APPLICATION OF HBO IN PROPHYLAXIS AND COMPLEX TREATING OF PURULENT COMPLICATIONS AFTER OPERATIONS ON LUNG AND PLEURA.

Practical recommendations.

Treating of purulent complications after operations on lung and pleura (PC), pyothorax, first of all (10 - 20% of operations) is one of the complicated problems of lung surgery. This is because the bacterial environment can change and improve its  resistance for the therapy. The most usual and dangerous are cocci (staphyllo-; strepto-; etc.) and some anaerobes (for these the complications are harder).

The development of PC directly depends on immunity; if it is lessened, the complications appear 3 times more regular.

An important factor of pathogenesis of PC is hypoxia (circulator; tissue; hemic) - it lessens immunologic homeostasis.

In complex with other activities HBO can be used to diminish that.

It is known that HBO reduces hypoxia and besides inhibits the toxicity of microbes; stimulates immune and adaptive systems of a sick.

Our investigations present high efficiency of application of HBO in prophylaxis and therapy of PC.

HBO before the operation diminishes the shortage of oxygen in body; improves metabolism and reduces functional violations; stimulates immunity and reparations in wound; also possesses the anesthysiological efficiency. As the result it reduces the PC by 2,5 times and improves the index of healed patients by 30%.

97 of sicks with PC were investigated; 47 of them were treated particularly with HBO.

The characterization of method.

The essence of HBO is to improve the partial pressure of oxygen in tissue as the result of respiration under improved pressure. HBO is based on physical laws of solvability of gases in liquids, predicting that concentration of solved gas (oxygen, in particular) is proportional to pressure and temperature. Partial pressure of gas is directly proportional to partial concentration and general pressure.

Treating courses can be held in common curing chambers with volume more than 3000 liters with the pressure regime of 10AT, which are fooled with pressed air. That chamber can contain the stuff simultaneously with sick person. Single place chambers (OLB) with volume less than 2500 liters, the internal pressure is no more than 3AT. These chambers are fooled with oxygen; the sick can seat or lye in the process of HBO.

In treating of PC the pressure of 1,5 - 2AT is used.

The extra pressure - is the pressure additional to the one in normal atmosphere. Sum of extra pressure and of atmosphere's one give us an absolute pressure.

If we have one extra AT of oxygen, its concentration in blood improves 3,5-4 times; carbon dioxide lessens at 2-3 mm of mercury (if pH of blood is about 7,40-7,43).

The oxygen therapy under improved pressure reduces any form of oxygen harvest; the blood is fooled completely with oxygen. The main role is of the oxygen solved in plasma of blood. Under the pressure of 3AT the oxygen achieve the tissue even without the use of erythrocital transport.

HBO can reduce any type of shortage of oxygen; the stock of it is being reserved; the effective path of penetration of oxygen in tissue also improves. In ordinary case the oxygen is contained in hemoglobin in blood; in HBO it is mainly solved directly in plasma.

HBO is more and more widely applied in clinical practice, for operated sicks in particular. The limitations are caverns in lung and probability of toxic influence of oxygen. Persuing of therapeutic recommendations and drainage of pleura help to avoid these complications.

Indications for application of HBO.

Before operation the indications are:

1) prophylaxis of purulent complications (bronchietatic disease with purulent intoxication; diabetes; leukocytopenia; hypogammaglobulinemia; patients after radiotherapy; weak patients);

2) prophylaxis of respiratory deficiency of patients with purulent-influential pathology.

2. After operation the indications are:

1) purulence of operational wound;

2) pleural empiema (especially in presence of unclostridal anaerobic bacterium);

3) immunosuppression (reduction of amount of lymphocytes after operation).

Probable complications and their prophylaxis.

After HBO the following complication are probable:

1. occult otorhinolaryngologic diseases (headaches; pain in forehead and ears). The continuation of course can be permitted after consultations with otorhinolaryngologist.

2. Barotrauma of nose or ear - a clinic treating is required.

3. Barotitis; barosinusitis - treating as of ordinary otitis or sinusitis.

4. Oxygental intoxication of patients with high sensitivity to oxygen. We know hypereximia to reduce the pulse and respiratoric indexes; sudden improvement of pulse index with its steady lessening from the beginning display the oxygental intoxication and demand to interrupt the procedure.

