolonged mechanical ventilation, the compliance of the lungs gradually decreases. This occurs as a result of obstructive atelectasis of the lungs due to a violation of the drainage function of the respiratory tract, ventilation and nerfusion, filtration according to the absorption ratio, as well as destruction of the surface active substance- surfactant. Long-term mechanical ventilation leads to the formation of atelectasis caused by disturbances in the drainage function of the bronchi and surfactant metabolism.

With mechanical ventilation based on the principle of insufflation, the suction effect of the chest, which provides a significant part of the venous return during natural inhalation, is disrupted. Since the pressure in the pulmonary capillaries is normally 10-12 mm Hg. Art., mechanical ventilation with higher. inspiratory pressure inevitably disrupts pulmonary blood flow. Displacement of blood from the lungs into the left atrium during artificial respiration and opposition to the ejection of the right ventricle of the heart introduce a significant imbalance in the functioning of the right and left halves of the heart. Therefore, disturbances in venous return and a decrease in cardiac output are considered one of the common complications of mechanical ventilation in the circulatory system.

In addition to the effect on the circulatory system, mechanical ventilation can lead to the development of severe respiratory alkalosis or acidosis (due to an inadequately chosen regimen: hyper- or hypoventilation, respectively). Complications of mechanical ventilation include prolonged annoea during the transition to spontaneous ventilation. It usually results from abnormal stimulation of lung receptors that suppress physiological reflexes.

During manipulations (suction, changing the endotracheal tube, tracheotomy cannula, sanitation of the tracheobronchial tree), acute hypoxemia with hypotension and subsequent cardiac and respiratory arrest may develop. During the genesis of such cardiac arrest in patients, respiratory and cardiac arrest can occur with a rapid decrease in pressure. For example, in response to hyperventilation after sanitation of the tracheobronchial tree.

Consequences of long-term tracheal intubation and tracheostomy. The group of complications of mechanical ventilation is pathological processes associated with prolonged stay in the respiratory tract of endotracheal or tracheotomy tubes. In this case, fibrinous hemorrhagic and necrotic laryngotracheo-bronchitis can develop (Fig. 59; see illustration). bedsores, bleeding from the respiratory tract. Tracheobronchitis occurs in 35–40% of patients undergoing mechanical ventilation. A high frequency of their occurrence was noted in patients. in a comatose state. In more than half of the patients, tracheobronchitis is detected on the 2nd 3rd day of mechanical ventilation. At the site of the cuff or the end of the endotracheal tube, areas of necrosis of the mucous membrane may develop. They are detected during fibrobronchoeconia when changing tubes in 12-13% of patients with long-term mechanical ventilation. Deep bedsore the wall of the trachea can itself lead to other complications (tracheoesophageal fistula, tracheal stenosis, bleeding from arrosive vessels) (Kassil V.L., 1987).

Barotrauma of the lungs. With an excessive volume of ventilation and desynchronization with the ventilator, pulmonary barotrauma can develop with overextension and rupture of the alveoli, with the occurrence of hemorrhages in the lung tissue. Manifestations of barotrauma can include bullous or interstitial emphysema, tension pneumothorax, especially in patients with inflammatory-destructive lung diseases.

In conditions of mechanical ventilation, pneumothorax is a very dangerous complication, since it always has the character of a tense and rapidly growing one. Clinically, this is manifested by asymmetry of respiratory movements, a sharp weakening of breathing on the side of the pneumothorax, as well as severe cyanosis. The latter is caused not only by impaired oxygenation due to collapse of the lung, but also by central venous hypertension in response to the bending of the vena cava when the mediastinum is displaced in the opposite direction. At the same time, the inspiratory resistance to the ventilator increases significantly. The radiograph shows air in the pleural cavity, collapse of the lung and displacement of the mediastinum.

In some patients, pneumothorax is accompanied by the development of mediastinal emphysema. V. L. Kassil (1987) describes a rare situation when, on the contrary, due to insufficient sealing between the tracheostomy cannula and the tracheal wall, air during artificial inspiration can penetrate into the mediastinum, and subsequently break through the mediastinal pleura into one or both pleura cavities. In the latter case, bilateral pneumothorax develops.

