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Correction of respiratory disorders in patients with ARDS on the background of having obesity
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Sviatlitskaya Volha Ivanovna, MD, Associate professor of Belarusian Medical Academy of Post-Graduate Education E-mail: [email protected]
Correction of respiratory disorders in patients with ARDS on the background of having obesity
Abstract: Obesity significantly alters lung mechanics, and creates the conditions for rapid decompensation of work of respiratory organs at infectious damage of lungs. Early transfer of patients with community-acquired pneumonia with diffuse bilateral infiltration and obesity in the ICU, the use of non-invasive ventilation and early transfer of mechanical ventilation with mandatory implementation of maneuver 'Recruitment' can effectively prosthesis lung function in these patients, helping to reduce the duration of mechanical ventilation and decrease mortality.
Keywords: community-acquired pneumonia, acute respiratory distress syndrome, obesity, respiratory support.
Relevance of the topic
In recent years the tendency to the serious course of community-acquired virus and bacterial pneumonia becomes perceptible [1; 2]. Reproduction of viruses' of influenza and a parainfluenza II type in an cells of epithelium of respiratory tracts and alveoluses leads to destruction of an respiratory epithelium of the lower respiratory tracts and disturbance of production of surfactant. The considerable part of pulmonary tissue damaged. Alveoli's are fallen down and multiple atelectasis develop, that is followed by a resistant hypoxia. Such pneumonia is characterized by the expressed intoxication syndrome, hemodynamic disturbances, a serious respiratory failure with development of the acute respiratory distress syndrome (ARDS). Despite development of medical technologies the mortality at ARDS remains high, making from 24 to 75% and more at development of a syndrome of multiple organ failure [3; 4].
For effective prophylaxis of development and treatment of ARDS it is necessary to consider the specific risk factors which promote development of this syndrome. It is noticed that patients with the overweight and an obesity have the heavy course of the community-acquired pneumonia which was complicated by development of ARDS, and demanded transfer to intensive care unit (ICU) and a long-term mechanical ventilation [1; 5].
Obesity significantly alters lung mechanics, and creates the conditions for rapid decompensation of work of respiratory organs at infectious damage oflungs. Obesity combines two mechanism of respiratory function disorders: lung volume reduction (restriction) and distal airway narrowing (obstruction), which causes predisposition of patients with obesity to development of ARDS.
In this context, the aim of our study was to improve the results of treatment of ARDS with community-acquired viral and bacterial pneumonia in obese patients by optimizing respiratory support.
Materials and methods
We analyzed the results of treatment of 251 patients with severe community-acquired viral and bacterial pneumonia, complicated by the development of ARDS who were treated in the ICU of City clinical hospital of emergency medical care of Minsk.
The study included patients who meet the following criteria: acute onset ofthe disease; time of onset (fervescence > 38 °C) prior to the development ofARDS is not more than 7 days; diffuse bilateral infiltration on radiographs; respiratory index (RI, PaO2/FiO2) < 300 mm Hg; no signs of cardiogenic pulmonary edema; the need for respiratory support.
Hypoxemia has been quantified by the PaO2/FiO2 ratio (the ratio of pulmonary arterial oxygen tension to the fraction of inspired oxygen con-
Section 7. Medical science
centration). According to the Berlin criteria of ARDS is divided into three forms: mild (200 < RI < 300 mm Hg), moderate (100 < RI < 200 mm Hg) and severe (RI < 100 mm Hg).
An indispensable condition is the use of mechanical ventilation. In patients with mild — non-invasive mechanical ventilation (NIV) with continuous positive airway pressure (CPAP) or mechanical ventilation with positive end-expiratory pressure (PEEP) levels > 5 cm H2O; in patients with moderate or severe form ofARDS — mechanical ventilation with PEEP levels > 5 cm H2O; patients with moderate or severe form of ARDS — mechanical ventilation with PEEP levels > 5 cm H2O.
