[The use of oscillatory respiratory therapy with positive expiratory pressure (PEP-therapy) to restore the functional state of the lungs in patients after cardiac surgery]. / Primenenie ostsillyatornoi respiratornoi terapii s polozhitel'nym davleniem na vydokhe (PEP-terapii) dlya vosstanovleniya funktsional'nogo sostoyaniya legkikh u bol'nykh posle kardiokhirurgicheskikh operatsii.

Postoperative pulmonary complications in cardiac surgery patients occur in 10-35% of cases, depending on differences in their definition, patient characteristics and type of surgical intervention, most of them are associated with ineffective coughing and evacuation of bronchial secretions. OBJECTIVE: To determine the effectiveness of stimulating the evacuation of bronchial secretions with the help of oscillating PEP therapy carried out during the first three days. MATERIAL AND METHODS: A randomized prospective study of 60 adult patients after elective cardiac surgery was performed (Clinical Trials.gov. protocol number NCT05159401). Oscillatory PEP-therapy was performed in 30 patients using Acapella DHGreen device (SmithMedicalASD, USA) 10-12 hours after tracheal extubation 3 times a day for 3 days after surgery. The control group (30 patients). The inclusion criteria: age over 18 years, spontaneous breathing after tracheal extubation, clear consciousness and productive contact with the patient, the ability to maintain adequate gas exchange on the low-flow oxygen inhalation, adequate analgesia (<2 points of VAS). Exclusion criteria: the need for re-intubation and mechanical ventilation, non-invasive mask ventilation, high-flow oxygen therapy, acute cerebrovascular accident, ongoing bleeding, cardiac insufficiency (inotropic index >10), shocks syndrome of various etiologies, the use of any extracorporeal support, any neuromuscular disorders, pneumothorax, hydro-or hemothorax. Before each session and 20 minutes after its end, when breathing air, blood oxygen saturation was recorded using a pulse oximeter (SpO2), the maximum inspiratory capacity (MIC) was measured using a Coach-2 incentive spirometer from SmithsMedical and spirometry with a portable ultrasonic spirometer Spiro Scout (Schiller, Switzerland). For the purposes of this work, the total index of the spirometry maximum inspiratory capacity (SMIC) was used - the sum of the respiratory volume and the reserve volume of inspiration in ml. RESULTS: Difficulties in evacuation of sputum were noted in 90% of patients. Three-day sessions of oscillating PEP- therapy are accompanied by a significant improvement in the passage of sputum, as evidenced by a 3-fold increase in the number of patients with productive cough. The increase in MIC in the main group was 46.9% and 21.3%, respectively (p=0.042), and the number of patients with values greater than MICo. 1500 ml increased from 23.3% to 7.6% (p<0.001). The effectiveness of oscillatory PEP-therapy is confirmed by a 7-fold decrease in the frequency of radiological changes in the lungs at the end of sessions (p<0.001), while in the control group the frequency of their occurrence practically did not change and remained at a high level. The total number of patients with respiratory insufficiency (SpO2≤92%) decreased by 8.6 times after completion of all PEP- therapy sessions (p=0.001), however, without statistically significant difference with the control group. CONCLUSIONS: Oscillatory PEP- therapy in cardiac surgery patients has a positive effect on sputum passage, ventilation parameters and oxygenating lung function. The procedure was well tolerated and there were no complications associated with it.

Postoperative acute respiratory failure in cardiac surgery. / Problema posleoperatsionnoi ostroi dykhatel'noi nedostatochnosti v kardiokhirurgii.

OBJECTIVE: To evaluate incidence, causes and outcomes of acute respiratory failure (ARF) in patients after cardiac and aortic surgery. MATERIAL AND METHODS: A retrospective trial included 3972 patients after elective cardiovascular procedures for the period 2013-2017. Inclusion criterion: sustained reduction of pulmonary function (PaO2/FiO2<300 mm Hg) in the postoperative period required mechanical ventilation or non-invasive positive pressure mask ventilation for at least 24 h. RESULTS: ARF developed in 138 (3.5%) cases. It was observed after aortic surgery as a rule (11.2%). Other operations were followed by ARF in 1-3.5% of cases. Incidence of ARF was less after off-pump coronary artery bypass surgery compared with on-pump interventions (1.6 vs. 3.5%, p=0.0469). Acute respiratory distress syndrome was the main reason of ARF (n=37, 26.8%). ARF as a consequence of neurological complications were observed in 25 (18.1%) patients. Exacerbation of COPD and bronchial asthma occurred in 23 (16.1%) patients, paresis of the diaphragm - in 15 (11.7%). In 15 (10.8%) patients, ARF was caused by pneumonia, in 12 (8.7%) cases - pulmonary congestion, in 10 (7.2%) patients - lung injury and haemothorax. Overall ARDS-associated mortality was 21.6%; 15.1% of patients with mild and moderate ARDS died. Severe ARDS was followed by unfavorable outcome in 75% of patients. Nosocomial pneumonia was found in 40.6%, there were no fatal outcomes from this complication. CONCLUSION: Acute respiratory failure developed in 3.5% of cardiac patients and was common thoracic and thoracoabdominal aortic surgery. The leading cause of mortality was ARDS (mortality rate 15.1% in mild and moderate syndrome, 75% in severe course of ARDS). Nosocomial pneumonia was diagnosed in 1.4% of patients and was not fatal.