Respiratory insufficiency is the pathological syndrome accompanying a number of diseases which cornerstone violation of gas exchange in lungs is. The basis of a clinical picture is made by signs of a gipoksemiya and a giperkapniya (cyanosis, tachycardia, sleep disorders and memories), a syndrome of exhaustion of respiratory muscles and short wind. DN is diagnosed on the basis of the clinical data confirmed with indicators of gas composition of blood, FVD. Treatment includes elimination of the reason of DN, oxygen support, if necessary - IVL.
External breath supports continuous gas exchange in an organism: intake of atmospheric oxygen and removal of carbon dioxide. Any malfunction of external breath leads to violation of gas exchange between alveolar air in lungs and gas composition of blood. As a result of these violations in blood the content of carbonic acid increases and the content of oxygen that leads to oxygen starvation, first of all, of zhiznennovazhny bodies – heart and a brain decreases.
At the respiratory insufficiency (RI) the necessary gas composition of blood is not provided, or it is supported at the expense of an overstrain of compensatory opportunities of system of external breath. The state menacing for an organism develops at the respiratory insufficiency which is characterized by decrease in partial pressure of oxygen in arterial blood less than 60 mm of mercury., and also increase in partial pressure of carbonic acid more than 45 mm of mercury.
Respiratory insufficiency can develop at various sharp and chronic inflammatory diseases, damages, tumoral damages of respiratory organs; at pathology from respiratory muscles and heart; at the states leading to restriction of mobility of a thorax. Can lead to violation of pulmonary ventilation and development of respiratory insufficiency:
- Obstructive violations. Respiratory insufficiency on obstructive type is observed at difficulty of passing of air on pneumatic ways – a trachea and bronchial tubes owing to a bronchospasm, an inflammation of bronchial tubes (bronchitis), hit of foreign matters, a striktura (narrowing) of a trachea and bronchial tubes, a sdavleniye of bronchial tubes and a trachea by a tumor etc.
- Restrictive violations. Respiratory insufficiency on restrictive (restrictive) type is characterized by restriction of ability of pulmonary fabric to expansion and falling off and meets at ekssudativny pleurisy, pheumothorax, a pneumosclerosis, adhesive process in a pleural cavity, limited mobility of a costal framework, a kifoskolioza etc.
- Haemo dynamic violations. The circulator frustration (for example, a thrombembolia) leading to impossibility of ventilation of the blocked site of a lung can serve as the reason of development of haemo dynamic respiratory insufficiency. Also leads the right-left shunting of blood through an open oval window at heart disease to development of respiratory insufficiency in haemo dynamic type. At the same time there is a mixture of blue and oxygenic arterial blood.
Respiratory insufficiency is classified by a number of signs:
1. On pathogenesis (the emergence mechanism):
- parenchymatous (gipoksemichesky, respiratory or pulmonary insufficiency of the I type). On parenchymatous type decrease in content and partial pressure of oxygen in arterial blood (gipoksemiya), difficult korrigiruyemy oxygen therapy is characteristic of respiratory insufficiency. As the most frequent reasons of this type of respiratory insufficiency serves pneumonia, a respiratory distress syndrome (a shock lung), cardiogenic hypostasis of lungs.
- ventilating ("pump", giperkapnichesky or respiratory insufficiency of the II type). As the leading manifestation of respiratory insufficiency on ventilating type serves increase in content and partial pressure of carbonic acid in arterial blood (giperkapniya). At blood there is also a gipoksemiya, however it well gives in to a kislorodoterapiya. Development of ventilating respiratory insufficiency is observed at weakness of respiratory muscles, mechanical defects of a muscular and costal framework of a thorax, violation of regulatory functions of the respiratory center.
2. On an etiology (reasons):
- obstructive. At this type functionality of the device of external breath suffers: the full breath is at a loss and especially exhaled, breath frequency is limited.
- restrictive (or restrictive). DN develops because of restriction of the greatest possible depth of a breath.
- combined (mixed). DN on the combined (mixed) type combines signs of obstructive and restrictive types with prevalence of one of them and develops at the long course of warm and pulmonary diseases.
- haemo dynamic. DN develops against the background of lack of a blood-groove or inadequate oxygenation of a part of a lung.
- diffusion. Respiratory insufficiency on diffusion type develops at violation of penetration of gases through a capillary and alveolar membrane of lungs at its pathological thickening.
3. On the speed of increase of signs:
- Sharp respiratory insufficiency develops promptly, in several hours or minutes, as a rule, is followed by haemo dynamic violations and poses hazard to life of patients (the emergency holding resuscitation actions and intensive therapy is required). Development of sharp respiratory insufficiency can be observed at the patients suffering from the DN chronic form at its aggravation or a decompensation.
- Chronic respiratory insufficiency can a narastatna an extent of several months and years, quite often gradually, with gradual increase of symptoms, can also be a consequence of incomplete restoration after sharp DN.
4. On indicators of gas composition of blood:
- compensated (gas composition of blood normal);
- dekompensirovanny (existence of a gipoksemiya or giperkapniya of arterial blood).
5. On degree of expressiveness of symptoms of DN:
- Degree DN I – is characterized by short wind at moderate or considerable loadings;
- Degree DN II – short wind is observed at insignificant loadings, the involvement of compensatory mechanisms at rest is noted;
- Degree DN III – is shown by short wind and cyanosis at rest, a gipoksemiya.
