Sanitation methods for lung diseases. Sanitary bronchoscopy Sanitary bronchoscopy under anesthesia

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

Endotracheal infusions with a laryngeal syringe are performed with or without a laryngeal mirror. 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 in a sitting position. The patient with the help of a gauze napkin pulls the tongue forward; 3 - 5 ml of the solution is injected behind the root of the tongue, and with visual control - more precisely into the larynx while inhaling.

If the infusion is 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 warmed solution (isotonic sodium chloride solution, a weak solution of furacilin) ​​is poured in.

The procedure is carried out daily. Infusions with a laryngeal syringe - good method bronchial drainage. After expectoration of sputum, medicinal substances can be administered, but the effectiveness and expediency of such administration of drugs is doubtful.

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.

The catheter, the tip of which is lubricated with oil, is passed through the nose shallowly into the trachea while inhaling. With the correct introduction, a feeling of a "failure" of the catheter, phonation disturbances, the appearance of a cough and a strong stream of air from the peripheral end of the catheter during coughing are characteristic.

The patient fixes the catheter at the nose with his fingers. It is convenient to use a 20-gram syringe. Usually, a heated solution of furacilin 1:5000 is used, injecting 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 obstructive syndrome, it is advisable to pre-use bronchodilators. Complications may include mild hemoptysis and allergic reactions to anesthetic solutions (requiring careful history taking and appropriate testing).

The method is very effective, especially with viscous and purulent sputum. The viscosity of sputum decreases, as well as its purulence and quantity, up to complete disappearance. Improvement in lung ventilation.

The expediency of administering drugs through a rubber catheter in chronic bronchitis is doubtful, but we sometimes inject 2-3 ml of 1-5% ascorbic acid solution 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 contribute to 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 of the drug. Patients with severe respiratory failure, especially with significant emphysema, the procedure is contraindicated, as it is extremely difficult for them to tolerate.

T. A. Grabiltseva et al. (1981) combined intratracheal infusions of a solution of furacilin 1:5000, Kalanchoe juice at a dilution of 1:2 or 1 - 0.5% dioxidine solution with inductothermy in the presence of infiltrative changes in the peribronchial tissue or with ultraviolet radiation along the fields - with endobronchial inflammation. OI Korol and VP Molodtsova (1977) noted a more pronounced effect of endobronchial sanitation with a pronounced activity of the inflammatory process in the bronchi.

Bronchoscopic sanitation of the bronchi is common. Transnasal fiberoptic bronchoscopy is preferred local anesthesia[Lukomsky G. I. et al., 1976], since this preserves independent breathing and cough reflex, auxiliary oxygenation is possible. The procedure is well tolerated even by seriously ill patients. In this case, aspiration of the 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 the directed administration of mucolytics can restore their patency. Fibrobronchoscopy can be performed daily.

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

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

Aerosol therapy. Aerosols of various medicinal substances are widely used for introduction into the respiratory tract, especially in last years in connection with the use of ultrasound for the production of aerosols.

Ultrasonic inhalers produce very homogeneous and dense aerosols with optimal size particles penetrating to the peripheral sections of the bronchial tree. The use of drugs in the form of aerosols allows you to create a high local concentration, promotes uniform distribution of the substance in the bronchial tree.

After being absorbed through the mucous membrane of the bronchi, medicinal substances through the bronchial veins and lymphatic pathways enter the right heart 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 non-specific lung diseases",
N.R. Paleev, L.N. Tsarkova, A.I. Borokhov

An active bacterial inflammatory process can be considered an indication for the appointment of antibacterial agents in chronic bronchitis. It has been observed that antibiotic 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 proceeds with low activity, which is largely determined by its endobronchial localization. With peribronchial inflammation ...

In recent years, drugs have been increasingly used, which, in the conditions of the struggle of the micro- and macroorganism, are aimed not at suppressing the pathogen, but at stimulating the body's defenses - immunoregulatory agents. In recent years, levamisole (decaris) has become widespread, the anti-infective effect of which was discovered in 1971 by G. Renoux and M. Renoux: the drug dramatically increased the protective effect ...

Highest value have purine derivatives, anticholinergics, ephedrine and β-agonists. Of the purine derivatives in our country, eufillin is widely used as a bronchodilator. According to the mechanism of action, eufillin 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 muscle bronchial tone. β-adrenergic receptor is represented by a cell membrane adenylcyclase molecule having a receptor ending ...

Ephedrine acts on α- and β-adrenergic receptors, and this is its frequent advantage over modern aerosols of selective β-agonists. First, 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, which in some cases comes to the fore. Accumulating in excess, bronchial mucus from a protective factor can become a pathogenic factor. Thick viscous mucus can easily clog the small bronchi and cause respiratory failure. With mucociliary insufficiency, conditions arise for the penetration of infection through the bronchial mucosa. Effective mucociliary…

Sanitation of the tracheobronchial tree is carried out by the following methods:

1. pastoral drainage

2. percussion, vibration and vacuum massage

3. an increase in intrapulmonary pressure, enhancing collateral ventilation

4. stimulation and imitation of cough

5. sputum aspiration

These methods are most effective with the simultaneous use of measures aimed at improving the rheological properties and drainage of sputum.

Pastoral drainage. Used to evacuate sputum from various lung zones in violation of the mechanisms of natural sputum drainage (pneumonia, bronchiectasis, bronchorrhea, pulmonary bleeding). Positions can be varied, it is important to take this into account, for finding the patient in an uncomfortable position can lead to respiratory and circulatory disorders.

Percussion massage. It is performed with the palms of the hands in the form of a cup laid flat on the chest. Tapping is carried out at a frequency of 40-60 times per minute for 1-2 minutes. Spend 2-3 series, then ask the patient to clear his throat, pause 1-2 minutes to rest. Then the cycle is repeated. Depending on the condition of the patient and the tolerability of manipulation, its duration is from 10 to 20 minutes.

Vibration massage. Performed by vibrating or shaking movements of the hands or with the help of special vibration massagers with a platform that vibrates at a high frequency with an adjustable shaking amplitude.

IVL and IVL. With an increase in inspiratory pressure up to 20-30 si water, ventilation improves collateral ventilation, improves drainage respiratory tract.

Stimulation and imitation of cough. Spend short-term pressure on the cricoid cartilage, then a deep breath and maximum exhalation, a sharp compression of the lower sections chest from two sides. Aerosols, percutaneous tracheal catheterization, catheter irritation of the nasal passages or nasopharynx are also used.

Sputum aspiration. Apply as the final stage of the above manipulations, as well as independently.

For some types of ARF, lavage (airway flushing) is effective.

Percutaneous catheterization of the trachea and bronchi. Allows you to enter into the tracheobronchial tree for a long time constantly and fractionally medications to stimulate cough, to improve the rheological properties of sputum, to treat obstructive inflammatory purulent processes, to restore the activity of the heart (instead of intracardiac administration of drugs), also carry out injector ventilation.

To perform percutaneous catheterization of the trachea and bronchi, you need:

§ special or serial injection needles with a diameter of 1.5-3 mm

§ catheters with a diameter of 1-1.4 mm

§ novocaine solution 0.5 and 0.25%

§ sterile material

1. the patient is laid on his back with rollers under his shoulders

2. after skin treatment, the surgical field is isolated with sterile material

3. perform anesthesia at the puncture site

4. puncture of the anterior wall of the trachea is performed along the midline at the level between the cricoid cartilage and the first ring of the trachea, or at the level of the 1st and 2nd rings of the trachea

5. to prevent injury to the posterior wall of the trachea and the anterior wall of the esophagus, the index finger is placed at a distance of 0.5-1 cm from the end of the needle

6. the advancement of the needle into the trachea is judged by the effect of falling through and the entry of air into the syringe

7. When a liquid is injected through a needle, a cough appears.

These signs indicate correct location needles and catheters in the trachea and bronchi. A small catheter can be inserted through the needle.

The transtracheal catheter allows for oxygen therapy, injector mechanical ventilation in case of hypoventilation, bronchial asthma, pulmonary edema, as well as to create optimal conditions for gas exchange in case of difficult intubation. Simultaneous administration of antibiotics and other antimicrobials increases the effectiveness of the treatment of pneumonia and abscesses.

Monitoring.

Monitoring (control of the patient's condition). If monitoring during surgery, then - intraoperative, before - preoperative, postoperative.

Monitoring objectives:

1. exercise control over body functions

2. exercise control over therapeutic actions

3. exercise control over environment(air temperature in the operating room, temperature of the operating table, CO 2 content in the operating room, concentration of gas-narcotic mixture)

Monitoring - vigilant continuous observation of the patient every 5 minutes.

