Современные аспекты неинвазивной вентиляции легких у

ÑÎÂÐÅÌÅÍÍÛÅ ÀÑÏÅÊÒÛ ÍÅÈÍÂÀÇÈÂÍÎÉ ÂÅÍÒÈËßÖÈÈ ËÅÃÊÈÕ Ó ÁÎËÜÍÛÕ Ñ
ÎÑÒÐÎÉ ÑÅÐÄÅ×ÍÎÉ ÍÅÄÎÑÒÀÒÎ×ÍÎÑÒÜÞ
Ä.Ì.ÑÀÁÈÐÎÂ, À.À.ÍÀÁÈÅÂ, À.Ê.ÊÎÉÈÐÎÂ
The modern aspects of noninvasive lungs ventilation of the patients nith the acute cardiogenic
failure
D.M.SABIROV, A.A.NABIEV, A.K.KAYIROV
Ðåñïóáëèêàíñêèé íàó÷íûé öåíòð ýêñòðåííîé ìåäèöèíñêîé ïîìîùè,
Òàøêåíòñêèé èíñòèòóò óñîâåðøåíñòâîâàíèÿ âðà÷åé
Ïîêàçàíà ýôôåêòèâíîñòü íåèíâàçèâíîé âåíòèëÿöèè ëåãêèõ (ÍÂË) ïðè îñòðîé ñåðäå÷íîé íåäîñòàòî÷íîñòè (ÎÑÍ),
ïðè ýòîì îòìå÷àåòñÿ óëó÷øåíèå ðåñïèðàòîðíîé ïîääåðæêè è ñåðäå÷íîé äåÿòåëüíîñòè. ÍÂË íå òðåáóåò áîëüøèõ
çàòðàò è õîðîøî ïåðåíîñèòñÿ áîëüíûìè.  òî æå âðåìÿ àâòîðû îòìå÷àþò íåäîñòàòî÷íóþ èçó÷åííîñòü è ïðîòèâîðå÷èâûå ðåçóëüòàòû ïóáëèêàöèé, ïîñâÿùåííûõ âëèÿíèþ ÍÂË íà ïîêàçàòåëè öåíòðàëüíîé ãåìîäèíàìèêè, êèñëîòíî-îñíîâíîãî ñîñòîÿíèÿ è âíåøíåãî äûõàíèÿ. Ñëàáî îñâåùåíû âîïðîñû âûáîðà ðåæèìà íåèíâàçèâíîé âåíòèëÿöèè â çàâèñèìîñòè îò êëèíè÷åñêîãî òå÷åíèÿ çàáîëåâàíèÿ.
The efficiency of noninvasive lungs ventilantion (NVL) is shown in this article and also the improvement of the
respiratory support and cardiogenic activity is noted. At the same time the authors underlined the insufficient learnings
and condradictory results of the publications devoted to the NVLS influence on the indexes of the CGA, AAC and
external respiration. The issues of the choice of the regimen of NVL depending on the clinical course of the disease
are weakly mentioned.
Îñòðàÿ ñåðäå÷íàÿ íåäîñòàòî÷íîñòü (ÎÑÍ) – íåîòëîæíîå ñîñòîÿíèå, õàðàêòåðèçèðóþùååñÿ ãåìîäèíàìè÷åñêèìè ðàññòðîéñòâàìè âñëåäñòâèå ïîðàæåíèÿ ñåðäöà è
íàðóøåíèÿ åãî ñîêðàòèìîñòè, ïðè êîòîðîì ïðîèñõîäèò
èçìåíåíèå ãàçîîáìåííîé ôóíêöèè ëåãêèõ ñ ðàçâèòèåì
êàðäèîãåííîé äûõàòåëüíîé íåäîñòàòî÷íîñòè è ãèïîêñèè,
ïðèâîäÿùåé ê êðèòè÷åñêîìó ñîñòîÿíèþ (îòåê ëåãêèõ) è
íåðåäêî ê ëåòàëüíîìó èñõîäó [7]. ÎÑÍ ÿâëÿåòñÿ îäíîé
èç îñíîâíûõ ïðè÷èí ëåòàëüíûõ èñõîäîâ ïðè îñòðîì èíôàðêòå ìèîêàðäà (ÎÈÌ). Ê ÎÑÍ ïðèâîäèò îñòðûé êîðîíàðíûé ñèíäðîì (ÎÊÑ) (31%) è õðîíè÷åñêàÿ ñåðäå÷íàÿ íåäîñòàòî÷íîñòü (ÕÑÍ) (14%) [1,3,12].
Âåäåíèå ïàöèåíòîâ ñ êàðäèîãåííîé äûõàòåëüíîé íåäîñòàòî÷íîñòüþ ïðè ÎÑÍ ÿâëÿåòñÿ îäíèì èç íàèáîëåå
ñëîæíûõ ðàçäåëîâ ìåäèöèíû. Ìåäèêàìåíòîçíîå ëå÷åíèå è êèñëîðîäîòåðàïèÿ â ðÿäå ñëó÷àåâ îêàçûâàþòñÿ
ìàëîýôôåêòèâíûìè. Äàæå ïðè íàïðÿæåíèè êîìïåíñàòîðíûõ ìåõàíèçìîâ âíåøíåãî äûõàíèÿ îðãàíèçìó íå
óäàåòñÿ ïîääåðæèâàòü íîðìàëüíûé ãàçîâûé ñîñòàâ êðîâè [7,8,11,12].
 íàñòîÿùåå âðåìÿ ïðè ëå÷åíèè ÎÑÍ ñ êàðäèîãåííîé äûõàòåëüíîé íåäîñòàòî÷íîñòüþ ïðèìåíÿþò ìåòîäû
ðåñïèðàòîðíîé ïîääåðæêè ñ èñïîëüçîâàíèåì íåèíâàçèâíîé âåíòèëÿöèè ëåãêèõ (ÍÂË), ïðè êîòîðîé íå ïðîèñõîäèò èíâàçèè (ïðîíèêíîâåíèÿ) â åñòåñòâåííûå âîçäóõîíîñíûå ïóòè. Íàëè÷èå äûõàòåëüíîé íåäîñòàòî÷íîñòè
îáñòðóêòèâíîãî ðåñïèðàòîðíîãî òèïà, íåðàâíîìåðíîñòü
ïåðôóçèîííî-âåíòèëÿöèîííûõ îòíîøåíèé, óâåëè÷åíèå
ðàáîòû äûõàíèÿ îáóñëîâëèâàþò âîçìîæíîñòü ïðèìåíåíèÿ ìåòîäîâ ðåñïèðàòîðíîé ïîääåðæêè ó áîëüíûõ ñ
ÎÈÌ, îñëîæíåííûì ëåâîæåëóäî÷êîâîé íåäîñòàòî÷íîñòüþ (ËÍ), è ñëåäîâàòåëüíî, êàðäèîãåííîé äûõàòåëüíîé
íåäîñòàòî÷íîñòüþ [3,7,14,16,20,22,26].
