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1
axalSobilTa respiratoruli
distres sindromi
klinikuri praqtikis erovnuli rekomendacia
(gaidlaini)
2
klinikuri praqtikis erovnuli rekomendacia (gaidlaini)
`axalSobilis respiratoruli distres sindromi~ miRebulia
klinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi) da
daavadebaTa marTvis saxelmwifo standartebis (protokolebi)
SemuSavebis, Sefasebis da danergvis erovnuli sabWos 2008 wlis 5
noembris #1 sxdomaze da damtkicebulia saqarTvelos Sromis,
janmrTelobisa da socialuri dacvis ministris 2009 wlis 14
aprilis # 147/o brZanebiT.
3
axalSobilTa respiratoruli distres sindromi
1. definicia, sinonimebi, terminologia:
definicia
respiratoruli distres sindromi upiratesad dRenaklul bavSvTa
paTologiaa, romelic gamowveulia surfaqtantis deficitiT. axasiaTebs
klinikurad _ taqipnoe, gulmkerdis retraqcia, cianozi da eqspiraciuli
xmauri, xolo rentgenologiurad _ fiWisebur-marcvlovani suraTi da
haerovani bronqograma.
sinonimi: hialinuri membranis daavadeba.
gaidlaini gankuTvnilia
⇒ samedicino personalisaTvis, romelic muSaobs axalSobilTan, rogorc
samSobiaro saxlSi, ise stacionarSi – neonatologi, pediatri.
gaidlainis samizne jgufi:
⇒ axalSobilebi, romlebsac aReniSnebaT respiratorul distres
sindromi an misi ganviTarebis riski.
gamoyenebuli Semoklebebi:
• rds – respiratoruli distres sindromi;
• rd _ respiratoruli distresi;
• bpd – bronqopulmonuri displazia;
• PEEP (Positive end expiratory pressure) – dadebiTi wneva amosunTqvis bolos; • CPAP (continiuos positive airway pressure) - mudmivi dadebiTi wneva sasunTq
gzebSi;
• fxv – filtvis xelovnuri ventilacia;
• PIP (Peak inspiratory pressure) – CasunTqvis pikuri wneva;
• FiO2 (Fraction of inspired oxygen) _ CasunTquli Jangbadis wili; • IMV (Intermittent Mandatory Ventilation) _ monacvleobiTi iZulebiTi
ventilacia; • SIMV (Synchronous Intermittent Mandatory Ventilation) _ sinqronuli
monacvleobiTi iZulebiTi ventilacia;
• HFV (High-frequency oscillatory ventilation) _ maRali sixSiriT ventilacia.
4
2. epidemiologia
aSS monacemebiT yovelwliurad vlindeba 40 000 - 60 000 rds-is SemTxveva1,2.
rds-is sixSire damokidebulia gestaciur asakze. gestaciis 28 kviramde
dabadebul axalSobilebSi misi sixSire daaxloebiT 60%, 28-34 kviris
dRenaklulebSi _ 30%, xolo 34 kviraze meti gestaciis axalSobilebSi -
mxolod 5% 3. rds ufro xSiria dabadebis Zlier mcire wonis
axalSobilebSi, rac ufro mcirea dabadebis wona, miT metia rds sixSire: 501-
750g – 86%, 751-1000g – 79%, 1001-1250 – 48%, 1251-1500 – 27% 2. rds-iT gamowveuli
letaloba Semcirda 25000-dan (1960 w) 831-mde (2003 w) da misi xvedriTi wili
axalSobilTa sikvdilobis struqturaSi 4%-s Seadgens4. norvegiaSi
daavadebis sixSire yovel 1000 cocxladSobilze Seadgens 2.7-s, xolo
letaloba 1,1-s.