Allocate monitoring: visual, instrumental, laboratory and combined. Moreover, all types can be, except for visual, invasive (penetrate into organs, tissues, blood vessels) and non-invasive (which do not penetrate into the body) - ECG, pulse oximeter, blood pressure measurement. Monitoring the patient's condition is carried out according to the following parameters:

1. appearance patient: color, temperature, skin moisture (sweating, hyperemia indicate hypercapnia, cyanosis - hypoxia, marbled and cold skin occurs with spasm of peripheral vessels)

2. the size and shape of the pupils, their expansion indicates pain, hypoxia; anisocoria - NMK.

3. indications of a manometer, a water lock (+ wetting of bandages, drainages - in the intensive care unit)

4. condition of cardio-vascular system: BP (systolic, diastolic, pulse and mid-dynamic), pulse, CVP. Systolic pressure is the state of the myocardium of the left ventricle. Diastolic pressure - is characterized by the degree of tone of the arterial walls. Pulse pressure - SD - DD. Average dynamic pressure - DD + 1/3 PD. BP is the pressure of blood on the walls of arteries. Venous pressure (in the diastolic phase): CVP and peripheral VD.

ECG is a recording of biocurrents from the heart muscle. V 1 -V 6 - if there is one electrode, then the recording is unipolar or single-channel.

I, II, III, IIIc - standard leads.

avR, avL, avF - enhanced limb leads.

V 1 - V 6 - chest leads.

A (anterio), J (interio), D (dorsalis) - special leads in the Sky.

Determination of the state of coronary blood flow. Standard leads show total indicators from all parts of the heart (LA, LV, LA, LV, coronary blood flow, impulse conduction time, frequency, rhythm, heart rate). Lead II is recorded on cardiac monitors.

Reinforced leads repeat the standard ones.

chest leads show the topic of the condition of the heart muscle:

§ V 1 - right heart

§ V 2 - partition

§ V 3 - apex (LV)

§ V 4 -V 6 - anterior wall of the left ventricle

§ II, III, avF - rear wall

§ D - special assignment from the back.

The active electrode is applied to the surface of the chest. Unipolar leads:

V 1 - 4th intercostal space along the parasternal line on the left

V 2 - 4th intercostal space along the parasternal line on the right

V 3 - middle position between V 1 and V 2

V 4 - 5th intercostal space along the midclavicular line

V 5 - 5th intercostal space along the anterior axillary line

V 6 - 5th intercostal space in the midaxillary line

To exclude respiratory arrhythmias, the IIIvd lead is removed.

5. state of the respiratory system. Types of breathing: spontaneous and hardware. With spontaneous breathing, frequency, uniformity (over the area of ​​all lungs: the apex or lower, posterior-lower sections are ventilated worse), depth, minute ventilation of the lungs are noted. With mechanical ventilation, this is MOD, DO, inspiratory and expiratory pressure. Adequate breathing is judged by clinical signs and blood gases.

6. state of the central nervous system. Based on the clinical data described above and special method EEG.

7. kidney function. Hourly diuresis. For 1 minute - 1 ml of urine. Oliguria (less than 40 ml) and anuria (less than 20 ml per hour) in anesthesia may develop as a result of inadequate analgesia, hypovolemia, and causes associated with the peculiarities of the operation.

8. Body temperature. In addition to skin temperature during major operations on the chest, abdominal cavity, with hypothermia, cardiopulmonary bypass, in children, the temperature is measured in the esophagus, and more often in the rectum. A decrease in body temperature may be due to cooling in the operating room, if the temperature is below 20 0 C, with large blood loss, cardiac arrest, poor anesthesia. The amount of blood loss can be calculated by BCC or by measurement and weighing.

9. Laboratory data, the volume of which depends on the severity of the patient, surgery, features of anesthesia and the possibilities of the LU. Usually, hematocrit (Ht), hemoglobin (Hb), CBS data, blood and urine sugar, clotting time, bleeding time, plasma and blood electrolytes, coagulogram according to indications are determined.

Currently, monitoring is being used more and more. A monitor is a device that has recorders (sensors), analyzers and alarms. There are four generations of monitors:

1st generation: register: ECG, pulse, respiratory rate.

2nd generation: register: ECG, blood pressure, pulse pressure, CVP, temperature, pulse, respiratory rate and make it possible to record parameters.

3rd generation: registers the same as 2nd generation, but has an alarm.

1st generation: not only register, record, but also take blood samples for analysis and, according to the results, change the treatment on their own. Such a monitor requires a block of memory (computer).

In 1986, a monitoring standard was published and adopted by the Department of Anesthesiology, Harvard University Medical School, Boston. According to the standard, its implementation should reduce the complications and mortality of patients with a minimum degree of operational risk, as well as the frequency and severity of side effects in anesthesia and finding patients in intensive care. Standard requirements:

§ Measurement and recording of all parameters every five minutes

§ Permanent presence nurse and a doctor.

During anesthesia, control over breathing and ventilation is mandatory (excursion of the chest, filling the breathing bag, color skin, the concentration of carbon dioxide on the capnometer); monitor the pressure in the "apparatus-sick" system, blood gases. Mandatory control of the gas flow on the dosimeter, Special attention behind the flow of oxygen.

According to this standard, there should be a meter for the concentration of oxygen in the inhaled mixture and, when it decreases, a signal.

Monitoring of blood circulation: after 5 minutes, blood pressure, CVP, ECG (permanently), pulse oximetry, measurement of pressure in the heart cavities using a Swans-Gans catheter.

Despite the high modern technical level of monitors, the human factor plays a leading role in the prevention of complications.

Requirements for nurse anesthetists when assessing the functional state:

Observe ethical and deontological principles when communicating with patients

Own the method of determining the pulse, blood pressure, CVP

Know the main types of breathing and be able to recognize pathological conditions associated with respiratory failure

Before manipulation, start assessing the functional state: usually determine the severity of the condition, and then move on to manipulation

Monitor the patient's condition after the manipulation and report to the anesthetist on changes in the patient's condition.

Among all endoscopic research methods, bronchoscopy has long occupied a special place, being not only one of the first diagnostic methods, but also the most important and effective method of treating patients with chronic inflammatory and suppurative lung diseases. 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, which have a dense cartilaginous skeleton, are less vulnerable to endoscopy than the soft walls of the esophagus. Together with his students Brunnings and Eicken, Killian invented a simplified bronchoscopic device, which was further improved significantly. In addition, they developed in detail the technique and methodology of bronchoscopy (quoted by Elova M. Ya.). Killian's first bronchoscopic intervention was removal of a foreign body (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 coined by Killian. Based on the generalization of literature data and his own observations, the author emphasizes the role of bronchoscopy in the recognition and extraction foreign bodies from the trachea and bronchi. In 1911, V. D. Sokolov, on the basis of his own observations, provided data on the successful use of bronchoscopy in the treatment of patients with lung abscess.

In 1924-1926, M. F. Tsitovich, V. K. Trutnev, A. G. Likhachev and others also published works on the use of bronchoscopy with therapeutic purpose with various diseases of the bronchi and lungs (quoted by Elova M. M.). Thus, the priority of introducing bronchoscopy into the clinic of internal diseases belongs to Russian doctors.

As shown by many years of experience in the use of endoscopy in pulmonology, single courses of therapeutic bronchoscopy are effective in pneumonia, abscessing pneumonia or lung abscess, and in obstructive pulmonary disease, it is necessary to conduct therapeutic bronchoscopy courses. Back in 1956, Soulas and Mounier-Kuhn divided the course of therapeutic bronchoscopy into 3 stages. The first stage is a trial treatment, the second stage is a fixation treatment, the third stage is a maintenance treatment.

The main medicinal substances that are used during therapeutic bronchoscopy are antiseptics, antibiotics, mucolytics and immunomodulators.

The best of the antiseptics was recognized as furagin potassium salt - one of the most common drugs of the nitrofuran series. A 0.1% solution of furagin potassium salt is prepared in isotonic sodium chloride solution. Dioxidine is an antiseptic, a derivative of quinoxoline, has a pronounced antibacterial effect. Prepare 0.1% or 0.2% dioxidine solution in 2% sodium bicarbonate solution. 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 spend from 60 to 140 ml sanitizing mixture.

Sanitary bronchoscopy begins with the removal of contents from the tracheobronchial tree using suction. After that, the most affected bronchi are washed with an antiseptic solution. At the same time, no more than 20 ml of the sanitizing mixture is injected, followed by its aspiration using suction. Therapeutic bronchoscopy ends with the introduction of a mucolytic and / or antibiotic.

The mucus produced by bronchial cells consists of glycoproteins, sulfomucins and water; it contains a large number of sulfhydryl groups capable of forming 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.