Ìíîãî ðàáîò ïîñâÿùåíî ëå÷åíèþ ïàöèåíòîâ ñ îñòðûì
àëüâåîëÿðíûì îò¸êîì ë¸ãêèõ (ÎË). ÎË – ýòî êëèíè÷åñêèé ñèíäðîì, ÿâëÿþùèéñÿ æèçíåóãðîæàþùèì ñîñòîÿíè-
åì, òðåáóþùèì ïðîâåäåíèÿ êîìïëåêñà ýêñòðåííûõ ìåðîïðèÿòèé. Îáùàÿ ñìåðòíîñòü áîëüíûõ ñ ÎË ëþáîé ýòèîëîãèè ñîñòàâëÿåò îêîëî 10–15%, ëåòàëüíîñòü ïðè ÎË,
âîçíèêøåì íà ôîíå îñòðîãî èíôàðêòà ìèîêàðäà, äîñòèãàåò 40% (ÎÑÍ ïî Êèëëèïó III) [3,7,15,17,25,34,47].
Ïî ìíåíèþ L.Brochard [25], íåèíâàçèâíàÿ âåíòèëÿöèÿ ë¸ãêèõ ïðåäïî÷òèòåëüíåå äëÿ ëå÷åíèÿ ðàííèõ ñòàäèé îò¸êà ë¸ãêèõ, ÷åì äëÿ åãî ðàçâ¸ðíóòûõ ôîðì, ïðè
êîòîðûõ èíâàçèâíàÿ èñêóññòâåííàÿ âåíòèëÿöèÿ ë¸ãêèõ
(ÈÂË) ÷àñòî ñòàíîâèòñÿ åäèíñòâåííûì ñïîñîáîì ðåñïèðàòîðíîé ïîääåðæêè. Ìàñî÷íàÿ âåíòèëÿöèÿ ïîçâîëÿåò
ñíèçèòü äî ìèíèìóìà ÷èñëî èíôåêöèîííûõ è «ìåõàíè÷åñêèõ» îñëîæíåíèé ðåñïèðàòîðíîé ïîääåðæêè è â òî
æå âðåìÿ ýôôåêòèâíî óëó÷øèòü ãàçîîáìåí è óìåíüøèòü
íàãðóçêó íà àïïàðàò äûõàíèÿ [4,30,47].
Cëåäóåò îòìåòèòü, ÷òî òðàäèöèîííàÿ ÈÂË, íåçàìåíèìàÿ ïðè ïðîòåçèðîâàíèè äûõàòåëüíîé ôóíêöèè áîëüíîãî, îêàçûâàåò íåêîòîðîå íåáëàãîïðèÿòíîå âîçäåéñòâèå íà ãåìîäèíàìè÷åñêèå ôóíêöèè. Îíà óõóäøàåò
ìåõàíè÷åñêèå ñâîéñòâà ëåãêèõ: ñíèæàåò èõ ðàñòÿæèìîñòü è ïîâûøàåò ñîïðîòèâëåíèå äûõàòåëüíûõ ïóòåé,
äëÿ åå ïðîâåäåíèÿ òðåáóåòñÿ ãåðìåòèçì êîíòóðà àïïàðàò-áîëüíîé. Îíà îòðèöàòåëüíî âîçäåéñòâóåò íà íåêîòîðûå æèçíåííî âàæíûå ôóíêöèè îðãàíèçìà, â ÷àñòíîñòè íà öåíòðàëüíóþ ãåìîäèíàìèêó, ëåãî÷íîå è ïåðèôåðè÷åñêîå êðîâîîáðàùåíèå [8,9].
Ñ ó÷åòîì ýòèõ ôàêòîðîâ è äëÿ ðåøåíèÿ íåêîòîðûõ
äðóãèõ çàäà÷ ðàçðàáîòàíû è àêòèâíî èñïîëüçóþòñÿ â
êëèíèêå ðàçëè÷íûå óñîâåðøåíñòâîâàííûå ìåòîäèêè îáùåïðèíÿòîé ÈÂË ïîëîæèòåëüíîãî äàâëåíèÿ â êîíöå âûäîõà, àêòèâíîãî âäîõà, ïåðåìåæàþùåéñÿ ïîëîæèòåëüíîé âåíòèëÿöèè è äð. [9,13]. Âìåñòå ñ òåì, îäíèì èç îáÿçàòåëüíûõ óñëîâèé ïðîâåäåíèÿ òðàäèöèîííûõ ìåòîäîâ
ÈÂË ÿâëÿåòñÿ ãåðìåòèçì êîíòóðà àïïàðàò-áîëüíîé, ÷òî
óõóäøàåò äðåíàæíûå ôóíêöèè ëåãêèõ, ÷ðåâàòî îïàñíîñòüþ èíôèöèðîâàíèÿ äûõàòåëüíûõ ïóòåé, ðàçâèòèÿ áà-
Âåñòíèê ýêñòðåííîé ìåäèöèíû, 2, 2009
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Ñîâðåìåííûå àñïåêòû íåèíâàçèâíîé âåíòèëÿöèè ëåãêèõ ó áîëüíûõ ñ îñòðîé ñåðäå÷íîé íåäîñòàòî÷íîñòüþ
ðîòðàâìû ëåãêèõ ïðè êàøëå è ñîïðîòèâëåíèè ðåñïèðàòîðó. Ñóùåñòâóåò íåîáõîäèìîñòü ñèíõðîíèçàöèè áîëüíîãî ñ äûõàòåëüíûì àïïàðàòîì è îòêëþ÷åíèÿ ðåñïèðàòîðà ïðè ñàíàöèè òðàõåîáðîíõèàëüíîãî äåðåâà [6,8,9].
Íàïðîòèâ, ïðèìåíåíèå ìàñî÷íîé âåíòèëÿöèè ó ïàöèåíòîâ ñ îñòðîé äûõàòåëüíîé íåäîñòàòî÷íîñòüþ (ÎÄÍ)
ïîçâîëÿåò ñíèçèòü äî ìèíèìóìà ÷èñëî èíôåêöèîííûõ è
ìåõàíè÷åñêèõ îñëîæíåíèé, óìåíüøèòü ïîòðåáíîñòü â
ìèîðåëàêñàíòàõ è òðàíêâèëèçàòîðàõ, îáåñïå÷èòü êîìôîðò áîëüíîìó. Ïðè ïðîâåäåíèè ÍÂË íå ïðîèñõîäèò
ïðÿìîãî êîíòàêòà ñ òðàõååé, è ãîëîñîâûå ñâÿçêè ñîõðàíÿþò ñâîþ åñòåñòâåííóþ ïîäâèæíîñòü. Ýòî óìåíüøàåò
âåðîÿòíîñòü àñïèðàöèè è ñèíóñèòîâ, êîòîðûå ÿâëÿþòñÿ
ïðè÷èíàìè íåîáúÿñíÿåìîé ëèõîðàäêè è áàêòåðèåìèè ó
ïàöèåíòîâ, ïîëó÷àâøèõ ðåñïèðàòîðíóþ ïîääåðæêó [18],
à òàêæå ñíèæàåò ðèñê ðàçâèòèÿ èíôåêöèîííûõ îñëîæíåíèé, ñîêðàùàåò ñðîêè ïðåáûâàíèÿ â îòäåëåíèè èíòåíñèâíîé òåðàïèè [14].
