RU2847623C1 - Method for endoscopic treatment of lung atelectasis in children - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely paediatric surgery. Method involves bronchoalveolar lavage and sanitation bronchoscopy. Lavage is carried out by introducing 3-5 portions of sterile saline heated to 37 °C, followed by immediate aspiration. For children weighing less than 5 kg, normal saline is used in a single volume of 3 ml. For children weighing 5 kg and more, up to 11 kg, normal saline is used in a single volume of 5 ml. For children weighing 11 kg and more, up to 20 kg, physiologic saline is used in a single volume of 7.5 ml. For children weighing 20 kg and more, normal saline is used in a single volume of 10 ml. Fluid is aspirated at negative pressure 50-100 mm Hg, while the volume of the aspirated fluid must be not less than 40 % of the injected volume of normal saline. Thereafter, a distal end of the bronchoscope is inserted into the bronchus of the atelectased lobe of the lung. Blower connected to an aspirator valve is used to force air at pressure 35-40 cm H₂O which is maintained for 3-5 seconds. To force air, the check valve on the blower is closed and the aspirator valve is clamped. After pause of 1 minute, the procedure of air supply is repeated 2 times, also every one minute, and visually assessed patency of subsegmental bronchi and bronchi of 3rd-4th orders.

EFFECT: method enables higher clinical effectiveness and safety of atelectasis in the children between ages of 0 to 3 years due to the adequate bronchial expansion taking into account the characteristics of different age categories of the paediatric patients.

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Description

The invention relates to medicine, namely to pediatric surgery, and can be used in the treatment of pulmonary atelectasis in children aged 0 to 3 years.

One of the indications for bronchoscopy in children is atelectasis of the lung, lobe or segment (Blokhin B.M. Pediatric Pulmonology: National Guidelines, Series "National Guidelines", Moscow, GEOTAR-Media, 2021, 960 p.). This determines the relevance of the search for new methods of endoscopic treatment and acceleration of the resolution of pulmonary atelectasis in children. Representatives of the domestic school of pathomorphologists and pulmonologists understand atelectasis as a complete collapse of the lumens of the respiratory section of the lungs (alveoli, alveolar sacs, ducts and respiratory bronchioles) (Chernyaev A.L. Pulmonary Atelectasis. In the book: Cellular Biology of the Lungs in Health and Pathology: A Manual for Physicians, Moscow, Medicine, 2000, Vol. 1, pp. 384-385).

The main treatment for pulmonary atelectasis in children, and in particular in premature infants, is the creation and maintenance of continuous positive airway pressure, achieved using special modes of mechanical ventilation (Volodin N.N. et al. Respiratory distress syndrome in newborns, Clinical guidelines of the Russian Federation, 2013-2017 (Russia), found on the Internet 10.10.2024 https://diseases.medelement.com/disease/респитарный-дистресс-синдром-у-новородных-кп-рф-2015/16799).

Thus, a method of therapeutic positioning under the influence of gravity is known in the prior art. Secretions from the peripheral bronchi are moved to the proximal bronchi, thereby enhancing mucociliary clearance (postural drainage), increasing lung volume, reducing the work of breathing, minimizing cardiac work, and optimizing the ventilation-perfusion ratio (Clini E. et al. Early physiotherapy in the respiratory intensive care unit, Respiratory medicine, 2005, 99(9), pp. 1096-1104).

A method for airway clearance and lung recruitment in patients with refractory unilateral atelectasis undergoing invasive mechanical ventilation is known (Herrada A.J.M. et al. A novel maneuver to treat refractory atelectasis in mechanically ventilated children, Journal of Pediatric Intensive Care, 2022, 11 (02), pp. 159-167). The method is performed under neuromuscular block and/or deep sedation, using an Ambu bag with a manometer. The operator firmly presses the unaffected hemithorax with the palm of the hand to limit inspiratory expansion of the other lung, while simultaneously squeezing the bag with the other hand to set the tidal volume. This inhalation should last 2-3 seconds, and the peak inspiratory pressure created should be approximately 35 cm H2O.

