HBO
IN COMPLEX THERAPY OF OBLITERATING DISEASES OF ARTERIES OF EXTREMITIES.
Practical
recommendations.
HBO,
when producing local hyperoxy, is an effective method against hypoxia of any
kind.
We
know obliterating endarteritis and obliterating sclerosis (OES) to damage
artery of legs and causing there hypoxia.
For
effective use of HBO one needs to be acquainted with mechanism of hypoxia and
the response of body on inlet of tremendous amount of oxygen.
Hyperbaric
oxygen touches upon practically all the systems of organism with corresponding
response. One of them is the responsibility on protection of tissue, brain
firstly from intoxication - based on chemical changes, changing of extreme
breathing and cardiovascular system.
The
system of arteries can be divided into three parts: central (heart, aorta),
regional (peripheral artery) and micro circular (capillary vessels). Each
group has individual response on HBO. Response of central hemodynamics
displays in lowering of pulse rate and cardiac outlet; deposition of part of
blood with resulting lowering of blood stream. Regional response - is the
narrowing of vessels, improving of resistance and also lowering of blood
stream. Capillary response is absent if tissue metabolism is unchanged and
appears only at large external pressure.
In
case the pathology of peripheral artery. Suffering from stable hypoxia tissue
improves its breathing. If that doesn't happen, then something is wrong with
hemodynamics.
Thus
the healing influence of HBO-therapy directly depends on reservation of
intensity of blood circulation: its reduction can damage healing effect of
HBO.
The
degrees of transgressions of supply of legs of sicks with OES are determined
by reography and intermittent lameness. Thus, reoindex RI = 0,5 and with
intermittent lameness above 500 m. represent relative compensation of supply
with blood; RI = 0,4-0,5 with IL 100-500 m. means sub compensation; RI less
0,4 and IL - decompensation, by the way the most usual RI is less than 0,2.
That is in general; but there are also some people with decompensation at
0,5-RI and complete compensation with RI = 0,2.
The
latest phenomena proves the role of central hemodynamics complete
compensation with RI = 0,2 is possible only with high outlet; on contrary
decompression is caused by low cardiac outlet.
It
is investigated, that hypo-form of cardiac outlet responds on HBO only in 50 %
of cases, improving the outlet to the normal one; other 50 % are in vain. The
use of HBO hyper- and normal outlet is more advantageous.
Thus
the conclusions on chronic arterial insufficiency can be done only after
investigation of all three systems of cardiocirculation. Oxygental regime of
tissue directly depends on the state of cardiocirculation and is decompensated
if any two of systems are reduced ones.
Thus
HBO depends on: protecting of power of outlet; bettering of regional
circulation; preventing of transgressions of capillary circulation.
A
number of indirect methods, such as reography, lateral reovasography and
capillaroscopy are to be used for estimation of systemic cardiocirculation.
These are safely methods; not difficult for patient and very informative on
the other hand. This, certainly, doesn't exclude other methods of control,
such as radiocardiography; policardiography; ultrasonic echocardiography;
integral reography these are for central outlet; lateral reovasography;
aortoarteriography; occlusive reopletizmography; Doppler's ultrasound
fluometry - for investigation of regional hemodynamics; biomicroscopy;
radiometrical determination of tissue circulation; capillaroscopy;
electrothermometry; thermography - for investigation of microcirculation;coagulogram
- for investigation of oxygental regime.
Indications
for use of HBO.
These
are two groups: absolute and conditional ones. The absolute are: cavities in
organs; epilepsy; claustrophobia; malignant tumor; sensitivity to oxygen.
Conditional contraindications are: chronic inflammations of
otorhinolaryngologic organs, hypertension of II-III degree.
Preparation
of patient for the treating by means of HBO.
The
roentgenogram of lung would be done, as well as inspection of
otorhinolaryngologist.
Just
before the course the instruction on security would be held (oil on skin;
static electricity; injurity of ear).
KMP
hasn't contraindications for HBO; brarycardia is neutralized by medicines in
advance (atropine, metacin, etc.)
Regime
and schemes of HBO.