Exclusion criteria in the study were as follows: age of patients less than 18 years old and over 80 years; if the patient has severe concomitant respiratory diseases: chronic obstructive pulmonary disease, asthma and others. For an objective assessment of the degree of lung injury severity scale used Lung Injury Score (LIS), proposed by J. Murray (1988). On this scale in points allow for 4 indicators: the degree of lung tissue infiltration according to X-ray of the chest, compliance, RI and the level of PEEP. All patients were calculated body mass index (BMI) as the ratio of body weight in kilograms by the square of height in meters. Ac-
cording to WHO recommendations overweight recorded at BMI > 25 kg/m 2, obesity, a BMI > 30 kg/m 2.
Determination of arterial blood gases were performed in patients at the time of admission to the ICU, after transfer to the ventilator, in the process of selection of the ventilation mode setting, but at least 2 times a day with the use of modular analyzer «ABL800 FLEX», Radiometer (Denmark).
Statistical analysis of the results of research carried out on a computer (Windows 8) using the software package Microsoft Excel. Check the normality of the distribution of the results was carried out using W-Shapiro-Wilk test. Since most of the studied parameters characterized nonparametric distribution, the results are expressed as median and interquartile range (Me [q25-q75]). Significant differences were assessed using the U-Mann Whitney test. The difference compared indicators recognized significant at a value ofp < 0,05 and p < 0,01.
Results and discussion
Among patients with community-acquired viral and bacterial pneumonia and ARDS, overweight has been registered in 89 (35.5%) and obesity in 91 (36.2%) patients. The respiratory evaluation index and severity of lung injury by LIS scale depending on the BMI are presented in table 1.
Table 1 - The respiratory evaluation index and severity of lung injury by LIS scale depending on the BMI
BMI, kg/m 2 Category The number of patients RI (PaO2/FiO2), mm Hg LIS, points
<18,5 underweight 4 (1,6%) 154,2 [113,7-182,4]* 1,7 [1,45-2,0]*
18,5-24,9 normal (healthy weight) 67 (26,7%) 189,1 [156,2-236,9]* 1,9 [1,5-2,1]*
25-29,9 overweight 89 (35,5%) 147,7 [125,3-195,4]* 2,7 [2,0-3,1]
> 30 obesity 91 (36,2%) 125,2 [99,2-141,7] 2,6 [2,1-3,2]
index of reliability in relation to parameters of patients with obesity (P < 0.05).
Note: * —
Thus, the respiratory index in obese patients — 125.2 [99,2141,7] mm Hg was significantly lower (p <0,01), than in other groups of patients, indicating severe damage alveolar-capillary membrane. In patients with overweight RI was 147.7 [125,3195,4] mm Hg, in patients with normal body weight RI was 189.1 [156,2-236,9] mmHg; in patients with underweight RI was 154.2 [113,7-182,4] mm Hg.
The biggest number of points in the evaluation of patients received the LIS scale overweight — 2,7 [2,0-3,1] score and obesity — 2.6 [2,1-3,2] points.
The deposition of fat around the edges and in the mediastinum limits the mobility of the lungs and makes it difficult to breath. Excessive fat accumulation in the abdominal cavity violates diaphragm function and limits its excursion. Expiratory reserve volume and functional reserve capacity is reduced, that affects the permeability of the distal airways. By reducing the expiratory reserve volume below the closing volume of a collapse of the alveoli with the development micro atelectasis.
Also decreases the elasticity of the lung tissue by increasing the blood supply vessels of the lungs, increasing resistance and collapse of the distal airways. In order to overcome the rigidity of the chest, and increased airway resistance patient spends a significant amount of additional energy. A progressive increase in load leads to breathing fatigue and weakness of respiratory muscles, which contributes to the development of acute respiratory failure.
Thus, obese patients (n 91) require a special approach to the intensive care, including the start time, the conditions of the selection mode and ventilation parameters. So we changed the tactics of intensive care for this group of patients, and proposed the concept of 'early transfer' in the ICU. Patients with community-acquired viral and bacterial pneumonia and bilateral infiltrates on chest radio-
graph, and obesity (BMI> 30 kg/m2) for the prevention of the development ofARDS must will be transfer in an ICU for supervision and treatment for 1-3 days. This approach led to a further significant reduction in the time between admission at the hospital, in the ICU and the beginning of respiratory support.