A method for the prevention and treatment of pulmonary atelectasis in children using non-invasive and invasive artificial ventilation is also known (Volodin N.N. et al. Respiratory distress syndrome in newborns, Clinical guidelines of the Russian Federation, 2013-2017 (Russia), found on the Internet 10.10.2024 https://diseases.medelement.com/disease/респитарный-дистресс-синдром-у-новородных-кп-рф-2015/16799). The creation and maintenance of continuous positive airway pressure is a necessary element of the early stabilization of the condition of a deeply premature baby, both during spontaneous breathing and during artificial ventilation. Continuous positive airway pressure helps create and maintain functional residual capacity of the lungs, prevents atelectasis, and reduces the work of breathing. Recent research has demonstrated the effectiveness of so-called "extended lung inflation" as an initial respiratory therapy for premature infants. The "extended lung inflation" maneuver involves an extended artificial breath.

Restoration of airway patency is achieved through selective sanitation bronchoscopy.

A method for reversing segmental pulmonary atelectasis in children using oxygen is known (USSR Author's Certificate SU 908338 A1, published February 28, 1982). Oxygen is introduced into the pleural cavity via puncture, the puncture site is then sealed, and after 20-30 minutes, the oxygen is removed by a second puncture.

A method for treating atelectasis is known, which involves the use of selective sanitation bronchoscopy and the administration of pulmonary surfactant in the form of "Surfactant-BL", administered once or 2-3 times at intervals of 2-3 days in a dose of 100-300 mg per administration. This method ensures a high rate of complete (or partial) resolution of atelectasis (patent RU 2149014 C1, published May 20, 2000). The instructions for this drug, Surfactant-BL, include the following indications for use: treatment of respiratory distress syndrome (RDS) in newborns, treatment of acute lung injury syndrome and acute respiratory distress syndrome in adults, and treatment of pulmonary tuberculosis. However, its use in children of other age groups is not prescribed. The use of surfactant therapy, according to the latest clinical guidelines, is indicated under certain conditions and according to certain criteria and cannot be used in all children with atelectasis.

Evidence for the effectiveness of the above-mentioned methods in children is extremely limited due to the size of existing studies (small sample sizes and lack of standardization of interventions). Therefore, the goal is to improve the quality of treatment for children with pulmonary atelectasis and accelerate its resolution.

The disadvantages of known methods are:

- considering that one of the causes of pulmonary atelectasis is mechanical obstruction, for example, by mucous-purulent secretion, mechanical ventilation of the lungs does not ensure the removal of secretion and restoration of airway patency;

- trauma and the need for puncture of the pleural cavity;

- the use of surfactant is carried out in neo- and perinatal centers for premature babies, including those with extremely low birth weight, by specially trained personnel and has many contraindications.

Also known in the prior art is a method for treating pulmonary atelectasis in children (Bonitenko E.Yu. et al. Bronchoalveolar lavage in the treatment of severe bronchopulmonary pathology in newborns and infants (literature review), Neonatology: News. Opinions. Training, Vol. 11, No. 3 (41), 2023, pp. 60-69), including bronchoalveolar lavage and sanitary bronchoscopy in newborns and pediatric patients. In their publication, the authors, based on a review of literary sources, developed an algorithm and indications for performing bronchoalveolar lavage of pathology in newborns and infants; however, no clinically confirmed results of BAL effectiveness were provided.

Thus, there is a need for a method for endoscopic treatment of pulmonary atelectasis in children that is free from the above-mentioned disadvantages.

The technical result of the proposed method is to increase the effectiveness and safety of treating atelectasis in children, due to adequate straightening of the bronchi, taking into account the characteristics of different age categories of pediatric patients.