ÍÂË ïðè ñïîíòàííîì äûõàíèè ïàöèåíòà ñ ïîâûøåííûì äàâëåíèåì â ðàçëè÷íûõ ðåæèìàõ (CPAP, BiPAP),
ïîìèìî ñíèæåíèÿ ðàáîòû äûõàíèÿ, ñïîñîáñòâóåò «âûäàâëèâàíèþ» æèäêîé ÷àñòè êðîâè èç àëüâåîë è èíòåðñòèöèè ëåãî÷íîé òêàíè â êðîâåíîñíîå ðóñëî, îáåñïå÷èâàÿ áîëåå ýôôåêòèâíûé ãàçîîáìåí è íèâåëèðóÿ îòðèöàòåëüíûé ýôôåêò øóíòà â ëåãêîì [7].
Îòëè÷èå ÑÐÀÐ è ÂiÐÀÐ îò òðàäèöèîííîé ÈÂË çàêëþ÷àåòñÿ â òîì, ÷òî âî âðåìÿ êàæäîãî âäîõà ñîçäàåòñÿ
çàäàííîå ïîëîæèòåëüíîå äàâëåíèå (Pins). Ðåçóëüòàòû 5
ðàíäîìèçèðîâàííûõ êîíòðîëèðóåìûõ èñïûòàíèé è 5 îáñåðâàöèîííûõ èññëåäîâàíèé ñâèäåòåëüñòâóþò î öåëåñîîáðàçíîñòè äîïîëíèòåëüíîãî ïðèìåíåíèÿ ïðè îáîñòðåíèÿõ õðîíè÷åñêèõ îáñòðóêòèâíûõ çàáîëåâàíèÿõ ëåãêèõ
(ÕÎÇË) íåèíâàçèâíîé âåíòèëÿöèè ëåãêèõ ñ ïîñòîÿííûì
ïîëîæèòåëüíûì äàâëåíèåì (ÂÏÏÄ), êîòîðàÿ ñíèæàåò
ïîòðåáíîñòü â ïðîâåäåíèè èíâàçèâíîé ÈÂË è, âîçìîæíî, ïîâûøàåò âûæèâàåìîñòü áîëüíûõ ñ äûõàòåëüíîé íåäîñòàòî÷íîñòüþ [21].
Ëå÷åíèå îáñòðóêòèâíûõ íàðóøåíèé äûõàíèÿ âî âðåìÿ ñíà ñ èñïîëüçîâàíèåì ïîñòîÿííîãî ïîëîæèòåëüíîãî
äàâëåíèÿ, ñîçäàâàåìîãî â âåðõíèõ äûõàòåëüíûõ ïóòÿõ,
âïåðâûå áûëî ïðåäëîæåíî àâñòðàëèéñêèì âðà÷îì
C.E.Sallivan â 1981 ã. Â íàñòîÿùåå âðåìÿ îíî ÿâëÿåòñÿ
íàèáîëåå ýôôåêòèâíûì (ýôôåêòèâíîñòü åãî ñîñòàâëÿåò 98,8%) ñïîñîáîì êîððåêöèè íî÷íûõ äûõàòåëüíûõ ðàññòðîéñòâ è íàçíà÷àåòñÿ ïðèáëèçèòåëüíî 80% ïàöèåíòîâ
ñ àïíîý âî âðåìÿ ñíà.  àíãëîÿçû÷íîé ëèòåðàòóðå ýòîò
ìåòîä ïîëó÷èë íàçâàíèå CPAP - òåðàïèè (Continues
Positive Airway Pressure), èëè ñîçäàíèå ïîñòîÿííîãî äàâëåíèÿ â âåðõíèõ äûõàòåëüíûõ ïóòÿõ. Îñíîâíûì ïðåèìóùåñòâîì èñïîëüçîâàíèÿ CPAP-òåðàïèè ÿâëÿåòñÿ áûñòðûé êëèíè÷åñêèé ýôôåêò. Ïðîâåäåíèå ÑÐÀÐ - òåðàïèè òðåáóåò ñîçäàíèÿ ïîëîæèòåëüíîãî ïîñòîÿííîãî äàâëåíèÿ â äûõàòåëüíûõ ïóòÿõ, êîòîðîå îñóùåñòâëÿåòñÿ
ïîäà÷åé îáû÷íîãî àòìîñôåðíîãî âîçäóõà ïîä äàâëåíèåì (èñïîëüçóÿ ñïåöèàëüíûå ìåäèöèíñêèå êîìïðåññîðû)
ïîä ëèöåâóþ ìàñêó [19,29].
 ñâÿçè ñ ýòèì â ïîñëåäíèå ãîäû áîëüøîå âíèìàíèå
óäåëÿåòñÿ èçó÷åíèþ âëèÿíèÿ ÍÂË íà äûõàòåëüíûå ôóíêöèè ëåãêèõ. Íåèíâàçèâíàÿ âåíòèëÿöèÿ ñ ïîëîæèòåëüíûì äàâëåíèåì (NIPPV) ìîæåò ïðîâîäèòüñÿ â íåñêîëüêèõ ðåæèìàõ. Êðîìå CPAP-ðåæèìà, ïðèìåíÿåòñÿ âåíòèëÿöèÿ ñ äâóõóðîâíåâûì ïîëîæèòåëüíûì äàâëåíèåì
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BiPAP. Ýòîò ìåòîä óíèêàëåí òåì, ÷òî åãî ìîæíî èñïîëüçîâàòü â êà÷åñòâå âñïîìîãàòåëüíîãî ðåæèìà. Áëàãîäàðÿ äîïîëíèòåëüíûì êëàïàíàì «ìÿãêîãî» ýëåêòðîííîãî
êîíòðîëÿ áîëüíîé ìîæåò äûøàòü â ëþáîé ôàçå àïïàðàòíîãî äûõàíèÿ. Ýòîò òèï âåíòèëÿöèè ìîæåò èñïîëüçîâàòüñÿ
ó òåõ áîëüíûõ, ó êîòîðûõ íåæåëàòåëüíà èíòóáàöèÿ òðàõåè, ò.å. ó áîëüíûõ ñ òåðìèíàëüíîé ñòàäèåé çàáîëåâàíèÿ èëè ñ íåêîòîðûìè òèïàìè äûõàòåëüíîé íåäîñòàòî÷íîñòè (íàïðèìåð, îáîñòðåíèåì ÕÎÇË ñ ãèïåðêàïíèåé).