At pathological conditions an increased number of disulfide bridges is formed, which leads to an increase in the viscosity and elasticity of the bronchial secretion and increases the risk of infection in secretion accumulations. Subsequently, purulent sputum is formed.

Among the first drugs that affect the rheological properties of bronchial secretions, enzyme preparations were used - trypsin, chymotrypsin, ribonuclease, deoxyribonuclease. The drugs were administered in the form of inhalations or endobronchial installations. Usually, a significant liquefaction of sputum and an improvement in its discharge were observed by the 5th - 7th day of treatment, the course was 10-15 days. Currently, the use of proteolytic enzymes, especially in the treatment

in patients with chronic obstructive pulmonary disease, it seems inappropriate due to the possible development of bronchospasm up to asthmatic status, an increase in the tendency to hemoptysis, allergic reactions and increased destruction of the interalveolar septa in alpha 1-antitrypsin deficiency.

Currently, in diseases of the respiratory system, accompanied by the formation of very viscous, difficult to separate sputum of a mucopurulent or purulent nature, are used medicines known as mucolytics or bronchosecretolytic drugs.

One of the most effective drugs of this group is N-acetylcysteine ​​(fluimucil) - it is an N-acetyl derivative of the natural amino acid L-acetylcysteine. Fluimucil is a drug that has a direct mucolytic effect; it acts on mucus formation 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, which makes it biologically active drug. As a result of exposure to fluimucil, molecules of a smaller molecular weight are formed, and mucus is thinned, since the drug reduces its viscosity. The effect of fluimucil on the viscosity and elasticity of mucus was evaluated in vitro on the material of the tracheobronchial secretion of animals, as well as in studies of patients with various lung diseases using various methods. These studies have shown 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 revealed a gradual decrease in the viscosity and elasticity of mucus with the introduction of increasing concentrations of fluimucil. The activity of the cilia of the epithelium of the respiratory tract depends on the degree of viscosity of the secret covering the epithelium. Optimal viscosity, combined with adequate cilia mobility, contributes to the correct and efficient elimination of mucus.

Animal studies have shown that fluimucil increases mucociliary activity. This favorable effect on mucociliary transport is explained by the improvement of cilia activity and leads to more efficient elimination of mucus and less 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 underlying mechanisms of inflammation, such as cytokine induction, proliferation, apoptosis, and gene regulation to protect cells. Oxidants act as signaling mediators. Thiol-containing reducing agents, including fluimucil, have been shown to suppress the activation of NFkB, 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 (VCAM-1) in human endothelial cells.

There is increasing evidence 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 cells) or external (eg, smoking).

Fluimucil can have a direct antioxidant effect due to the fact that it is a carrier of a free thiol group capable of interacting with electrophilic groups of oxygen free radicals (reactive oxygen species - RCH). Interaction with RCH leads to the 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 the lung tissue. Glutathione is a tripeptide composed of glutamic acid, cysteine ​​and glycine. This tripeptide is the main factor in protecting against the effects of internal toxic agents (associated, for example, with aerobic cell respiration and metabolism in phagocytes) and external agents (for example, nitrogen oxide, sulfur oxide and other components of tobacco smoke, as well as air pollutants) . The sulfhydryl group of cysteine ​​has a neutralizing effect on these agents. Toxic agents cause damage to any tissue, however, the epithelium of the bronchi and alveoli of the lungs, due to its location, anatomy and physiology, is especially prone to the occurrence of lesions caused by toxic substances.

There are a number of diseases (acute respiratory distress syndrome, COPD, lung cancer, 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 in the direction of reducing the amount of glutathione. In these cases, damage to the epithelium of the respiratory tract, called "oxidative stress", develops. Oxidative stress is believed to play an important role in the pathogenesis of various lung diseases. An imbalance between oxidants and antioxidants is caused by an increased amount of oxidants and/or deficiency of the antioxidant system. RSCs are present in the lungs normally and play a critical role in their functioning. In addition, the lungs have a developed system of intra- and extracellular antioxidants. Glutathione is synthesized mainly in the liver (acting as a depot of glutathione) and in the lungs, but it is distributed throughout the body. Synthesis is carried out 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 gamma-glutamylcysteine ​​dipeptide under the action of glutathione synthetase to form glutathione. Fluimucil plays the role of a precursor of glutathione, since it easily penetrates into 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 contained in cells in a smaller amount compared to glutamic acid and glycine. Thus, the synthesis of glutathione depends on the presence of cysteine. The level of glutathione can be increased by the additional administration of cysteine. However, the possibility of introducing active form cysteine ​​- L-acetylcysteine ​​- absent due to low level intestinal absorption, low water solubility, and rapid conversion during liver metabolism.

These shortcomings are overcome by using fluimucil, in which the acetyl radical is connected to an amino group. Thus, it becomes possible to administer as much cysteine ​​as is necessary to maintain an adequate level of glutathione in the lungs.

During therapeutic bronchoscopy, 2 ml of a 5% solution of fluimucil (N-acetylcysteine) is used, which is injected into the bronchial tree at the end of sanitation. The action of the drug begins 30 minutes after administration and lasts up to 2-4 hours. At the same time, sputum liquefies, it leaves more easily and in greater quantities than before sanitation, so it gives the impression of a significant increase in sputum volume. In fact, fluimucil does not stimulate secretion production, but only dilutes it. Fluimucil has a slight smell of hydrogen sulfide, so it should be used with caution in patients with bronchial asthma because of the risk of developing bronchospasm, however, for more than 5 years of experience with the drug, no such complication was noted. Fluimucil during instillations should not be mixed with antibiotics, since this causes mutual inactivation of the drugs. Therefore, for example, one of the firms (Zambon) has released a unique drug - fluimucil antibiotic IT, which consists of the antibiotic thiamphenicol and N-acetylcysteine. The drug has a wide spectrum of antibacterial activity. It is active against many strains resistant to beta-lactam antibiotics, against intracellular pathogens (Legionella, Chlamidia, micoplasma), as well as against strains of Staphylococcus aureus VISA and many resistant strains of S. Aureus. Another advantage of the antibiotic is its high bioavailability and high coefficient of penetration into the lung tissue. Another important feature is that it is the only antibiotic in the chloramphenicol class without haematological toxicity. Thus, fluimucil IT antibiotic remains among the first choice antibiotics in therapy. respiratory infections. The antibiotic is administered at the end of the sanitation bronchoscopy in the amount of 500 mg, diluted in 5 ml of water for injection.

It follows that from the very beginning of its existence, bronchoscopy has become the most important therapeutic and surgical endoscopic method in patients with diseases of the broncho-pulmonary system.

Sanitation methods for lung disease

Leading pulmonologists in Rostov-on-Don

Anufriev Igor Ivanovich pulmonologist - Associate Professor of the Department of Phthisiology and Pulmonology of the Rostov State medical university, Head of the Department of Pulmonology, Rostov State Medical University.

Bokhanova Elena Grigoryevna — Head of the Therapeutic Department, Candidate of Medical Sciences, Doctor the highest category, assistant of the department of propaedeutics of internal diseases of Rostov State Medical University, pulmonologist.

Kirtanasova Lyudmila Nikolaevna — pulmonologist of the highest qualification category.

Page editor: Sanitation methods for lung diseases: Turbeeva E.A.

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The book "Diseases of the Respiratory Organs Volume 1." (Author N.R. Paleeva).

Sanitation methods

Bronchological methods used for therapeutic purposes include the so-called sanation methods, which clean the bronchial tree from excess contents and endobronchial drug effects on the pathological process in the lung, as well as various endoscopic instrumental therapeutic interventions in the trachea and large bronchi.

Endobronchial therapy, called the debridement of the bronchial tree, includes various techniques, most of which are associated with the use of bronchoscopy.

Bronchoscopy for therapeutic purposes can be performed with a bronchoscope and a rigid bronchoscope under both local and general anesthesia. For sanitation of the bronchial tree in adults, bronchofibroscopy is often used under local anesthesia. Therapeutic bronchofibroscopy is performed in the bronchoscopic room, but it can also be performed in other rooms, including when the patient is in a serious condition directly in the ward.

The first stage of bronchoscopy is examination of the trachea and bronchi, establishing the nature and extent of inflammatory changes. Inspection and sanitation of the bronchi usually begin on the side where the pathology is presumably less pronounced, and end with the area of ​​the main lesion. The toilet of the bronchial tree includes a thorough sequential aspiration of the contents from the lobar and segmental branches, washing them with an indifferent or antiseptic solution, and the introduction of medicinal substances.

Aspiration of the contents of the bronchi during therapeutic bronchofibroscopy is performed through the instrumental channel of the bronchofibroscope.

Due to the small diameter of the instrumental canal, aspiration of viscous bronchial secretions often becomes possible only after endobronchial instillation of an isotonic sodium chloride solution or other solution, which is produced in portions of 5-20 ml. The total amount of instilled solution varies from 20 to 100 ml.

