The editorial assesses the diagnostic criteria for acute lung lesion (ALL), which are based on its clinical manifestations, oxygenation index, X-ray signs, and pulmonary wedge pressure. The clinical experience suggests that the majority of the above signs do not reflect the early stages of acute lung lesion. The authors propose to use additional diagnostic tests, such as determination of pulmonary extravascular water, pulmonary capillary permeability index, identification of systemic inflammatory response markers, and information on which can be provided by up-to-date technologies. It is necessary to detect early signs of acute lung lesion to perform appropriate therapy for the prevention of subsequent complications.

Objective: to elucidate the pattern of morphological changes in the lung during artificial ventilation.

Materials and methods. Experiments were carried out on 30 non-inbred albino male rats weighing 250—320 g. The anesthetized animals were ventilated for 1—4 hours by a TSE Animal Respirator at a flow of 0.6—4 l/min, a respiration rate of 60 min, a tidal volume of 10—12 ml, and a peak inspiratory pressure of 100—400 mm H2O. Artificial ventilation was not made in control animals. Following 1, 2, and 3 hours and 1, 1.5, 2, and 3 days, the anesthetized animals were withdrawn from the experiment through cardiac vascular fascicle ligation. Lung pieces were fixed in neural 4% formalin and embedded in paraffin. Histological sections were stained with hematoxylin-eosin and the periodic acid Schiff reaction was performed. Morphometric studies were conducted and the data were then statistically processed (Student’s t-test).

Results. An hour after artificial ventilation, the interalveolar septa were thickened due to edema and cellular infiltration. There were microatelectases. The bronchioles were deformed; their lumens contained desquamated epithelium and mucus. The alveolar lumens contained red blood cells and macrophages. Perivascular connective tissue was edematous and exhibited epithelial desquamation. Later on, the observed changes increased. There were individual differences in the rate of morphological changes during artificial ventilation (AV).

Conclusion. AV is followed by the development of structural changes that are typical of acute lung lesion. 

Early changes in the content of extravascular fluid in the lung and in the permeability of pulmonary vessels were studied in patients experiencing a severe concomitant injury with acute massive blood loss. It has been found that monitoring of the parameters of extravascular liquid in the lung and the permeability of pulmonary vessels by a PiCCOplus (Pulsion Medical Systems, Germany) invasive monitor in the early posttraumatic period enables the early stages of pulmonary edema and pulmonary vascular permeability to be verified and the risk of acute lung lesion to be assessed.

 

The authors describe the theoretical bases of a new ventilatory support procedure that is called by the authors as continuous flow ventilatory support (CFVS). In the theoretical part they provide evidence for this procedure of ventilatory support and explain the basic mathematical and physiological principles of the described procedure and artificial ventilation and compare the possibilities of using CFVS with a multi-jet insufflation catheter (VIK®) versus a terminal orifice one (JTO). Physical and mathematical analyses on a model of the artificial lung in the static and dynamic modes revealed that there was a difference in the values of the maximum inspiratory pressure and positive end-expiratory pressure (PEEP), which was greater with the terminal orifice catheter. There was evidence that the use of CFVS with a multi-jet insufflation catheter or a terminal one-orifice one presented a risk of barotrauma and made the value of dynamic PEEP with a gas flow of as high as 20—26 l/min minimal when CFVS. The latter with a multi-jet insufflation catheter is most suitable when higher gas flows Qin above 25—28 l/min are applied. In conclusion, the authors consider that CFVS with a multi-jet insufflation catheter is technically more effective and substantially higher gas flows may be used as in the application of a terminal one-orifice catheter without a risk of elevated airway pressure and without increased ventilation performance on expiration.

Objective: to study the accuracy of pulmonary extravascular water (PEVW) measurement by thermochromodilution (TCD) and isolated thermodilution (ITD) on a model of pneumonectomy and subsequent ventilator-induced lung lesion (VILL) in sheep.