In order to achieve the specified technical result in the method of endoscopic treatment of pulmonary atelectasis in children, including bronchoalveolar lavage and sanitary bronchoscopy, it is proposed to perform bronchoalveolar lavage by introducing 3-5 portions of sterile saline solution heated to 37°C, followed by immediate aspiration, while for children weighing less than 5 kg, saline solution is used in a single volume of 3 ml; for children weighing 5 kg and more, up to 11 kg, saline solution is used in a single volume of 5 ml; for children weighing 11 kg and more, up to 20 kg, saline solution is used in a single volume of 7.5 ml; for children weighing 20 kg and more, saline solution is used in a single volume of 10 ml, the fluid is aspirated at a negative pressure of 50-100 mm Hg. Art., while the volume of aspirated fluid should be at least 40% of the introduced volume of physiological solution; after bronchoalveolar lavage, the distal end of the bronchoscope is inserted into the lobar or alternately into the segmental bronchi of the atelectatic lobe of the lung, using a pumping device connected to the aspirator valve, a forced air supply is carried out under a pressure of 35-40 cm H2O, which is maintained for 3-5 seconds, while to pump air, the check valve on the pumping device is closed and the aspirator valve is clamped, after a break of 1 minute, the air supply procedure is repeated 2 times, also with a minute interval, followed by a visual assessment of the patency of the subsegmental and 3-4 order bronchi.

In case of laryngeal spasm or arrhythmia after bronchoalveolar lavage, treatment of atelectasis is recommended to be interrupted in order to relieve symptoms of hypoxemia; if symptoms of hypoxemia persist, endotracheal intubation is performed.

In case of destabilization of ventilation parameters after a 1-minute break after forced air supply, such as an increase in peak airway pressure, a decrease in tidal volume, a decrease in minute ventilation, hypoxemia _SpO2 <90% and an increase in the level of _CO2 on exhalation, these parameters are first stabilized, after which the air supply procedure is repeated.

In cases where atelectasis persists according to radiographic data, the method is repeated in full after 24 hours.

The method is carried out as follows.

The procedure is performed on hemodynamically stable patients and children without concomitant pathologies that could aggravate the condition with fluctuations in intrathoracic pressure.

A 6-hour fast is required before the procedure. The study is performed in the operating room or intensive care unit, under inhalation anesthesia using a laryngeal mask airway or endotracheal anesthesia for children on mechanical ventilation.

During the administration of anesthesia, the following were monitored: non-invasive blood pressure, _SpO2 , ECG.

The procedure is performed using a bronchoscope (we used an Olympus one with an insertion diameter of 2.8 mm (for children under 3 years old) and 4.8 mm (for children 3 years and older)).

Examination of the tracheobronchial tree is performed using standard techniques.

The patient undergoes sanitary bronchoscopy and bronchoalveolar lavage (BAL) for therapeutic purposes (as well as for microbiological examination of lavage waters). BAL involves the administration of 3-5 portions of sterile saline solution heated to 37°C, followed by immediate aspiration. For children weighing less than 5 kg, a single dose of 3 ml of saline solution is used; for children weighing 5 kg and more, up to 11 kg, a single dose of 5 ml of saline solution is used; for children weighing 11 kg and more, up to 20 kg, a single dose of 7.5 ml of saline solution is used; for children weighing 20 kg and more, a single dose of 10 ml of saline solution is used. The concept of a single volume refers to the volume of saline solution administered in one portion. The fluid is aspirated under a negative pressure of 50-100 mm Hg. Aspiration of BAL fluid is at least 40% of the injected volume.

If laryngeal spasm or arrhythmia occurs, the bronchoscope is removed, followed by appropriate symptom management. If symptoms persist, endotracheal intubation is performed to maintain oxygenation.

In case of destabilization of ventilation parameters after a 1-minute break after forced air supply, such as an increase in peak airway pressure, a decrease in tidal volume, a decrease in minute ventilation, hypoxemia _SpO2 <90% and an increase in the level of _CO2 on exhalation, these parameters are first stabilized, after which the air supply procedure is repeated.

After performing bronchoalveolar lavage, the distal end of the bronchoscope is placed in the lobar or alternately in the segmental bronchi of the atelectatic lobe of the lung.

