Bbronqo - pulmonaruli displazia

Transcription

Bbronqo - pulmonaruli
displazia
Nnino solomonia
neonatologi
“NRP” – programis regionaluri instruqtori
“S.T.A.B.L.E.” - programis mTavari instruqtori
21/5/2013
bronqo –pulmonaruli displazia
pirvelad aRweril iqna 1967 wels
norveis da kolegebis mier
norveis definicia:
respiratoruli simptomebi da filtvis
rentgenografiuli cvlilebebi pacientebSi,
romlebsac esaWiroebaT JangbadiT mkurnaloba
postmenstrualuri asakis (PMA) 36-e kviraze.
pacientTa populacia:
gestaciuri asaki 33kv; dabadebis wona 1900gr
risk jgufi:
dRenakluli axalSobili
sxeulis mcire wona dabadebisas < 1500gr
(axalSobilTa > 20%)
rac ufro mcirea sxeulis wona dabadebisas miT
metia davadebis ganviTrebis riski
pacintTa 1/3 – dabadebisas iwonis 750 -1000gr
pacintTa 2/3 – dabadebisas iwonis < 750gr
respiratoruli sistemis embrionaluri
ganviTarebis stadiebi
bronqo – pulmonaruli displazia
risk faqtorebi:
umwifari filtvi
antioqsidantebis daqveiTebuli aqtivoba
(superoqsid desmutaza, katalaza, glutaTion peroqsidaza)
liberaluri intravenuri infuzia
Ria arteriuli sadinari da marcxnidan marjvena
mrxivi Sunti
perinataluri infeqcia (Ureaplasma urealiticum)
filtvis xelovnuri ventilacia
oqsigenoTerapia
datvirTuli ojaxuri anamnezi (asTma)
filtvis qsovilis mwvave dazianeba
(oqsigenoTerapia, barotramva, volutramva)
anTebis markerebis, citokinebis gamoyofa:
interleikini: IL-6; IL-8; IL-11
interleikini - 1ß
ß
seleqtini - E
neotrofiluri elastazani
endoTelini – 1
TNF – a
IV tipis kolageni
normaluri da dazianebuli alveolebi
bronqo-pulmonaruli displazia
1
2
1. normaluri filtvis qsovili
2. mZime formis bronqo – pulmonaruli displazia
Ddaavadebis ganviTarebis rentgenografiuli
stadiebi norveis mixedviT (Norway 1967)
I stadia
respiratoruli distres sindromis
suraTi
II stadia
4 – 10 dRis asakSi; “dabinduli”
filtvebi
III stadia mcire zomis difuzuri cistebi
IV stadia didi zomis cistebi,
intersticialuri fibrozi,
ateleqtazi
bronqo-pulmonaruli displaziis
Bbronqo – pulmonaruli displazia
(a) “Zveli” tipi
(b) “axali” tipi
a
b
norveis mier 1967w aRwerili daavadeba cnobilia
“Zveli” tipis bronqo – pulmonaruli daavadebis
saxelwodebiT
saSualo gestaciuri asaki 33kv, wona 2000g
mcire kalibris haergamtari gzebis dazianeba,
fibrozi da emfizema
surfaqtantis xana ukavSirdeba “ axali” tipis
bronqopulmonaruli displazias
saSualo gestaciuri asaki 28kv, wona <1000g
alveolarizaciis procesis Seferxeba
1
2
3
1. normaluri filtvis qsovili
2. “Zveli” tipis bronqo – pulmonaruli displazia
3. “axali” tipis bronqo – pulmonaruli displazia
Bbronqo – pulmonaruli displazia (BPD);
filtvis qronikuli daavadeba (CLD)
“Zveli” ti pis –
dazianeba da fibrozi
“axali” ti pis –
ganuviTarebeli filtvi
alveolebi
ateleqtazuri da haeriT
gadavsebuli alveolebi
mcire raodenobis didi
zomis alveolebi
haergamtari
gzebi
dazianebuli epiTeliumi,
gluvi kunTovani qsovilis
hi perplazia
dazianebuli epiTeliumi,
gluvi kunTovani
qsovilis hi perplazia
sisxlZarRvebi
gasqelebuli arteriebi,
pulmonaruli hi pertenzia
mcire raodenobiT
dismorfuli kapilarebi
Zveli tipis bronqo-pulmonaruli
displazia (Old BPD)
axali tipis bronqo-pulmonaruli
displazia (New BPD)
mZime formis bronqopulmonaruli displazia,
pulmonaruli hipertenzia
Bbronqo – pulmonaruli displazia (BPD)
bronqo – pulmonaruli displaziis definicia da
diagnositikuri kriteriumebi (Jobe & Bancalari 2001)
gestaciuri
asaki
asaki
Sefasebisas
< 32 kv
≥ 32 kv
36kv (PMA)
) an
>28dR; magram < 56dR
(
binaze gawerisas *
an binaze gawerisas *
JangbadiT (> 21%) mkurnaloba 28dR manZilze
+
msubuqi
saSualo
mZime
*
36kv. aRar saWiroebs O₂₂
36kv. an gawerisas*
gawerisas*
esaWiroeba <30% O₂₂
> 30% O₂₂ ; NCPAP; PPV
36kv. an gawerisas*
gawerisas*
56 dR an gawerisas aRar
saWiroebs O₂₂ *
56 dR. an gawerisas*
gawerisas*
esaWiroeba <30% O₂₂
> 30% O₂₂ ; NCPAP; PPV
56dR. an gawerisas*
gawerisas*
romelic moxdeba pirvelad; PPV – dadebiTi wneviT ventilacia
klinikuri prezentacia
taqipnea, retraqciebi
hipoqsemia, hiperkarbia metaboluri kompensaciiT
rentgenografiuli cvlilebebi
ECG –
marjvena parkuWis hipertrofia – cor pulmonales SemTxvevaSi
marcxena parkuWis hipertrofia – sistemuri hipertenziis dros
ECHO
marcxnidan marjvena mxrivi Sunti
pulmonaruli hipertenzia
hospitaluri mkurnaloba
marTva iwyeba samSobiaro blokidan!!!