Therapeutic bronchoscopy with a rigid bronchoscope is often performed under anesthesia. The contents of the bronchi are aspirated using special metal aspiration tubes, and the use of tubes with rubber tips ensures minimal trauma to the mucous membrane. The relatively large diameter of the suction tubes makes it possible to remove secretions of almost any consistency.

The choice of drugs for endobronchial administration at the end of bronchoscopy depends on the nature of the inflammatory process.

Therapeutic catheterization of the bronchi for the rehabilitation of single cavities of decay or limited foci of inflammation in the lung can be an auxiliary procedure performed during bronchoscopy, or be an independent treatment technique.

Bronchial catheterization during bronchofibroscopy is carried out with a polyethylene catheter passed through the instrumental channel of the bronchofibroscope. The mouth of the segmental or subsegmental bronchus to be catheterized is determined based on the clarification of the localization of the pathological process according to chest radiographs, taking into account endoscopic data (the flow of purulent contents from the mouth of the bronchus draining the decay cavity).

During bronchoscopy with a rigid bronchoscope, bronchial catheterization is performed with radiopaque cardiac catheters with a diameter of 2.5-3.5 mm. The end of the catheter is pre-curved to facilitate passage to the desired segment. To control the catheter and advance it in the intended direction, special metal guide tubes or an elastic steel mandrel inserted into the catheter lumen are used.

Self-reliant medical procedure is bronchial catheterization, not associated with therapeutic bronchoscopy or ending with the catheter left in the decay cavity for a long time.

Such benefits, in particular, include the technique of passing a cardiac catheter through a rubber tube with a diameter of 5-8 mm, inserted into the trachea. The catheter, modeled in accordance with the location of the draining bronchus, is passed into the disintegration cavity under X-ray control. As with any method of catheterization, the bronchi and decay cavities are washed through the catheter, and medicinal substances are administered. This technique of conducting a catheter can also be used for long-term catheterization of the abscess cavity.

Another type of long-term catheterization of the abscess cavity is a method associated with the use of bronchofibroscopy [Lukomsky GI et al., 1982].

A thin radiopaque guiding catheter is passed through the instrumental channel of the bronchofibroscope into the decay cavity under the control of X-ray television, the length of which is twice the length of the bronchoscope. As a guide, a conventional polyethylene catheter with a thin steel wire inserted into it for contrasting or a special conductor for percutaneous catheterization of blood vessels and the heart according to the Seldinger method can be used. Then the bronchofibroscope is removed, and a radiopaque catheter with a wider lumen is passed through the left guide catheter into the abscess cavity. Through the catheter, the contents are aspirated 2-3 times a day, the abscess cavity is washed, and drugs are administered. The length of stay of the catheter in the cavity is 4-8 days.

Sanitation of the bronchi using microtracheocentesis is performed through a thin catheter inserted into the tracheobronchial tree percutaneously.

In the position of the patient on the back with a cushion under the shoulders and a tilted head, under aseptic conditions, under local infiltration anesthesia in the intercartilaginous space below the cricoid cartilage, the tracheal wall is pierced with a needle with a lumen diameter of 2 mm. A catheter with a diameter of 1.5-2 mm is passed through the needle to the bifurcation of the trachea.

It is convenient to perform microtracheocentesis under the control of bronchofibroscopy. In such cases, local anesthesia of the upper respiratory tract is preliminarily performed. After performing microtracheocentesis, a bronchofibroscope is inserted into the trachea and, under visual control, using bronchofibroscopic forceps, the catheter is directed to the desired section of the tracheobronchial tree.

The catheter is fixed on the neck with adhesive plaster, applied sterile dressing. Istillation of medicinal substances through a catheter is performed 2-4 times a day.

Endotracheal infusions are performed through a rubber catheter or with a laryngeal syringe under local anesthesia. In patients with a reduced cough reflex, the procedure can be performed without anesthesia.

The catheter is inserted into the trachea through the nasal passage in a sitting position. Direction to the trachea is achieved by tilting the head back and pulling the tongue forward. The catheter is passed through the vocal folds with a deep breath.

Endotracheal infusions can also be performed with a laryngeal syringe under the control of indirect laryngoscopy. Instillation of medicinal substances is carried out when the patient's torso is tilted towards the affected lung.

Before the procedure, the patient coughs up sputum as much as possible using postural drainage.

When sanitizing the bronchial tree, medicinal substances are installed endobronchially that suppress the pathogenic microbial flora, thin the bronchial secretion, have an anti-inflammatory and anti-edematous effect on the mucous membrane, and help eliminate bronchospasm.

Parenteral antibiotics are often used as antimicrobials. The choice of antibiotic depends on the sensitivity of the microbial flora. For the rehabilitation of the bronchial tree against the background of general antibiotic therapy, the same antibiotics are prescribed endobronchially and parenterally. Endobronchially administered antibiotics include penicillin and semi-synthetic penicillins, streptomycin, cephalosporins (ceporin, kefzol), tetracyclines, chloramphenicol, etc.

The dose of the instilled antibiotic is similar to that for intramuscular injection.

For sanitation of the bronchial tree, antiseptic agents are also used - 0.02% solution of furacilin and 0.1% solution of furagin, which have a wide spectrum of antimicrobial bacteriostatic and bactericidal activity. Antiseptic solutions are used both for washing the bronchi before the introduction of other drugs, and as the main active ingredient.

Relatively rarely, for the purpose of antibacterial action, solutions of sulfonamides are instilled.

To reduce the viscosity of bronchial secretions, mucolytic drugs are used. These include, in particular, proteolytic enzymes that catalyze the hydrolysis of peptide bonds in proteins. For endobronchial administration, trypsin, chymotrypsin, RNase, DNase are used in the amount of 25-50 IU. Trypsin and chymotrypsin have a stronger lytic effect on acid glycoprotein fibers, which determine the viscosity of the mucous secretion, RNase, DNase, on ribonuclein fibers contained in the purulent secretion. Proteolytic enzymes also have anti-inflammatory properties, increase the sensitivity of microflora to antibiotics. Before instillation, enzymes are dissolved in 3 ml of isotonic sodium chloride solution.

Acetylcysteine ​​has a pronounced mucolytic effect. Endobronchially injected 5-10% solution of acetylcysteine ​​in the amount of 3-10 ml. The drug contains free sulfhydride groups that can destroy the disulfide bonds of glycosaminoglycans, causing depolarization of the latter and a decrease in the viscosity of both mucous and purulent secretions.

Mucolytic drugs used endobronchially also include bromhexine, which causes depolarization and cleavage of mucoprotein and glycosaminoglycan fibers.

For endobronchial use, an ampoule containing 2-4 ml of the drug is diluted 1:1 with distilled water.

The bronchodilator effect is exerted by drugs of three main groups: adrenergic (ephedrine, adrenaline, naphthyzine, etc.), anticholinergic (atropine), methylxanthines (eufillin). Endobronchially more often instilled with 1 ml of 5% ephedrine solution, 1 ml of 0.1% adrenaline solution, 5-10 ml of 2.4% solution of aminophylline. With the introduction of adrenomimetic drugs, improvement in bronchial patency occurs due to both bronchodilation and a decrease in swelling of the bronchial mucosa due to local vasoconstriction. Effective bronchodilators administered by inhalation to prevent or combat bronchospasm include p-adrenomimetic substances: isadrin (berotek), salbutamol, alupent (asthmoment).

To combat edema and inflammation, hormonal preparations are used endobronchially, in particular, a suspension of hydrocortisone in an amount of 1-2 ml (25-50 mg).

Indications for use and the choice of methods for the rehabilitation of the bronchial tree in various lung diseases depend on the type of pathology, the nature of inflammatory changes in the bronchi. Before prescribing a course of endobronchial therapy, along with an assessment of the characteristics of the clinical course of the disease, x-ray picture, and the effectiveness of drug treatment, therapeutic and diagnostic bronchoscopy is usually performed. Bronchoscopic examination allows assessing the extent and severity of inflammatory changes in the bronchial tree, getting an idea of ​​the area of ​​greatest damage, diagnosing functional disorders type of tracheobronchial dyskinesia.

The detection of a purulent inflammatory process during endoscopy serves as the basis for the endobronchial use of substances that have an antimicrobial effect. In the presence of a viscous mucous secretion, the use of mucolytic agents is indicated.

The duration of the rehabilitation course varies from 10 to 20 days. Only a few patients with a widespread suppurative process are prescribed a longer endobronchial treatment. A frequent option for endobronchial therapy is the combination of repeated therapeutic bronchoscopies with endotracheal infusions of drugs in the time intervals between bronchoscopies. Therapeutic bronchoscopy with a rigid bronchoscope is performed 1-2 times a week, sometimes more often - 3-4 times a week. During the course of rehabilitation, as a rule, no more than 8-10 therapeutic bronchoscopies are performed.

