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Prolonged breathing by command is not a fatal sentence
With the nsometimes it is necessary to improve the oxygen saturation of the blood 6 to 7 times by activating the abdomen for 12 hours. The method has been used in our clinic since 1993, a Bulgarian colleague is applying it in Barcelona.
Mechanical weaning “weaning” is a difficult process and takes 1/2 to 2/3 of the time during which the patient breathes.
To get severe patients out of prolonged mechanical ventilation, we have to wait, wait, wait … And at one point we say to ourselves: I’m tired of waiting! And then you know what to do? You have to start waiting again
This is what Dr. Filip Abedinov said in an interview for “24 Chasa”.
Since 1993 he has worked at the Anesthesia and Intensive Care Clinic at St. Catherine Hospital. He is the main assistant of the Department of Anesthesia and Intensive Care of MU – Sofia. He has gained experience in Germany, the United States, Italy, the Netherlands. She graduated in medicine from Pleven and until her admission in “St. Ekaterina” she works successively as anesthesiologist-resuscitator in the city of Levski and the Transport Hospital – Sofia.
– Dr. Abedinov, why are resuscitation and intensive care specialists among the front-line doctors in treating pandemic infection?
– I wouldn’t say we are on the front line. Rather, we are the “last resort on the first line” in the case of an unfavorable course of infection. Infected people in most cases are not sick, they are only contagious carriers of the virus. Patients do not always become hospital patients when the course is mild. And not all patients in the hospital are seriously injured. Nursing care and medical supervision are needed to monitor the progress of the disease. Only in case of deterioration, the patient should be admitted to the intensive care unit. This does not mean that he is hopelessly ill. Information: Prime Minister of Great Britain. He is at work again. Achieving mechanical ventilation (command breathing) can now be reported as a severe condition. But it is not a “death sentence”. With timely intubation, the condition is reversible and a person recovers even after prolonged command breathing: in “Pirogov” a patient was extubated after 39 days.
However, when we intervene immediately in the patient’s admission to the hospital, things are not favorable: help is sought very late. In this sense, we can say that the specialty is on the front line.
– What is the right time for hospital treatment?
– Early treatment gives us more opportunities to be successful in recovery. It is difficult to define which moment is “correct”. I will present my opinion as a result of the accumulated experience and the information received from colleagues abroad. For unknown reasons, the virus makes patients less sensitive to oxygen deficiency. Very insidious condition. Even at critically low blood oxygen saturation, these people do not feel short of breath. When they feel it and seek medical help, the condition is already very serious, the lack of oxygen has caused irreversible damage. Even if we take immediate action to save lives, things can be unfavorable. I share the recommendations of the Robert Koch Institute. They advise admitting patients with fever, elevated levels of C-reactive protein, ferritin, D-dimers, lymphopenia, and evidence of X-ray or scanner pneumonia to the hospital. The methodology of the head of the Infectious Disease Clinic at the Military Medical Academy, associate professor Georgi Popov, to positively monitor the coronavirus with a personal oximeter and send the data electronically is a great idea. My recommendation for people with the infection who are being treated at home is, when saturation began to permanently drop to 92-93%, seek medical attention. Their behavior should be reevaluated with additional questions and possible laboratory tests. Please note that I do not mention patients with cough, fever and shortness of breath. I think in this condition it is normal for the patient to be in the hospital.
– When can the oxygen supply be insufficient?
– This occurs by reducing the “aerial part” of the lungs. It is made up of many small “hollow clusters” – approximately 100 million with an area of 100 square meters. Each of them is covered by fine blood vessels similar to the twisting of vine stems. The oxygen-rich air enters the “clusters”. Blood vessels “suck up” oxygen and carry it throughout the body. When the virus enters the lungs, it enters the cells and, once it multiplies enough, destroys them. These cellular “wastes” fall into the “clumps” and clog them. Air cannot fill hollow spaces, and blood vessels have nothing to “suck on.” They then flow into the general canal, but with “empty hands”: they do not carry oxygen. When the process involves a large part of the lungs, respiratory failure begins, shortness of breath. The supply of oxygen-rich air helps some people. If the virus damage process deepens, we go to the supply of oxygen-enriched compressed air through additional assistive devices – order breathing with special face masks without the need to place a tube in the trachea or, as is popular in colloquial language, crooked throat. This method is not highly recommended because it increases the risk of virus aerosols in the patient’s air in the surrounding area; there is a danger to personnel.
If oxygen saturation does not permanently increase above 94%, switch to controlled breathing: mechanical ventilation. My opinion is that this is the “right” time for intubation: it gives us a better chance of preventing serious body disorders from lack of oxygen.
– Better early or as a last resort?
– Better early, and why, explains everything said so far.
– What exactly happens to a person during intubation?