Using a pumping device (Fig. 1, 2) connected to the aspirator valve, a forced air supply is performed at a pressure of 35 to 40 cm H2O, which is maintained for 3-5 seconds (1 press of the bulb equals approximately 40 cm H2O, in the range of 35 to 40 cm H2O). To pump air, the check valve on the pumping device is closed and the aspirator valve is clamped (to prevent air leakage through the bronchoscope). Then, after a 1-minute break or stabilization of ventilation parameters, this procedure is repeated twice, also with a one-minute interval. During forced air pumping, the effect is applied to the lobar bronchus (second-order) or alternately to the segmental bronchus (third-order), blowing according to the above technique with a one-minute interval. Since the breathing circuit is not closed during bronchoscopy, air is released, thereby eliminating the risk of pulmonary barotrauma. The patency of the subsegmental and third- and fourth-order bronchi is then assessed under visual control.

The effectiveness of the procedure is assessed based on the results of a chest x-ray examination after 2-3 hours using the modified radiological assessment of atelectasis (m-RAS) (Parke R.L. et al. A new system for assessing atelectasis on chest x-ray after sternotomy for cardiac surgery, Med Imaging Radiol., 2014, 2 (1), p. 2). If atelectasis persists, the procedure is repeated after 24 hours using the same technique.

The clinical effect is achieved through gentle mechanical straightening of the adherent distal sections of the bronchi, bronchioles and alveoli.

The high efficiency of the proposed method is illustrated by the clinical examples below.

Example 1. A 2-month-old girl weighing 5,000 g was transferred to the pediatric intensive care unit of the Moscow Regional Clinical Institute (MONIKI) from another facility on mechanical ventilation with a diagnosis of bilateral pneumonia and atelectasis of the upper lobe of the right lung (m-RAS = 3 points). The transfer was due to non-resolving atelectasis of the upper lobe of the right lung (Fig. 3, m-RAS = 2 points).

The child underwent two atelectasis treatments using the proposed method, after which the pulmonary atelectasis did not resolve according to control radiography. To enhance the therapeutic effect of selective bronchoscopy, we performed mechanical inflation of the bronchi of the atelectatic lobe using the above-described technique after 24 hours. Initially, the child underwent bronchoscopy with bronchoalveolar lavage under endotracheal anesthesia. Five portions of sterile saline, heated to 37°C, were administered at a single volume, followed by immediate aspiration of the contents at a negative pressure of 50 mmHg. The aspirated fluid volume was 40% of the administered volume of saline.

The bronchoscope was inserted into the right upper lobe bronchus. Using a pumping device connected to the aspirator valve, atmospheric air was supplied at a pressure of 35 cm H2O, which was maintained for 5 seconds, then after a 1-minute break, the procedure was repeated 2 times, also with a 1-minute interval.

The child was extubated and placed on spontaneous respiration, but the following day, due to increasing respiratory failure, the child was intubated and placed on mechanical ventilation. Radiography again revealed atelectasis of the upper lobe of the right lung (m-RAS = 3 points).

A repeat selective bronchoscopy with mechanical bronchial inflation was performed using the technique described above. A follow-up chest radiograph revealed that atelectasis had resolved and was not detectable over time (m-RAS = 1 point). The child was extubated and transferred to the pediatric department on spontaneous breathing, where conservative treatment for bilateral pneumonia continued.

On control radiography, atelectasis resolved (Fig. 4), the lungs were straightened, moderate infiltration of the upper lobe of the right lung was noted, m-RAS=1 point.

Example 2. Boy D., 22 days old. Weight 3200 g. Transferred to the pediatric intensive care unit of MONIKI from the perinatal center of the Moscow region with a diagnosis of bilateral polysegmental pneumonia and atelectasis of the upper lobe of the left lung.

The child's condition upon admission was severe due to respiratory failure. He was on mechanical ventilation. Chest X-ray revealed bilateral polysegmental pneumonia and atelectasis of the upper lobe of the left lung (m-RAS score 4). Under endotracheal anesthesia, the child underwent bronchoscopy with bronchoalveolar lavage. Three portions of sterile saline, heated to 37°C, were administered in a single volume, followed by immediate aspiration of the contents at a negative pressure of 50 mmHg. The aspirated fluid volume was 50% of the administered volume of saline. To enhance the effect of the bronchoscopy, mechanical inflation of the bronchi of the atelectatic lobe of the left lung was performed. A bronchoscope was inserted into the left upper lobe bronchus. Using a pumping device connected to the aspirator valve, atmospheric air was applied at a pressure of 35 cm H2O for 3 seconds, then after a 1-minute break, the procedure was repeated twice, also at 1-minute intervals. Visual inspection revealed that the segmental and third- and fourth-order bronchi were straightened and patent. The procedure was completed. Radiography 3 hours after the bronchoscopy showed the lungs were straightened (m-RAS score 1).

