In medical settings and at home, there are patients whose sputum and mucus block the path of air movement necessary for breathing. In some cases, these secretions can accumulate in the nose, mouth, larynx and trachea.

If the evacuation of secretions from the oral cavity can be performed by mechanically emptying the respiratory tract with a napkin placed on a finger or spatula, then it is almost impossible to perform a similar mechanical emptying of the nose, larynx and trachea.

This problem is especially relevant for patients with strokes and impaired swallowing function, with other neurological pathologies, and after a number of surgical interventions. In this regard, the most correct would be to use devices that aspirate (suck out) sputum.

Currently, the range of such devices is quite large. One example is the ATMOS series aspirators, which can be used in a medical organization and at home. These devices have small overall dimensions and weight, the ability to operate on mains or battery power, and a high aspiration rate ranging from 16 to 25 l/min.

Carrying out the aspiration procedure requires special and fairly simple training of the nurse and/or the patient’s relatives. It is advisable to perform the first aspiration procedures on a particular patient not by one, but by two medical workers, in order to be able to warn the patient about possible unpleasant sensations, support and reassure him, and give him the opportunity to adapt.

If necessary, one medical worker will be able to perform the aspiration procedure, and the second will measure pulse, blood pressure, support the patient during manipulation, etc.

The causative factors leading to an increase in the population of patients with tracheostomies are combined injuries of the hollow organs of the neck, post-intubation stenosis of the larynx and trachea, various surgical interventions on the organs of the neck, malignant neoplasms of the upper respiratory tract, severe somatic diseases that impair vital functions - breathing and digestion, requiring prosthetics of the respiratory and digestive tracts.

Despite the successes of laryngeal-tracheal surgery, a significant number of patients remain forced to use a tracheostomy permanently due to the impossibility or ineffectiveness of surgical restorative treatment.

The presence of a tracheostomy is a source of danger for the patient, and in the absence of proper care and medical monitoring it can pose a direct threat to life. In tracheostomized patients, along with aspirations, in some cases, periodic replacement of tracheostomy tubes and their cleaning are required.

Nasotracheal and orotracheal aspiration

Target: freeing the patient’s nose, mouth and trachea from mucus and sputum that interfere with normal breathing.

Indications: impaired evacuation of mucus and sputum from the respiratory tract.

Possible complications

Will be required: vacuum suction (aspirator), sterile suction catheter, gloves (sterile for the hand that handles the sterile catheter), garbage bag, protective mask, safety glasses, disposable apron, gown, sodium chloride solution 0.9%, sterile gel - lubricant (for example, “Katedzhel”), a garbage bag, and, if necessary, a nebulizer for subsequent inhalation.

• The patient is placed in a “sitting” or “half-sitting” position (half-Fowler position), the essence of the procedure is explained to him, instructions are given on how to behave, and attention is drawn to the fact that each aspiration takes no more than 10-15 seconds and is not dangerous. If necessary, removable dentures can be temporarily removed.

• Ask the patient to take 5 deep breaths, using oxygen if possible.

• A lubricating gel should be applied to the tip of the catheter to improve the passage of the catheter into the patient’s nose and mouth, while inhaling, insert the catheter into the mouth, and later into the patient’s nose (if nasal breathing is difficult and the mouth is filled with mucus, the patient may be afraid that he will suffocate, so they begin aspiration from the oral cavity) to a depth no more than the distance from the tip of the nose to the earlobe of this patient and turn on the aspirator.

• Remove the catheter using rotating movements without stopping aspiration, while trying not to touch the palate, uvula, or tongue of the patient, so as not to cause nausea and vomiting.

• Auscultate the lungs to ensure that breathing is being carried out to all parts of the lungs. If a patient with obstructive pulmonary disease develops dry wheezing, it can be recommended to inhale a bronchodilator solution through a nebulizer.

Tracheostomy aspiration

Target: freeing the lower part of the larynx and trachea of ​​a patient with a tracheostomy from mucus and sputum that interfere with normal breathing.

Indications: impaired evacuation of mucus and sputum from the respiratory tract in a tracheostomized patient.

Possible complications: bleeding from the nose or nasopharynx, damage to the trachea, hypoxia, cardiac arrhythmia (including bradycardia or tachycardia), suffocation, nausea, vomiting, cough, infection in the respiratory tract.

Will be required: vacuum suction (aspirator), sterile suction catheter, gloves (sterile for the hand that handles the sterile catheter), garbage bag, protective mask, safety glasses, disposable apron, gown, sodium chloride solution 0.9%, sterile gel -lubricant (for example, “Katedzhel”), a garbage bag, if necessary, a nebulizer for subsequent inhalation and a pressure gauge for monitoring the air in the cuff of the tracheostomy tube.

Algorithm for performing the manipulation

• The patient is placed in a “sitting” or “half-sitting” position (half-Fowler position), the essence of the procedure is explained to him, instructions are given on how to behave, and attention is drawn to the fact that each aspiration takes no more than 10-15 seconds and is not dangerous.

• The medical worker or the patient’s relative wears a gown and/or a disposable apron, disposable gloves, a mask, and safety glasses.

• The suction catheter is connected to the aspirator, the aspirator is set to a suction power of 80-120 mmHg. Art. or up to 0.4 Bar in adults and up to 0.2 Bar in children and adolescents.

• Place a few drops of 0.9% sodium chloride solution into the tracheostomy tube to liquefy the secretions.