5. Barotrauma of lung and underskinnal emphysema of thorax - for its prophylaxis the control of drain of lung is required.

Investigation of patients before HBO.

These investigations help to strengthen the efficiency of treating and avoid complications.

1. Roentgen and roentgenocontrast investigations of lung.

2. Bronchoscopy and biopsy of phlegm.

3. Investigation of respiration.

4. Consultation of otorhinolaryngologist.

5. Electroencephalogram (to avoid cerebral convulsions).

6. Electrocardiogram.

7. Clinical and biochemical analysis of blood with the investigation of serum transminases.

8. Thymol and sublimate probes.

9. Diastase analysis of urine.

10. Immunological investigations of T- and B-cellular immunity.

11. Bacteriologic investigations.

12. Investigation of blood electrolytic composition.

13. Acidic-alkaline investigations.

14. Consultation of psychiatrist.

Regime and methods of HBO.

Curing doctor would consult with HBO-specialist on scheme of HBO-therapy for every patient particularly: amount of procedures; their regime; exposition; medicinal therapy. Just before the procedure oil and creams would be removed from the skin; patient would be dressed in cotton (including special hat on his hair). Electrical termination with earth is necessary. The procedure would teak place no less than 30-40 min. after food reception. Ephedrine or adrenaline are desirable for prophylaxis of otorhinilaryngoligic complications. For prophylaxis of hypertension pressure in vascular system would be medically reduced to normal.

HBO would be begun in presence of curing doctor to indicate immediately claustrophobia, improved sensitivity to oxygen and compression. An instruction would take place before it. Patient wouldn't smoke for three hours after the procedure. Arterial pressure and pulse would be controlled.

Special attention would be paid to existence of caverns in lung and pleura. Patient would be placed in chamber with continuing aspiration according to Bjulau. In case the existence of purulence the procedure would take place with open wound; its surface would be treated with antiseptics and 1% solution of dioxydin with interruption of drain for 50 - 60 min. This is a checking up of drain system and is  especially important for patients with bronchial fistula - they suffer from probability of development of tensed pneumothorax and underskin emphysema of thorax; fistula would be firmly covered after drain.

The regimes of HBO for purulent-septic sicks and for prophylaxis of that are quite different.

In treating of purulent operational infections HBO would immediately (as soon as possible) follow the drain or operation. Dependently of hardness of degree of sick and development of intoxication The optimal regime can be selected. The principal indexes are:

1. Investigation of the efficiency of HBO as a pathogenic factor. That is persued by means of chromatograph "Tsvet (color)-06" (bacteriologic express-diagnosis; density of pollution with microbes; identification of infection dangerous microbes. Gaseous chromatography for determination of character of infection: aerobe or anaerobe one  is especially important. Prolongation of these investigations can be  an effective method of control of the treatment.

2. Immunological investigations of resistivity of body. Helper's and suppressing activity of lymphocytes is investigated; improvement of concentration of immune cells displays the success of treating process.

3. Investigation of level of intoxication of patient. Central and peripheral hemodynamics are investigated by means of integral reography; in particular - hemodynamics of liver by means of reohepathography.

Recommendations.

1. Five (5) procedures for prophylaxis and 12 for treating pleural empiema for 45 min. with pressure of 1,5-2AT are recommended.

2. Individual values for pressure and exposition are selected individually.

3. For antibacterial prophylaxis before the procedure deinfection of wound would be done with interrupting of drain for 50 - 60 min; in case the fistula it would be firmly covered after corresponding drain.

4. Criteria of the success of treating are directly observed changes; Dynamics of bacteriologic and immunologic changes and state of central and peripheral hemodynamics.

5. HBO is recommended for prophylaxis for patients with additional diseases: chronic diseases combined with purulent intoxication; diabetes; hypogammaglobulinemia; patients after radiotherapy; weak patients.

6. Unclostridal anaerobes would be therapeutically suppressed, if any, in time of HBO-course.

7. Dynamic immunologic control is desired to prevent purulent complications before and after operation.

Thus, application of HBO in complex therapy of patients with operated lung and pleura can reduce the probability of after operational purulent complications and improve the amount of healed patients.

Hope, these recommendations will be of use in practice of application of HBO in treating of purulent complications after lung and pleural operations.