Example 3. Girl R., 1 year old. Weight 10,900 g. Admitted to the pediatric intensive care unit of MONIKI with a diagnosis of right-sided polysegmental pneumonia, atelectasis of the upper lobe of the right lung.

The patient's condition upon admission was serious. He was on spontaneous respiration with _O2 support. Chest X-ray revealed right-sided polysegmental pneumonia and atelectasis of the upper and middle lobes of the right lung (m-RAS score of 5).

A child underwent bronchoscopy with bronchoalveolar lavage under inhalation anesthesia using a laryngeal mask. Five ml of sterile saline warmed to 37°C was administered, followed by aspiration of the contents. A child underwent bronchoscopy with bronchoalveolar lavage under endotracheal anesthesia. Three portions of sterile saline warmed to 37°C were administered at a single volume, followed by immediate aspiration of the contents at a negative pressure of 80 mmHg. The aspirated fluid volume was 52% of the administered volume of saline. To enhance the effect of bronchoscopy, mechanical inflation of the bronchi of the atelectatic lobe of the right lung was performed using the proposed method.

The bronchoscope was inserted into the right upper lobe bronchus. Using a pumping device connected to the aspirator valve, atmospheric air was applied at a pressure of 40 cm H2O for 5 seconds. After a 1-minute break, the procedure was repeated twice, also at 1-minute intervals. The bronchoscope was then advanced to the middle lobe bronchus, and mechanical inflation of the middle lobe was performed using the same technique. Upon visual inspection, the segmental and third- and fourth-order bronchi were straightened and patent. The procedure was completed.

According to X-ray data 3 hours after bronchoscopy, the lungs were straightened (1 point according to m-RAS).

Example 4. Girl R., 2 years 10 months old. Weight 14,750 g. Admitted to the pediatric intensive care unit of MONIKI with a diagnosis of bilateral polysegmental pneumonia, atelectasis of the upper and middle lobes of the right lung.

The patient's condition upon admission was serious. He was on mechanical ventilation. A chest X-ray revealed right-sided polysegmental pneumonia and atelectasis of the upper lobe of the right lung (m-RAS score 6).

A child underwent bronchoscopy with bronchoalveolar lavage under inhalation anesthesia using a laryngeal mask. A child underwent bronchoscopy with bronchoalveolar lavage under endotracheal anesthesia. A single dose of 7.5 ml of sterile saline, heated to 37°C, was administered in five portions, followed by immediate aspiration of the contents at a negative pressure of 100 mmHg. The aspirated fluid volume was 48% of the administered volume of saline. To enhance the effect of the bronchoscopy, mechanical inflation of the bronchi of the atelectatic lobes of the right lung was performed.

The bronchoscope was inserted into the right upper lobe bronchus. Using a pumping device connected to the aspirator valve, atmospheric air was applied at a pressure of 35 to 40 cm H2O for 3-5 seconds. After a 1-minute break, the procedure was repeated twice. The bronchoscope was then advanced to the middle lobe bronchus, and mechanical inflation of the middle lobe was performed using the same technique. Upon visual inspection, the segmental and third- and fourth-order bronchi were straightened and patent. The procedure was completed.

According to X-ray data 2 hours after bronchoscopy, the lungs were straightened (1 point according to m-RAS).

Example 5. Boy P., 3 years old. Weight 20050 g. Admitted to the pediatric intensive care unit of MONIKI with a diagnosis of bilateral polysegmental pneumonia, atelectasis of the upper lobe of the right lung.