• Insert the tip of the catheter to a depth of no more than the length of the tracheocanula.
• Remove the catheter using a rotating motion without stopping suction.
• If necessary, repeat aspiration using a different catheter to prevent spread of infection.
• Encourage the patient to rinse their mouth with water or mouthwash.
• After aspiration, rinse the hose system with an antiseptic solution.
• Estimate the volume of the aspirate and record it in a temperature sheet or patient observation diary.

• Auscultate the lungs to ensure that breathing is being carried out to all parts of the lungs. If a patient with obstructive pulmonary disease develops dry wheezing, it can be recommended to inhale a bronchodilator solution through a nebulizer connected to a tracheostomy tube.

• Remove the disposable apron, mask, gloves, and wash your hands.

Cleaning the tracheocanula

Target: cleaning the tracheocanula from mucus, sputum, blood for its further use.

Indications: contamination of the tracheocanula with mucus, sputum, blood and other foreign components, creating conditions for disrupting the movement of air through it.

Possible complications

Will be required: spare tracheocannula (in case of damage to the tracheocannula that needs to be replaced), a cleaning container, a brush (brush) for cleaning, an antiseptic, oil or ointment for tracheostomy, a tap with running water.

Algorithm for performing the manipulation

• Remove the tracheocannula using running water and a brush to remove surface contamination.

• Place the internal and external tracheocannulas in a container with an antiseptic cleaning solution and leave them for 10 minutes.

• Rinse the cannulas of the cleaning solution under running water.
• Treat the tracheostomy with tracheostomy oil or ointment.
• Place the cannula into the stoma.

• If bleeding occurs as a result of trauma to the trachea due to inaccurate manipulations, it is advisable to consult the patient with an otolaryngologist. If the bleeding is profuse, then before examination by a specialist, the patient is placed on his stomach with the head end down to prevent blood from entering the bronchial tree.

• If suffocation occurs during the installation of a tracheostomy, it is advisable to ask the patient to cough in order to eliminate the phenomenon of blockage of the airways; if coughing does not bring a positive result, then the internal cannula must be removed to check its patency.

• Wash your hands.

Replacing the tracheocanula

Target: changing a tracheocanula that has become unusable.

Indications: tracheocanula is unsuitable for further use.

Possible complications: bleeding from the trachea, damage to the trachea, blockage of the tracheostomy tube and the development of hypoxia.

Will be required: tracheocanula, fixing bandage, sterile tracheostomy napkins (1-, 2- or 3-layer), 10 ml syringe, oil or ointment for tracheostomy, 0.9% sodium chloride solution, gauze napkins.

Algorithm for performing the manipulation

• The patient is placed in a “sitting” or “half-sitting” position (half-Fowler position), the essence of the procedure is explained to him, and instructions are given on how to behave.

• At the first stage, to ensure patency of the airway while changing the cannula, aspiration of the airway is performed.

• The cannula is removed. If it is blocked, then careful attempts are made to remove the block and remove the cannula.

• The tracheostomy is cleaned with sterile wipes soaked in 0.9% sodium chloride solution or special wipes for cleaning tracheostomy.

• It is necessary to check the reliability of the tracheostomy cannula so that it does not fall out of the stoma, but is removed only when necessary.

• To replace the cannula, sterile napkins with a Y-shaped incision are inserted under its ears. Oil or ointment for treating the tracheostomy tube is placed on the surface of the cannula. You need to stretch and hold the tracheostomy opening with two fingers, then insert the cannula, following its curves and being careful. Attach the fixing ties to the neck and check the fixation of the cannula. The bandages securing the cannula should be stretched between the skin of the neck and the ties so that 1 finger can be inserted.

• Wash your hands.

Thus, carrying out nasotracheal, orotracheal and tracheostomy aspiration using special devices, as well as caring for a tracheostomy, are integral skills that a nurse can teach to the patient’s relatives who provide care at home.

The rehabilitation of the bronchial tree must be approached in a comprehensive manner. There are several methods of sanitation:

· Therapeutic bronchoscopy.

· Endobronchial infusion.

· Inhalation.

· Postural drainage.

1. Bronchoscopy for therapeutic purposes. Therapeutic bronchoscopy at the present stage is the main method of sanitation of the bronchial tree, as it has a number of advantages over other methods. During the procedure, the following steps are carried out sequentially: aspiration of bronchial contents and administration of medicinal substances that have a direct effect on the bronchial microflora and dilute sputum, facilitating its expectoration. Bronchoscopy for therapeutic purposes should be performed only in cases where conservative therapy is ineffective, i.e. at the stage of treatment when mucus production exceeds the evacuation capabilities of the respiratory tract, which leads to obstruction of the bronchi, and then to infection and suppuration in them.

Therapeutic bronchoscopy can be performed with a fiberoptic bronchoscope (Fig. 1) under both local and general anesthesia. For sanitation of the bronchial tree in adults, fibrobronchoscopy (FBS) under local anesthesia is more often used. It is carried out in the bronchoscopic room, but can also be performed in other rooms, including in the case of a serious condition of the patient directly in the ward.

Rice. 1. Bronchoscope

Inspection and sanitation of the bronchi usually begins on the side where the pathology is supposedly less pronounced, and ends with the area of ​​the main lesion. Toilet of the bronchial tree includes careful sequential aspiration of contents from the lobar and segmental branches, washing them with an indifferent or antiseptic solution, and administration of medicinal substances.

