APPLICATION
OF HBO IN COMPLEX THERAPY OF TIREOTOXICAL GOITER.
Practical recommendations.
Tireotoxic goiter (TG) is a
broadcast and continuing to propagate disease.
The principle way of treating TG
is a surgical one. The pre-operational therapy includes reception of
antireoidal medicines, methiluracil, propiltyouracil and imidazol which can
reduce the production of tireoidal hormones at iodine tyrosine's level. This
is usually done for 25-30 days before operation and often in vain because of
allergic reflection of patient, weak sensitivity to medicines of goiter and
other reasons.
The probability of complication
directly deals with the pre-operational activities. The most complicated is
the problem of after-operational toxic crisis: it is difficultly treated. The
published data assess the probability of that complication in 15% and even
more (Ch.Bairiev et al.,1975; I.Rybchak,1975; V.Steinberg,1977). The lethality
is also large: 0,4-5% (I.Rybchak,1975;Yu.Michailov,1980; G.Lukomsky et
al.,1981).
The stuff of Surgical Clinic of
Bashkir Medical Institute has worked out a new method of treating TG. It
includes HBO-therapy as an addition to the operation and medicinal therapy.
Including of HBO improves the quality of treating; reduces the amount of
complications and cuts down the clinical period by 4,8 days on average.
Pathophysiological reasons for
the use of HBO in therapy of TG.
In process of tireotoxicose the
thyroid gland products usually accelerate the oxidation in tissue and improve
general exchange directly or by means of central nervous system. This
improvement is caused by abundance of oxygen. But the limit of speed of
oxygental utilization in body can nevertheless cause prolonged hypoxia in
tissue. From the beginning the
concentration of oxygen in blood after lung is large; but the potential
deficiency of oxygen in tissue still exists.
Tireotoxicos can cause the blood
circulation damage in lung and the deficiency in supply of blood with oxygen.
Development of cardiac deficiency reduces the circulation of blood, especially
on a little path of circulation and then lessens the penetration of oxygen
through the alveolar membrane.
The investigations represent the
improvement of alveolar ventilation because of the deepness of respiration (if
tireotoxicos is slight) and because of more regular respiration (in case the
hard one). The volume of aerial exchange per minute is proportional to
the development of disease. Saturation of blood with oxygen can be large for
some time, being caused by the development of external respiration. Reduction
of volume and ventilation of lung are directly caused by intermissions in
circulation of blood and weakening of muscles that are responsible for
respiration.
Regular weakness, sleeping
disorder, aggressiveness, trembling of hands and body on the whole, cardiac
violations - these are the characteristics of hypoxemia. Arrhythmic
respiration is a conformation reaction, which helps to saturate blood with
oxygen and displays its deficiency in tissue.
tissue hypoxia is a result of
wrong utilization of oxygen. Other kinds of hypoxia can be the sequence of
cardiovascular and respiratory violations. Chronic anemia (caused by the
production of not ripe erythrocytes of tireotoxicosal sicks) stimulates all of
that.
Thus the hypoxia of TG sicks is
of a complicated origin - because of damaging of the delivery of oxygen and of
its application in tissue.
Many organs can be violated as
the result of hypoxia and tireoidal hormones - central nervous system, heart,
liver and others. Hypoxia lessens the efficiency of antitiroidal medicines.
After operation difficultly
treated tireotoxical crisis are usual. They are caused generally by
reabsorbtion of tireoidal hormones to blood. This is strengthened by acute
hypoxia (circulatory and tissue ones). Any result can be: from absence of
reaction to lethality this depends on preparation
to the operation. The complications appear usually one day after operation as
an acute form of tireotoxicos accompanied with hypoxia.
That requires an additional
supply of body with oxygen (by means of oxygen pillow, in particular); but
that can't solve the problem completely in ordinary way.
The principle property of
tireotoxicos is the hypoxia of various origin; the application of HBO-therapy
in treating of TG becomes reasonable.
Reasons for use and the process
of treating.
Medical treating of tireotoxicos
includes: iodine protection of thyroid gland (mercasolil, diiodtyrosin
lowering of function of symptoadrenal system (reserpine, beta-blockers -
absidan and anaprilin), normalization of nervous system (sedative medicines,
tranquilizers) substitution therapy (hydrocortisone, prednisolon), symptomatic
therapy.
Indications for HBO.
1. TG; tireotoxicos of any
degree; indirect and sharp hypoxia; cardiac and respiratoric disorder; damages
of function of parechimatous organs.
2. After-operational tireotoxical
reaction of any degree.
3. HBO can be used if goiter is a
low-deposited one; if it is large; if the respiration is mechanically reduced
(deformation of trachea; squeezing of larynx, lung, etc.).
HBO can be applied only after the
selection of doses of medicines is done. The contraindications are: epilepsy;
lung caverns; claustrophobia and individual sensitivity to oxygen.
