Exacerbation of bronchial asthma, status asthmaticus

Bronchial asthma (BA) is a chronic inflammatory disease of the respiratory tract, which involves many cells and cellular elements. Life-threatening exacerbation of asthma (status asthma) should be understood as severe DN due to asthma or COPD, when airway obstruction is caused not only by bronchiolospasm, but by inflammatory changes in the bronchi, impaired sputum evacuation and expiratory closure of the airways. Asthmatic status can develop with prolonged contact with allergens, under the influence of acute or exacerbation of chronic inflammatory processes in the respiratory tract, an overdose of inhaled bronchodilators, erroneous prescription of beta-blockers in patients with asthma, etc.

Severe exacerbation of BA is manifested by severe shortness of breath, suffocation, unproductive cough; the patient often takes a forced semi-vertical position (a symptom of orthopnea), the auxiliary muscles are actively involved in breathing, tachypnea and tachycardia occur. The auscultatory picture characterizes a pronounced obstruction: dry whistling rales, with an increase in the severity of the condition – “silent lung”. Asthmatic status in stage I is characterized by the same symptoms as a protracted asthma attack, but there is no effect from the introduction of sympathomimetics. During the transition to stage II, there is a rapid increase in bronchial obstruction. The patient is extremely excited, takes a forced (sitting) position, resting his hands on the edges of the bed. Exhalation is sharply difficult and is given by great physical effort. Swelling of the neck veins. Pulse above 120 in 1 min. Characteristic is the symptom of “silent lung”, which consists in the gradual weakening and then the disappearance of respiratory noise over the peripheral parts of the lungs. Following this, a hypoxic-hypercapnic coma develops (stage III). The combination of “silent lung”, bradypnea (< 12 per minute), depression of consciousness are signs of an immediate threat to the patient's life. Changes in peak expiratory flow (PS exp ) compared to the proper or best value more accurately reflect the degree of asthma exacerbation than clinical signs.

It is extremely important for the treatment of exacerbations of asthma is monitoring of clinical symptoms of asthma, PS vyd , indicators of blood gases.

First aid. If possible, stop the patient’s contact with the allergen. Provide access to fresh air, unbutton tight clothing, give plenty of warm drink. Reassure the patient. With difficulty in expectoration of sputum, percussion massage of the chest. If the patient has previously selected metered-dose aerosol or powder inhalers for treatment with sympathomimetics and anticholinergics, etc. – 1-2 inhalations, but not more than 4-6 times a day. Distracting procedures (hot foot baths, hot drinks).

Call for medical assistance. If it is not possible – the fastest delivery on a stretcher to the nearest medical facility.

First aid. If possible, ECG recording, pulse oximetry. Humidified oxygen inhalation. Catheterization of the cubital vein.

Medicines in the form of metered-dose inhalers: salbutamol 400 mcg, or fenoterol 200 mcg, or ipratropium bromide + fenoterol every 20 minutes for 1 hour, then, if necessary, no more than 6-8 times a day.

Sympathomimetics (epinephrine), sedatives are contraindicated at the stage.

First aid. Perform ECG recording, pulse oximetry. Humidified oxygen inhalation. Catheterization of the cubital vein.

Medicines in the form of metered-dose inhalers: salbutamol 400 mcg, or fenoterol 200 mcg, or ipratropium bromide + fenoterol every 20 minutes for 1 hour, then, if necessary, no more than 6-8 times a day. In the absence of inhalers, it is possible to use epinephrine subcutaneously at a dose of 0.3 mg according to the same scheme: every 20 minutes during the first hour and then every 4-6 hours. If there is no effect, inject intravenously 5 ml of a 2.4% solution of aminophylline and 120-180 mg of prednisolone in 200 ml of a 0.9% solution of sodium chloride.

With signs of asthmatic status against the background of dehydration, an infusion of sodium chloride 0.9% solution of 400-800 ml is indicated during the first hour (in a volume of 2-3 l / day).

Evacuation to a military hospital or the nearest specialized medical institution, on a stretcher by ambulance, accompanied by a doctor (paramedic), continuing to carry out emergency measures.

Pulmonary bleeding

It develops as a complication of diseases of the respiratory system in acute and chronic nonspecific and purulent-destructive processes in the lungs, bronchiectasis, pneumosclerosis, pulmonary tuberculosis, against the background of an overdose of anticoagulants. Pulmonary haemorrhage (PCH) can also develop with lung barotrauma in Navy diving professionals.

The main source of LA is the bronchial arteries, the vessels of the pulmonary circulation give LA extremely rarely. According to the volume of LC, they distinguish:

moderate (less than 100 ml per day),

medium (100-600 ml per day),

massive (more than 600 ml per day).

Blood loss in LC is rarely large enough to cause hemic hypoxia. Ventilation hypoxia is more common.

The main diagnostic criterion is the coughing up of blood in the form of an impurity in the sputum, often foamy, in an amount exceeding 50 ml per day. The scarlet color is characteristic of bleeding from the bronchial arteries, and the dark color is from the pulmonary artery system. As a rule, pulmonary bleeding causes patients to develop a feeling of significant anxiety, fear for life. Weakness, dizziness, restlessness are noted. Sometimes fainting develops. Various manifestations of respiratory discomfort, the appearance of a feeling of “lack of air” are not uncommon. Pallor of the skin, the appearance of sticky cold sweat is noted. The respiratory rate increases to 30-35 per minute, various wet rales are heard over the lungs from the side of the lesion. When blood enters the lumen of the bronchial tree of a healthy lung, moist rales can be bilateral. The pulse rate reaches 100-120 beats / min, its qualities are characterized by weak filling and tension. Blood pressure indicators tend to decrease, but in the initial period of pulmonary hemorrhage, with severe anxiety of patients, they can be even slightly higher than normal values for a short time.

Diagnosis is based on the analysis of the clinical picture, the results X-ray allows you to localize the source of LA in 48-82% of cases. Computed tomography in contrast mode, or angiography, is more informative. The most informative fibrobronchoscopy in terms of establishing the source of bleeding and stopping it, the possibility of holding the toilet of the respiratory tract. In LC, laboratory evaluation of the blood coagulation system is important.

Principles of emergency care in LC. When stopping LC, one should not rely on drug therapy: more reliable methods are endoscopic effects on the respiratory tract and pulmonary vessels. Therefore, with signs of LC, it is necessary to ensure the speedy delivery of the patient to a specialized hospital, where such assistance can be provided.

First aid. The patient must be kept in a semi-sitting position. Help the patient to take a sitting or semi-sitting position while tilting to the side corresponding to the lesion – this will prevent blood from entering the healthy lung. Reassure the patient. Ensure complete physical rest. An ice pack or a cold compress is applied to the area of the affected half of the chest, systematically removed to avoid hypothermia of the patient (every 15 minutes).

Call for medical assistance. If it is not possible, prompt delivery on a stretcher to the nearest medical facility, where emergency medical care can be started in case of LC.

Pre-medical and first medical aid. Implementation of the activities of the previous stage.

Carrying out hemostatic therapy: the introduction of a 5% solution of aminocaproic acid. Humidified oxygen inhalation. Replenishment of the volume of circulating blood by the introduction of 0.9% sodium chloride solution in a volume of up to 1000 ml. In case of heavy bleeding, inject intravenously 10 ml of a 10% solution of calcium gluconate. With pronounced manifestations of the patient’s anxiety – intramuscular injection of 2 ml of a 0.5% solution of diazepam.

Evacuation to a military hospital or the nearest specialized medical institution, on a stretcher by ambulance, accompanied by a doctor (paramedic), continuing to carry out emergency measures.

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