For the sanitation of single decay cavities or limited foci of inflammation in the lung can be used therapeutic catheterization of the bronchi, performed during bronchoscopy or as an independent method. Under the control of FBS it is possible to produce microtracheocentesis, during which a thin catheter is injected into the tracheobronchial tree percutaneously for long-term and frequent (2-4 times a day) instillation of medicinal substances.

The choice of drugs for endobronchial administration depends on the nature of the inflammatory process; they can be divided into the following groups:

· Antimicrobials. Endobronchial administration helps create high concentrations of the antibiotic directly at the lesion site with a relatively low content in the blood, which reduces the possibility of developing toxic reactions. At the same time, other routes of administration retain their importance, that is, combined administration of antibiotics is used, taking into account the compatibility of the drugs.

Before treatment begins, sputum is collected for bacteriological examination, then secretion is aspirated, followed by bronchial lavage. The choice of antibiotic depends on the sensitivity of the microbial flora. For therapeutic bronchoscopy, gentamicin 160 mg, ceporin 0.5 g, lincomycin 0.5 g, polymyxin M 0.25 g and other antibiotics are used. The same antibiotics in the above doses are used for other methods of endobronchial administration.

In severe cases of the disease, complicated by bronchiectasis, and in the presence of purulent bronchitis, a comprehensive method of sanitation of the bronchial tree is most effective. In this case, bronchoscopic sanitation is carried out periodically (about once a week), and in the intervals between bronchoscopy, an antibiotic is administered endotracheally through a rubber catheter every other day. Inhalation therapy is carried out on days free from bronchoscopy and endobronchial sanitation through a catheter. The number of bronchoscopy for various diseases ranges from 3-4 to 11-12.

· Antiseptics. In addition to antibiotics for endobronchial administration, 5-10 ml of a 1% solution of dioxidin, a solution of furatsilin 1:5000, and a 0.1% solution of furagin are used as the main active ingredients. In addition, antiseptic solutions are used to wash the bronchi before administering other medications. This procedure is carried out by repeated instillations of 10-15 ml followed by aspiration. The total amount of fluid administered can vary from 40 to 100 ml depending on the amount of sputum.

· Mucolytics used to reduce the viscosity of bronchial secretions. For endobronchial administration, trypsin, chymotrypsin, RNase, DNase are used in an amount of 25-50 units. Before instillation, enzymes are dissolved in 3 ml of isotonic sodium chloride solution. Proteolytic enzymes also have anti-inflammatory properties and increase the sensitivity of microflora to antibiotics.

Acetylcysteine ​​has a pronounced mucolytic effect. A 5-10% solution is administered endobronchially in an amount of 3-10 ml.

· Bronchodilators. Currently, three main groups of bronchodilators are used: adrenomimetics, anticholinergics and methylxanthines. Endobronchially, 1 ml of a 5% ephedrine solution and 5-10 ml of a 2.4% euphilin solution are often instilled.

2. Endobronchial administration using a rubber catheter(Nelaton catheter).

This method is especially recommended for complications of bronchiectasis and the presence of widespread purulent bronchitis. The procedure is performed under local anesthesia. The first stage - in a sitting position, the nose and nasopharynx (up to the glottis) are anesthetized with a 0.5% dicaine solution. In this case, the patient must breathe correctly: inhale through the nose, exhale through the mouth. When inhaling, a 0.5% solution of dicaine is first instilled into the nostril, which has the best patency, and then a full pipette is poured, which is evenly distributed over the mucous membrane and reaches the glottis. After 5-7 minutes, when anesthesia sets in (this is determined by a feeling of awkwardness in the throat), the catheter is advanced through the corresponding nostril to the glottis, and then, with a deep inhalation, it is pushed through the glottis into the trachea. This is determined by the appearance of hoarseness. 3-5 ml of a mixture consisting of 1-2 ml of 0.5% dicaine solution and 2-3 ml of 10% novocaine solution is poured into the trachea. After this, the cough goes away. First, the bronchi are washed; for this, 10-12 ml of physiological solution or 3% soda solution, furatsilin solution 1:5000, 0.1% furagin solution are injected through the catheter. After this, the bronchial contents are aspirated using an electric suction. This bronchial lavage is performed up to 8-10 times or more. In a bilateral process, bronchial lavage is carried out sequentially on both sides. The procedure is completed by filling with antibiotic. The administration is repeated every other day, for a course of treatment - 8-12 procedures.

3. Inhalation method. The preferred inhalation technique is the use of a nebulizer (Fig. 2): no forced inspiratory maneuvers are required, good coordination of the patient's inhalation with the release of the drug is ensured, and a more significant supply of the drug into the respiratory tract is achieved. In addition, longer inhalation when using a nebulizer (about 10-12 minutes) guarantees greater effectiveness of the drug, since the barrier created by sputum between the drug and the receptors is more successfully overcome. The combination of a nebulizer and compressor has a number of advantages over an ultrasonic nebulizer. When using a nebulizer, better dispersion is achieved, in which the inhaled drug penetrates into smaller respiratory tracts; In addition, the ultrasonic inhaler slightly heats the drug, which can change the properties of the antibiotic.

Rice. 2. Nebulizer

Antibiotics, mucolytics, bronchodilators, antiseptics, etc. are used for inhalation. Aerosol inhalation antibiotics carried out 2 times a day for 10-12 days. More often, daily inhalations of gentamicin at a dose of 80-160 mg/day and a special sulfate-free form of tobramycin in large doses (300 mg 2 times a day) are used, which allows achieving maximum concentrations of the drug in sputum.

