Nebulizer therapy in newborns with pneumonia complicated by broncho-obstructive syndrome
The effectiveness of nebulizing inhalations with ventolin-albuterol.com in 41 newborn infants with broncho-obstructive syndrome on the background of mechanical ventilation-associated pneumonia and tracheobronchitis was assessed in comparison with 25 children with similar pathology on standard basic therapy. It was established that inhalation therapy in both full-term and premature babies contributed to a significant decrease in the duration of the broncho-obstructive syndrome, a reduction in the duration of antibacterial therapy and hospital stay.
Despite the long history of clinical experience and research, pneumonia in newborns continues to be a pressing issue, accounting for a large proportion in the structure of diseases and mortality in newborns. In recent years, researchers have attracted the attention of pneumonia that develops in newborns who are on prolonged mechanical ventilation (ALV) for severe disorders of the postnatal adaptation of the respiratory, cardiovascular and nervous systems of the body (respiratory distress syndrome, severe ischemic damage to the central nervous system, aspiration of the membranes waters, etc.). The hospital flora predominantly prevails in the etiological structure of such pneumonia. They are characterized by a severe course, the presence of symptoms of infectious toxicosis, the common nature of inflammation on chest radiographs, the development of secondary atelectasis, and the appearance of broncho-obstructive syndrome, previously rarely seen in newborns [1]. Particularly noteworthy are children with bronchopulmonary dysplasia, in whom bronchoobstructive syndrome is one of the characteristic symptoms of the disease.
With mechanical ventilation-associated pneumonia, broncho-obstructive syndrome occurs on the 2nd or 3rd week of the disease in the post-ventilation period.
and is manifested by increased symptoms of respiratory failure (anxiety of the child, contraction of compliant chest areas, the presence of cyanosis, despite oxygen subsidies, the appearance of dry, wheezing wheezing on the exhale in the lungs against persistent moist and repetitive breathing fluids, increased pCO2 in the blood). Episodes of persistent obstructive syndrome may be one of the signs of emerging bronchopulmonary dysplasia, especially if it concerns extremely premature babies.
In the pathogenesis of the broncho-obstructive syndrome in newborns, the following mechanisms are distinguished [2]:
Х narrowing of the lumen of the respiratory tract: hyperplasia and metaplasia of the bronchiolar epithelium,
Х increased production and delayed elimination of bronchial mucus;
Х swelling of the mucous membrane of the respiratory tract and alveolar epithelium as a result of inflammation (traumatic with intubation, mechanical
exposure to air flow and increased oxygen concentration during mechanical ventilation, as well as infectious);
Х increase in fluid content in the lungs, including interstitial (open arterial duct, infusion overload, increased vascular permeability);
Х smooth muscle spasm and increased hyperreactivity of the bronchopulmonary tract.
The role of the latter factor is in doubt in some authors due to the fact that these children are underdeveloped receptor apparatus and smooth muscles of the bronchi. However, according to a number of studies, ?2-adrenoreceptors appear in the respiratory tract of the fetus early, already from the 16th week of gestation, which is confirmed by a positive effect when used in newborns with broncho-obstruction of selective adrenergic mimetic drugs (salbutamol) [3].
Thus, based on the pathogenesis of the bronchial-obstructive syndrome in newborns, the aim of therapy should be the elimination of inflammatory
edema of the bronchial mucosa, stimulation of mucociliary clearance, reduction of mucus secretion in the airways, normalization of sputum discharge, elimination of possible spasm of smooth muscles of the bronchi [4].
In the complex treatment of newborn diseases, accompanied by the development of bronchial obstruction, now there is a large
value is given to inhalation nebulizer therapy. The name “nebulizer” comes from the word “nebula” – a little cloud. Nebulizers are inhalers of a new generation, which, thanks to the compressor or ultrasonic inhaler they contain, allow the inhaled drug (solution) to be converted into a fine aerosol, particles of which are 2Ц5 microns in size, can quickly penetrate into the zone of inflammation and edema and have an immediate effect on the receptor apparatus lower tracheobronchial tree. Since newborns cannot perform the deep, coordinated breathing required for inhalation, they are pre-emptive compressor nebulizers that use the energy of the air flow generated by the compressor. The advantages of compressor inhalation, compared with ultrasound, is also the absence of destruction of solutions (suspensions), such as, for example, PulmicortЃ.
The advantages of nebulizer therapy in the newborn also include the possibility of including the device in the oxygen supply circuit and the ventilation circuit, the absence of freon and other propellants (which can enhance bronchial reactivity), use at any time of day, easy handling, portability [5, 6] . Nebulizing inhalations, being a non-invasive method of administering drugs, prevent the systemic side effects of drugs that are observed when administered parenterally. For nebulizer therapy, special solutions of drugs are created, which are in a bottle or plastic container – nebul.