Symptoms of respiratory insufficiency
Signs of DN depend on the reasons of its emergence, type and weight. Are classical signs of respiratory insufficiency:
- manifestations of a gipoksemiya
Gipoksemiya is clinically shown by cyanosis (cyanosis) which degree expresses weight of respiratory insufficiency and observed at decrease in partial pressure of oxygen (Rao2) in arterial blood lower than 60 mm of mercury. Also the violations of haemo dynamics which are expressed in tachycardia and moderate arterial hypotonia are characteristic of a gipoksemiya. At decrease in Rao2 in arterial blood to 55 mm of mercury. violations of memory on the taking place events are observed, and at decrease in Rao2 to 30 mm of mercury. the patient faints. The chronic gipoksemiya is shown by pulmonary hypertensia.
- manifestations of a giperkapniya
As manifestations of a giperkapniya serve tachycardia, sleep disorders (sleeplessness at night and drowsiness in the afternoon), nausea, headaches. Bystry increase in arterial blood of partial pressure of carbonic acid (RASO2) can lead to a condition of the giperkapnichesky coma connected with strengthening of a brain blood-groove, increase in intra cranial pressure and development of hypostasis of a brain. The syndrome of weakness and exhaustion of respiratory muscles is characterized by increase in the breath frequency (BF) and active involvement in process of breath of auxiliary muscles (muscles of the top airways, muscles of a neck, belly muscles).
- syndrome of weakness and exhaustion of respiratory muscles
ChD of more than 25 in min. can be an initial sign of exhaustion of respiratory muscles. Urezheny ChD of less than 12 in min. can foretell respiratory standstill. As extreme option of a syndrome of weakness and exhaustion of respiratory muscles serves paradoxical breath.
- short wind
Short wind is subjectively felt by patients as shortage of air at excessive respiratory efforts. Short wind at respiratory insufficiency can be observed both at a physical tension, and in a quiet state. In late stages of chronic respiratory insufficiency with accession of the phenomena of heart failure patients can have hypostases.
Respiratory insufficiency is the urgent, threatening for health and life state. At not rendering a timely resuscitation grant sharp respiratory insufficiency can lead of the patient to death. The long course and progressing of chronic respiratory insufficiency leads to development of right ventricular heart failure as a result of deficiency of supply of a cardiac muscle with oxygen and its constant overloads. The alveolar hypoxia and inadequate ventilation of lungs at respiratory insufficiency causes development of pulmonary hypertensia. The hypertrophy of the right ventricle and further decrease in its sokratitelny function lead to development of the pulmonary heart which is shown in stagnation of blood circulation in vessels of a big circle.
The anamnesis of life and associated diseases for the purpose of identification of the possible reasons of development of respiratory insufficiency carefully gathers on an initial diagnostic stage. At survey of the patient the attention to existence of cyanosis of integuments is paid, the frequency of respiratory movements is counted, the involvement in breath of auxiliary groups of muscles is estimated.
Further functional tests for a research of function of external breath (spirometry, a pikfloumetriya) allowing to carry out assessment of ventilating ability of lungs are carried out. At the same time the vital capacity of lungs, minute volume of breath, speed of the movement of air on various departments of airways at the forced breath is measured etc.
Mandatory diagnostic test at diagnostics of respiratory insufficiency is the laboratory analysis of gas composition of blood allowing to determine extent of saturation of arterial blood by oxygen and carbon dioxide (Rao2 and RASO2) and an acid-base state (blood BRAIDS). When carrying out a X-ray analysis of lungs damages of a thorax and a parenchyma of lungs, vessels, bronchial tubes come to light.
Treatment of respiratory insufficiency
Treatment of patients with respiratory insufficiency provides:
- restoration and maintenance of ventilation of lungs, optimum for life support, and oxygenation of blood;
- treatment of the diseases which were the prime cause of development of respiratory insufficiency (pneumonia, ekssudativny pleurisy, pheumothorax, chronic inflammatory processes in bronchial tubes and pulmonary fabric etc.).
At the expressed symptoms of a hypoxia first of all oxygenotherapy (oxygen therapy) is carried out. Oxygen inhalations move in the concentration providing maintenance Rao2 = 55 — 60 mm of mercury., at careful monitoring and RASO2 blood, conditions of the patient. At independent breath of the patient oxygen moves masochno or through a nasal catheter, at coma the intubation and the supporting artificial ventilation of lungs is carried out.
Along with an oksignoterapiya the events directed to improvement of drainage function of bronchial tubes are held: antibacterial medicines, bronchial spasmolytics, mucolytics, massage of a thorax, ultrasonic inhalations, physiotherapy exercises are appointed, active aspiration of a secret of bronchial tubes via the endobronchoscope is carried out. At the respiratory insufficiency complicated by pulmonary heart diuretics are appointed. Further treatment of respiratory insufficiency is directed to elimination of the reasons which caused it.
Forecast and prevention
Respiratory insufficiency is a terrible complication of many diseases and quite often leads to a lethal outcome. At chronic obstructive diseases of lungs respiratory insufficiency develops at 30% of patients. Predictively manifestation of respiratory insufficiency at patients with the progressing neuromuscular diseases is adverse (the BASS, a miotoniya, etc.). Without the corresponding therapy the lethal outcome can come within one year.
At all other pathologies leading to development of respiratory insufficiency, the forecast different however it is impossible to deny that DN is the factor reducing life expectancy of patients. The prevention of development of respiratory insufficiency provides an exception of pathogenetic and etiologichesky risk factors.