In obese patients the following tactics respiratory support has been chosen: early non-invasive ventilation (NIV), an early transfer to the mechanical ventilation (translation criteria: PaO2/FiO2 <175 mmHg after 1 hour of NIV). Mechanical ventilation compliance with key provisions of the concept of 'safe' ventilator.
Given the high risk of hypoventilation and aspiration during tracheal intubation, intubation was performed in all patients in the state with the head of the bed elevated. Criterion for proper placement of the patient — a horizontal line connecting the sternum and the patient's ear. Immediately after intubation to improve oxygenation and to prevent/eliminate atelectasis carry out maneuver 'Recruitment' under the control of hemodynamic parameters.
As a result, transfer into the mechanical ventilation was required 69 (75.8%) of 91 patients with obesity. These patients were divided into 2 groups. The control group consisted of 31 patients who were treated with mechanical ventilation according to conventional techniques (2009-2010). The main group consisted of 38 patients who underwent respiratory support the proposed method (20112016). According to age, sex, severity of damage to the alveolar-capillary membrane patients of comparison groups were comparable. Comparative characteristics of patients main and control group are presented in table 2.
As a result of the proposed method the time from admission to hospital before being transferred to the ICU decreased and was in the main group on average 1,2 ± 0,4 hours versus 2,04 ± ± 1,1 days in the control group.
Landscape of transition of microorganisms to internal organs during the experimantal bacterial translocation
Table 2. - Comparative characteristics of patients main and control group
Parameters Main group (n=38) Control group (n=31)
Sex male 25 (65,8%) 17 (54,8%)
female 13 (34,2%) 14 (45,2%)
Age, years 48,9 [42,5-58,7] 48,0 [38,2-53,7]
RI, mmHg 143,0 [127,4-173,2] 137,0±18,2
LIS, points 2,6 [2,1-2,91] 2,7 [2,45-3,1]
Dynamics of changes in RI are presented in Figure 1.
Fig. 1. Dynamics
As shown in the graph presented, in patients of the main group respiratory index increased much faster than the control (p <0,05). This suggests that early and mandatory implementation of 'Recruitment' maneuver in patients with ARDS on the background of obesity is already possible to eliminate atelectasis during the 1st day of mechanical ventilation has led to the progressive improvement of oxygenation. Number of days on mechanical ventilation, decreased from 11,1 ± 10,2 to 8,2 ± 3,6 days. The mortality rate decreased from 42% (corresponding to world statistics) to 15.8%.
of respiratory index Conclusions
Obesity — a risk factor for ARDS and severe course in patients with community-acquired pneumonia. Early transfer of patients with bilateral infiltrates on chest radiograph and obesity in the ICU, early non-invasive ventilation and early transfer to mechanical ventilation (translation criteria: PaO2/FiO2 <175 mmHg after 1 hour conducting NIV) c mandatory implementation of maneuver 'Recruitment' can effectively prosthesis lung function in these patients, helping to reduce the duration of mechanical ventilation and decrease mortality.
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Suwonov Qayim Jahonovich, PhD, Senior scientific employee-researcher, Research Institute of Sanitation, Hygiene and Occupational Diseases Ministry of Health of Uzbekistan,
Landscape of transition of microorganisms to internal organs during the experimantal bacterial translocation
Abstract: The purpose of the scientific work was study of the landscape of microorga-nisms grown (LMG) from the internal organs of laboratory animals in experimental acute obstru-ction of the small (EAOSI) and large intestine (EAOLI). It has been established that Gram-ne-gative sticks, Gram-positive cocci and anaerobes were identified in the experimental model EAOSI. Anaerobic translocation low level of ability. With the increase in the duration of mic-roorganisms translocation (MT) the shutter all the members are equally spread. EAOSI there is a big difference between the recovered Staphylococcus spp and Enterococcus spp recognized as one of the main microbiological criteria.
Keywords: experimental obstruction, the small intestine, the large intestine, landscape of microorganisms, bacterial translocation, Gram-positive cocci.