In previous years, with broncho-obstructive syndrome in newborns, parenteral was used as a bronchodilator.
and in inhalation the drug methylxanthine series – aminophylline. However, aminophylline, even when administered by inhalation, has a systemic effect, has a long half-life, as a result of which it often causes side effects from the cardiovascular, central nervous systems, as well as metabolic disorders. Currently, it is proposed to use short-acting bronchodilators as a bronchodilator therapy in bronchial-obstructive syndrome in newborns, such as the selective ?2-agonist salbutamol and berodual, in the form of the corresponding drugs ventolinnebulyЃ, berodualЃ [7].
It is believed that corticosteroids have the most powerful anti-inflammatory properties, which reduce vascular permeability, prevent swelling of the bronchial wall, reduce the output of effector inflammatory cells and block the production of inflammatory mediators. For this purpose, in previous years, parenteral administration of systemic glucocorticoids (hydrocortisone, prednisolone, dexazone) was used in young children and newborns with broncho-obstructive syndrome, which was also often accompanied by a pronounced systemic effect (first of all, suppression of the function of the adrenal cortex, as well as hyperglycemia, arteries hypertension, osteoporosis).
Recently, in foreign studies for the treatment of broncho-obstructive syndrome in newborns, by analogy with the treatment of young children, the inhalation corticosteroid budesonide (the drug PulmicortЃ) has been used. Budesonide is a non-halogenated glucocorticosteroid, which is the only inhaled glucocorticosteroid allowed for use in pregnant women.
The difference in inhalation glucocorticosteroid budesonide from systemic are the following pharmacological properties: 20% absorption into the systemic circulation, rapid inactivation, short half-life from blood plasma. This ensures its pronounced local anti-inflammatory effect and the absence of a systemic effect in children of this age group [8]. Lipophilicity of inhaled glucocorticoids, including budesonide, is a key property that determines local anti-inflammatory activity. Due to the lipophilicity of inhaled glucocorticosteroids, their affinity for the glucocorticoid receptor is ensured, which contributes to the accumulation of the drug in the respiratory tract and slows its release from the tissues. Inhaled glucocorticosteroids have a direct inhibitory effect on inflammatory cells: macrophages, T-lymphocytes, eosinophils, epithelial cells, thereby acting on all phases of inflammation, regardless of its nature. When this occurs, the bronchial mucous membrane is moistened, which promotes the discharge of sputum, improves mucociliary
clearance, relief of spasm of smooth muscles of the bronchi.
In modern scientific literature, there is a small amount of work on the use of budesonide in newborns (mostly undernourished) children on mechanical ventilation [5, 9]. A number of authors note the positive effect of inhalation use of the drug in newborns:
reduction of ventilation parameters, oxygen dependence and the absence of side effects [8, 10].
A comparative study of parenteral administration of dexamethasone and budesonide inhalation in premature newborns with a high risk of bronchopulmonary dysplasia on artificial lung ventilation showed no significant differences in the duration of mechanical ventilation and further oxygen support, but there was an improvement in lung function in children who received budesonide. In their works, these authors did not mention pronounced side effects during inhalation of budesonide. According to the literature, the most pronounced positive therapeutic effect in bronchial obstructive syndrome in children of early and older age is observed with the combined use of salbutamol and budesonide [11].
CHARACTERISTICS OF CHILDREN AND RESEARCH METHODS
Considering the ambiguity of data on the effectiveness of these drugs, as well as the lack of information on their combined use, in 2006 we conducted our own studies in 41 newborns with broncho-obstructive syndrome developing on the background of mechanical ventilation-associated pneumonia and tracheobronchitis (including 5 children). with outcome in bronchopulmonary dysplasia), in comparison with 25 children with similar pathology who were in the wards for premature babies in 2004, when nebulizing inhalations with these drugs are not used were (see. Table).
Characterization of the course of mechanical ventilation-associated pneumonia in children who received (1st group) and who did not receive (2nd group) inhalation therapy
Nebulizing inhalations were prescribed to newborns with the following clinical symptoms: appearance of dry, “wheezing” wheezes in the lungs against the background of moist crepes; tachypnea (increase in respiratory rate up to 60 or more per minute); participation in the act of breathing auxiliary muscles; the presence of mucous or mucopurulent discharge from the upper respiratory tract; change in gas
blood homeostasis (decrease in pO2 less than 50 mm Hg, increase in pCO2 more than 50 mm Hg); changes in radiographs of the lungs (inflammatory foci, areas of emphysema, segmental and lobar atelek-tazy, interstitial changes).