Ó áîëüíûõ ñ òåðìèíàëüíîé ñòàäèåé çàáîëåâàíèÿ, èìåþùèõ äûõàòåëüíûå ðàññòðîéñòâà, ïðîâåäåíèå NIPPV ÿâëÿåòñÿ áîëåå íàä¸æíûì, ýôôåêòèâíûì è êîìôîðòíûì
ñðåäñòâîì ïîääåðæêè âåíòèëÿöèè, ÷åì äðóãèå ìåòîäû.
Ìåòîä íå ñòîëü ñëîæåí è ïîçâîëÿåò ïàöèåíòó ñîõðàíÿòü
ñàìîñòîÿòåëüíîñòü è ñëîâåñíûé êîíòàêò; îêîí÷àíèå íåèíâàçèâíîé âåíòèëÿöèè ñîïðÿæåíî ñ ìåíüøèì ñòðåññîì
[1,5,46].
ÍÂË êàê îäèí èç ìåòîäîâ èíòåíñèâíîé òåðàïèè äûõàòåëüíîé íåäîñòàòî÷íîñòè (ÄÍ) äàâíî è ïðî÷íî âîøëà â
ðóòèííóþ ïðàêòèêó îòäåëåíèé ðåàíèìàöèè è èíòåíñèâíîé òåðàïèè (ÎÐÈÒ) çàðóáåæíûõ êëèíèê. Ýêîíîìè÷åñêàÿ ýôôåêòèâíîñòü ÍÂË íå âûçûâàåò ñîìíåíèé [2].
À.Serra è ñîàâò. [44] ïîêàçàëè, ÷òî íåèíâàçèâíàÿ ðåñïèðàòîðíàÿ ïîääåðæêà â ðåæèìàõ Pressure Support è
Proportional Assist Ventilation ïðèâîäèò ê ñíèæåíèþ ýëåêòðè÷åñêîé àêòèâíîñòè äèàôðàãìû ó âçðîñëûõ áîëüíûõ c
ÄÍ ñîîòâåòñòâåííî íà 20 è 30%.
A.Gray è ñîàâò. [28] ïîëàãàþò, ÷òî íåèíâàçèâíàÿ âåíòèëÿöèÿ ëåãêèõ (â ðåæèìàõ CPAP è NIPPV) äîëæíà ðàññìàòðèâàòüñÿ â êà÷åñòâå âñïîìîãàòåëüíîé òåðàïèè ó
áîëüíûõ ñ îñòðûì êàðäèîãåííûì îòåêîì ëåãêèõ, èìåþùèõ òÿæåëûé ðåñïèðàòîðíûé äèñòðåññ-ñèíäðîì ëèáî íå
îòâå÷àþùèõ óëó÷øåíèåì íà ôàðìàêîëîãè÷åñêîå ëå÷åíèå.
N.Kramer è ñîàâò. [31] ïðîâåðèëè âëèÿíèå ÍÂË ñ ïîëîæèòåëüíûì äàâëåíèåì íà ÷àñòîòó äûõàíèÿ, îùóùåíèå
íåõâàòêè âîçäóõà, ïîòðåáíîñòü â ýíäîòðàõåàëüíîé èíòóáàöèè è ïðîäîëæèòåëüíîñòü ãîñïèòàëèçàöèè áîëüíûõ ñ
õðîíè÷åñêèìè îáñòðóêòèâíûìè çàáîëåâàíèÿìè ëåãêèõ.
ÍÂË ÷åðåç íîñîâóþ ìàñêó ñíèæàëà íåîáõîäèìîñòü ïðîâåäåíèÿ èíòóáàöèè ïðè îñòðîé äûõàòåëüíîé íåäîñòàòî÷íîñòè.
L.Brochard è ñîàâò. [25] èçó÷àëè ýôôåêòèâíîñòü ÍÂË
ñ ïîëîæèòåëüíûì äàâëåíèåì ó 375 áîëüíûõ ñ ÕÎÇË.
Ïîòðåáíîñòü â ýíäîòðàõåàëüíîé èíòóáàöèè â ãðóïïå ñòàíäàðòíîãî ëå÷åíèÿ áûëà âûøå, ÷åì â ãðóïïå íåèíâàçèâíîé âåíòèëÿöèè (ñîîòâåòñòâåííî 74 è 26%; Ð<0,001).
Ðåæèìû íåèíâàçèâíîé âåíòèëÿöèè ëåãêèõ ÑÐÀÐ è
ÂiÐÀÐ äîñòîâåðíî óëó÷øàþò ïîêàçàòåëè ãåìîäèíàìèêè
ó áîëüíûõ ñ äåêîìïåíñàöèåé ÕÑÍ, îäíàêî ÂiÐÀÐ áîëåå
çíà÷èìî âëèÿåò íà èíòåãðàëüíûé èíäåêñ ñèñòîëî-äèàñòîëè÷åñêîé ôóíêöèè ëåâîãî æåëóäî÷êà (ËÆ) [15].
Ïåðâûå ðàíäîìèçèðîâàííûå êëèíè÷åñêèå èññëåäîâàíèÿ (ÐÊÈ) ýôôåêòèâíîñòè ìàñî÷íîé ÑÐÀÐ ó áîëüíûõ
ñ òÿæåëûì êàðäèîãåííûì îòåêîì ëåãêèõ (ÊÎË) ïîçâîëèëè ñäåëàòü âûâîä, ÷òî äàííàÿ òåðàïèÿ ñïîñîáíà çíà÷èòåëüíî ñíèçèòü ÷èñëî ÈÒ: 0 vs 35% (P<0,005) [24] è 18 vs
43% (P<0,01) [32]. Êðîìå òîãî, ïðàêòè÷åñêè âñå ïðîâåäåííûå èññëåäîâàíèÿ ïîêàçàëè, ÷òî ÑÐÀЖòåðàïèÿ ó
áîëüíûõ ñ ÊÎË áûñòðåå, ÷åì êèñëîðîäîòåðàïèÿ, ïðèâîäèò ê çíà÷èìûì ïîëîæèòåëüíûì êëèíè÷åñêèì è ôóíêöèîíàëüíûì èçìåíåíèÿì, íåêîòîðûõ ïàðàìåòðîâ: òàõèï-
Shoshilinch tibbiyot axborotnomasi, 2, 2009
Ä.Ì.Ñàáèðîâ, À.À.Íàáèåâ, À.Ê.Êîéèðîâ
íîý, äèñïíîý, òàõèêàðäèè, ÐàÎ 2/FiÎ 2, pH è ÐàÑÎ 2
[24,32,41].