In some patients, in particular in patients with increased reactivity of the tracheobronchial tree, manifested by massive hypersecretion of mucus or bronchospastic reaction to endobronchial administration of medicinal substances, the sanitation of the bronchial tree is difficult and does not allow to achieve a clear therapeutic effect. The use of antispasmodics to prevent bronchospasm, as a rule, makes it possible to conduct a full-fledged endobronchial therapy.

Massive hemoptysis and bleeding are contraindications to sanitation of the bronchial tree. In the treatment of patients with angina pectoris, it is not advisable to use endobronchial methods until the effects of coronary insufficiency are eliminated, as well as in patients with hypertension with high blood pressure. The effectiveness of endobronchial therapy decreases with severe cardiopulmonary insufficiency. However, given that in such cases, bronchial obstruction with a viscous secret is an aggravating, and often leading factor, cardiopulmonary insufficiency cannot be considered an absolute contraindication to the rehabilitation of the bronchial tree.

The instillation of a relatively small amount of liquid is an integral part of therapeutic bronchoscopy and sanitation of the bronchial tree, ensuring the removal of the contents of predominantly large and medium-sized bronchi. Bronchial lavage, or therapeutic BAL, is an independent medical procedure in which a significant volume of fluid is instilled endobronchially - from 100 to 1500 ml into the bronchi of one lung. In this way, the contents are washed out from all parts of the respiratory tract, including from the smallest bronchial branches and alveoli.

In clinical practice, two main types of therapeutic BAL have been used - washing the bronchial tree through a bronchoscope and lavage of the lung through an endotracheal tube.

Bronchoscopic BAL is usually performed through a rigid bronchoscope under anesthesia.

Ventilation of the lungs is carried out by an injection method that provides adequate gas exchange with the bronchoscope tube open, which creates more favorable conditions to complete the procedure and reduce its execution time. Endobronchially through a catheter with a diameter of 2.5-3 mm, isotonic sodium chloride solution is instilled, heated to body temperature.

Sequential lavage of the bronchial branches of each lobe of the lung has proven itself well [Lukomsky GI et al., 1982]. The introduction of a catheter into the desired lobar or segmental bronchus is performed using guides and other devices. 100-200 ml of isotonic sodium chloride solution is instilled into each share. In some lung diseases (cystic fibrosis), acetylcysteine ​​solution is used for lavage.

It is convenient to inject the solution with a 150 ml syringe. Immediately after instillation, aspiration of the solution coming from the lumen of the bronchi and the washed out bronchial contents is carried out. Instillation and aspiration of the solution can be performed simultaneously. To do this, in parallel with the catheter, a metal tube is inserted into the bronchial tree - an aspirator. If during aspiration there is a significant admixture of bronchial secretions and small casts of the bronchi, then the bronchial lavage is repeated. The volume of instilled solution during bronchoscopic bronchial lavage usually varies from 500 to 1500 ml. With obstructive changes in the bronchial tree, it is possible to aspirate half or one third of the injected volume of fluid.

The fluid installed during bronchial lavage reaches both the smallest bronchial branches and alveoli, interacting with the surfactant coating and alveolar cellular elements. As a result, partial leaching of the surfactant, cell alteration occur, interstitial edema develops, lung extensibility decreases, and gas exchange conditions worsen. However, the resulting moderate respiratory dysfunction disappears after 24-48 hours.

Therapeutic BAL has found application in patients with bronchial asthma with attacks of suffocation and an asthmatic condition that is difficult to respond to conventional treatment. As intensive drug therapy bronchial asthma indications for the use of BAL appear less and less.

Since bronchial contents enter the alveoli along with the installed solution, massive BAL should be avoided in case of purulent inflammatory process in the bronchial tree. In case of a suppurative process, which is often observed in diseases such as cystic fibrosis, in order to prevent infection of the alveoli and ensure effective removal of bronchial contents, it is more rational to perform BAL with a small amount of solution with a single injection of no more than 10-20 ml and the total volume of the installed fluid is no more than 200 ml. This technique was called BAL with small volumes of liquid, or “sparing” BAL, and has found application both in bronchoscopy with a rigid bronchoscope and in conditions of bronchofibroscopy.

Total BAL through an endotracheal tube is performed under anesthesia against the background of one-lung ventilation (Fig. 37.1). The use of a double-lumen endotracheal tube with inflatable rubber cuffs provides sealing of both lungs for the purpose of both separate ventilation and prevention of the instilled fluid being thrown into the bronchial tree of the opposite side. To control the correct position of the double-lumen endotracheal tube, lung auscultation data, X-ray examination, and a bronchofibroscope with a tube diameter of 3 mm, passed through one of the tube lumen, can be used.

First, mechanical ventilation of both lungs is performed, then the lavaged lung is switched off from the breathing process. Through the lumen of the endotracheal tube, a polyethylene catheter with a diameter of 2.5-3 mm is introduced into the main or intermediate bronchus, through which isotonic sodium chloride solution heated to body temperature is instilled. The method provides for total filling lung fluid. This is achieved by a single instillation of 1000-1500 ml of solution. Total filling is evidenced by the reverse flow of fluid through the lumen of the endotracheal tube. The incoming fluid, together with the washed out bronchoalveolar contents, is aspirated through the catheter or the lumen of the endotracheal tube * In the absence of pronounced obstructive changes in the bronchi, 90-95% of the injected fluid is aspirated. BAL is usually repeated several times.

The number of lung lavages during one procedure and the total volume of the solution to be instilled are set on the basis of a visual assessment of the fluid coming from the lung. BAL is completed after the admixture of bronchoalveolar contents becomes insignificant, and the incoming fluid becomes almost transparent. The volume of instilled isotonic sodium chloride solution during total lavage of the lung in some volunteers is 10 liters or more. If well tolerated, consecutive BAL of both lungs can be performed within one session. Total BAL through an endotracheal tube provides leaching of the contents of both bronchi and alveoli, and is the most effective way to treat alveolar proteinosis.

Bronchoscopic removal of foreign bodies of the bronchi. Modern bronchological instruments ensure the removal of the vast majority of foreign bodies in the bronchi.

The extraction of a foreign body in the bronchi is preceded by an endoscopic specification of its variety, size and location. In accordance with these data, the extraction method and bronchoscopic instruments are selected. Bronchoscopy with a rigid bronchoscope has a higher ability to extract foreign bodies than bronchoscopy. The advantage of the first method is largely related to the provision of a more secure grasp of the foreign body with forceps, which is one of the main elements of the procedure. But the bronchofibroscopic instrumentation, despite the relative diminutiveness, allows you to quite firmly capture and remove bronchial foreign bodies in most patients. If a foreign body is suspected, bronchofibroscopy under local anesthesia is shown as the first therapeutic and diagnostic bronchological examination as a more easily tolerated and simple method. Only if bronchofibroscopic extraction of a foreign body is impossible, it is advisable to use bronchoscopy with a rigid bronchoscope under anesthesia. From the very beginning, this method should be used in children under 10 years of age, with large foreign bodies complicated by respiratory failure and massive hemoptysis, with contraindications to the use of local anesthesia.

Sometimes it is advisable to combine the use of both types of bronchoscopy with conducting a bronchofibroscope through the tube of a rigid bronchoscope, in particular in children with a foreign body in segmental bronchial branches that are difficult to reach for "rigid" forceps.

To remove foreign bodies of the bronchi with a bronchofibroscope, it is preferable to inject it through oral cavity. The main type of instruments used to extract foreign bodies are flexible forceps with a diameter of about 2 mm with serrated jaws (such as "alligator", etc.). Grasping forceps with serrated or spoon-shaped grips are less commonly used. For rounded foreign bodies, basket-type grips are used, which are also used in gastroenterology to remove gallstones.

The bronchofiberscope can be brought to a foreign body located in any part of the bronchial tree from the trachea to the subsegmental branches.

After capturing the foreign body with forceps, it is removed along with a bronchofibroscope. Visual control over the progress of the foreign body through the bronchi and trachea is continued continuously until it is passed through the glottis and removed into the oral cavity.

When extracting a foreign body through a rigid bronchoscope, forceps with serrated jaws are most often used, which are convenient to extract solid foreign bodies of a flat or irregular shape that are not prone to crumbling. To remove the nut kernel or other objects that can be easily crushed when grasped, forceps with corrugated fenestrated or relatively thin flattened jaws are used. In order to extract rounded foreign bodies, forceps with spherical jaws are used.