The studies we have begun on the use of nebulizer therapy with salbutamol and budesonide, administered successively in newborns with mechanical ventilation-associated pneumonia complicated by broncho-obstructive syndrome, required a special adaptation of the inhalation technique [3, 12]. It was as follows:
Х Replacing the nebulizer mask attached to the device with a mask with a soft obturator to ensure a snug fit to the face to reduce aerosol loss and prevent damage to the tissues of the face of the newborn (you can use a mask from the ventilator for newborns);
Х carrying out inhalations in a quiet state of the child, in the position of a child lying on his back in an incubator or baby cots 1.5 hours after feeding, with suction of mucus before inhalation (15Ц20 minutes), removal of the gastric feeding probe, putting a source under the mask supplemental oxygen and the observance of a 2Ц5-minute period in which the child gets used to the mask;
Method of nebulizing inhalation:
Х inhalations were performed on a Pary Junior Boy compressor nebulizer (Germany) 1.5 hours after feeding the child under monitor control with continuously recorded indicators of heart rate and blood oxygen saturation (SaO2) using a pulse oximeter. 15Ц20 minutes before inhalation of the newborn, the upper respiratory tract was sanitized, removing mucus with a vacuum apparatus. If a newborn baby had a feeding probe inserted into the stomach through the nasal passage, immediately before inhalation, the probe was removed and the mucus from the nasal cavity was sucked off.
Х Parts of the nebulizer were assembled, the device was connected to the network.
Х The child was placed on his back with the head turning in the direction opposite to the side of the lungs with more pronounced auscultatory disorders. During inhalation, the cervical spine was not re-extended.
Х Prepared inhalation solutions.
Previously checked the shelf life of drugs (pharmacy packaging with a medicinal substance should be stored in the refrigerator and be carefully closed).
Х A physiological solution in a volume of 1Ц1.5 ml was poured into the nebulizer, and then ventolinnebulyЃ was added in a single dose of 0.15 mg / kg. It is important that during inhalation the nebulizer cup is positioned vertically relative to the position of the child for faster spraying of the prepared solution.
Х Immediately before inhalation of the drug, an oxygen mask was applied tightly to the face of the child, and inhalation was carried out
against the background of oxygen therapy with the use of inhalation oxygen concentration.
Х After complete spraying of ventolin-nebulaЃ solution, pulmicortЃ inhalation was carried out sequentially. For this purpose, 1 ml of physiological solution was re-introduced into the nebulizer, and PulmicortЃ was added to it as suspensions for inhalation in a single dose (0.125 mg during inhalation 2 times a day or 0.25 mg in a single inhalation).
Inhalation was carried out until complete spraying of the aerosol.
Х Inhalations were carried out 2-3 times a day in the first two days of treatment, followed by a change in the frequency of administration depending on the state of the child. Usually, the inhalation session consisted of inhalation of ventolin nebulaЃ for an average of 7Ц8 minutes, followed by inhalation of pulmicortЃ (9Ц10 minutes). The course of inhalation ranged from 3 to 14 days.
Х During inhalation, the child should be calm. If the baby is crying, inhalation should be carried out with the simultaneous use of the nipple.
Х At the end of the inhalation of ventolin-nebulaЃ and pulmicortЃ, the baby’s mouth was wiped with a clean, wet gauze cloth moistened with boiled water to prevent oral mucosa candidiasis.
Processing parts of the nebulizer after a session of inhalation
For each child, an individual mask was applied, which was stored in a separate clean diaper signed after the course
inhalations were soaked for 30 minutes in a 0.03% УAnolyteФ solution (or otherchlorine-free disinfectant), after which it was washed with saline or distilled water and dried. Clean masks were kept in a sterile diaper.
After inhalation, the nebulizer was disconnected from the compressor and disassembled. The plastic parts of the nebulizer were disconnected (the cover was removed,
the nebulizer cup was disconnected from the airway tube), was rinsed under running water (to prevent preparations from crystallizing and bacterial contamination) and boiled in water for 10 minutes. Processing vozduhovodnogo tube was carried out similarly to the processing of masks. It is necessary to remove water droplets from the lumen of the tube-duct, due to the possibility of bacterial contamination. After boiling, the plastic parts of the nebulizer were reconnected, and the assembled nebulizer was ready for the next inhalation session (dry, wrapped in a clean diaper).
The indications for completion of the course of nebulizer therapy and the drugs listed above were the following symptoms: disappearance of dry, УwheezingФ wheezes, decrease or disappearance of wet wheezes while maintaining a small amount of wire and crepitus wheezes); decrease in respiratory rate at rest (below 60 per minute); a decrease in the degree of depression of compliant places of the chest (to 0Ц1 point); sustained improvement in acid-base status, blood gases: pO2?50 mm Hg, pCO2<50 mm Hg. and SaO2> 94%; relief of acute manifestations of tracheobronchitis; improvement of the X-ray picture: averaging of atelectasis, reduction of pulmonary veiled fields.