Excessive ventilation can lead to mechanical desquamation of the tracheobronchial epithelium. At the same time, fragments of the epithelium of the tracheobronchial tree can be detected histologically in the alveoli of patients who underwent mechanical ventilation in the mode of excessive hyperventilation.

Consequences of hyperoxic and drying effects of oxygen. It should be borne in mind that breathing 100% oxygen, especially for a long time, leads to hyperoxic damage to the epithelium of the tracheobronchial tree and alveolar capillary membrane, followed by diffuse sclerosis of the lungs (Matsubara O. et al., 1986). It is known that oxygen, especially in high concentrations, dries out the respiratory surface of the lungs, which is advisable for cardio pulmonary edema. This is due to the fact that after drying, the protein masses “stick” to the respiratory surface, catastrophically increasing the diffusion path and even stopping diffusion. In this regard, the oxygen concentration in the inhaled air should not exceed 40-50% unless absolutely necessary.

Infectious complications of mechanical ventilation. Among infectious processes associated with mechanical ventilation, laryngo- and tracheobronchitis are often encountered. But according to V.L. Kassil (1987), 36-40% of patients on mechanical ventilation develop pneumonia. In gepes inflammatory lesions In the lungs, infection, including cross infection, is very important. During bacteriological examination of sputum, staphylococcal and hemolytic flora, Pseudomonas aeruginosa and microbes are most often sown intestinal group in various associations. When taking samples at the same time from patients. patients in different rooms, the flora in the respiratory tract is usually the same. Unfortunately, infection of the lungs through ventilators (for example, the “RO” family) contributes to the occurrence of pneumonia. This is due to the impossibility of completely disinfecting the internal parts of these devices.

Most often, pneumonia begins on the 2-6th day of mechanical ventilation. It is usually manifested by hyperthermia up to 38 °C, the appearance of crepitus and moist fine bubbling rales in the lungs, shortness of breath, and other symptoms of hypoxemia. An x-ray reveals an increase in the vascular pattern, focal darkening in the lungs.

One of serious complications And VL through a mask is the inflation of the stomach with air. Most often this complication occurs when using high blood pressure during mechanical ventilation in conditions of partial or complete airway obstruction. As a result, air forcefully enters the esophagus and stomach. Significant accumulation of air in the stomach not only creates the preconditions for regurgitation and limits the functional reserves of the lung, but can contribute to the development of rupture of the stomach wall during resuscitation.

701) Do all patients who undergo artificial ventilation experience difficulties in resuming spontaneous breathing?

Many patients who require short-term artificial ventilation lungs, can restore spontaneous breathing without much difficulty.

Before extubation, the patient's ability to breathe spontaneously through a T-tube or respiratory circuit should be assessed. Although breathing through the ventilator's breathing circuit may increase the patient's work of breathing and is therefore not recommended.

702) What is “weaning” from mechanical ventilation?

The process of stopping mechanical ventilation is usually called weaning by intensive care unit workers in everyday professional language. In the strict sense of the word "weaning" is a gradual reduction in respiratory support, while the patient gradually takes over all most work of breathing. However, the term is usually used more broadly to refer to all methods of stopping mechanical ventilation. In accordance with general practice this concept is used in this book to describe the entire process of withdrawal of respiratory support, rather than the slow and gradual transition of the patient to spontaneous breathing.

703) Explain the place of “weaning” from mechanical ventilation in general process treatment of respiratory failure. What determines the successful transition of a patient to spontaneous breathing and what are the parameters that predict the success of “weaning”?

Most patients can be easily weaned off mechanical ventilation, but there are many patients who have significant difficulties. This group of patients drives too much of the healthcare sector's costs and poses enormous clinical, economic and ethical challenges. The main determinants of the results of "weaning" are the adequacy of pulmonary gas exchange, the function of the respiratory muscles and psychological condition sick. The ratio of respiratory rate to tidal volume is the most reliable parameter for predicting outcome.