After bringing the bronchoscope tube as close as possible to the foreign body, it is grasped with forceps, pulled up to the tube and removed through its lumen if it is small, and if it is larger than the diameter of the bronchoscope tube, it is removed together with the bronchoscope.

Removal of foreign bodies of organic origin that have been in the bronchial tree for a long time is difficult due to the accompanying suppurative process and bronchus stenosis due to growth granulation tissue and thickening of the mucous membrane. The procedure is facilitated if certain conditions are met. Care should be taken to inspect the bronchi and aspirate bronchial contents, without touching the easily bleeding mucous membrane with an optical telescope and aspirator in order to avoid even slight bleeding. Before capturing a foreign body, it is sometimes necessary to remove the granulations covering it with biters. To reduce bleeding and swelling, it is advisable to treat the mucous membrane with vasoconstrictor drugs.

Of the errors and dangers associated with the removal of foreign bodies of the bronchi, first of all, it should be noted the possibility of displacement, and sometimes wedging of a foreign body in the bronchial branch, after which bronchoscopic extraction becomes impossible. The cause of this complication is pressure during grasping with forceps on a foreign body that is weakly fixed in the lumen of the bronchus. With a needle-shaped body, displacement may be accompanied by penetration into the bronchial wall. If during bronchoscopy it is not possible to capture a foreign body without displacing it, then it is necessary to change the method of extraction.

Another danger is the possibility of fragmentation of a fragile foreign body and the ingress of fragments into small bronchial branches. This complication can be avoided by not applying strong compression of the foreign body at the time of grasping and by using the appropriate type of forceps.

Rare complications include damage to the bronchial wall and bleeding. Preventive measures include: right choice the direction in which the foreign body should be removed, the exclusion of the gripping of the bronchial wall by the jaws of the forceps, constant visual monitoring of the progress of the foreign body.

Temporary therapeutic occlusion, or bronchial tamponade. It is used as a method of treating pyopneumothorax and stopping massive pulmonary hemorrhage.

Temporary bronchial occlusion in the treatment of acute pyopneumothorax was first performed in children with staphylococcal lung destruction, later the method was introduced in the treatment of adult patients [Putov NV et al., 1981]. Its use is preceded by drainage and active aspiration of the contents of the pleural cavity. Indications for bronchial occlusion occur with continued massive intake of air through the drainage, which prevents the expansion of the lung.

Bronchoscopic occlusion of the bronchi is often performed on the 2nd-5th day after drainage of the pleural cavity. During this time, intensive antibacterial, detoxifying and restorative therapy is carried out, which improves the patient's condition.

Before performing therapeutic bronchial occlusion, it is necessary to determine the localization of bronchopleural fistulas. Chest X-ray, especially in the presence of radiographs taken before the development of pyopneumothorax, provides a topical diagnosis of fistulas based on the localization of a limited destructive process in a specific area of ​​the lung. Instrumental diagnostic methods using bronchoscopy are based on stopping the flow of air into the pleural cavity during tamponade of the corresponding bronchi, as well as on identifying bronchopleural communication by introducing a colored liquid or gas endobronchially or into the pleural cavity.

Therapeutic occlusion of the bronchi with a foam sponge is performed during bronchoscopy with a rigid bronchoscope under anesthesia, preferably in an X-ray bronchology room.

The tube of the bronchoscope is placed above the mouth of the bronchus to be occluded. The contents of the bronchi are carefully aspirated, an antibiotic solution is instilled into the occlusion zone. The diameter of the sponge-blocker should be 2-3 times the diameter of the occluded bronchus so that it does not move to other parts of the bronchial tree. For the purpose of radiological control of the position of the sponge, it is treated with a liquid or powdered contrast agent. The foam rubber sponge is twisted, grasped with forceps and inserted through the tube of the bronchoscope into the lumen of the bronchus, in which it straightens and fits snugly against the bronchial walls.

Successful occlusion of the bronchi is evidenced by the cessation of air flow from the pleural cavity through the drainage. Fluoroscopically, one can observe a decrease in the residual pleural cavity and straightening of the lung.

The duration of stay of the foam rubber sponge in the lumen of the bronchus is 7-10 days. With repeated bronchoscopy, it is removed, the secret accumulated distally to the occlusion zone is aspirated, and the bronchial branches are washed with an antiseptic solution. If during bronchoscopy or in the coming days, the flow of air into the pleural cavity resumes, then the bronchi can be re-occluded with a fresh foam rubber sponge.

As a result complex treatment with the use of temporary occlusion, the healing of bronchopleural fistulas and the elimination of the pleuropulmonary suppurative process are achieved in 80% of patients. Sometimes there is a small "dry" residual pleural cavity. Achieving a therapeutic effect is difficult with a large extent of the destructive process and its progressive nature, with multiple bronchopleural fistulas in various lobes of the lung.

Complications of temporary bronchial occlusion are relatively rare. These include an increase in the length of the destructive process in the lung, the advancement of the foam rubber sponge into the subsegmental bronchial branches and the impossibility of extracting it, the migration of the sponge into the proximal airways, the development of inflammation of the bronchial wall with the involvement of cartilage in the process and the formation of cicatricial bronchus stenosis in the long term, the formation of bronchiectasis.

An indication for therapeutic bronchoscopic tamponade of the bronchi is massive pulmonary bleeding, which threatens the development of asphyxia and cannot be stopped with the help of intensive drug therapy. Bronchial tamponade can be an element of preparation for urgent surgical intervention (lung resection) or be an independent method of treatment, in particular if there are contraindications to surgical treatment.

The technique of bronchial tamponade in massive pulmonary hemorrhage is basically similar to temporary endobronchial occlusion in pyopneumothorax. The procedure is performed during bronchoscopy with a rigid bronchoscope under anesthesia in an endoscopy room or operating room. Bronchoscopy begins with aspiration of blood from the respiratory tract and visual diagnostics. After clarifying the lobar localization of the source of bleeding, the foam rubber sponge is injected into the lobar bronchus.

The duration of bronchial tamponade with massive pulmonary bleeding is 24-48 hours. The sponge is removed during repeated bronchoscopy. The resumption of bleeding after removal of the sponge and aspiration of blood clots is observed in a third of patients, being the basis for repeated bronchus tamponade.

Approximately as effective is temporary occlusion of the bronchi with a Fogerty probe, which is performed during broncho-fibroscopy under local anesthesia.

To endobronchial surgical interventions include bronchoscopic instrumental therapeutic manipulations aimed at eliminating pathological formations of the trachea and bronchi. Such interventions can be an independent type of radical treatment of certain respiratory diseases or serve as an auxiliary procedure that facilitates preparation for reconstructive and other transthoracic operations, and can also be palliative. therapeutic effect aimed at restoring the patency of the airways in inoperable neoplasms.

Along with traditional endobronchial surgical interventions based on mechanical action using forceps or other special instruments, methods associated with the use of electrosurgical, cryosurgical, laser and other special equipment have found application in clinical practice.

Bronchoscopic surgical interventions, conditionally called mechanical, are performed using conventional endoscopic instruments and some devices that facilitate the performance of endobronchial therapeutic manipulations. The main purposes of surgical interventions are the removal of neoplasms and the elimination of stenosis of the respiratory tract.

The most common way to remove pathological formations of the trachea and bronchi is to bite them with biopsy or other forceps during bronchoscopy with a rigid bronchoscope. A relatively small volume of tissue (about 3 mm), which can be captured by the jaws of the forceps, allows using this method to remove relatively small benign tumors, granulation growths. By biting, it is preferable to remove neoplasms that have a well-formed leg [Perelman M.I. et al., 1981].

Mechanical removal is performed in the absence of severe bleeding of the tumor tissue. If moderate bleeding occurs during biting of one of the tissue fragments, then the manipulation is stopped and measures are taken to stop the bleeding, using both drugs and bronchial tamponade.

So-called mechanical surgical interventions are rarely performed for large tumors of the trachea and bronchi as a radical type of treatment. In some patients, successful removal of large neoplasms is achieved by using special techniques (cutting the tissue with a steel loop for polypectomy or carefully peeling the tumor from the bronchial wall with a bronchoscope tube).

Bougienage is more often used to treat cicatricial stenosis of the trachea and main bronchi. Therapeutic bronchoscopy with bougienage is preceded by diagnostic bronchofibroscopy, during which the type and degree of stenosis, its extent are determined, and a neoplastic process is excluded.

The most favorable conditions for bougienage are created during bronchoscopy with a rigid bronchoscope under anesthesia.