Ðåçóëüòàòû ðÿäà èññëåäîâàíèé ñâèäåòåëüñòâóþò î
äîñòîâåðíîì óìåíüøåíèè ïîòðåáíîñòè â èíâàçèâíîé
èñêóññòâåííîé âåíòèëÿöèè ëåãêèõ, òðåáóþùåé èíòóáàöèè òðàõåè, ó áîëüíûõ ñ îñòðûì êàðäèîãåííûì îòåêîì
ëåãêèõ ïðè ïðèìåíåíèè äûõàòåëüíîé ïîääåðæêè, âêëþ÷àþùåé äûõàíèå ÷åðåç ìàñêó ïîä ïîñòîÿííûì ïîëîæèòåëüíûì äàâëåíèåì ÑÐÀÐ è äâóõóðîâíåâóþ íåèíâàçèâíóþ ÈÂË ÂiÐÀÐ [5,39].
Ñîâîêóïíûé àíàëèç ïîêàçàë, ÷òî ïðè äûõàíèè ïîä
ÏÏÄ èìååòñÿ òåíäåíöèÿ ê óìåíüøåíèþ ëåòàëüíîñòè â
ïåðèîä ãîñïèòàëèçàöèè [39]. Ñ äðóãîé ñòîðîíû, â îäíîì
èç êëèíè÷åñêèõ èñïûòàíèé ÍÂË áûëà ñîïðÿæåíà ñ áîëåå
âûñîêîé ÷àñòîòîé âîçíèêíîâåíèÿ èíôàðêòà ìèîêàðäà,
÷åì ïðè äûõàíèè ïîä ÑÐÀÐ [36]. ×òîáû âûÿñíèòü äåéñòâèå ýòèõ ñïîñîáîâ äûõàòåëüíîé ïîääåðæêè íà êëèíè÷åñêè çíà÷èìûå èñõîäû çàáîëåâàíèÿ áûë ïðîâåäåí ìåòààíàëèç ðåçóëüòàòîâ ñðàâíèòåëüíûõ èñïûòàíèé, âûïîëíåííûõ ñ 1966 ã. ïî ìàé 2005 ã. Ïî äàííûì ýòîãî ìåòààíàëèçà, ó áîëüíûõ ñ îñòðûì ÊÎË äûõàíèå ïîä ÑÐÀÐ è
ÂÐÀÐ ïîçâîëÿåò óìåíüøèòü ïîòðåáíîñòü â èíâàçèâíîé
ÈÂË, âîçíèêàþùóþ â ñâÿçè ñ íåäîñòàòî÷íîé ýôôåêòèâíîñòüþ ñòàíäàðòíîãî ëå÷åíèÿ, âêëþ÷àþùåãî äûõàíèå
êèñëîðîäîì ÷åðåç ìàñêó. Ïðè ýòîì äûõàíèå ïîä ÑÐÀÐ
ñïîñîáñòâóåò ñíèæåíèþ ëåòàëüíîñòè â ïåðèîä ãîñïèòàëèçàöèè [40].
Âêëþ÷åíèå ÍÂË â êîìïëåêñíîå ëå÷åíèå ÎÑÍ III–IV
ñòåïåíè ïî Killip–Kimball, ðåôðàêòåðíîé ê «ñòàíäàðòíîé ìåäèêàìåíòîçíîé òåðàïèè», îáåñïå÷èâàåò áûñòðûé
ïîëîæèòåëüíûé êëèíè÷åñêèé ýôôåêò è ñòàáèëèçàöèþ
ñîñòîÿíèÿ ïàöèåíòîâ ñ ÎÈÌ, óñòðàíÿåò êëèíè÷åñêèå
ïðèçíàêè öåíòðàëüíîé è ïåðèôåðè÷åñêîé ãèïîêñåìèè
(óìåíüøàåò êîëè÷åñòâî è èíòåíñèâíîñòü âëàæíûõ õðèïîâ, àêðîöèàíîç è öèàíîç âèäèìûõ ñëèçèñòûõ, ñîñòîÿíèå òðåâîãè) [7,10].
Íåñìîòðÿ íà òî, ÷òî ÑÐÀЖòåðàïèÿ ïðèçíàíà «çîëîòûì ñòàíäàðòîì» òåðàïèè áîëüíûõ ñ ÎÄÍ íà ôîíå òÿæåëîãî ÊÎË [37], ïî-ïðåæíåìó îñòàåòñÿ íå ðåøåííûì
âîïðîñ î öåëåñîîáðàçíîñòè èñïîëüçîâàíèÿ ïðè äàííîé
ïàòîëîãèè äðóãèõ ðåæèìîâ ÍÂË, íàïðèìåð, PSV/PEEP èëè
BiPAP. Â ñðàâíèòåëüíûõ èññëåäîâàíèÿõ áûëî ïîêàçàíî,
÷òî ýòè ðåæèìû, â îòëè÷èå îò ÑÐÀÐ, áîëåå ýôôåêòèâíî
óìåíüøàþò íàãðóçêó íà àïïàðàò äûõàíèÿ, ñíèæàþò ðàáîòó äûõàíèÿ è ïîâûøàþò äûõàòåëüíûé îáúåì è ìèíóòíóþ âåíòèëÿöèþ [26,42].  îäíîì èç ïåðâûõ ÐÊÈ, ñðàâíèâàâøèõ ÑÐÀÐ è BiPAP ó áîëüíûõ ñ ÊÎË, áûëî îòìå÷åíî, ÷òî ÍÂË â ðåæèìå BiPAP ïðèâîäèëà ê áûñòðîìó
óìåíüøåíèþ îäûøêè è óëó÷øåíèþ ïàðàìåòðîâ ãàçîîáìåíà, îäíàêî ÷èñëî íîâûõ èíôàêòîâ ìèîêàðäà â ãðóïïå
BiPAP îêàçàëîñü âûøå [37]. Ýòà òðåâîæíàÿ òåíäåíöèÿ
áûëà îòìå÷åíà â äðóãîì ÐÊÈ, ñðàâíèâàâøåì ýôôåêòèâíîñòü BiPAP ñ âûñîêèìè äîçàìè íèòðàòîâ [44].