As mucolytics Usually N-acetylcysteine ​​(ACC, mucosolvin) and ambroxol (lasolvan) are used. ACC is usually prescribed 300-400 mg 2-3 times a day, ambroxol - 30 mg 3 times a day.

Nebulizers make it possible to inhale large doses at once bronchodilators. Typically β 2 -agonists and anticholinergics are used. Of the β 2 -agonists, the effects of salbutamol (Ventolin) and fenoterol (Beroteca) have been better studied. A single dose of salbutamol for nebulization is 2.5-5 mg, fenoterol - 0.5-0.75 mg, frequency of inhalations up to 4 times a day. The only available anticholinergic drug for nebulization today remains ipratropium bromide (Atrovent). The usual inhalation dose when administering the drug via nebulizer is 0.5 mg every 6-8 hours.

4. Postural (positional) drainage. When performing postural drainage, the patient takes a position that ensures the separation of secretions from the affected bronchi. Thus, with the most common localization of bronchiectasis in the basal segments, the patient in the prone position hangs the head end of the body from the bed at an angle of 40-45%. The effectiveness of postural drainage increases significantly with the simultaneous administration of expectorants and mucolytics, breathing exercises and chest massage. The procedure is carried out at least 2-3 times a day.

An alternative to traditional postural drainage is a recently proposed method high-frequency compressions (oscillations) of the chest using special devices.

Literature

1. Avdeev S. N. Use of nebulizers in clinical practice // Russian Medical Journal. - 2001. - No. 5. - pp. 189-196.

2. Saperov V.N. Practical pulmonology: Textbook. allowance / V. N. Saperov, I. I. Andreeva, G. G. Musalimov. - Cheboksary: ​​Chuvash Publishing House. Univ., 2006. - 658 p.

3. Smirnova M. S., Kuznetsov A. N., Menkov N. V. Inhalation therapy in pulmonology: Textbook. - Nizhny Novgorod: From the Nizhny Novgorod State Medical Academy, 2003. 102 p.

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3.3. THERAPEUTIC ENDOSCOPY

The therapeutic value of endoscopic methods is somewhat inferior to their role in the diagnosis of diseases of the chest organs. However, at present, complex therapy for most inflammatory and obstructive diseases of the respiratory system can hardly be considered complete without the use of one or another endoscopic intervention. Patients with acute and chronic suppuration of the lungs, for whom surgical treatment is indicated, often require lengthy preoperative preparation, which is carried out by endoscopic sanitation of purulent foci. When complications develop in the postoperative period, indications for therapeutic endoscopy often arise. In some cases, endoscopic treatment plays a major role and is the only effective way to treat patients. Most often, bronchoscopy is used for this purpose, and less often, thoracoscopy in its modern versions.

SANATION OF THE BRONCHICS IN CHRONIC BRONCHITIS

The importance of therapeutic bronchoscopy becomes obvious when we consider the role that bronchial inflammation plays in the development of most chronic inflammatory lung diseases. Long-term research by I.E. Esipova (1976), G.I. Nepomnyashchikh (1978), T. Knowsp (1951), B. Yasin (1963), N. Oz showed that one way or another, primary or secondary, the bronchial system is involved in the pathological process in all types of bronchopulmonary inflammation. In this case, first of all, the evacuation, cleansing function of the bronchi suffers, and with an increase in contents in the respiratory tract, ventilation and gas exchange are disrupted. In this regard, the need for measures aimed at maintaining and restoring bronchial patency, as well as the mechanism of self-cleaning of the bronchi, is obvious. Naturally, these measures cannot be reduced only to bronchoscopy. It is advisable to resort to it only in those situations when conservative therapy, the general principles of which for diseases of the bronchopulmonary system are described by B.E. Votchal (1965), D. M. Zlydnikov (1969), V. I. Struchkov et al. (1973). N.V. Putov and G.B. Fedoseev (1978), turns out to be ineffective, i.e. at the stage when mucus production exceeds the evacuation capabilities of the respiratory tract and obstruction of the bronchi develops, and then suppuration in them.
The therapeutic effect of bronchoscopy for chronic inflammation of the bronchial system depends on two main points: aspiration of bronchial contents and the administration of medicinal substances that have a direct effect on the bronchial microflora and dilute sputum to facilitate its spontaneous removal. With the development of granulations and ulcerations of the mucous membrane in parts of the bronchial tree accessible to bronchoscopic instruments, their direct treatment is advisable. However, such changes are more common in tuberculosis of the respiratory tract, so the frequency of use of mechanical action in the bronchi during their nonspecific inflammation is relatively low.
It should be noted that, just as in the diagnosis of lung diseases, although to a slightly lesser extent, the progress of bronchoscopic treatment methods is currently due to the creation of the bronchofibroscope, which has turned therapeutic bronchoscopy under local anesthesia into a relatively safe procedure that is easily tolerated by patients. Currently, various methods and schemes of “bronchoscopy therapy” are used. Let's list some of them.

Sanitation bronchofiberscopies and intrabronchial installations under local anesthesia.