With
use of supporting medicines the optimal constants can deviate (that is
respectively to the state of diseasive extremities: amount of procedures - 5 -
40; pressure - 1,3 - 3,0AT; 1-2-3 procedures per day. The ordinary are: 40
minutes once a day with fifteen procedures in sum. In general for OES-sicks
the working pressure would be 2,0 3,0AT. If a patient is a newly sick, the
regime would be more tender: 40 - 60 minutes and 10 - 15 procedures - that
could be enough. For prolonged patients with ulcer and necrosis in distal
regions of extremities 2 - 3 procedures per day would be done with 30 - 40 on
the whole.
After
15 procedures oxygental intoxication can arrive; the regime would be changed
to more tender one. If such diseases as ishemia; cardiosclerosis; insult;
hypertension are present, the pressure would be 1, 3AT at the beginning with
steadily improvement to 2,0AT (titration). Control on ventricular rate,
electrocardiogram, arterial pressure would be done as well as on individual
sensations.
The
control of efficiency of HBO would be done permanently for feasibility of
correction of constants, if required. The indexes of efficiency of HBO are (after
5 - 6 procedures): lessening of dyspnea, pain in heart, headaches, feeling of
jollity and freshness.
The
display of adequate constants of HBO-therapy are lessening of intermittent
lameness; lessening of inflation; warming and paling of skin of extremity;
arriving of granulation and marginal epithelisation.
Functional
criteria are: improvement of cardiac outlet, regional circulation and
microcirculation. If the outlet is large from the beginning this control is
required anyhow as HBO can also reduce outlet sometimes and that worthens the
tissue circulation. That lessens the HBO till its complete diminishing. These
sicks have a low outlet during all the course and the effect of HBO-therapy is
absent. If the outlet remains low after course, a medicinal correction is
required otherwise a complete refuse from HBO.
Figures
of regional hemodynamics are less variable with unpredictable changes. On the
top of hyperoxy vessels can contract after oxygental influence. Temperate
lessening of regional hemodynamics doesn't depend on the effect of HBO; its
significant reduction would cause the changes in course - as usual for
tendering it. Improvement of regional circulation shows the normalization of
vascular tension. This can be the result of bettering the system hemodynamics
(improvement of arterial pressure; blood inlet dealing with bettering of
pumping function of heart).
The
figures of micro circulation (capillaroscopy; electrothermia) are
characterizing primarily the transgressions of tissue metabolism. Blood
circulation in capillaries completely depends on that of regional circulation
(its tension, volume, speed) and not on activity of neurons. Vasospasm of
capillaries is aused by products of metabolism in tissue (amines, polypeptides).
Bettering of capillary picture confirms the bettering of oxidization in tissue
and satisfactorily support with oxygen; continuing shortage of HBO needs the
correction of course.
Prophylaxis
of complications.
To
avoid barotraumes the absence of caverns and conductivity of ear's tubes would
be investigated. The most difficult is the prophylaxis of sharp and prolonged
oxygental intoxication. Its immediate displays are: hardening of breathing;
dizziness; vomity and sweatiness. The arterial pressure and pulse can improve
soon after that. HBO would be interrupted or marginally continued with the
lowest constants and careful control. Chronic intoxication can arrive after
prolonged course of HBO, thus after the 15th procedure of acute or sub acute
inflammation of respiratoric system. Its displays are anemia and improvement
of SOE. The course would be interrupted for some time. If barootitis develops
- the course would be temporary interrupted for curing of otitis; continuation
compulsory requires the use of ephedrine or naphtizin.
Clinical
aspects of rational use of HBO in complex therapy of chronic pathology of
extremities. Many medicines are used now for treating of
obliterate diseases of extremities. These are nine groups:
1.