Îäíî èç íåäàâíî îïóáëèêîâàííûõ ðàíäîìèçèðîâàííûõ êëèíè÷åñêèõ èññëåäîâàíèé áûëî ïîñâÿùåíî èçó÷åíèþ âîçìîæíîñòè ðàçâèòèÿ èíôàðêòà ìèîêàðäà íà ôîíå
ÑÐÀÐ è BiPAP [22].  èññëåäîâàíèå âêëþ÷åíû 46 áîëüíûõ ñ ÊÎË, ðàíäîìèçèðîâàííûå â ãðóïïû ÑÐÀÐ (10 ñì
âîä.ñò.) è BiPAP (15/5 ñì âîä.ñò.). Êàê îêàçàëîñü, ïî ÷èñëó ðàçâèòèÿ èíôàðêòîâ ìèîêàðäà 2 ãðóïïû áîëüíûõ ñ
ÊÎË ïðàêòè÷åñêè íå ðàçëè÷àëèñü ìåæäó ñîáîé (13,6 vs
8,3%), ò.å. ðåæèì ïîääåðæêè äàâëåíèåì ñàì ïî ñåáå íå
ïðèâîäèò ê ðàçâèòèþ ýòîãî îñëîæíåíèÿ. Êðîìå òîãî, îáà
ðåæèìà îêàçàëèñü îäèíàêîâî ýôôåêòèâíû â ïëàíå óëó÷øåíèÿ ÐàÑÎ2, ðÍ, SpO2 è ðàçðåøåíèÿ òàõèïíîý è íå
îòëè÷àëèñü ïî òàêèì êîíå÷íûì òî÷êàì, êàê ÈÒ è ãîñïèòàëüíàÿ ëåòàëüíîñòü.
 ìóëüòèöåíòðîâîì ÐÊÈ S.Nava è ñîàâò. [38] â óñëîâèÿõ îòäåëåíèÿ íåîòëîæíîé ïîìîùè ïðîâîäèëè ñðàâíåíèå BiPAP (10/5 ìì ðò.ñò.) è ñòàíäàðòíîé ìåäèêàìåíòîçíîé òåðàïèè ó 130 áîëüíûõ ñ òÿæåëûì ÊÎË. ÍÂË
ñïîñîáñòâîâàëà áûñòðîìó óëó÷øåíèþ êëèíè÷åñêèõ è
ôóíêöèîíàëüíûõ ïàðàìåòðîâ, òàêèõ êàê òàõèïíîý, äèïíîý, PaO2/FiO 2, îäíàêî ïî ÷èñëó òàêèõ ñîáûòèé êàê ÈÒ,
ãîñïèòàëüíàÿ ëåòàëüíîñòü, äëèòåëüíîñòü ãîñïèòàëèçàöèè,
äîñòîâåðíûõ ðàçëè÷èé íå îáíàðóæåíà. ×àñòîòà íîâûõ
èíôàðêòîâ ìèîêàðäà â 2-õ ãðóïïàõ áîëüíûõ òàêæå îêàçàëèñü ñõîäíîé (8 vs 11%, ð = 0,76). Àâòîðû äàííîãî
èññëåäîâàíèÿ ïðèøëè ê âûâîäó, ÷òî BiPAP èìååò ïðåèìóùåñòâà ó áîëüíûõ ñ ÊÎË è ãèïåðêàïíèåé.
Âàæíåéøåé çàäà÷åé â ëå÷åíèè ÎÑÍ ÿâëÿåòñÿ îáåñïå÷åíèå àäåêâàòíîé îêñèãåíàöèè òêàíåé äëÿ ïðåäóïðåæäåíèÿ èõ äèñôóíêöèè è ðàçâèòèÿ ïîëèîðãàííîé íåäîñòàòî÷íîñòè. Äëÿ ýòîãî êðàéíå âàæíî ïîääåðæèâàòü PaÎ2
àðòåðèàëüíîé êðîâè â ïðåäåëàõ íîðìàëüíûõ âåëè÷èí (9598%).  ýòîé ñâÿçè ïðåäñòàâëÿåòñÿ çíà÷èìûì èñïîëüçîâàíèå ó ïîäîáíûõ áîëüíûõ íåèíâàçèâíóþ âåíòèëÿöèþ
ëåãêèõ (ÍÂË), êîòîðàÿ ïîçâîëÿåò ïðîâîäèòü ðåñïèðàòîðíóþ ïîääåðæêó áåç èíòóáàöèè òðàõåè [4,10,15,24,28].
Íàëè÷èå äûõàòåëüíîé íåäîñòàòî÷íîñòè îáñòðóêòèâíîãî
è ðåñòðèêòèâíîãî òèïà, íåðàâíîìåðíîñòü ïåðôóçèîííî-âåíòèëÿöèîííûõ îòíîøåíèé, óâåëè÷åíèå ðàáîòû äûõàíèÿ îáóñëîâëèâàþò âîçìîæíîñòü ïðèìåíåíèÿ ìåòîäîâ ðåñïèðàòîðíîé ïîääåðæêè ó áîëüíûõ ñ ÎÈÌ, îñëîæíåííûì ëåâîæåëóäî÷êîâîé íåäîñòàòî÷íîñòüþ (ÎËÍ)
è ñëåäîâàòåëüíî, êàðäèîãåííîé äûõàòåëüíîé íåäîñòàòî÷íîñòüþ [3,7,14,16,20,22,26].
 èññëåäîâàíèÿõ Ñ.Ï.Ãðà÷åâà è ñîàâò. [7] óñòàíîâëåíî, ÷òî ÍÂË õîðîøî ïåðåíîñèòñÿ ïàöèåíòàìè ñ ÎÈÌ,
îñëîæíåííûì îñòðîé ëåâîæåëóäî÷êîâîé íåäîñòàòî÷íîñòüþ. Ïîä âëèÿíèåì NIPPV ó íèõ ïðîèñõîäèëî äîñòîâåðíîå ñíèæåíèå ãèäðîñòàòè÷åñêîãî ëåãî÷íîãî êàïèëëÿðíîãî äàâëåíèÿ áåç óãíåòåíèÿ íàñîñíîé ôóíêöèè ñåðäöà.
ÍÂË ïîçâîëÿëà äîñòîâåðíî óìåíüøèòü ñòåïåíü ãèïîêñåìèè, ñíèçèòü ïðîöåíò øóíòèðîâàíèÿ êðîâè â ëåãêèõ áåç
óâåëè÷åíèÿ ôðàêöèè âäûõàåìîãî êèñëîðîäà. Íà ôîíå
ÍÂË ïðîèñõîäèëî áûñòðîå êëèíè÷åñêîå óëó÷øåíèå ñîñòîÿíèÿ ïàöèåíòîâ çà ñ÷åò êóïèðîâàíèÿ èëè óìåíüøåíèÿ ñòåïåíè îòåêà ëåãêèõ.