3. etiopaTogenezi 5-9:
rds-is ZiriTadi gamomwvevi mizezebia surfaqtantis deficiti da filtvis
qsovilis umwifroba.
surfaqtanti kompleqsuri lipoproteinia, romelic Sedgeba lecitinis,
fosfatidilglicerolis, qolesterolis da 4 apoproteinisgan (A,B,C,D).
surfaqtantis sinTezi da sekrecia iwyeba gestaciis 20-24 kviraze, Zlierdeba
gestaciuri asakis matebasTan erTad da 36 kvirisTvis maqsimums aRwevs.
mSobiarobis momentSi mkveTrad matulobs misi sinTezi. nayofis hipoqsia,
asfiqsia, acidozi, hipoTermia da hipotenzia amcirebs surfaqtantis sinTezs.
surfaqtanti amofens alveolebis Sida zedapirs, amcirebs zedapirul
daWimulobas, riTac xels uSlis filtvis kolabirebas amosunTqvis bolos.
vadaze adre mSobiarobis dros surfaqtantis deficitis gamo viTardeba
ateleqtazuri ubnebi, romlebSic mimdinareobs perfuzia, Tumca ar xdeba
ventilacia (ventilacia-perfuziis cdoma), rac TavisTavad iwvevs hipoqsemia-
hipoqsias. mcirdeba funqciuri narCeni moculoba da alveoluri ventilacia,
izrdeba “mkvdari” sivrce, qveiTdeba filtvis Wimvadunarianoba, rac
saWiroebs maRali wneviT CasunTqvis aucileblobas distaluri
ateleqtazebis gasaSlelad. hipoqsemia da sistemuri hipoperfuzia iwvevs
anaerobuli metabolizmis gaZlierebas da laqtat acidozis ganviTarebas.
hipoqsemia, hiperkapnia da acidozi ganapirobebs filtvis sisxlZarRvebis
vazokonstriqcias da marjvena-marcxena Suntis gazrdas ovaluri xvrelis an
botalis sadinris gziT. aRniSnuli TavisTavad iwvevs pulmonuri sisxlis
mimoqcevis Semcirebas da surfaqtantis warmomqneli ujredebis iSemiur
dazianebas. es ukanaskneli sxva faqtorebTan erTad, rogoricaa
baro/volumotramva da maRali FiO2 iwvevs anTebiTi citokinebis da
qemokinebis gamoyofas, rac aZlierebs endo da epiTeluri ujredebis
dazianebas, mcirdeba surfaqtantis sinTezi da izrdeba endoTeliumis
ganvladoba, rasac moyveba alveolebSi plazmis cilebis gaJonva,
surfaqtantis inaqtivacia, alveolebis amomfeni hialinuri membranebis da
filtvis SeSupebis ganviTareba. aRniSnulis gamo, filtvis qsovili naklebad
Wimvadunariani xdeba.
5
sqema
6
4. klinikuri simptomatika 5-9:
rds-is ganviTarebis risk-faqtorebi:
• rds-s sixSire SedarebiT maRalia:
⇒ dRenaklulebSi
⇒ mamrobiTi sqesis axalSobilebSi
⇒ diabetiT daavadebuli dedebis axalSobilebSi
⇒ sakeisro kveTiT dabadebul axalSobilebSi
⇒ tyupebis SemTxvevaSi meore tyupiscalTan
⇒ perinataluri asfiqsiis dros
⇒ rds-is ojaxuri anamnezis mqone axalSobilebSi
⇒ qorioamnionitis dros
• surfaqtantis nakleboba meoradad SeiZleba ganviTardes, Tu vlindeba:
⇒ intra da postnataluri asfiqsia
⇒ pulmonuri infeqcia
⇒ pulmonuri hemoragia
⇒ mekoniumis aspiraciis sindromi
⇒ filtvze Jangbadis toqsiuri moqmedeba baro- da volumtravmasTan
erTad
rds-is ganviTarebis riski mcirdeba Semdeg SemTxvevebSi:
⇒ antenataluri steroidebis gamoyeneba
⇒ orsulobiT gamowveuli an qronikuli hipertenza
⇒ gaxangrZlivebuli mSrali periodi (sanayofe wylebis daRvris Semdeg)
⇒ gestaciur asakTan SedarebiT mcire wona
⇒ axalSobilTa hemolizuri daavadeba
⇒ dedis mier narkotikebis moxmareba
klinikuri simptomebi:
respiratoruli distresis niSnebi uxSiresad vlindeba dabadebisTanave an
ramdenime wuTSi, iSviaTad pirveli saaTebis ganmavlobaSi (ara ugvianes 6 sT-
isa). Tu respiratoruli distresis niSnebi vlindeba mogvianebiT,
savaraudoa sxva paTologiis arseboba.
