IVL complications – the negative consequences of artificial ventilation of lungs arising right after its beginning or which are result of long respiratory support. The symptomatology is defined by type of violations. Signs of respiratory insufficiency, emphysema, the inflammatory phenomena, changes in work of internals can come to light. Pathology is diagnosed on the basis of a clinical picture and data of objective inspection: X-ray analysis, ultrasonography, computer or magnetic and resonant tomography, definition of pH of blood. Specific treatment includes control of parameters of the equipment, knocking over of an inflammation, an ushivaniye of damages of pulmonary fabric, drainage of a chest cavity.
Complications of respiratory support at its correct carrying out meet rather seldom. Most often at patients, it is long being in ORIT, stagnant pneumonia develops. The aspiration kind of pneumonia is sometimes diagnosed for the patients who are on support of noninvasive type (through a front mask) more than a day. At the wrong choice of the mode in 100% of cases gas acidosis or varying severity is found. Hardware breath for 2-3 weeks and more exponentiates formation of pathological processes in internals. The barotrauma is the most rare kind of complications, occurs mainly at children and patients of an asthenic constitution.
Reasons of complications of IVL
As a rule, the accompanying pathological states become result of violation of the rules of ventilation. In the absence of such violations of difficulty, caused by inevitable changes in an organism, come to light at the certain patients forced to be long time on external life support. Similar occurs at severe injuries, ekzo-or endotoxic defeat of the respiratory center, krupozny pneumonia. Complications of IVL develop for the following reasons:
- High pressure on a breath. Elevated pressure provokes ruptures of pulmonary fabric, usually arises at an indicator higher than 50 mm of mercury., however can take place and at lower figures if ventilation is carried out to patients of advanced age or small to children. The wrong choice of pressure – one of the reasons leading to the heaviest failures in work of an organism.
- Violation of hygiene of airways. Removal of the slime which accumulated in an intubatsionny or trakheostomichesky tube has to be made each 2-3 hours or as required. If this rule is not followed, the slime containing bacterial strains accumulates in a trachea, bronchial tubes, lungs that increases probability of development of infectious processes.
- Irregular control of KShchS. Definition of acid-base balance and content of electrolytes in plasma of blood is a main type of laboratory control of a condition of the patient. By its results estimate pH of the internal environment, before development of clinical manifestations define existence of acidosis or an alkaloz, correct an operating mode of the device. In the absence of data of this research it is impossible to diagnose IVL complications at an early stage.
- Insufficient visual control. If the staff of medical institution does not provide constant visual control of a condition of the equipment and the patient, the risk that the patient will independently disconnect a respiratory contour increases, will remove an intubatsionny tube, will undergo a hypoxia and will die. The special attention is required by the patients having encephalopathy of any origin and being in a post-narcotic state.
- Long hardware gas exchange. Leads to gradual disorder of exchange processes, disadaptation of the respiratory center, violation of electrolytic balance. It is almost impossible to prevent the similar phenomena as they are natural reaction of an organism to long-term hardware breath and insufficient mobility.
The pathogenesis of complications of IVL is defined by their character and the reasons. Infectious processes develop at a congestion in alveoluses and bronchial tubes of a large number of the phlegm containing pathogenic microorganisms. Easing of immunity owing to the main pathology sharply increases probability of an inflammation of affected areas. Aspiration kinds of pneumonia turn out to be consequence of an incomplete raspravleniye of a lung at the insufficient volume of a breath and long lying situation. At the same time in badly ventilated sites anaerobic flora quickly develops.
Respiratory acidosises arise at decrease in level of oxygenation and increase in partial pressure of carbon dioxide. There is a shift of curve dissociation of hemoglobin to the right, concentration of H+ grows, pH is displaced in the sour party. The return process connected with a hyperventilation decrease in pCO2 and the H+ level leads to formation of an alkaloz of gas type. At a barotrauma the pathogenesis is based on a mechanical rupture of tissues of lung with an air outlet and blood in okololegochny space and hypodermic fatty cellulose. The lung can be drawn in by the streamed liquid and gas that initiates its incomplete participation in breath process.