Çà ïîñëåäíèå ãîäû áûëî ïðîâåäåíî áîëüøîå êîëè÷åñòâî èññëåäîâàíèé, ïîñâÿùåííûõ èçó÷åíèþ ðîëè ÍÂË
ïðè ÊÎË. Áûëè ïðåäñòàâëåíû ðåçóëüòàòû ìåòà-àíàëèçà,
âûïîëíåííîãî íà îñíîâàíèè ÐÊÈ [30]. Ñîãëàñíî ñîâîêóïíûì äàííûì, ÑÐÀÐ è BiPAP ïðèâîäÿò ê äîñòîâåðíîìó
ñíèæåíèþ ÷èñëà ÈÒ íà 20% è ëåòàëüíîñòè íà 17%. Ïîëîæèòåëüíûé ýôôåêò ÍÂË ïðè îòåêå ëåãêèõ íàáëþäàåòñÿ íå òîëüêî ïðè ñèñòîëè÷åñêîé äèñôóíêöèè ËÆ, íî è
ïðè äèàñòîëè÷åñêîé äèñôóíêöèè [23].
Ïðèìåíåíèå íåèíâàçèâíîé âåíòèëÿöèè â ðåæèìå ïîääåðæêè âäîõà äàâëåíèåì 9 ñì Í2O è ÏÄÊÂ 3 ñì Í2Î
ïðè FiO2 40% ìîæåò ñ óñïåõîì ïðèìåíÿòüñÿ äëÿ áûñòðîãî êóïèðîâàíèÿ ÎÑÍ II ïî Êèëëèïó. Ýòî óìåíüøàåò
âåðîÿòíîñòü òðàíñôîðìàöèè â ÎÑÍ III, îêàçûâàåò íåïîñðåäñòâåííûé áûñòðûé òåðàïåâòè÷åñêèé ýôôåêò è
Âåñòíèê ýêñòðåííîé ìåäèöèíû, 2, 2009
WWW.STA.UZ
87
Ñîâðåìåííûå àñïåêòû íåèíâàçèâíîé âåíòèëÿöèè ëåãêèõ ó áîëüíûõ ñ îñòðîé ñåðäå÷íîé íåäîñòàòî÷íîñòüþ
ïîçâîëÿåò âûèãðàòü âðåìÿ äëÿ íà÷àëà äåéñòâèÿ ìåäèêàìåíòîâ [11].
 èññëåäîâàíèÿõ Å.Ì.Ëåâèíîé [12] ó áîëüíûõ ñ îñòðûì èíôàðêòîì ìèîêàðäà íà íà÷àëüíûõ ñòàäèÿõ àëüâåîëÿðíîãî îò¸êà ë¸ãêèõ (îñòðàÿ ñåðäå÷íàÿ íåäîñòàòî÷íîñòü II ñò. ïî Êèëëèïó) ïðèìåíåíèå ÍÂË íàðÿäó ñî ñòàíäàðòíîé òåðàïèåé äàâàëî áûñòðûé òåðàïåâòè÷åñêèé
ýôôåêò, ïðèâîäèëî ê óëó÷øåíèþ ãåìîäèíàìè÷åñêèõ
ïîêàçàòåëåé, êèñëîðîäíîãî îáåñïå÷åíèÿ.
Ðåçóëüòàòû íåêîòîðûõ èññëåäîâàíèé íîñÿò ïðîòèâîðå÷èâûé õàðàêòåð. Òàê, ïðåäñòàâëÿþò èíòåðåñ
äàííûå èññëåäîâàíèÿ, êóäà âîøëè 1069 ïàöèåíòîâ
(ñðåäíèé âîçðàñò 77,7+9,7 ãîäà; 56,9% æåíùèíû), â
òîì ÷èñëå â ãðóïïó ñòàíäàðòíîé êèñëîðîäîòåðàïèè
– 367, â ãðóïïó CPAP – 346 è â ãðóïïó BiPAP – 356.
Ñòàòèñòè÷åñêè çíà÷èìûõ ðàçëè÷èé ïî ÷àñòîòå ïåðâè÷íîé êîíå÷íîé òî÷êè íå ïîëó÷åíî íè ìåæäó îáúåäèíåííîé ãðóïïîé íåèíâàçèâíîé ÈÂË è êîíòðîëåì
(9,5 ïðîòèâ 9,8% ñîîòâåòñòâåííî; 95% äîâåðèòåëüíûé èíòåðâàë [ÄÈ] 0,63–1,48; Ð=0,87), íè ìåæäó
ãðóïïàìè CPAP è BiPAP (11,7 ïðîòèâ 11,1% ñîîòâåòñòâåííî; ÄÈ 0,59–1,51; Ð=0,81). Ïðè ýòîì íå îòìå÷åíî äîñòîâåðíîãî âçàèìîäåéñòâèÿ ýôôåêòèâíîñòè âìåøàòåëüñòâ îò òÿæåñòè ÊÎË, îïðåäåëåííîé ïî
óðîâíÿì èñõîäíîãî ðÍ (Ð=0,94) è ñèñòîëè÷åñêîãî
àðòåðèàëüíîãî äàâëåíèÿ (Ð=0,17), âîçðàñòà ïàöèåíòà (Ð=0,52), ïîëà (Ð=0,33), íàëè÷èÿ èëè îòñóòñòâèÿ
ñåðäå÷íîé íåäîñòàòî÷íîñòè â àíàìíåçå (Ð=0,28).
Ïðè àíàëèçå âòîðè÷íûõ êîíå÷íûõ òî÷åê íå âûÿâëåíî ðàçëè÷èé ìåæäó ãðóïïàìè íåèíâàçèâíîé ÈÂË
è ñòàíäàðòíîé êèñëîðîäîòåðàïèè â ÷àñòîòå ñìåðòíîñòè çà 30 ñóòîê (15,2 ïðîòèâ 16,4%; Ð=0,64); ìåæäó
ãðóïïàìè CPAP è BiPAP â ÷àñòîòå ñìåðòíîñòè çà 7 è
30 ñóòîê (9,6 ïðîòèâ 9,4%; Ð=0,91 è 15,4 ïðîòèâ
15,1%; Ð=0,92 ñîîòâåòñòâåííî). Òåì íå ìåíåå, â ñðàâíåíèè ñ êîíòðîëåì íåèíâàçèâíàÿ äûõàòåëüíàÿ ïîääåðæêà ñîïðîâîæäàëàñü áîëüøèì óìåíüøåíèåì
îäûøêè (ðàçíèöà – 0,7 áàëëà ïî ÂÀØ; ð=0,008), ñíèæåíèåì ÷àñòîòû ñåðäå÷íûõ ñîêðàùåíèé (ðàçíèöà –
4 óäàðà â ìèíóòó; Ð=0,004), óìåíüøåíèåì àöèäîçà
(ðàçíèöà ðÍ – 0,03; Ð < 0,001) è ãèïåðêàïíèè (ðàçíèöà – 0,7 êÏà; Ð < 0,001) ïðè ñîïîñòàâèìîé ÷àñòîòå ïðîâåäåííûõ èíòóáàöèé òðàõåè, ïîñòóïëåíèé â
ðåàíèìàöèîííîå îòäåëåíèå è èíôàðêòà ìèîêàðäà.