Materials and methods: the study was conducted at the Research Laboratory of University of Tromse. The experiment included 12 sheep weighing 35.6±4.6 kg. Thoracotomy and right-sided pneumonectomy were performed in the animals under general anesthesia and controlled artificial ventilation. After measurement of the parameters of systemic hemodynamics and PEVW, the animals were divided into 2 groups: 1) 1) those undergoing protective ventilation (PV, n=6) with a tidal volume (TV) of 6 ml/kg and a positive end-expiratory pressure (PEEP) of 2 cm H2O and 2) those with VILL (n=6) with a TV of 12 ml/kg and a PEEP of 0 cm H2O. TCD and ITD (Cold Z-021 and PiCCOplus monitors, respectively (Pulsion, Germany)) were used to measure volumetric parameters and PEVW. The parameters of pulmonary hemodynamics, respiratory mechanics, and blood gas composition were recorded. After euthanasia of the animals, their lungs were taken to determine the control value of PEVW by postmortem gravimetry (PG).

Results: in the VILL group, significant pulmonary alveolar edema developed, which was followed by hyperthermia, elevated pulmonary pressure, and increased intrapulmonary shunting. Analysis of the data indicated a close correlation between the PEVW values obtained by TCD and ITD with PG (r=0.95 and r=0.81, respectively; p<0.01; n=12). The PG deviation was 0.57±2.05 and 2.68±3.61 ml/kg for TCD and ITD, respectively (M±2d, p<0.05).

Conclusion: both used techniques have an acceptable accuracy and adequately reflect both a reduction in PEVW after pneumectomy and its increase in the presence of VILL. Volumotrauma may be the key factor that provokes the development of postpneumectomic edema of the lung.

 

The purpose of the study was to define a role of thrombocytic-vascular hemostasis in the development of pulmonary complications in severe brain injury. Forty-six patients with severe brain injury were studied over time. Thrombocytic-vascular hemostasis was evaluated by the venous and arterial blood count of platelets and their aggregation induced by epinephrine, ristomycin, and adenosine diphosphate. The studies indicated that there was a reduction in the count of platelets in both venous and arterial blood. At the same time, with a greater degree of lung lesion, there were a reduction and cessation of the venous-arterial difference by the count of platelets, as well as an increase in the aggregatory properties of platelets, which was most profound in arterial blood. The progressive reduction in the levels of platelets in both venous and arterial blood reflected the involvement of platelets in aggregates, on the one hand, and a response to pulmonary vascular endothelial damage and the severity of lung lesion, on the other.

Lipid peroxidation products and antioxidative system components were studied in 56 patients with a systemic inflammatory response of various genesis. The arterial blood levels of prooxidants were found to be associated with a poor outcome. The findings that there is an inverse correlation between lipid peroxidation products and the respiratory index allow the diagnostic and prognostic value of blood free radical oxidation products to be determined as markers of acute lung lesion.

systemic inflammatory response; acute lung lesion; lipid peroxidation; diagnostic and predictive markers

Morphological studies were studied to examine the lungs of the persons who had died due to severe mechanical trauma unaccompanied by head injury (и=85). The purpose of the investigation was to study the pattern and timing of pulmonary structural changes in the early period of mechanical trauma. It has been found that the early pulmonary structural changes in trauma are circulatory disorders, bronchial and bronchiolar mucosal damage, and the development of acute emphysema and focal atelectases and dystelectases. In subsequent hours, pulmonary structural changes significantly progress. Pulmonary edema and signs of a systemic inflammatory reaction develop just in the first hours after trauma.

The results of examination and treatment in 274 patients with severe gunshot wounds suggest that abnormal pain, external respiratory and circulatory disorders, impaired cell utilization of oxygen and energy plastic substrates induce acute lung lesion syndrome (ALLS). The timely inclusion of respiratory support into intensive care and the optimization of therapy, by supplementing early enteral feeding, reduce the incidence of ALLS and improve the results of treatment.

 

The paper provides the results of use of the «lung opening» maneuver under artificial ventilation (AV) in adult patients with acute respiratory distress syndrome of various genesis. It shows it possible to improve gas exchange by this method in severe acute respiratory failure of the parynchematous type. It has been found that there is a more effective recovery of lung function, less AV timing, and a shorter length of stay in a intensive care unit in patients with acute respiratory distress syndrome in whom the «lung opening» maneuver is regularly (4—6 times daily) used under AV than in those undergoing a traditional support in accordance with the principles of safe AV. The paper shows it possible to select the optimum end-expiratory positive pressure during this maneuver. The authors also describe the «lung opening» maneuver protocol used by them, indications for and contraindications to the maneuver.