At an independent detachment from the equipment the main problem is lack of adequate gas exchange in lungs and development of a hypoxia. Oxidizing processes in cages are broken, there is an accumulation of carbon dioxide. The brain and a myocardium experience the oxygen starvation which is coming to the end with death of the patient. If the detachment was the result of removal of an intubatsionny tube, there are trachea injuries. It provokes hypostasis and mechanical impassability of airways. Repeatedly it is possible to intubirovat patients not always, often the doctor should resort to the emergency trakheostomiya.
All complications of IVL are considered as heavy and can threaten the patient's life therefore systematization on severity is not used. Classification by current speed according to which all states divide on lightning (an independent ekstubation against the background of lack of spontaneous breath, a barotrauma), sharp (pneumonia), chronic (stressful ulcers, hypostases) can be applied. The similar principle of division is extremely conditional and has no clinical value. In practice experts usually are based on systematization by the pathogenetic principle:
- Barotrauma. Depending on localization and the sizes of a gap can lead to formation of interstitsialny emphysema, a pnevmomediastenum, hypodermic emphysema, pheumothorax. The valvate kind of the last at which the air which accumulated in a pleural cavity squeezes a lung is considered the most dangerous and completely excludes it from breath process.
- Infectious complications. The main versions – aspiration and stagnant pneumonia. Differ in a heavy current, therapies badly give in. As the activator are intrahospital strains, antibiotic treatment not always happens effective. Selection of medicines is carried out by results of the analysis of a phlegm on sensitivity to antimicrobic medicines. Besides, there can be tracheitises, bronchitis, abscesses of airways or lungs.
- Violations of KShchS. In the compensated option (shift of pH on the 100-th shares) do not pose a threat to life. The subcompensated and dekompensirovanny forms lead to violation of structure of proteins, including hormones and receptors. System failures in work of all systems of an organism, polyorgan insufficiency turn out to be consequence.
- Patomimiya. Independent intervention of the patient in process of ventilation of lungs, removal of a tube, contour detachment, shutdown of the device. It is critically life-threatening, it has to be stopped by medical personnel up to soft fixing of the patient to a bed and introductions of antipsychotic medicines for knocking over of psychomotor excitement.
- Exchange violations. The IVL complications arising with long support and leading to formation of chronic pathological processes. Include , hypostases, an urolithic disease, stressful stomach ulcers and a duodenum. Remain for the entire period of artificial ventilation, demand separate treatment after restoration of independent breath.
Symptoms of complications of IVL
The barotrauma is shown by sharp breast pain, signs of respiratory insufficiency against the background of the continuing ventilation. The thorax of the patient can visually increase in volume, take the barrel-shaped form. Skin tsianotichny or pale, is covered then. When forming hypodermic emphysema the palpation allows to reveal the characteristic crunch arising at the expense of the vials of air which accumulated in hypodermic cellulose. The device can normally work or signal about violation of calculated parameters. At big blood loss there is tachycardia, hypotonia, consciousness violations, in hard cases – a coma.
Pneumonia is shown by temperature increase of a body, the general deterioration in health, pain and an ache in muscles, hyperaemia of the person on the party of an inflammation, feeling of shortage of air. Violations of haemo dynamics, development of infectious and toxic shock can be observed. At the weakened patients clinical manifestations are expressed poorly, the picture greased. On an intubatsionny tube a large number of a fetid purulent phlegm separates. Vomiting is possible. The patient thirsts, drinks much if the equipment allows to make it.