704) Name the conditions under which immediate cessation of artificial ventilation and rapid extubation of the trachea are possible.

Immediate cessation of mechanical ventilation followed by rapid extubation of the trachea can be safely performed in the majority of postoperative patients. It is important to ensure that the patient is able to maintain a patent airway without an endotracheal tube and maintain spontaneous breathing. Quantitative physiological parameters help predict the likelihood of weaning success and this is discussed in the related questions.

705) How difficult is it to stop respiratory support? How important is it to choose the right time to begin “weaning” from mechanical ventilation?

Cessation of respiratory support is difficult in approximately 20% of patients, and the main reasons are dysfunction of the respiratory muscles as a result of a mismatch between the respiratory load and the ability of the respiratory muscles to withstand it, deterioration of oxygenation and psychological factors. This procedure is easy in patients who required short-term support, but can be quite problematic in patients recovering from severe acute respiratory failure. Weaning these patients off the respirator is sometimes a significant clinical challenge and accounts for the majority of the workload in the intensive care unit. Beginning the weaning process requires careful timing: if it is unnecessarily delayed, the patient is at risk of complications associated with mechanical ventilation, and premature initiation of weaning carries the risk of serious cardiopulmonary decompensation, and extubation will be delayed even more.

706) Are paradoxical contractions of the abdominal wall muscles and frequent shallow breathing reliable indicators of respiratory muscle fatigue? Is muscle fatigue the cause of unsuccessful weaning?

In the past, a paradoxical reduction abdominal muscles during inspiration and frequent shallow breathing were considered signs of fatigue of the respiratory muscles. Accordingly, it was believed that the latter is common cause unsuccessful "weaning". Recent studies have shown that fatigue is neither a necessary nor a sufficient condition for the development of pathological movements of the thoracic and abdominal walls or frequent shallow breathing. However, the presence of a connection between fatigue and the pathological nature of breathing does not exclude fatigue from among the reasons for unsuccessful “weaning”. Unfortunately, we simply do not know whether muscle fatigue actually occurs in patients with these features, and if so, how important it is in determining clinical outcome.

707) Which factor needs to be assessed before tracheal extubation?

In addition to the patient's ability to sustain spontaneous breathing without undue effort, the patient's ability to protect his upper airway and cough up secretions must also be assessed before tracheal extubation. Patients who can tolerate spontaneous ventilation without extreme strain may have difficulty post-extubation due to upper airway obstruction, inability to prevent aspiration, or to clear secretions. Unlike many of the parameters that have been proposed to predict weaning outcomes, metrics to reliably predict the likelihood of complications after extubation have not been developed and rely on clinical factors such as level of consciousness, amount of secretions, and the patient's ability to cough.

708) What criteria are used to determine the optimal time to remove the endotracheal tube (extubation) after weaning off respiratory support is completed?

Patients with upper respiratory tract obstruction, excessive secretion in the airways and a weakened or absent pharyngeal reflex (with high risk massive aspiration of food or stomach contents) may require continued tracheal intubation even after interruption of artificial ventilation. If such disorders are absent, it is recommended to check spontaneous breathing using a T-tube before extubation. Because swallowing function may be impaired for several hours or days after tracheal extubation, caution is recommended when feeding these patients orally.

709) How can you predict the success of extubation in an intubated patient who does not have respiratory distress after cessation of respiratory support?

If the patient does not gag in response to vigorous pressing of the tongue back wall oropharynx, this is often considered a contraindication to tracheal extubation. However, this reflex is absent in approximately 20% healthy people, and aspiration pneumonia can still develop even when the pharyngeal reflex is preserved. The ability to cough is important because the expulsive forces that accompany coughing can normally clear the airways down to the level of the medium-sized bronchi. The cough reflex can be tested by stimulating the patient's airway with a suction catheter. The patient should be closely monitored for some time after extubation to determine whether reintubation of the trachea is necessary.