sicocxlis pirveli “oqros” wuTi
dadebiTi wneviT ventilacia
funqciuri rezidualuri tevadoba
invaziuri Tu arainvaziuri ventilacia?
surfaqtanti – profil. /samkurnalo?
filtvis xelovnuri ventilacia
(SIMV PCPS, VG, HFOV)
1. mwvave faza
araagresiuli ventilacia; Vt = 3 - 5 ml/kg;
permisiuili hiperkarbia
2. qronikuli faza
SedarebiT dabali suTqvis sixSire,
gaxangrZlivebuli CasunTqva Ti
NIPPV - Nasal intermittent positive pressure ventilation
nazaluri ventilacia wyvetili dadebiTi wneviT
NCPAP – Nasal continuous positive pressure ventilation
nazaluri ventilacia mudmivi dadebiTi wneviT
Jangbadi – amcirebs filtvis sisxlZarRvebis
rezistentobas da iwvevs cor pulmonales prevencias
pulmonaruli hipertenzia bronqo-pulmonaruli
displaziis seriozuli garTulebaa
sikvdilobis riski izrdeba pulmonaruli
hipertenziis SemTxvevaSi
Sesabamisad, Jangbadi mniSvnelovani faqtoria
daavadebis mkurnalobis procesSi
xangZlivi oqsigenoTerapiis garTulebebi:
filtvis qsovilis dazianeba
dRenaklul axalSobilTa retinopaTia
Sesabamisad, sasurveli arteriuli saturacia:
SaO₂ 90% - 95% (monitoris limiti 88% – 95%)
prevencia
A vitamini
5000 erTeuli i.m. 3 x kviraSi pirveli 28 dRis manZilze
populacia: dabadebis wona < 1000gr
(RR=0.89, 95% CI = 0.80 – 0.99)
kofeinis citrati
populacia: dabadebis wona < 1200gr
20mg/kg, Semdeg 5 mg/kg dReSi pirveli 10 dRis manZilze
(OR=0.64, 95% CI = 0.52 – 0.78)
xangZlivi parenteraluri kveba (lipidebi >
naxSirwylebi)
enteraluri kveba adeqtvaturi kaloraJiT
(filtvis qsovilisa da sisxlZarRvebis optimaluri zrda!!)
miRebuli dRedRe-Ramuri siTxis raodenobis mkacri
kontroli, diurezis gaTvaliswinebiT
(110 – 130 ml/kg, an 150 ml/kg msubuqi formis dros)
Suntis SemTxvevaSi Ria arteriuli sadinris
medikamentozuri an qirurgiuli mkurnaloba
kaloriebi!!!!!