respiratoruli distresisaTvis damaxasiaTebelia Semdegi ZiriTadi
klinikuri niSnebi:
⇒ taqipnoe (>60-ze 1 wuTis ganmvalobaSi) - kompensatoruli reaqcia
Semcirebuli sunTqvis moculobis fonze wuTmoculobis
gasazrdelad;
⇒ eqspiraciuli xmianoba (grunting) - warmoiqmneba amosunTqvis dros
yiis nawilobrivi daxurvis gamo (yia viwrovdeba, raTa gaizardos
funqciuri narCeni moculoba);
⇒ neknTaSua areebis da gulmkerdis qveda nawilis Cadreka
(retraqcia), cxviris nestoebis vibracia sunTqvis dros. retraqcia
7
viTardeba maRali intraTorakaluri wnevis Sesaqmnelad filtvis
naklebad Wimvadi ubnebis gaSlis mizniT.
⇒ centraluri cianozi
Tu axalSobils aReniSneba 2 an meti zemoaRniSnuli niSani mas aqvs
respiratoruli distresi.
Rrma dRenaklulebs SeiZleba damatebiT ganuviTardeT apnoe da/an hipoTermia.
filtvebis auskultaciiT SesaZlebelia gamoxatuli iyos sveli xixini an
Sesustebuli sunTqva.
respiratoruli distresis simZimis Sefaseba tardeba daunsis Skalis
mixedviT. mocemuli Skala gamoiyeneba ara mxolod rds, aramed sxva geneziT
ganpirobebuli respiratoruli distresis Sefasebis drosac.
respiratoruli distresis simZimis klinikuri Sefaseba
J. Downes-is da Tanaavtorebis mixedviT
qula
sunTqvis
sixSire
wT-Si
cianozi
mkerdis
Zvlis
retraqcia
Eeqspiraciuli
xmauri
Afiltvis
auskultaciuri
monacemebi
0 <60 ar vlindeba 21% O2-
is fonze Aara ara
pueruli
sunTqva
1 60-80 ixsneba 40% O2- is
fonze zomieri
Mmoismineba
stetoskopiT
sunTqva
Secvlili an
Sesustebulia
2 >80 an
apnoe
saWiroebs
oqsigenoTerapias
maRali koncentra-
ciis JangbadiT O O2-
>40%
Zlieri
Mmoismineba
manZilidan
(stetoskopis
gareSe)
sunTqva tardeba
cudad
• 1-3 qula _ msubuqi respiratoruli distresi (minimaluri distresi)
• 4-6 qula _ saSualo simZimis respiratoruli distresi (zomieri distresi)
• 7 qula da meti _ mZime respiratoruli distresi
janmos mier mowodebulia respiratoruli distresis simZimis Sefasebis
Semdegi sqema10:
sunTqvis sixSire wuTSi gulmkerdis retraqcia
an eqpiraciuli xmianoba
klasifikacia
> 90 gamoxatulia mZime rd
> 90 ar aris saSualo simZimis rd
60-90 gamoxatulia saSualo simZimis rd
60-90 ar aris msubuqi
8
rds-is dros mdgomareobis damZimebasTan erTad Zlierdeba taqipnoe, cianozi,
vlindeba arteriuli wnevis daqveiTeba, oliguria, eqpiraciuli xmianobis
Sesusteba srul gaqrobamde.