The patient's condition upon admission was moderate. He was breathing spontaneously. Chest X-ray revealed bilateral polysegmental pneumonia and atelectasis of the right upper lobe (m-RAS score 6).

A child underwent bronchoscopy with bronchoalveolar lavage under endotracheal anesthesia. Two portions of sterile saline, heated to 37°C, were administered, followed by immediate aspiration of the contents under a negative pressure of 100 mmHg. The aspirated fluid volume was 48% of the administered volume of saline. During aspiration of the contents from the tracheobronchial tree, destabilization of ventilation parameters was noted (decrease in _SpO2 to <90%, increase in peak airway pressure, decrease in tidal volume, and increase in exhaled _CO2 ). Bronchoscopy was discontinued. The anesthesiologist achieved stabilization of ventilation parameters, after which treatment was continued. 10 ml of sterile saline solution heated to 37°C was administered in 3 portions, followed by immediate aspiration of the contents under a negative pressure of 100 mmHg, with the volume of aspirated fluid amounting to 50% of the administered volume of saline solution.

In order to enhance the effect of sanitation bronchoscopy, mechanical inflation of the bronchi of the atelectatic lobes of the right lung was performed.

The bronchoscope was inserted into the right upper lobe bronchus. Using a pumping device connected to the aspirator valve, atmospheric air was applied at a pressure of 40 cm H2O for 5 seconds, followed by a 1-minute rest, and the procedure was repeated twice. Upon visual inspection, the segmental and third- and fourth-order bronchi were straightened and patent. The procedure was completed.

According to X-ray data 2 hours after bronchoscopy, the lungs were straightened (1 point according to m-RAS).

Claims (6)

1. A method for endoscopic treatment of pulmonary atelectasis in children, including bronchoalveolar lavage and sanitary bronchoscopy, characterized in that bronchoalveolar lavage is performed by introducing 3-5 portions of sterile saline solution heated to 37°C, followed by immediate aspiration, wherein for children weighing less than 5 kg, saline solution is used in a single volume of 3 ml; for children weighing 5 kg and more, up to 11 kg, saline solution is used in a single volume of 5 ml; for children weighing 11 kg and more, up to 20 kg, saline solution is used in a single volume of 7.5 ml; for children weighing 20 kg and more, saline solution is used in a single volume of 10 ml, the fluid is aspirated at a negative pressure of 50-100 mm Hg. Art., while the volume of aspirated fluid should be at least 40% of the introduced volume of physiological solution; after bronchoalveolar lavage, the distal end of the bronchoscope is inserted into the bronchus of the atelectatic lobe of the lung, using a pumping device connected to the aspirator valve, forced air is supplied under a pressure of 35-40 cm H2O, which is maintained for 3-5 seconds, while to pump air, the check valve on the pumping device is closed and the aspirator valve is clamped, after a break of 1 minute, the air supply procedure is repeated 2 times, also with a minute interval, followed by a visual assessment of the patency of the subsegmental and 3-4 order bronchi. 2. The method according to paragraph 1, characterized in that after performing bronchoalveolar lavage, the distal end of the bronchoscope is installed in the lobar bronchus of the atelectatic lobe of the lung. 3. The method according to paragraph 1, characterized in that after performing bronchoalveolar lavage, the distal end of the bronchoscope is installed alternately into the segmental bronchi of the atelectatic lobe of the lung. 4. The method according to paragraph 1, characterized in that in the event of laryngeal spasm or arrhythmia occurring after bronchoalveolar lavage, treatment of atelectasis is interrupted in order to relieve symptoms of hypoxemia; if symptoms of hypoxemia persist, endotracheal intubation is performed. 5. The method according to claim 1, characterized in that in the event of destabilization of ventilation parameters after a 1-minute break after forced air supply, such as an increase in peak airway pressure, a decrease in tidal volume, a decrease in minute ventilation, hypoxemia _SpO2 <90% and an increase in the level of _CO2 on exhalation, stabilization of these parameters is first achieved, after which the procedure of forced air supply is repeated. 6. The method according to paragraph 1, characterized in that in cases of persistence of atelectasis according to radiography data, the method is repeated after 24 hours.