– The patient must be brought into an unconscious state: an artificial coma, with medications placed in a vein. An additional muscle-blocking drug is introduced: a muscle relaxant. The manipulation is unpleasant, so it is done under an absolutely unconscious state of the patient and without any physical effort. Then, with a device with a light bulb on top, a laryngoscope, the vocal cords are reached through the patient’s mouth, slightly moving the tongue. A breathing tube is punctured through the vocal cords into the trachea. In medical parlance, this is called intubation. A respirator (ventilator), a special machine for controlled breathing, is activated. It expels air, the exact word is “inject”, with elevated levels of oxygen in the lungs. The ventilator has a humidifier that adds heat and humidity to match the patient’s body temperature. Medications are used to relax the respiratory (relaxing) muscles so that the machine can fully regulate your breathing.
Relaxers are generally used when a person has very serious lung damage and stop as quickly as possible, but always before removing the ventilator support. Also, due to discomfort from the tube placed, sedatives and sleeping medications are given. The secretions that we humans secrete during normal respiration are cleaned here by suction (aspiration) with “tubes” connected to vacuum catheters. The fan does not cause pain. You cannot speak, of course, because the tube passes between the vocal cords, feeding through the mouth is also impossible.
– What are the subtleties and critical moments in mechanical ventilation?
“These people are defenseless.” The main functions of the body are monitored and maintained or replaced depending on the capabilities of the technology: maintaining blood pressure, breathing with a respirator, monitoring the amount of urine. Nutrition and hygiene are needed. The rehabilitation team is also involved in the processes of relieving respiratory regimes. Patients bathe daily due to lack of body movement and at bedtime. Special mattresses are placed to prevent pressure ulcers: pressure ulcers.
However, there are additional difficulties in treating coronavirus patients. All people in the intensive care unit who have achieved respiratory distress syndrome need prolonged mechanical ventilation, and the damage to the lungs has occurred acutely and the body has not had time to adapt to the new circumstances. With a favorable result, the duration of mechanical ventilation is usually 2-3 weeks. A difficult time may be the mass admission of seriously ill patients for a short period of time before respirators are released. In all cases, patients are highly contagious and medical personnel must wear protective clothing. The equipment is also incredibly difficult because very often patients need additional manipulation to improve the oxygen supply to the body: abdominoplasty. Activity is difficult to maintain. It requires a lot of staff, from 4 to 5 people, and a long presence of the team in the room, is risky for both the patient and the staff.
Our medical community is very aware of this condition. My colleague from a Barcelona hospital, with whom we worked together in “St. Ekaterina”, in this way I saved my colleague, an anesthesiologist infected with the coronavirus, after 12 days of controlled breathing and 6 times on an upset stomach. At 12 o’clock I am very proud of him This is a method that has been used in our clinic since 1993. What is new is that it occurs more frequently in patients with controlled-breathing coronavirus.
There are a number of critical moments when complications occur. These are respiratory distress syndrome, acute kidney failure (the kidney temporarily stops excreting urine), pulmonary thromboembolism … During prolonged stay in the mechanically ventilated intensive care unit you may develop sepsis, an infection with bacteria, but in the blood. People call it blood poisoning, the most common cause of death in intensive care units around the world. These conditions are associated with the often-mentioned cytokine storm: The body releases substances with which it seeks to combat severe external irritation. These substances are as useful as they are harmful to your own body.
In moderation, the “army” of cytokines protects us. When it is extremely powerful, it hurts. Cytokines must be removed from the body due to the danger of self-destruction. In recent years, with new technologies, methods for purifying extracorporeal blood with special cytokine filters have been successfully applied. Due to a strong postoperative cytokine storm in our clinic, we applied the method to a 17-year-old patient 2 weeks ago. The boy went after an artificial heart implantation due to terminal heart failure. The purification of the blood with cytokine filters allowed us to successfully extubate the adolescent after 7 days of controlled breathing.
– How does the duration of intubation affect in general?
– Controlled breathing is not a cure. This is the support or replacement of a basic function of the body. Its main objective is to give time to apply the treatment to the patient. It is usually removed from the respirator as soon as it can effectively breathe on its own. The process is called weaning. Due to the relief the body has received from the machine, it adjusts the nervous system to accept it as part of the body. Something like addiction, addiction is created. Therefore, the weaning process is very difficult and lengthy. It takes about half or two thirds of the time for the patient to breathe. This is art.
It takes a lot of patience and knowledge. A series of tests are done to assess a person’s ability to breathe on their own. This is especially necessary with prolonged mechanical ventilation. In accordance with global standards for continuous mechanical ventilation, more than 21 days are accepted per device.
I hasten to assure you that we have been familiar with the problem for 50 years and that we are prepared to overcome it. Many textbooks have been written, engineering thinking has created modern machines for continuous mechanical ventilation. However, the doctor is still the most important. Therefore, knowledge of caring for patients in such conditions should be included in anesthesiology and intensive care training standards. The minimum term to obtain a certificate of independence in the specialty is 4 years, after the successful approval of an exam. When we overcome complications and improve the patient’s condition, other challenges arise.
– Than?