Manipulations are performed primarily in a transnasal manner, in which the patient can freely cough, spitting out sputum and medicinal solutions injected into the bronchi. After anesthesia of the mucous membrane of the bronchial tree and its examination, the contents of the bronchi are removed through the lumen of the bronchofiberscope using a vacuum suction, bringing the distal end of the flexible tube directly to the accumulations of sputum. To facilitate aspiration through the biopsy channel, 10 ml of a warm 1% solution of furagin potassium salt (furagin dissolved with sodium chloride) is first injected into the bronchial lumen with the addition of 1-3 ml of a mucolytics solution (cysteine, mistabron, mucosolvin).
In case of diffuse bilateral bronchitis with abundant hypersecretion, repeated instillations of the above-mentioned drugs are performed, introducing them through a catheter into the mouth of each lobar bronchus, and then aspirating the bronchial contents under visual control. At the time of fluid administration, the patient is asked to hold his breath, and during aspiration, to clear his throat. During one of the bronchofibroscopy, depending on the degree and extent of endobronchitis, the bronchi are washed with 20-80 ml of liquid. Before removing the bronchofibroscope, proteolytic enzymes, mucolytics and antibiotics are installed into the lumen of the bronchi (taking into account the nature of endobronchitis and the sensitivity of the microflora). In the presence of purulent sputum with an ichorous odor, instillations of 5-10 ml of 0.5-1% dioxidine solution are used. In patients with a bronchospastic component, 10 ml of a 2.4% aminophylline solution is added to intrabronchially administered solutions. After the procedure, the patient is placed for 5-7 minutes alternately on the right and left side, and then asked to actively cough. The course of treatment consists of 5-20 bronchofiberscopies, depending on the nature of the pathology and the effect of the therapy. The procedures are repeated every other day, and if well tolerated - daily, including on an outpatient basis.

Sanitation bronchoscopy under anesthesia.

The procedure is performed using a rigid bronchoscope according to the generally accepted technique. They begin by removing the contents from the visible parts of the bronchi using a rigid aspirator, after which the most affected parts of the bronchial tree are washed with a 1% solution of furagin K, making repeated instillations of 10-15 ml, followed by aspiration. The total amount of fluid administered ranges from 40 to 80-100 ml, depending on the severity of endobronchitis and the amount of sputum. According to indications, as well as during therapeutic bronchofibroscopy, antibiotics, dioxidine, mucolytics, and proteolytic enzymes are injected into the bronchi. The procedures are repeated at intervals of 2-3 days. The duration of the course of treatment is determined by the number of bronchoscopy required to relieve the inflammatory process - from 3-4 to 11-12.
Combined sanitation therapy. Therapeutic bronchoscopy is performed under anesthesia and bronchoscopy is performed under local anesthesia in the intervals between them. At the beginning of the course of treatment, endobronchial procedures are carried out daily, and after the patient’s condition improves and the symptoms of endobronchitis subside - at increasing intervals. On average, for every two to three bronchoscopy performed under anesthesia, there are five to eight bronchofiberscopies. In the absence of a bronchofiberscope, sanitation bronchoscopy, which is performed under anesthesia, can be successfully combined with intrabronchial installations of medicinal solutions using a laryngeal syringe [Molodtsova V.P., 1978].
A comparative study of the effectiveness of various types of bronchoscopic therapy in 179 patients with chronic bronchitis showed that a course of treatment using a rigid bronchoscope under anesthesia for non-purulent forms of the disease gives positive results in 86.6% of cases, therapeutic bronchofibroscopy under local anesthesia and combination therapy are equally effective - 78.4% and 85.7%, respectively. In purulent forms of chronic bronchitis, rigid bronchoscopy leads to success in 73.3% of cases, bronchofibroscopy in 86.7%, and their combination in 94.4%.
The use of bronchofibroscopy during the treatment of chronic bronchitis made it possible to intensify bronchoscopic sanitation by changing treatment regimens. In all likelihood, the frequency of sanitary bronchoscopy at intervals of 2-3 days or more, recommended earlier, is declared not so much by the true need for such episodic removal of bronchial contents, and especially the introduction of antibacterial drugs, as by the possibilities of patients who cannot withstand more frequent repetitions of “hard » bronchoscopy.
Daily intrabronchial administration of antibiotics and mucolytics in the form of aerosols in the intervals between bronchoscopy compensates for this deficiency to some extent. However, aerosols, even ultrasonic ones, as studies by V.P. show. Molodtsova (1978), are ineffective for purulent bronchitis with pronounced bronchial secretion.
The treatment effect increases significantly with a combination of bronchoscopy and daily intrabronchial installations of medicinal solutions, and to an even greater extent when using bronchofibroscopy. Bronchofibroscopy, which requires local anesthesia and which differs little in its burdensome effect on the patient from intrabronchial instillation using a laryngeal syringe or transnasal catheter, has broader capabilities, since it allows not only the targeted administration of drugs, but also a thorough, visually controlled toilet of the bronchial tree. The advantages of performing sanitation bronchofibroscopy under local anesthesia also include: that the patient may actively cough up at the time of aspiration of the contents of the bronchi, as a result of which sputum is removed from the deeper parts of the bronchial tree. Finally, bronchofiberscopy under local anesthesia allows you to conduct courses of therapeutic bronchofiberscopies on an outpatient basis or to begin treatment started in a hospital in a clinic with significantly less risk than when using general anesthesia.

Effective treatment of chronic bronchitis requires the widespread use of various methods of endobronchial sanitation and aerosols of drugs. The simplest endobronchial sanitation is using a laryngeal syringe or a rubber catheter inserted through the nose.

Endotracheal infusions with a laryngeal syringe are performed with or without a laryngeal speculum. In persons with an increased gag reflex, the mucous membrane of the root of the tongue is anesthetized. The procedure is performed with the patient sitting. The patient uses a gauze pad to pull his tongue anteriorly; 3 - 5 ml of solution is injected behind the root of the tongue, and with visual control - more precisely into the larynx during inspiration.