Vasodilators (no-spa, papaverin, galidor, nikospan);
2.
specimen of vessels and micro circulation (complamin, nicotin acid,
repoliglucin);
3.
cholinotics of peripheral activity (undecaline);
4.
gangliblocators (bensogecsony, midocalm, pachycarpin;
5.
specimen of reological properties of blood - reopolyglucin, heparin,
salycilates, curtanil;
6.
specimen of venous outflow - escusan and troxevasin;
7.
specimen acting on central group - complamin, trental, cardiac glecosides;
8.
specimen acting on the activity of metabolism of tissue - these are vitamins
A, B, C, E, trental, ATF, glutamine acid; antigistamine specimen - tavegil,
dimedrol, suprastine, antichinin devices.
Clinical aspects of rational use of HBO in complex
therapy of chronic pathology of obliterate endarteritis and aterosclerosis are
represented in Table 1.
The peculiarity of proposed tactics of treating is that
it above all takes into account the cardio-outlet of patient. The efficiency
of HBO depends on the state of central hemodynamics and its changing. Thus, if
a patient has the I degree of transgression of supplying of extremities and
low outlet the HBO-therapy will be the same as for the II degree.
The most complicated are sicks with permanent pain and
destructive changes in tissue. The medicines that are usually injected into
tissue, here are used into artery; sympatoectomies; novocain blockades of
parts of neural system.
Table 1. Clinical aspects of rational use of HBO in
complex therapy of chronic pathology of extremities.
|
Stage of transgressions
of regional circulation |
I degree (compensations) |
II degree (subcompensations) |
|
Main clinic phenomena |
Intermittent
claudication above 500m. |
Intermittent
claudication less than 500 m., pain |
|
Functional figures for
regional circulation |
RI =+0,5 and above spasmodic capillaries |
RI = +0,4-0,5 spasmodic capillaries |
|
Functional state of
central hemodynamics |
high outlet, low outlet |
high outlet, low outlet |
|
Regimes and schemes of
HBO-therapy |
10-15proc; 1,3-3AT; 1 a
day control after 10
procedures. |
10-15proc; 1,3-3AT; 1 a
day; |
|
Volume of complex
therapy |
Vasodilators,antiagrigants, stimulators of tissue
respiration |
Vasodilators,antiagregants, stimulators of tissue
respiration |
|
improvers of reology of
blood |
improvers of reology of
blood + therapy, improving outlet. |
|
|
|
|
|
|
Degree of transgression
of regional circulation
|
III degree (decompensation) |
|
|
Main clinic phenomena |
Intermittent
claudication less 100m., destruction
of tissue less 25m., destruction of tissue
permanent pain |
Intermittent
claudication strong pain |
|
Functional figures for
regional circulation |
RI =+0,4-0,2 spasmodic capillaries |
RI = +0,2 and above spasmodic capillaries |
|
Functional state of
central hemodynamics |
high outlet
low outlet |
high outlet low outlet |
|
Regimes and schemes of
HBO-therapy |
15-40proc; 1,3-3AT; 1-2
a day |
15-40proc; 1,3-3AT; 1 a
day; control after 10
procedures. |
|
Volume of complex
therapy |
Vasodilators,antiagrigants, stimulators of tissue
respiration improvers of reology of
blood in-arterial infusions,
"little" |
Vasodilators,antiagrigants stimulators of tissue
respiration improvers of reology of
blood in-arterial infusions,
"little" |
|
amputations, blockades |
amputations, blockades |
if the outlet doesn't
improve HBO has no use; cardinal amputation |
The
intensity of HBO also improves - from 15 to 30-40 procedures -
the limit is oxygental intoxication or other
complications. The device of intensive therapy is in-arterial catheter for
infusions. The compound for infusions is: reopoliglucin - 400,0 (or
physiological solution - 500,0) + complamin - 2ml (no-spa - 4ml, papaverin - 4
ml) + solcoseril - 8 ml + dimedrol-1% - 2ml + novocain-0,5% - 20 ml + vitamin
C-5% - 6ml + vitamin B1-1% - 1ml + vitamin B6-2,5% - 2 ml + antibiotics
according the indications.
In addition we would to stress once else the principle
role of the assessment of cardiovascular system in general for treating the
chronic pathology of extremities; and the role of central hemodynamics first
of all.
Doctor
V.Pakhomov,
Professor
R.Zubarev,
Doctor
V.Kostiunin.