 

The study was undertaken to evaluate the efficiency of various medical procedures in the treatment of acute lung injury (ALL) and the acute respiratory distress syndrome (ARDS) in different categories of surgical patients. The study was carried out at the intensive care unit, Academician N. N. Burdenko Main Military Clinical Hospital. The findings demonstrate the efficiency of the proposed procedures that are justified in each specific case and that reduce the length of stay in an intensive care unit and total mortality. Three independent studies were conducted in 75 surgical patients diagnosed as having ALL/ARDS in accordance with the traditional criteria. The use of one or another procedure in the groups was defined as an etiological factor for a group. The findings indicate that the proposed procedures are effective, but have side effects and, accordingly, cannot be recommended as the gold standard. According to the performed study, treatment policy should be chosen on an individual basis, pathogenetically justified, in terms of effectiveness and safety.

 

Background. The world literature contains no reports on the clinical application of continuous flow ventilatory support by an insufflation catheter. Despite the use of different forms of ventilatory support, disconnection of patients from artificial ventilation is unsuccessful in 10—30% of cases despite the fact that the clinical and biochemical criteria are met.

Objective: to discuss the efficiency of the new ventilation regime — continuous flow ventilatory support in the clinical setting.

Methods: continuous flow ventilatory support with an original licensed multi-jet insufflation catheter or a terminal one-orifice catheter nasally inserted into the trachea was applied to 70 patients. It was used in a subgroup of 64 patients with chronic obstructive lung disease (COLD) due to the occurrence of global respiratory insufficiency caused by infectious complications and in a group of 6 patients as a ventilatory regime for their disconnection from long-term artificial ventilation, whose disconnection other ventilatory regimens being used were unsuccessful.

Results. None patient with COLD should be intubated, and just 30 minutes after the initiation of ventilatory support with a multi-jet catheter, there were decreases in the mean respiration rate from 33±2.8 to 27±2.5 cycles/min and in paCo₂ from 11.9±1.7 to 10.8±1.6 kPa and an increase in paCo₂ from 5.7±1.1 to 6.8±1.3 kPa at FiO₂ =0.3. Within 24 hours after the initiation of ventilatory support, blood gas levels changed in response to the values typical of partial respiratory insufficiency. The spontaneous ventilation rate decreased to 20±2.2, paCO₂ reduced to 6.4±1.2  kPa  and  pO₂ continuously  increased  up  to  the  value  8.9±1.4  kPa  (FiO₂ =0.3)  at  hour  24  of  ventilatory  support. Ventilatory support lasted an average of 5 days. Statistical comparison of the study parameters showed a significant improvement (p<0.05) just 6 hours after ventilatory support and a marked improvement of the parameters (p<0.01) following 72 hours. In the other group of patients, continuous flow ventilatory support was used due to failing disconnection of the patients from long-term artificial ventilation. After extubation and 30 minutes after the initiation of continuous flow ventilatory support, the ventilation rated decreased to 27±2.5 cycles/min, there was a continuous reduction in paCO₂ to 3.9±0.9 kPa as a manifestation of hyperventilation that had been likely to be induced by a continuous decrease of paCO₂ to 8.8±1.4 kPa. Only 60 minutes after the initiation of ventilatory support, with the equal ventilation rate, the values of blood gases (paO₂ =9.9±1.5 kPa, paCO₂=5.2±1.1 kPa) increased, as did VT (0.38±0.30), which permitted one to proceed with continuous flow ventilatory support that could be interrupted following 48 hours.

Conclusion. The findings lead to the conclusion that continuous flow ventilatory support is an effective ventilation regimen that is applicable to patients with chronic obstructive lung disease in global respiratory insufficiency and makes it possible to overcome the period of, for example, infectious complications without  intubation  and  artificial  ventilation.  It  may  also  be  used  as  a  non-invasive  ventilation  regime  in  the  disconnection  of patients from long-term artificial ventilation. Its application in acute respiratory failure (acute respiratory failure, acute respiratory distress syndrome) requires further prospective studies.