If infusions are carried out without visual control, then the criterion for the effectiveness of the procedure is the appearance of a cough immediately after the infusion. The number of infusions is determined by the effectiveness of the procedure, the amount and purulence of sputum, usually 30 - 50 ml of an indifferent heated solution (isotonic sodium chloride solution, weak furatsilin solution) is infused.

The procedure is carried out daily. Infusion with a laryngeal syringe is a good method of bronchial drainage. After coughing up sputum, drugs can be administered, but the effectiveness and feasibility of such drug administration are questionable.

When infusing solutions through a rubber catheter, the mucous membrane of the nose, pharynx and larynx is anesthetized with a solution of novocaine, dicaine, trimecaine or Hirsch's mixture, instilling them with a pipette through the nose while inhaling. The patient notes a feeling of numbness and a lump in the throat.

A catheter, the tip of which is lubricated with oil, is passed through the nose shallowly into the trachea while inhaling. When inserted correctly, a feeling of “failure” of the catheter, disturbances in phonation, coughing and a strong stream of air from the peripheral end of the catheter when coughing are characteristic.

The patient fixes the catheter near the nose with his fingers. It is convenient to use a 20 gram syringe. Usually a heated solution of furatsilin 1:5000 is used, introducing it in small portions of 3 - 5 ml during inhalation (50 - 150 ml in total), which is coughed up along with sputum during the washing process. The procedure is performed daily.

In case of obstructive syndrome, it is advisable to pre-use bronchodilators. Complications may include minor hemoptysis and allergic reactions to anesthetic solutions (which requires careful history taking and the use of appropriate tests).

The method is very effective, especially for viscous and purulent sputum. The viscosity of sputum decreases, as well as its purulence and quantity, until it disappears completely. Lung ventilation rates improve.

The advisability of administering medications through a rubber catheter for chronic bronchitis is questionable, but we sometimes administer 2 - 3 ml of a 1 - 5% solution of ascorbic acid and 1 ml of aloe extract.

In the presence of bronchiectasis or concomitant chronic pneumonia, 3-5 ml of an antibiotic or mucolytic solution can be administered intratracheally, and the position of the body at the time of administration should facilitate their entry into the affected area.

Medicines are administered at the end of the procedure after washing with a 0.25% novocaine solution, which reduces the sensitivity of cough receptors and prevents immediate coughing up of the drug. For patients with severe respiratory failure, especially with significant pulmonary emphysema, the procedure is contraindicated, as it is extremely difficult for them to tolerate.

T. A. Grabiltseva et al. (1981) successfully combined intratracheal infusions of a solution of furatsilin 1:5000, Kalanchoe juice diluted 1:2 or 1 - 0.5% dioxidine solution with inductothermy in the presence of infiltrative changes in the peribronchial tissue or with ultraviolet irradiation across the fields in case of endobronchial inflammation. O. I. Korol and V. P. Molodtsova (1977) noted a more pronounced effect of endobronchial sanitation with pronounced activity of the inflammatory process in the bronchi.

Bronchoscopic sanitation of the bronchi is common. Transnasal fibrobronchoscopy under local anesthesia is preferable [Lukomsky G.I. et al., 1976], since spontaneous breathing and cough reflex are preserved, and auxiliary oxygenation is possible. The procedure is well tolerated even by seriously ill patients. In this case, aspiration of contents from all lobar and segmental bronchi is possible.

After aspiration, the bronchi are washed with a warm indifferent solution (isotonic sodium chloride solution). In cases of atelectasis due to bronchial obstruction, aspiration of mucus and targeted administration of mucolytics can restore their patency. Fiberoptic bronchoscopy can be performed daily.

Bronchial lavage is also used using a large amount of liquid, however, according to G.I. Lukomskaya et al. (1982), for chronic bronchitis this method is less effective than therapeutic bronchoscopy.

When using various methods of endobronchial sanitation several times a day, postural drainage is required.

Aerosol therapy. Aerosols of various medicinal substances have become widespread for administration into the respiratory tract, especially in recent years in connection with the use of ultrasound to produce aerosols.

Ultrasonic inhalers make it possible to obtain very homogeneous and dense aerosols with optimal particle size, penetrating to the peripheral parts of the bronchial tree. The use of drugs in the form of aerosols makes it possible to create a high local concentration and promotes uniform distribution of the substance in the bronchial tree.

Having been absorbed through the mucous membrane of the bronchi, the medicinal substances enter the right heart through the bronchial veins and lymphatic tracts and again enter the lungs. Drugs administered endobronchially can remain in the lung tissue for a long time.

The methods of endobronchial sanitation and aerosol therapy do not replace, but complement each other and are used to achieve different goals.

"Chronic nonspecific lung diseases"
N.R.Paleev, L.N.Tsarkova, A.I.Borokhov

An active bacterial inflammatory process can be considered an indication for the prescription of antibacterial agents for chronic bronchitis. It has been noted that antibacterial therapy is more effective, the more pronounced the activity of inflammation. Antibiotics. The basic principles of antibiotic therapy are outlined in the chapter “Chronic pneumonia”. In chronic bronchitis, the inflammatory process often occurs with low activity, which is largely determined by its endobronchial localization. With peribronchial inflammation...

In recent years, drugs have been increasingly used that, in the context of a struggle between micro- and macroorganisms, are aimed not at suppressing the pathogen, but at stimulating the body’s defenses - immunoregulatory agents. Levamisole (Decaris) has become widespread in recent years, the anti-infective effect of which was discovered in 1971 by G. Renoux and M. Renoux: the drug sharply enhanced the protective effect...