48-72 saaTisTvis pacientis mdgomareoba uaresdeba. letaluri gamosavali
uxSiresad vlindeba me-2-7 dReebSi intersticiuli emfizemis, pnevmoToraqsis,
filtvidan sisxldenis an parkuWSi sisxlCaqcevis gamo. bronqopulmonuri
displaziis Camoyalibebis SemTxvevaSi sikvdili SeiZleba ganviTardes
ramdenime kviris an Tvis Semdeg.
garTulebebi 5-9:
mwvave garTulebebi:
• haeris gaJonva _ pnevmoToraqsi, pnevmomediastinumi, pnevmoperikardiumi,
intersticiuli emfizema. aseT dros axalSobilis mdgomareoba uecrad
mZimdeba, vlindeba hipotenzia, apnoe, bradikardia, saturaciis uecari
daqveiTeba, hipoqsiisa da hiperkapniis gaRrmaveba, metaboluri acidozi
da Sesabamisi rentgenologiuri suraTi;
• infeqcia: infeqciam SeiZleba gaarTulos rds–is mimdinareoba. infeqciis
arseboba saeWvoa Tu ar aris klinikuri mdgomareobis gaumjobeseba, an
mdgomareoba uecrad mZimdeba, vlindeba leikocitozi, formulis
marcxniv gadaxriT, an Trombocitopenia. invaziuri procedurebis (venis
punqcia, kaTeterizacia, respiratoruli uzrunvelyofa) da
postnatalurad steroidebis gamoyeneba zrdis septicemiis ganviTarebis
risks;
• intrakraniuli sisxlCaqceva da periventrikuluri leikomalacia:
intraventrikuluri sisxlCaqceva gvxvdeba dRenaklul axalSobilebis
20-40%-Si, gansakuTrebiT xSiria im axalSobilebTan, romlebic
saWiroeben meqanikur ventilacias. saeWvo SemTxvevaSi saWiroa
ultrasonografiuli kvlevis Catareba;
• Ria botalis sadinari gazrdili marjvena-marcxena SuntiT: Suntma
SeiZleba gaarTulos rds-is mimdinareoba, gansakuTrebiT ganmeorebiTi
surfaqtantuli Terapiis Semdeg. Ria botalis sadinarze eWvi unda
mivitanoT im axalSobilebTan, romelTa mdgomareoba Tavdapirveli
gaumjobesebis Semdeg gauaresda an aReniSnaT sisxliani sekreti
traqeidan. diagnostikaSi gvexmareba Suilis arseboba da maRali
pulsuri wneva, Tumca es niSnebi yovelTvis ar vlindeba kritikul
mdgomareobaSi myof axalSobilebSi. Ediagnozis dadastureba xdeba
eqokardiografiuli kvleviT. botalis Ria sadinaris persistirebis
dros mizanSewonilia ibuprofeniT an indometaciniT mkurnaloba,
SesaZlebelia NO-s (azotis oqsidi) gamoyeneba persistirebadi
pulmonuri hipertenziis an pulmonuri hipertenziuli krizebis
samkurnalod. sxva SemTxvevaSi NO-m SeiZleba gazardos marcxena
marjvena Sunti da gaauaresos filtvebis parenqimuli dazianeba.
refraqterul SemTxvevaSi mimarTaven qirurgiul Carevas;
• pulmonuri sisxldena: xSiria dRenaklul axalSobilebSi,
gansakuTrebiT surfaqtantiT Terapiis Semdeg. am SemTxvevaSi saWiroa
marTviTi sunTqvis aparatiT amosunTqvis bolos dadebiTi wnevis (PEEP)
9
Seqmna da intratraqeulad epinefrinis gamoyeneba. zogierT pacientebSi
pulmonuri sisxldena asocirdeba Ria botalis sadinarTan;
• wylulovan-nekrozuli enterokoliti da/an perforacia: aRniSnuli
paTologiis arseboba SesaZlebelia, Tu vlindeba gastro-intestinuri
traqtis dazianebis klinikuri da rentgenologiuri niSnebi.