maRali kaloriulobis 24, 27 an 30kal/30ml
(cal/ounce) xelovnuri narevi
adeqvaturi zrdis maCvenebeli: wonis namati
10 -15 mg/kg/dR
dRenaklulTa xelovnuri sakvebis (maRali
cilis, natriumis, mineralebis) gamoyeneba
Bbronqo-pulmonaruli displazia da
Sardmdeni saSualebebi
furosemidi
hidroqlorTiazidi an
qlorTiazidi
spirinolaqtoni
hipoqloremiis (Cl < 90mg/dL)
Tavidan acilebis mizniT KCl (24 mEq/kg/); NaCl Tuki Na < 130meq/L
* diurezuli saSualebebis
gamoyeneba asocirdeba
respiratoruli statusis
xanmokle droiT
gaumjobesebasTan
pulmonaruli vazodilatatorebi
inhalaciuri azotis oqsidi (iNO)
sildenafili
kvlavac kvlevis sagania
gamoiyeneba pulmonaruli hipertenziisas
(kardiologisa da pulmonologis zedamxedvelobiT)
inhalaciuri saSualebebi
beta adrenerguli preparatebi
albuteroli (levalbuteroli) 1 CasunT. 6 sT 1x
(qronikuli xmareba ar aris mizanSewonili)
beta adrenerguli da muskarinuli efeqtis
Semcveli kombinirebuli preparatebi - kombivanti
kortikosteroidebi
flutikazoni
(44mcg/puff)
1 – 2 puff dR 2x
beklomeTazoni (40mcg/puff)
1 – 2 puff dR 2x
1 – 4 kviris manZilze
sistemuri steroidebi
adreuli Tu gviani mkurnaloba (> 7dR; < 7dR)???
deqsametazoni
hidrokortizoni 5mg/kg/dReSi pirveli 3 dRis
manZilze, dozis SemcirebiT momdevno 7 – 10
dRis ganmalobaSi
gverdiTi efeqtebi: hipertenzia, hiperglikemia,
nawlavis spontanuri perforacia, parkuWTaSua
Zgidis hipertrofia, nevrologiur ganviTarebasa da
zrdaSi CamorCena, gansakuTrebiT deqsametazonis
SemTxvevaSi.
mkurnaloba
sedacia da analgezia
morfini, fentanili, midazolami, qloral hidrati
eleqtronuli disbalansis koreqcia
hipokalemia, hiponatremia, hipoqloremia
sisxlis transfuzia, Tuki
Hct < 30 – 35 %, Hg < 8 -10g/dL
garTulebebi
zeda sasunTqi gzebis obstruqcia, traqeomalacia
pulmonaruli hipertenzia, sistemuri hipertenzia
metaboluri disbalansi
infeqcia
retinopaTia, siyrue, eqstrapiramiduli simptomatika
nefrokalcinozi
dRenaklulTa osteopenia
gastroezofagaluri refluqsi
sazardulis Tiaqari
sxeulis zrdaSi CamorCena
stacionaridan gaweris mzaoba
wonis matebis dadebiTi dinamika
apnoes, bradikardiisa da desaturaciis mwvave
epizodebis ar arseboba
saWiroebis SemTxvevaSi
xelovnuri ventilacia saxlis pirobebSi
JangbadiT binaze mkurnaloba
mSoblebis ganaTleba!!!
(movlis, kvebis, medikamentebis miRebis, aparaturis moxmarebis swavleba)
staconaridan gaweris dRes
sasicocxlo maCveneblebi
sxeulis wona
Tavis garSemoweriloba
sisxlis gazebi, hematokriti, eleqtrolitebi
saturacia (rogorc oTaxis ise miwodebuli
jangbadis koncentraciis gaTvaliswinebiT)
gulmkerdis rentgenografia
smenis skriningi
ofTalmologiuri gamokvleva
ukanaskneli eqokardiografiis Sedegebi
ambulatoriuli mkurnaloba
Jangbadi
medikamentebi (bronqodilatatorebi, diuretikebi)
imunizacia (pneumococcal, influenza, palivisumab)
wonis matebis monitoringi
aseTi bavSvis garSemo Tambqos moxmareba
kategoriulad miuRebelia
multidisciplinaruli sistemuri meTvalyureoba!
sikvdiloba
10 - 20 % sicocxlis pirvel wels
avadoba
1. bronqioliti, pnevmonia, sasunTqi gzebis
reaqtiruli daavadebebi
2. cerebraluri dambla
3. zrdaSi CamorCena
gamoyenebuli literatura
Jessie R. Groothuis – Doris Makari. Definition and outpatient management of very low- birth- weight infant with
Broncho pulmonary dysplaisa. Adv. Ther. 2012 29 (4); 297 -311
Jobe AH. The new bronchopulmonary dysplasia. Curr Opin. Pediatr. 2011;23(2):167-172
Watterberg KI: American Academy of Pediatrics, Committee on Fetus and Newborn. Policy statement – postnatal
corticosteroids to prevent or treat bronchopulmonary dysplasia. Pediatrcs 2010;126 (4): 800 – 808
Kinsella JP. Greenough A. Abman SH.Bronchopulmonary Dysplasia. Lancet 2006 :367 (9520): 1421-1431
Cristian P. Speer Chorioamnionitis,Postnatal Factors and Proinflammatory Response in the Pathogenetic Sequence of
Bronchopulmonary Dysplasia. Neonatology 2009: 95: 353 – 361
Rasgasami Ramanathan. Pharmacology review: Bronchopulmonary dysplasia and diuretics. Neoreviews2008;9; e 260
SekiTxvebi????

Bbronqo - pulmonaruli displazia

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