The expansion of stenotic airways is carried out with a bronchoscope tube or special bougies. The most crucial moment is the initial advancement of the bronchoscope tube or dilator through the area of ​​stenosis. To prevent rupture of the tracheobronchial wall, the diameter of the bronchoscope tube should not exceed the diameter of the airways at the site of stenosis by more than 2 mm. It is expedient to introduce a bronchoscopic tube with rotational-translational movements, which have a more gentle effect on the tissues than the direct advancement of the instrument. You can apply force only if you are sure that the bronchoscope tube moves exactly through the lumen of the narrowed bronchus, and does not move away from it. Visual control through the bronchoscopic tube at the time of bougienage ensures that it is correctly directed.

After passing through the area of ​​stenosis, the bronchoscope is removed and the bougienage is repeated with a bronchoscopic tube of a larger diameter. For the dissection of very dense scar tissue with membranous stenoses that are not amenable to bougienage, special long knives have been used.

Bougienage in most patients allows you to quickly eliminate cicatricial stenosis of the trachea and bronchi, eliminate ventilation disorders. However, permanent restoration of normal airway patency is rarely achieved. As a rule, after 3-6 weeks or earlier, a recurrence of stenosis is observed, requiring repeated therapeutic manipulations.

Before implementation in clinical practice For cryosurgical and laser endoscopic interventions, bougienage was one of the leading bronchoscopic methods for the treatment of tracheal and bronchial stenoses. In recent years, it has become less common and serves mainly as an adjuvant treatment in preparation for other types of endobronchial surgery.

Bronchoscopic bougienage performed without strict adherence to methodological requirements may be complicated by rupture or perforation of the tracheobronchial walls, as well as bleeding.

Endoscopic electrosurgical interventions are performed using two main techniques: tumor electroexcision with a diathermic loop and tissue electrocoagulation with a single electrode - an electroknife.

The equipment includes an electrosurgical unit with a power source that generates a high-frequency diathermic current in a continuous cutting mode or in an intermittent coagulation mode, as well as in a mixed mode. Two electrodes are attached to this block: passive - a metal plate with a large contact surface, attached to the patient's thigh or lower leg, and active - one of the endoscopic instruments (diathermic loop or electric knife).

In accordance with the ratio of the areas of the contact surfaces of the electrodes, the current power is negligible in the area of ​​the passive electrode and very high in the area of ​​the active electrode. The heat generation that occurs during the interaction of the active electrode with the tissue is sufficient for its dissection or destruction.

Bronchoscopic electrosurgical interventions are performed during bronchoscopy with a rigid bronchoscope under anesthesia or during bronchoscopy under local anesthesia. A diathermic loop is inserted endobronchially inside a fluoroplastic catheter through the instrumental channel of a bronchofibroscope. For bronchoscopy with a rigid bronchoscope, a special guide combined with an optical telescope can also be used for this purpose.

A diathermic loop is thrown over the neoplasm of the trachea or bronchi, brought under its base and tightened. Then, against the background of the diathermic current, the loop is slowly drawn into the catheter and the tumor is electroexcised.

If the diathermy loop is retracted too quickly into the catheter, mechanical intersection of the base of the tumor without electrocoagulation, accompanied by bleeding, may occur.

Depending on the size of the neoplasm, the duration of electroexcision varies from 3 to 80 s. Extraction of the tumor from the tracheobronchial tree is carried out using forceps to remove foreign bodies of the bronchi. If the size of the tumor exceeds the diameter of the tube of the rigid bronchoscope, then after grasping it with forceps, it is removed together with the bronchoscope.

Removal of the tumor of the trachea and bronchi can be achieved as a result of both single and repeated electrical excision of the tissue with a diathermic loop. Simultaneous removal is possible when the tumor is located in the trachea or one of the bronchial trunks. When spreading to two or more bronchial branches, the tumor is removed in parts. The use of interventions with the help of a diathermic loop is limited mainly by the impossibility of bringing it under the base of the tumor. Such a situation can occur with a tumor on a broad base and its invasive growth, dense obstruction of the bronchial lumen by a tumor, and the location of the neoplasm in hard-to-reach segmental branches.

Possibilities of electrosurgical surgical interventions using an electroknife are lower than when using a diathermic loop. Electrodestruction of large neoplasms requires numerous actions during multiple bronchoscopy. This method is more often used for electrocoagulation of granulation growths, bleeding areas of the bronchial walls, the mucous membrane of bronchial fistulas and is much less often used to restore airway patency in inoperable neoplasms [Ovchinnikov A. A., Filippov M. V., 1984].

Cryosurgical surgeries are performed by exposing tissues to ultra-low temperatures (-160-180 °C). Cryotherapy through a bronchoscope is carried out with a special cryoprobe with a diameter of about 5 mm, a length of 50-55 cm. Cooling to ultra-low temperatures is achieved by liquid nitrogen circulating inside the cryoprobe through a system of thin tubes. Ultra-low temperature is created only at the end of the cryoinstrument; the rest of the cryoprobe surface is not subjected to significant cooling due to vacuum thermal insulation.

Cryosurgical interventions are performed during bronchoscopy with a rigid bronchoscope.

The cryoprobe is passed into the tracheobronchial tree through a bronchoscopic tube. After contact of the tip with a pathological formation of the trachea or bronchi, liquid nitrogen is supplied to the cryoinstrument and the tissue is frozen to -160 °C. The duration of a single cryotherapy is 1-3 minutes. Then the supply of liquid nitrogen is stopped and the cryo-tip and frozen tissue are thawed. After that, the cryoprobe can be removed or moved to another area of ​​the tissue.

The volume of frozen tissue depends on the duration of cryotherapy. With a significant size of the pathological formation, cryoapplication on different parts of the tissue is repeated several times during one procedure.

Freezing of the tissue is accompanied by its necrosis, followed by rejection and regeneration process. As a result of cryotherapy, a reduction in the size of pathological formations is achieved up to a complete reverse development.

In clinical practice, two options for cryosurgical interventions have found application: cryodestruction, in which only tissue is frozen, and cryoresection, including cryotherapy followed by mechanical removal of necrotic tissue with biopsy forceps or other instruments.

Endobronchial cryosurgical intervention is performed for partial removal inoperable tumors of the trachea and bronchi with the restoration of airway patency, as well as for the treatment of cicatricial stenosis of the trachea, laryngo-tracheal papillomatosis [Rusakov M. A., 1981; Sanderson D. et al 1981].

Complications of cryodestruction include an increase in the degree of stenosis of the trachea and bronchi due to tissue edema in the zone of cryotherapy, bleeding.

The bronchological application of high-energy lasers has made it possible to develop fundamentally the new kind endobronchial surgery - non-contact surgical interventions, in which the destruction of 'pathological formations of the trachea and bronchi occurs under the influence of laser radiation.

The introduction of endobronchial laser surgery into clinical practice became possible after the design of special light guides and focusing systems that ensure the transmission of high power density radiation to the site of exposure.

In bronchoscopic surgery, two main types of lasers are used: CO2 laser and neodymium yttrium aluminum garnet (YAG) laser. In order to transmit CO2 laser radiation, rigid light guides are used, therefore its use is limited to bronchoscopy with a rigid bronchoscope. More versatile are endoscopic laser units with a neodymium YAG laser, the beam of which is transmitted through a flexible fiber light guide.

Laser surgical interventions using a neodymium YAG laser with a power of 100-120 W are performed during both bronchoscopy under local anesthesia and bronchoscopy with a rigid bronchoscope under anesthesia. The use of monofilament quartz light guides with a diameter of 0.5 mm makes it possible to create a power density of up to 100 W/mm2 in a radiation spot with a diameter of 1–1.5 mm.

The fiber light guide is mounted in a fluoroplastic catheter with a diameter of about 2 mm, while maintaining space for compressed air supply.

The radiation of a neodymium YAG laser with a wavelength of 1060 nm is in the infrared part of the spectrum and is not perceived by the eye. To guide laser radiation, a low-energy helium-neon laser with a wavelength of 630 nm is included in the endoscopic laser installation, which gives the beam a red color. A helium-neon laser beam is projected onto the tracheobronchial walls in the form of a red spot about 1 mm in diameter.

In the bronchofibroscopic technique, a catheter with a monofilament light guide is inserted into the tracheobronchial tree through the instrumental channel of the bronchofibroscope. The fiber light guide is installed at a distance of about 0.5 cm from the pathological formation of the trachea or bronchi. Focusing on the location of the red spot of the helium-neon laser beam, choose the place of exposure. Laser photocoagulation is carried out under continuous visual control. The radiation of a neodymium YAG laser is supplied in series of pulses (5-6) with short breaks between series.

The total duration of exposure depends on the size of the pathological formation. During one procedure, 200 or more pulses may be required. Change of direction laser beam for the purpose of photocoagulation of various parts of the tissue, it is carried out by bending the distal end of the bronchofibroscope. At the time of laser intervention, the distal end of the light guide is blown with compressed air in order to protect it from products formed during interaction with tissues.