During the procedure a permanent
control is required as well as preparation of patient in advance. A 3%
ephedrine or 1% solution of adrenaline is dropped into nose. A special care is
to be during the first procedure.
The most advantageous are the
relative low pressures in barochamber that are less than 2AT with
compression speed of 0,05 - 0,06 AT per minute at the beginning and 0,1 - 0,12
AT per minute at the end. As the result we have 60-75 minutes on the whole and
20-25 minutes of the saturation. The pressures above 2AT for patients with
tireotoxicos are contraindicated.
The dose of oxygen depends on the
complicity of tireotoxicos and on the degree of deficiency
of oxygen. The damaging of cardiac, respiratoric, nervous systems,
accompanying diseases and the age of
patient would be taken
into account.
Four regimes for
HBO-therapy can be recommended:
1. Relatively recent sicks
(6-12 months) with slight tiretoxicos (pulse -90-100 per minute; main exchange
+30 - +40; iodine-131 absorption - 25-30% after 2 hours and 30-40%
after 24 hours); absence of disorder of cardiac, respiratoric and
parenchimatous organs. Many of sicks suffer from indirect respiratoric
deficiency; some of them - from vascular hypoxemia.
Oxygental pressure would
be 1,5-2AT (Table 1); period of saturation 40-50 minutes. Course of 6 -10
procedures, once a day, can improve the efficiency of medicinal therapy and
cut down the oxygental deficiency.
2. Severe tireotoxicos.
Sicks suffer for many years without an effective medicinal therapy. Acute
violations of cardiac, respiratoric, nervous and parenchimatous organs. The
results are: fibrillation arrhythmia; tachycardia (pulse is 140 per minute);
arrhythmia of respiration; aggressiveness; improved appetite; improvement of
temperature and of size of the liver. General
exchange
improves by 50 - 100%; iodine-131 absorption - 50-70%; acute anemia and
change of biochemical constants. Usually is supported by hypertension and
rheumatism.
The hypoxia is usually of
a complicated origin. Oxygental tension would be 1,5-2AT; period of saturation
- 40-50 minutes. Two procedures a day are recommended if acute violations of
cardiac, respiratoric and parenchimatous systems are present. Already after
3-4 procedures the changes can be observed: respiration and pulse are
normalizing; the hypoxia is reducing as well as the headaches.
3. Sicks with slight
after-operational tireotoxy. Oxygental pressure would be 1,5-2AT; period of
saturation - 40-50 minutes. Together with hormonal (hydrocortisone,
prednisalon) and symptomatic therapy it usually causes the diminishing of
toxic reactions in 3 - 4 days. HBO can be applied on the second day after
strumectomia, before the appearance of tireotoxic reactions. If everything is
all right the procedures can be finished on the 3 - 4-th day.
4.
Sicks with severe after-operation tireotoxy. Oxygental pressure would
be 2AT; period of saturation - 60-70 minutes;
up to three procedures a day in combination with medicinal therapy can
be held.
HBO would be applied
several hours after operation, if:
a) tireotoxicos isn't completely
diminished before the operation;
b) strumectomia was of vital
importance;
c) the wound after operation is
large;
d) bleedings and other
complications (resulting in the acute cardiac and respiratoric violations).
Amount of procedures is
determined individually. 5 or 6 procedures are recommended to be held in the
first two days.
The application of these
regimes significantly heals the patient respiration and pulse become more
rational. When the circulatory and respiratoric hypoxia are diminishing,
cardiac and respiratoric systems are returning
into order.
Table 1. Scheme of
application of HBO for TG-sicks.
Group
complicity of diagnosis
pressure
procedures
amount
of oxygen
per day
of courses
1
slight tireotoxicos
1,5-2
1
6-10
2
strong tireotoxicos 2,0
1-2
12-20
3
slight tireotoxicosafter operation
1,5-2
1
3-6
4
strong tireotoxicos after operation
2,0
1-3
6-12
In analysis of efficiency changes before and after
operation in basal
metabolism, biochemical
and hormonal investigations and respiration would be taken into account.
Diminishing of hyper
function of thyroid gland, normalization of the basal metabolism and the level
of thyroid hormones prove the effectiveness of HBO.
The application of complex
therapy of HBO and tireotoxic medicines permitted to achieve the eutiroidal
state in 15,6 days (without HBO 20,4 days) - the reduction is of 4,8 days!
HBO after operation
diminishes hypoxia, toxic reactions, improves the results of surgical
treating.
Thus the TG is usually
accompanied with hypoxia as the result of abundance of tireoidal hormones.
Medicinal therapy is usually not sufficient. The results of surgical treating
directly depend on pre-operational state. The application of HBO efficiently
results in achieving of eutiroidal state of patient and guarantees the quality
of pre-operational preparation. After operation it prevents toxications and
other complications.
The practical
recommendations are composed at faculty's surgery division.
Doctor
Rachmatullin Ibragim Gaizullovich,
Professor
Galeev Machmut Achmet Valeevich.