- Symptoms of the Asthmatic status
- Reasons of the Asthmatic status
- Treatment of the Asthmatic status
The asthmatic status (Status astmaticus) — the heavy life-threatening complication of bronchial asthma resulting from usually long not stopped attack. It is characterized by hypostasis of bronchioles, accumulation in them of a dense phlegm that leads to increase of suffocation and hypoxia.
Symptoms of the Asthmatic status:
In a clinical picture of the asthmatic status distinguish 3 stages:
I Stage (initial): The patient accepts forced situation with fixing of a shoulder girdle. Consciousness is not broken, but the strong fear, excitement can appear. Lips are cyanotic. A respiration rate 26 — 40 in min., the exhalation is complicated, the phlegm does not depart. When listening lungs breath is carried out to all departments, but the set of dry rattles is heard. OFV1 decreases to 30%. Cardiac sounds are muffled, tachycardia, arterial hypertension. Rao2 comes nearer to 70 мм.рт.ст, and [[RASO2]] about 30-35 mm Hg because of development of a compensatory respiratory alkalosis decrease.
II Stage (decompensations): The patient is inadequate, exhausted, cannot eat, drink, fall asleep. Cyanosis of skin and visible mucous, bulk up cervical veins. The respiration rate becomes more than 40 in a minute, rattles are heard at distance. When listening lungs sites of "a mute lung" (a characteristic sign of the II stage) come to light. OFV1 decreases to 20%. рН blood it is displaced towards acidosis. Rao2 decreases to 60 mm Hg and below, RASO2 increases to 50-60 mm Hg.
III Stage (giperkapnichesky atsidotichesky coma). The patient in critical condition, unconscious, spasms are possible. Diffuse cyanosis, pupils are expanded, more than 60 poorly react to light, a respiration rate in a minute, when listening - a picture of "a mute lung" (respiratory noise are not listened). ChSS of more than 140 in a minute, is sharply lowered by the ABP. Rao2 it is lower than 50 mm Hg, RASO2 increases to 70-80 mm Hg and above.
Reasons of the Asthmatic status:
Can be the reasons leading to development of the asthmatic status in patients with bronchial asthma:
* Aggravation chronic or development of acute bacterial and viral inflammatory diseases of bronchopulmonary system;
* The hyposensibilizing therapy which is carried out to a phase of an exacerbation of bronchial asthma;
* Excess use sedative and hypnagogues;
* A withdrawal at treatment by glucocorticoids;
* Allergic reaction with a bronkhoobstruktion to medicinal substances: salicylates, analginum, antibiotics, vaccines, serums;
* Excess reception of sympathomimetics (influence on β2-адренорецепторы that promotes obstruction of bronchial tubes).
Treatment of the Asthmatic status:
At development of the asthmatic status the emergency hospitalization on "ambulance" is shown. The status of the I stage is subject to treatment in therapeutic department, the II-III stage - in chambers of an intensive care and resuscitation.
The general directions of treatment regardless of a stage:
1. Elimination of a hypovolemia
2. Stopping of hypostasis mucous bronchioles
3. Stimulation of β-adrenoceptors
4. Recovery of passability of bronchial tubes
[to correct] Treatment of a metabolic form
Oxygenotherapy: for the purpose of stopping of a hypoxia the moistened oxygen in number of 3 — 5 l/min moves. Perhaps also use helium - oxygen mix which property is better penetration into badly ventilated sites of lungs.
Infusional therapy: it is recommended to carry out through a subclavial catheter. In the first 24 hours it is recommended to enter 3 — 4 liters of 5% of glucose or the polarizing mix, then in calculation of 1,6 l/m ² body surfaces. Addition in the volume of infusion of 400 ml of a reopoliglyukin is possible. Use of physical solution for elimination of a hypovolemia is not recommended because of its ability to strengthen swelled bronchial tubes. Introduction of buffered solutions to the I stages is not shown.
* An Euphyllinum of 2,4% solution intravenously kapelno in a dose of 4 — 6 mg/kg of body weight.
* Corticosteroids: have nonspecific antiinflammatory effect, increase sensitivity of β-adrenoceptors.......... Each 3 — 4 hours are entered intravenously kapelno or struyno. Average dose of Prednisolonum of 200 — 400 mg.
* Fluidifying of a phlegm: grate solution iodide in/in, Ambroxol (лазолван) in/in or 30 mg in oil 2 — 3 times a day, inhalation introduction.
* β-adrenomimetik are applied in case of lack of their overdose at the persons which do not have the accompanying cardiac pathology in the absence of arrhythmias and ChSS no more than 130 beats/min, the ABP is not higher than 160/95 mm hg.
* Antibiotics. Are applied only in the presence of infiltration of pulmonary fabric according to a X-ray analysis or at an exacerbation of chronic bronchitis with department of a purulent phlegm.
* Diuretics - are contraindicated (strengthen dehydration). Use is possible in the presence of HSN with initially high TsVD. In the presence of high TsVD with haemo concentration bloodletting is preferable.
* Calcium chloratum, ATP, cocarboxylase are not shown in view of doubtfulness of effect and danger of emergence of allergic reactions.
* Drugs, sedative - are contraindicated in connection with a possibility of oppression of a respiratory center. Use of a haloperidol is possible.
* Holinoblokatora (atropine, Scopolaminum, Methacinum) reduce secretion of bronchial glands, complicating otkhozhdeny phlegms, the porimeneniye during the status is not shown.
* Mucolyticums (AZZ, trypsin) during the status are not shown in connection with difficulty of their penetration into phlegm clots.
* Infusional therapy as at the first stage. Correction of acidosis buffered solutions.
* Medicamentous therapy is similar. Increase in a dose of corticosteroids in one and a half - two times, introduction each hour in/in kapelno.
* Bronkhoskopiya with posegmentarny to lavages of lungs. Indications: lack of effect within 2 - 3 hours with preservation of a picture of "a mute lung".
* Transfer into IVL at emergence of signs of acute respiratory insufficiency of the II-III degree.
* Artificial ventilation of the lungs
* Bronkhoskopiya, posegmentarny lavage of lungs
* Increase in a dose of corticosteroids up to 120 mg of Prednisolonum an hour
* Correction of acidosis in/in administration of sodium bicarbonate
* Extracorporal membrane oxygenation of blood.
Treatment of an anaphylactic form:
Anaphylactic and anaphylactoid forms of the asthmatic status are conducted according to the identical scheme.
* Introduction to 0,1% of solution of adrenaline, Prednisolonum, Atropini sulfas, Euphyllinum;
* Antihistamines (Suprastinum, tavegil) in/in struyno;
* The Ftorotanovy anesthesia on an open contour. In the absence of effect transfer into IVL;
* Direct massage of lungs at a total bronchospasm with impossibility of an exhalation and "a stop of lungs" on a breath.
Signs of efficiency of therapy:
Exit comes from the status slowly, decrease in ChSS, hypercapnia, disappearance of fear and excitement, drowsiness can be the most precursory symptoms.
The main sign of stopping of the status - emergence of productive cough with the viscous phlegm which is replaced by a plentiful liquid phlegm. At auscultation wet rattles come to light.
Signs of progressing of the asthmatic status
* Increase in the area of mute zones over lungs;
* Increase in ChSS;
* Thorax swelling (restretching of lungs);
* The accruing cyanosis and block of the patient.