The most important are purine derivatives, anticholinergic drugs, ephedrine and β-adrenergic stimulants. Of the purine derivatives, aminophylline is widely used in our country as a bronchodilator. According to the mechanism of action, aminophylline is an inhibitor of cAMP phosphodiesterase. According to the hypothesis put forward by A. Szentivanyi (1968), β-adrenergic receptors play an important role in the regulation of bronchial muscle tone. The β-adrenergic receptor is represented by a molecule of adenyl cyclase of cell membranes, which has a receptor ending...

Ephedrine acts on α- and β-adrenergic receptors, and this is its frequent advantage over modern aerosols of selective β-adrenergic stimulants. Firstly, ephedrine reduces bronchospasm by acting on bronchial β2-adrenergic receptors; secondly, it reduces swelling of the bronchial mucosa by acting on α-adrenergic receptors of the bronchial vessels. It should also be said that shortness of breath in the morning, characteristic of chronic bronchitis, is largely due to sputum retention, ...

The accumulation of sputum in the bronchi is an important link in the pathogenesis of chronic bronchitis, in some cases coming to the fore. Accumulating in excess quantities, bronchial mucus can turn from a protective factor into a pathogenic factor. Thick, viscous mucus can easily clog small bronchi and cause breathing problems. With mucociliary insufficiency, conditions arise for infection to penetrate through the bronchial mucosa. Effective mucociliary...

The consistent development of direct methods for examining the larynx, trachea and bronchi began with the introduction of direct laryngoscopy in 1884 by Kirstein. Based on in-depth anatomical studies, Killian proved that the bronchi are less vulnerable to endoscopy than the soft walls of the esophagus. Together with his students Brunnings and Eicken Killian, he invented a bronchoscopic device, which was further improved. In addition, they developed a technique and methodology for bronchoscopy (cited by M.Ya. Elova). Killian's first bronchoscopic intervention was the removal of a foreign body (a piece of bone) in 1897. In 1904, Jackson wrote the first monograph on tracheobronchoscopy, in which he calls Killian the father of bronchoscopy. The term "bronchoscopy" was also proposed by Killian. Based on literary data and his own observations, the author emphasizes the role of bronchoscopy in removing foreign bodies from the trachea and bronchi. In 1911, V.D. Sokolov, based on his own observations, provided data on the successful use of bronchoscopy in the treatment of lung abscesses. In 1924-1926 M.F. Tsitovich, V.K. Trutnev, A.G. Likhachev and others also published works on the use of bronchoscopy for therapeutic purposes in various diseases of the bronchi and lungs (cited by M.M. Elova). Thus, from the very beginning of its existence, bronchoscopy has become the most important therapeutic and surgical endoscopic method, and the priority of introducing bronchoscopy in internal medicine belongs to the Russians.

As our many years of experience have shown, it is necessary to conduct therapeutic bronchoscopy in courses. Back in 1956, Soulas and Mounier-Kuhn divided the course of therapeutic bronchoscopy into 3 stages. The first stage is trial treatment, the second stage is treatment for consolidation, the third stage is treatment for maintenance.

Furagin potassium salt, one of the most common drugs of the nitrofuran series, is recognized as the best antiseptic. Prepare a 0.1% solution of furagin potassium salt.

Dioxidin is an antiseptic, a derivative of quinoxoline, which has a pronounced antibacterial effect. Prepare a 0.1% or 0.2% solution of dioxidine in a 2% solution of sodium bicarbonate.

The sanitizing solution is prepared immediately before use. Before introduction into the bronchial tree, it must be heated to a temperature of 36-37°. For one sanitation, use from 60 to 140 ml of the mixture.

Sanitation bronchoscopy begins with the removal of contents from the tracheobronchial tree using suction. After this, the most affected bronchi are washed with an antiseptic solution. No more than 20 ml of the sanitizing mixture is injected at a time, followed by aspiration using suction. Therapeutic bronchoscopy is completed with the administration of a mucolytic and/or.

The mucus produced by bronchial cells contains a large number of sulfhydryl groups that can form bonds with each other to form a three-dimensional mucoid structure. These bonds, called "disulfide bridges", are very strong and can only be broken by reducing agents.

Currently, for diseases of the respiratory system, accompanied by the formation of viscous sputum of a mucopurulent or purulent nature, bronchosecretolytic drugs are used.

One of the effective drugs in this group is N-acetylcysteine ​​(fluimucil) - this is an N-acetyl derivative of the natural amino acid L-acetylcysteine.

Fluimucil is a drug that has a direct mucolytic effect; it affects the formation of mucus by breaking the disulfide bridges of mucoprotein macromolecules present in bronchial secretions. This pharmacological action is associated with the presence of a free sulfhydryl group in the fluimucil molecule, making it a biologically active drug. As a result of the effect of fluimucil, molecules of a lower molecular weight are formed, and the mucus thins out, since the drug reduces its viscosity.

The effect of fluimucil on the viscosity and elasticity of mucus was assessed in vitro using material from the tracheobronchial secretions of animals, as well as in studies of patients with lung diseases using various methods. These studies showed that fluimucil effectively reduces the viscosity and elasticity of mucus, and there is a relationship

between the dose of the drug and the time interval preceding the reaction. A gradual increase in the concentration of fluimucil leads to a more pronounced and rapid decrease in viscosity. Studies using mucin models have shown a gradual decrease in mucus viscosity and elasticity with the introduction of increasing concentrations of fluimucil.