– These people are going through a state of critical illness. It is defined as a disease of the peripheral nervous system, often associated with severe intensive care. The main factors for its development are sepsis, multi-organ failure, and prolonged ventilation. Also, muscle weakness occurs due to its atrophy. This makes it difficult to get used to the respirator. Sometimes we have to teach these people to walk again.
Another point is the strong tension in the psyche. The patients fall into a state of delirium. They become inadequate, highly irritable, sometimes aggressive, and generally difficult to maintain. This is a natural reaction as a result of great suffering.
The body “excludes” conscious activity that distinguishes us from animals and includes the instincts of self-preservation. The process is transitory and reversible, but it further complicates our work and prolongs the stay.
In this case, delirium is not related to drunkenness. It is just that for a short time the patients behave like mentally ill, but they recover without remembering what happened. These conditions are known in all specialties associated with severe interventions on the human body.
– Forecasts after removal of artificial ventilation?
– After regaining their own breathing, patients recover until fully recovered. Depending on the age and accompanying diseases, a different time is needed. Only a small proportion remain disabled with limited respiratory resources and impaired quality of life. Most often, these are people with previous lung disease, in whom prolonged mechanical ventilation has caused additional damage. However, we must specify that with prolonged mechanical ventilation of every 10 patients, four or six survive. It is reassuring that in the current infection, the severe course is rare. About 10 out of 100 people treated in the hospital for coronavirus disease need intensive monitoring. There are no data yet on how many of them require prolonged mechanical ventilation. Typically, there were previously 2-4 patients for every 100 admitted to the intensive care unit.
– Can you say that your intensive care units are in relative “comfort” now?
– Such conclusions are wrong. As the pandemic is a serious challenge for any health system, the most prepared structures in the country, elite hospitals and their staff have been mobilized. Due to the strong contagion of the disease, patient care is carried out in a special order: the staff is divided into two, the hospital wards are doubled.
This implies covering a schedule and medical activity with half the usual staff. Severe workload. In this sense, the low levels of employment in the rooms help us. I hope it continues to be so to support the staff. This largely depends on our responsibility as a nation to continue to protect ourselves and our loved ones from infection.
Furthermore, access to medical care has been hampered by severe restrictions for the rest of the population. It stands to reason that people are afraid of contacts in the face of the unknown. I have a feeling that most of us grit our teeth and don’t complain, we seek help only as a last resort. This explains the fact that patients with very advanced diseases were operated on in our clinic or as a matter of urgency, of course, with all the measures to prevent infection. We hope that they understand us, we protect ourselves, because healthy we will be more useful to society.
– At this time, his specialty is more than ever in the limelight, but if he leaves us in the “kitchen”, what will we see an intensive care doctor on an “ordinary” day in intensive care with patients who do not have coronavirus?
– In the course of any disease it can affect important organs: the brain, the heart, the circulatory system, the liver, the lungs, the kidneys. If any one of them doesn’t “work,” it is definitely fatal to existence. Thanks to the accumulated knowledge and genius of engineering thinking, medicine manages to maintain or replace difficult organ work.
When the function of one or more of them is affected or lost, the patient enters a critical condition. His life cannot continue if he does not receive help from abroad. This is the time when you should enter the intensive care unit. Here is our role as specialists. Има две нива на критичното състояние – “горно” след което започва самостоятелното функциониране на тялото, и “долно” след което настъпва фаталният край.
Нашата работа е чрез знания, технически умения и апаратура да поддържаме жизнените функции на пациет Преведено, означава: да подкрепим или заместим белия дроб – с дихателна ила еройство за ект. подкрепа или заместване на сърцето – с лекарства, интрааортна балонна помпа, изкуствено сърце; вливане на кръвни продукти; заместване на бъбречната функция с хемофилтрация и хемодиализа; подкрепа и протекция на мозъчната функция или да забавим метаболизма с лекарства или чрез свалянена
Има и още, но и това дава представа. Нарочно ги изброих сложно, за да се разбере, че критичното състояние на пациента изисква особениу Това сам човек не може да го направи. Помагат ни сестри, рехабилитатори, санитари. Медицината днес е мултидисциплинарна дейност. И пак трудно може да се направи прогноза за оздравителния процес. С посочените методики и натрупани знания ние имитираме природата на отказалите органи и “купуваме” в Надеждата е, че като ги оставим на “спокойствие”, ще се съвземат и възстановят.
– В какво е майсторството на специалиста по интензивно лечение?
– Нашата работа е правилно да изтълкуваме “сигналите” които ни изпраща пациентът, и бавно, методично да отнемем подкрепата на организма до пълна самостоятелност. Това се постига с едно качество – търпение. За целта се налага да чакаме. Да умеем да чакаме, да искаме да чакаме, да трябва да чакаме, да чакаме, ане, чакаме… И в И тогава знаете ли какво трябва да се направи? Отново трябва да започнете да чакате. Това е в общи линии работата, която трябва да свършим, за да изведем един пациент от критична сит Колко му е? Има-няма 20-25 г. четене и трупане на умения и опит.
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