Ðàçëè÷èé â îòíîøåíèè âñåõ ïåðå÷èñëåííûõ ñîáûòèé
ìåæäó ãðóïïàìè CPAP è BiPAP íå îòìå÷åíî [28].
Íåñìîòðÿ íà ðàííåå óëó÷øåíèå êëèíè÷åñêèõ ñèìïòîìîâ è ñóððîãàòíûõ ïîêàçàòåëåé òÿæåñòè çàáîëåâàíèÿ, íåèíâàçèâíûå ìåòîäû ðåñïèðàòîðíîé ïîääåðæêè íå ïðèâåëè ê óëó÷øåíèþ êðàòêîñðî÷íîé âûæèâàåìîñòè áîëüíûõ ñ îñòðûì ÊÎË â ñðàâíåíèè ñî ñòàíäàðòíîé êèñëîðîäîòåðàïèåé. Íå îòìå÷åíî òàêæå
ðàçëè÷èé â ýôôåêòèâíîñòè è áåçîïàñíîñòè ìåæäó
äâóìÿ ðåæèìàìè íåèíâàçèâíîé ÈÂË CPAP è BiPAP
[28]. Â èññëåäîâàíèÿõ S.Esteban [27] óñòàíîâëåíî, ÷òî
ÍÂË íå èìååò ïðåèìóùåñòâ â ïðåäîòâðàùåíèè ðåèíòóáàöèè.
Çàêëþ÷åíèå
Ïðèìåíåíèå ìåòîäîâ íåèíâàçèâíîé ðåñïèðàòîðíîé
ïîääåðæêè ïðè ëå÷åíèè áîëüíûõ ñ ÎÑÍ – îäíà èç àêòóàëüíûõ ïðîáëåì ñîâðåìåííîé ìåäèöèíû. Àíàëèç ëèòå88
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ðàòóðíûõ äàííûõ ñâèäåòåëüñòâóåò îá ýôôåêòèâíîñòè
ïðèìåíåíèÿ ÍÂË ïðè ëå÷åíèè áîëüíûõ ñ ÎÑÍ, ïðè ýòîì
îòìå÷àåòñÿ óëó÷øåíèå ðåñïèðàòîðíîé ïîääåðæêè è ñåðäå÷íîé äåÿòåëüíîñòè. ÍÂË íå òðåáóåò áîëüøèõ çàòðàò è
õîðîøî ïåðåíîñèòñÿ áîëüíûìè. Îäíàêî, õîòÿ â áîëüøèíñòâå èññëåäîâàíèé, ïîñâÿùåííûõ èçó÷åíèþ âëèÿíèÿ ÍÂË
ó ïàöèåíòîâ ñ ÎÑÍ è ÕÑÍ, ïîëó÷åíû ïîëîæèòåëüíûå
ðåçóëüòàòû, îíè çà÷àñòóþ ïðîòèâîðå÷èâû. Êðîìå òîãî,
íåäîñòàòî÷íî èçó÷åíî âëèÿíèå ÍÂË íà ïîêàçàòåëè öåíòðàëüíîé ãåìîäèíàìèêè, êèñëîòíî-îñíîâíîãî ñîñòîÿíèÿ
è âíåøíåãî äûõàíèÿ ó áîëüíûõ ñ ÎÑÍ â çàâèñèìîñòè îò
êëèíè÷åñêîãî òå÷åíèÿ çàáîëåâàíèÿ, íåò äèôôåðåíöèðîâàííîãî ïîäõîäà ê íàçíà÷åíèþ êàæäîãî ðåæèìà (ÑÐÀÐ
è ÂÐÀÐ) ó áîëüíûõ ñ ÎÑÍ. Áîëüøàÿ ÷àñòü èññëåäîâàíèé
âêëþ÷àåò íåäîñòàòî÷íîå ÷èñëî áîëüíûõ. Íåñìîòðÿ íà
óñïåõè â ëå÷åíèè áîëüíûõ ñ ÎÑÍ â ïîñëåäíèå ãîäû, îíà
îñòàåòñÿ ðåôðàêòåðíîé ê ïðèìåíåíèþ ñòàíäàðòíîé òåðàïèè, ïîýòîìó ÍÂË ìîæíî ðàññìàòðèâàòü êàê îäèí èç
ìåòîäîâ, êîòîðûé íóæäàåòñÿ â äàëüíåéøåì èçó÷åíèè.
ËÈÒÅÐÀÒÓÐÀ
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¤òêèð þðàê åòèøìîâ÷èëèãè á´ëãàí
áåìîðëàðäà íîèíâàçèâ ´ïêà
âåíòèëÿöèÿñèíèíã çàìîíàâèé
æàáµàëàðè
Ä.Ì.Ñàáèðîâ, À.À.Íàáèåâ, À.Ê.Êîéèðîâ
Ðåñïóáëèêà øîøèëèí÷ òèááèé ¸ðäàì èëìèé ìàðêàçè,
Òîøêåíò âðà÷ëàð ìàëàêàñèíè îøèðèø èíñòèòóòè
Ìà³îëàäà ´òêèð þðàê åòèøìîâ÷èëèãèäà íîèíâàçèâ óïêà
âåíòèëÿöèÿñèíèíã (ÍÓÂ) ñàìàðàäîðëèãè ¸ðèòèëãàí.
ÍÓÂíèíã áåìîð îðãàíèçìèãà ðåñïèðàòîð ê´ìàãè âà þðàê
ôàîëèÿòèíèíã ÿõøèëàíèøè ê´ðñàòèëãàí. Óøáó âåíòèëÿöèÿ
óñëóáè êàì õàðàæàòëè á´ëèá, áåìîðëàð óíè åíãèë
ê´òàðàäè. Øó áèëàí áèðãà ìóàëëèôëàð ÍÓÂíèíã ìàðêàçèé
ãåìîäèíàìèêà, êèñëîòà-èø³îð µîëàòè âà òàø³è íàôàñ
ê´ ðñàòêè ÷ëà ðèãà
òàú ñè ðè
å òàðëè
äà ðàæà äà
´ðãàíèëìàãàíëèãèíè, îëèíãàí íàòèæàëàð ýñà ´çàðî
òàâîâóòëè ýêàíëèãèíè òàúêèäëàéäèëàð. Êàñàëëèêíèíã
êëèíèê êå÷èøè áî²ëè³ ðàâèøäà ÍÓÂíèíã îïòèìàë
ðåæèìèíè òàíëàø ìàñàëàëàðè µàì êàì ¸ðèòèëãàíëèãè
ó³òèðèëãàí.
Shoshilinch tibbiyot axborotnomasi, 2, 2009