Clinical manifestations of violations of KShchS and exchange failures vary over a wide range. The symptomatology depends on a look and extent of defeat of this or that body. Most often there is an anury, diarrhea or locks, coloring of a chair changes, skin gets a yellowish shade. Nausea, desires on vomiting is noted. The patient refuses food, water. The takhiaritmiya, bradycardia, premature ventricular contraction, decrease in level HELL comes to light. Symptoms of encephalopathy of endotoxic genesis are found. Patomimiya who is followed by interruption in supply of respiratory mix leads to emergence of signs of sharp respiratory insufficiency: cyanosis of skin and lips, the rare or completely absent breath, consciousness oppression.
Diagnostics is made by the doctor the intensivist. Consultations of other experts, in particular – the hepatologist, the pulmonologist, the cardiologist are required. In addition, to the patient in chamber conduct radiological survey, ultrasonography, an electrocardiography. Actions for definition of complications have to be realized in short terms, is optimum – within 1-2 hours from the moment of emergence of symptoms. Then begin urgent therapy or transport the patient in the operational block. Carry to number of diagnostic actions:
- Survey and fizikalny inspection. At survey pay attention to clinical signs of insufficiency of breath, blood circulation, work of kidneys or a liver. At pheumothorax percussion reveals timpanit, a sound of a cracked pot, at emphysema – a box sound. At pneumonia in lungs rattles are listened, breath is carried out not to all departments. At an independent ekstubation suffocation symptoms are noted.
- Laboratory inspection. In results of the analysis increase or decrease in pH, violation in gas and electrolytic composition of blood is defined on KShchS. Usually what stronger expressed laboratory changes, especially the condition of the patient is heavy. In the biochemical analysis of an aberration arise at development of system pathological processes. Growth of activity of hepatic enzymes, increase in concentration of creatinine and urea is possible.
- Tool inspection. At pneumonia the X-ray analysis of lungs allows to reveal the inflammation centers which are visualized as sites of blackout. At ruptures of a lung the displaced sredosteniye, a collapse of body is looked through. Injuries of airways are found when carrying out a bronkhoskopiya. For specification of the diagnosis use a computer tomography of an affected area.
Treatment of complications of IVL
Treatment of a barotrauma is performed by surgical methods. At pheumothorax the puncture of a pleural cavity with installation of a drainage is shown. For a raspravleniye of a lung it is used . For a stop of bleeding haemo static medicines are shown. If low-invasive treatment is inefficient, the patient is transported in an operblok for carrying out a torakotomiya and audit of bodies of a thorax. Defect is taken in, carry out coagulation, delete the accumulated exudate and blood from a pleural cavity.
Complications of IVL of infectious character demand purpose of the antibacterial and mukolitichesky medicines facilitating otkhozhdeny phlegms. Use of immunoexcitants, bacteriophages is admissible. An indispensable condition is timely sanitation of a trachea with removal of the separating phlegm. It is possible to stimulate its otkhozhdeniye by means of vibromassage, percussion in shovels. If necessary the medical bronkhoskopiya is appointed.
Correction of violations of KShchS is made by setup of the respiratory device. At acidosis the volume and frequency of a breath are increased, at an alkaloza – reduced. Oxygenation by increase in a percentage share of oxygen in respiratory mix more than to 40% is allowed only for a short time (no more than 5-10 minutes), otherwise there is so-called oxygen intoxication. Metabolic violations during stay of the patient in resuscitation eliminate posimptomno. At hypostases enter loopback diuretics, at a functional holestaz – bile-expelling medicines. Locks demand purpose of depletive and carrying out a cleaning enema. At a renal failure the hemodialysis is shown.
Forecast and prevention
The forecast depends on type and weight of violation. In most cases in due time found negative changes manage to be stopped without serious consequences. Prevention consists in competent selection of the modes of ventilation, regular cleaning of airways, early activization of the patient within a bed. Patients in a condition of psychomotor excitement have to be fixed to a bed, alternative option of actions of the resuscitator in similar cases is introduction of psychotropic drugs and gipnotik. When using artificial respiratory support to all patients the round-the-clock supervision from average medical personnel is required.