Under the influence of neodymium YAG laser radiation, three zones are formed in the tissue, differing in temperature increase and the nature of cell damage. In the first zone, the temperature rises to 900-1000 °C, which causes the evaporation and eruption of tissue particles, the formation of an amorphous mass of coagulated cells. The second zone is characterized by an increase in temperature up to 300-400 °C, evaporation of part of the tissue fluid with the development of numerous cavities lined with compressed and deformed cells. In the third zone of the tissue, where the temperature reaches 70-200 °C, coagulation necrosis occurs without vaporization. Due to the short duration of the laser pulse, the instantaneously released heat does not have time to spread beyond the irradiation zone and, unlike other thermal lesions, burns under the influence of laser pulses have a sharp border between the affected and surrounding intact tissue [Gamaleya N.F., 1981]. Obviously, therefore, laser surgical interventions are accompanied by a slight reaction of the tissues surrounding the photocoagulation zone.

Endoscopically, laser photocoagulation is manifested by the appearance of crater-shaped tissue depressions with a whitish or brownish surface. During one pulse, about 3 mm2 of tissue is coagulated. At the same time, smoke is released from the respiratory tract when exhaled. With repeated pulsed laser exposure, charring (carbonization) of the tissue occurs.

Bronchoscopic laser surgical interventions have proven to be effective method treatment of neoplasms of the trachea and bronchi. At benign tumors laser photocoagulation allows you to completely remove a neoplasm with endobronchial growth and is a radical type of treatment.

In malignant neoplasms, endoscopic exposure to a high-energy laser is usually used as a palliative intervention in cases of contraindications to transthoracic surgical treatment to remove the endobronchial part of the tumor and restore airway patency. With the help of laser photocoagulation, complete destruction of the tumor can be achieved only at the stage of non-invasive growth of bronchogenic cancer.

Endobronchial laser exposure makes it possible to destroy not only tumor, but also scar tissue and eliminate cicatricial stenosis of the trachea and bronchi. Laser interventions are most effective for cicatricial stenoses no more than 1 cm long.

Bronchoscopic laser photocoagulation allows you to eliminate bleeding formations of the trachea and bronchi, granulation and papillomatous growths, as well as some other types of pathology.

Complications of bronchoscopic laser interventions (perforation of the tracheal or bronchus wall, bleeding, asphyxia, cardiac arrest) are rare. Complications with a fatal outcome develop mainly in patients with inoperable malignant neoplasms, who are in serious condition, and occur with a frequency of up to 0.3%.

Therapeutic thoracoscopy. It is used to sanitize the pleural cavity and to perform various endopleural surgical interventions. Along with the instruments used in diagnostic thoracoscopy, a special surgical thoracoscope is used for therapeutic endopleural manipulations, in which the tube is combined with an optical telescope and has an instrumental channel.

The main indications for thoracoscopic sanation of the pleural cavity are acute and chronic pleural empyema.

Therapeutic thoracoscopy is usually performed under anesthesia, but in the absence of severe respiratory failure it can also be performed under local anesthesia.

The location of thoracocentesis depends on the location of the empyema cavity and is preliminarily established on the basis of radiographic data. After the introduction of the thoracoscope, a visual assessment of the state of the pleural cavity is performed, intrapleural adhesions, fibrin overlays, signs of bronchopleural fistulas are detected, and the degree of lung collapse is assessed. Sanitation of the empyema cavity includes aspiration of purulent contents, removal of fibrinous and purulent-necrotic deposits, destruction of loose adhesions, washing with an antiseptic solution.

The possibilities of endopleural therapeutic interventions are expanded with the simultaneous introduction into the pleural cavity through an additional thoracocentesis hole of the second tube of the thoracoscope, designed for endoscopic instruments or optical telescopes. To remove purulent-fibrous deposits and separate adhesions, special probes and forceps are used, for the same purpose, as well as for washing the empyema cavity - ultrasonic equipment [Kabanov A. N., Sitko L. A., 1985]. Therapeutic thoracoscopy is completed by inserting a rubber drainage tube through the thoracoscope.

The types of sanation thoracoscopy include therapeutic thoracoabscessoscopy. This method is used for large lung abscesses with sequestration of lung tissue.

The place of thoracocentesis is located above the center of the decay cavity, and in the presence of liquid contents - 1-2 cm above its level. After the control puncture of the abscess at the intended point, the needle is not removed; it serves as a guide for the introduction of a trocar next to it. After examining the cavity of the abscess and aspiration of the liquid contents, the sequestered necrotic lung tissue and fibrin clots are carefully removed. The resulting slight bleeding is stopped by electrocoagulation. The procedure is completed by washing the decay cavity with an antiseptic solution and thoracoscopic drainage.

Thoracoabcessoscopy allows to eliminate the phenomena of intoxication and accelerates the healing of the focus of destruction in the lung.

Therapeutic thoracoscopy is used to sanitize the pleural cavity in traumatic hemothorax, removing both unclotting blood and its folds [Avilova OM et al., 1986].

The first thoracoscopic surgical interventions include thoracoacoustics - burning of pleural adhesions in patients with pulmonary tuberculosis, introduced by Jacobeus in 1913. In recent years, operative thoracoscopy is most often performed with spontaneous pneumothorax in order to destroy the bullae and adhesions that cause pneumothorax and prevent lung expansion. A diathermocoagulator and laser equipment are used as thoracoscopic surgical instruments.

During electrosurgical interventions, the diathermocoagulator is introduced through the instrumental channel of the surgical thoracoscope or with the help of an additional thoracocentesis. After bringing the diathermocoagulator to the surface of the bulla, the electrical destruction of its wall is carried out with coagulation of the base. In a similar way, single adhesions between the parietal and visceral pleura are destroyed.

For laser surgical interventions, as in bronchoscopy, a neodymium YAG laser with a flexible monofilament light guide is used. The light guide is guided into the pleural cavity using a special guide. For this purpose, fiber endoscopes can also be used. By directing the laser beam at the bullous formation, photocoagulation of its wall and base is performed.

Diathermic and laser coagulation is used with well-accessible medium and small bullae, striving for their obliteration. The advantages of laser photocoagulation are non-contact destruction of bullae, the possibility of precise dosing of energy and constant visual control of the coagulation process.

Endopleural spraying of talc or other chemicals can be used to form adhesions in the pleural cavity and prevent recurrence of the disease.

More rare thoracoscopic surgical interventions include parietal pleurectomy, intrapleural sympathectomy and vagotomy, removal of foreign bodies, etc.

Used drugs:

Sanitation of the bronchial tree is the most effective treatment. Sanitation methods are usually divided into passive, which include postural (positional) drainage and expectorants, and active, consisting in the aspiration of the contents of the bronchi, their washing (lavage) and the subsequent introduction of medicinal substances into the bronchi [Struchkov V. I., Lokhvitsky S. V., 1972].

Positional drainage of the bronchial tree, which is carried out in strict accordance with localization, must be considered mandatory. With basal bronchiectasis, the secret from the bronchi is removed by hanging the torso over the edge of the bed or by significantly raising the foot end of the bed; with the localization of bronchiectasis in the IV and V segments - lying on your back with the head end of the bed lowered and with a pillow placed under the patient's side.

Postural drainage is mandatory for patients with bronchiectasis at least 2 times a day (in the morning after sleep and in the evening before bedtime). During the exacerbation of the disease, drainage should be used repeatedly, each time until the bronchial tree is possibly completely freed from the contents.

The effect of postural drainage can be enhanced by the appointment of expectorants: 3% potassium iodide solution, thermopsis herb infusion (0.6: 180.0), 1 tablespoon of each solution 4 - 6 - 8 times a day; bromhexine or bisolvon tablets 4-8 mg 3 times a day or in the form of inhalations; mucovista in the form of an aerosol of 3 ml of a 20% solution, etc. It has been shown that postural drainage in combination with vibromassage and coughing in patients with chronic lung diseases increases the rate of forced vital capacity of the lungs.

Active methods of sanitation of the bronchi. Emphasizing the importance of passive methods of sanitation of the bronchial tree, it should, however, be noted that the pronounced inhibition of the self-purification reflex of the bronchi in patients with COPD and especially with bronchiectasis does not allow one to rely on the effective release of the bronchial tree from its contents by using only these methods.

Active, a kind of invasive methods of drainage of bronchiectasis and affected bronchi - microdrainage of the trachea and bronchi (percutaneous microtracheostomy), bronchoscopic drainage, lavage of the bronchial tree, endobronchial directed catheterization under X-ray control with aspiration of the contents of bronchiectasis and subsequent administration of antimicrobial, anti-inflammatory, bronchodilator and other medicines.