The activity of the cilia of the respiratory tract epithelium depends on the degree of viscosity of the secretion covering the epithelium. Optimal viscosity combined with adequate cilia mobility contribute to the correct and effective elimination of mucus. Animal studies have shown that fluimucil increases mucociliary activity. This beneficial effect on mucociliary transport is explained by improved cilia activity and leads to more efficient elimination of mucus and a lower degree of its adhesion to the epithelium.

Treatment with fluimucil leads to a significant decrease in elastase activity - both in bronchoalveolar secretions and in blood plasma - which indicates the ability of this drug to prevent the destruction of pulmonary elastin caused by a chronic inflammatory process.

Redox signaling is part of the basic mechanisms of inflammation, such as cytokine induction, proliferation, apoptosis, and gene regulation to protect cells. Oxidants act as signal transduction mediators. Thiol-containing reducing agents, including fluimucil, have been shown to suppress the activation of MBkB, which controls cellular genes responsible for intracellular adhesion molecules in intact cells. In addition, fluimucil has been shown to suppress the expression of vascular cell adhesion molecule-1 (USLM-1) in human endothelial cells.

Increasing evidence shows that oxidative stress plays an important role in the development of various human diseases. The source of stress can be internal (eg, activated inflammatory cells, xenobiotic redox cycling cells) or external (eg, tobacco smoking).

Fluimucil can have a direct antioxidant effect due to the fact that it is a carrier of a free thiol group that can interact with the electrophilic groups of free oxygen radicals (reactive oxygen species - ROS). Interaction with ROS leads to

intermediate formation of thiol radicals; the main cellular product is fluimucil disulfide.

Fluimucil has an indirect antioxidant effect due to the fact that it is a precursor of glutathione and protects the epithelium of the respiratory tract from the aggressive effects of toxic substances, thus preventing damage to lung tissue. . This tripeptide is a major protective factor against internal toxic agents (associated, for example, with aerobic cellular respiration and phagocyte metabolism) and external agents (for example, nitric oxide and other components of tobacco smoke). The sulfhydryl group of cysteine ​​has a neutralizing effect on these agents.

Toxic agents cause damage to any tissue, but the epithelium of the bronchi and alveoli of the lungs, due to its location, anatomy and physiology, is especially prone to the occurrence of damage caused by toxic substances. There are a number of diseases (acute respiratory distress syndrome, COPD, interstitial lung diseases, cystic fibrosis, bronchial asthma) in which an excess of toxic agents is present on the surface of the epithelium of the respiratory tract, leading to an imbalance between glutathione and toxic agents towards a decrease in the amount of glutathione. In these cases, damage to the epithelium of the respiratory tract develops, called “oxidative stress”.

Glutathione is synthesized primarily in the liver (which acts as a glutathione depot) and in the lungs, but it is distributed throughout the body. Synthesis occurs in the cytoplasm of the cell in two separate enzymatic steps. At the first stage, glutamic acid and cysteine ​​are combined under the influence of gamma-glutamylcysteine ​​synthetase, and at the second stage, glycine is added to the dipeptide gamma-glutamylcysteine ​​under the action of glutathione synthetase to form glutathione. Fluimucil acts as a precursor to glutathione, since it easily penetrates cells and is easily deacylated to form cysteine.

The availability of amino acids for use in glutathione synthesis is a major factor in the regulation of glutathione synthesis. Cysteine ​​is found in cells in smaller quantities compared to glutamic acid and glycine. Thus, the synthesis of glutathione depends on the presence of cysteine. Glutathione levels can be increased by supplementing with cysteine. However, the possibility of introducing the active form of cysteine ​​- L-acetylcysteine ​​- is absent due to the low level of absorption in the intestine, low level of solubility in water and rapid conversion during metabolism in the liver. These disadvantages are overcome by using fluimucil, in which the acetyl radical is connected to an amino group. Thus, it becomes possible to administer the amount of cysteine ​​needed to maintain adequate glutathione levels in the lungs.

During therapeutic bronchoscopy, 2 ml of a 5% solution of fluimucil (N-acetylcysteine) is used, which is administered at the end of sanitation. The effect of the drug begins after 30 minutes and lasts up to 2 - 4 hours. In this case, the sputum is liquefied, it comes off more easily and in larger quantities than before sanitation, so it seems that there is a significant increase in the volume of sputum. In fact, fluimucil does not stimulate the production of secretions, but only dilutes it. Fluimucil has a faint odor of hydrogen sulfide, so it should be used with caution in patients with bronchial asthma due to the risk of developing bronchospasm, however, over more than 5 years of experience in using the drug, we have not had such a complication.

When instilled, Fluimucil should not be mixed with antibiotics, as this results in mutual inactivation of the drugs. Therefore, Zambon has released a unique drug - fluimucil antibiotic IT, which consists of the antibiotic thiamphenicol and N-acetylcysteine; it remains among the first choice antibiotics in the treatment of respiratory infections. The antibiotic is administered at the end of sanitation bronchoscopy in an amount of 500 mg, having previously diluted it in 5 ml of water for injection.

Until recently, antibiotics were installed into the lumen of the bronchial tree at the end of therapeutic bronchoscopy, against the background of a severe cough, which was provoked by the introduction of a sanitizing substance, so antibiotics were coughed up in larger quantities by the patient, and their role was small. In this regard, we have developed and widely introduced into clinical practice a method of intrabronchial regional antibiotic therapy.

The article was prepared and edited by: surgeon