Monitoring of the blood circulation and liquid sectors in patients with lung lesion due to severe acute intoxications makes it possible to perform infusion therapy that does not induce thoracic hyperhydration. The inclusion of gelofusin and cytoflavin into the infusion regimen by the proposed procedure substantially enhances the efficiency of treatment of patients with this pathology even when acute lung lesion syndrome develops.

 

The paper presents the results of a study of blood gas composition and acid-base balance (ABB) in the use of the Russian drug Surfactant BL in preterm neonatal infants with respiratory distress syndrome (RDS). The surfactant was given to 57 preterm neonates. A control group consisted of 52 children with RDS who had received a course of treatment before the use of the drug in the hospital. Statistical analysis indicated the virtual similarity of the study and control groups. The study demonstrated that that in Surfactant BL-treated patients, blood oxygenation (pO2, %SO2c, A-a DO2, respiratory coefficient) improved much more rapidly and the mean values of these parameters remained statistically significantly better from the end of 24 hours of treatment than in the control neonates up to the end of therapy in the intensive care unit of the maternity hospital. Studies of blood ABB showed that the neonates of both groups had moderate metabolic acidosis at the initiation of therapy. With the therapy performed, the parameters of ABB generally reached normal values within the first 24 hours of therapy. There were no obvious differences in the changes of blood ABB parameters in the neonatal infants of both groups. Analysis of the results of treatment in neonates with ABB showed a statistically significant advantage in terms of positive outcomes of treatment in the group of Surfactant BL-treated patients.

 

Biphasic positive airway pressure (BIPAP) (also known as DuoPAP, BiLevel, BiVent, PCV+, SPAP) is a mode of ventilation with cycling variations between two continuous positive airway pressure levels. It is a mixture of pressure controlled ventilation and spontaneous breathing, which is unrestricted in each phase of the respiratory cycle. The volume displacement caused by the difference between Phigh and Plow airway pressure level. The phase time ratio (PTR — the BIPAP frequency) is calculated as the ratio between the durations of the two pressure phases, a PTR greater than 1:1 is called APRV (airway pressure release ventilation). In patients with ARDS maintained spontaneous breathing with BIPAP resulted in lower venous admixture and better arterial blood oxygenation as compared with A/C. Only a few studies with BIPAP have been performed in newborn and infants until now. We studied the use of BIPAP in newborn (body mass > 3kg) and randomised 40 patients with respiratory failure for ventilation with BIPAP (n=20) or conventional mechanical ventilatory support (assist-control A/C) — synchronised intermittent mandatory ventilation (SIMV)) (n=20). The Pediatric Risk of Mortality score (PRISM) were collected for each patient. Fentanyl, diazepam, GABA were used as sedatives and adjusted in accordance with the Cook scale. We compared ventilatory parameters, information pertaining to pulmonary function and oxygen delivery, cardiac output, additional descriptors of organ system functions, duration and complications of ventilation and number and dosages of sedatives administered. All the patients that we intended to ventilate with BIPAP were successfully ventilated, we can conclude that biphasic ventilatory support suitable mode of ventilation for newborn with a decreased need of analgetics and sedatives than A/C. Finally, BIPAP is an a effective safe, and easy to use for personal mode of mechanical ventilatory support in newborn.

 

The paper analyzes the data available in the literature on the diagnostic value of biological markers of acute lung lesion (ALL) in critical conditions. The study of the diagnostic and prognostic values of biological markers of ALL is shown to be a promising line in the section of critical conditions. The biological markers of ALL will have the highest effectiveness in evaluating the development of ALL at the preclinical stage, in differentiating the exudative and proliferative stages of ALL/acute respiratory distress syndrome, and defining indications for respiratory support. The biological markers of ALL are capable to predict the development of ventilator-induced lung lesion. The analysis of gene expression and the study of an array of DNA nucleotide sequence in the cells are of the greatest diagnostic and prognostic value in determining the predisposition of cytokines and intercellular signal molecules to synthesis.