perforacia vlindeba kritikul mdgomareobaSi myof axalSobilebSi da
xSirad asocirdeba indometaciniT da steroidebiT mkurnalobasTan;
• dRenaklulTa apnoe: xSiria umwifar axalSobilebSi. SemTxvevaTa
sixSire izrdeba surfaqtantuli Terapiis dros. apnoes marTva xdeba
meTilqsantinebis gamoyenebiT (Teofilini, kofeini). refraqterul
SemTxvevaSi saWiroa sasunTq gzebSi mudmivi dadebiTi wnevis (CPAP) Seqmna. unda gamoiricxos septicemiis, krunCxvis, gastroezofaguri
refluqsis da metaboluri darRvevebis arseboba.
qronikuli garTulebebi:
• bronqopulmonuri displazia (bpd): filtvis qronikuli daavadebaa,
romelic xSirad asocirdeba meqanikuri ventilaciis dros wnevis da
Jangbadis koncentraciis maRal maCveneblebTan, infeqciasTan, anTebiT
procesTan da vitamin A-s deficitTan. rac ufro mcirea gestaciuri
asaki, miT metia misi ganviTarebis riski. postnataluri surfaqtantuli
Terapia, ventilaciis damzogveli reJimi, vitamin A-s gamoyeneba,
steroidebis dabali doza da azotis oqsidis inhalacia amcirebs am
paTologiis ganviTarebis risks. bronqopulmonuri displazia
asocirdeba agreTve gastroezofagur refluqsTan, auxsnel apnoesTan
da uecar sikvdilTan;
• dRenaklulTa retinopaTia (retrolenturi fibroplazia): Tu
axalSobilebSi rds–iT, romelTac utardebaT oqsigenoTerapia an fxv,
PaO2 >100 mmHg retrolenturi fibroplaziis ganviTarebis riski
maRalia. PaO2-is zusti monitoringi da misi SenarCuneba 50-70mm Hg-is doneze, agreTve pulsoqsimetriis gamoyeneba yvela dRenaklul
axalSobilTan uzrunvelyofs am paTologiis ganviTarebis prevencias.
paTologiis progresirebis SemTxvevaSi gamoiyeneba lazeroTerapia an
krioTerapia retinis CamoSlis da sibrmavis prevenciis mizniT; N
• nevrologiuri dazianebebi: gamovlindeba 10-70%-Si, sixSire gestaciuri
asakis ukuproporciulia da damokidebulia intrakraniuli dazianebis
tipze, agreTve hipoqsiasa da infeqciaze. xSirad vlindeba smenis da
mxedvelobis darRvevebi, momavalSi ki _ swavlis da qcevis problemebi.
5. daavadebis diagnozi 5-9:
rds-is pre/postnataluri diagnostika
diagnozi efuZneba klinikur suraTs (taqipnoe, gulmkerdis retraqcia,
cianozi da eqspiraciuli xmauri), rentgenologiur (fiWisebur-marcvlovani
suraTi da haerovani bronqograma) da laboratoriul monacemebs:
• sanayofe siTxeSi sfingomielin-lecitinis Tanafardobis Seswavla -
Tu sanayofe siTxeSi sfingomielin-lecitinis Tanafardoba 2 is
10
tolia, rds-s ganviTarebis riski 2 %-ia, Tu < 2-ze – 50%, xolo Tu <
1-ze – 100%.
• ”qafis” testi – tardeba mSobiarobamde amniocenteziT miRebuli
amnionuri siTxis da mSobiarobidan 30 wT-Si miRebuli kuWis
aspiratis gamoyenebiT – 0,5 ml amnionur siTxes (an kuWis aspirats)
1sm diametris sinjaraSi amateben 0,5 ml 95% eTilis spirts,
anjRreven 15wm da naxuloben testis Sedegs 15wT-Si. am mizniT
sinjaras aTavseben Sav qaRaldze da afaseben warmoqmnili
buStukebis raodenobas.
1. testi uaryofiTia, Tu zedapirze buStukebi ar aris. es Sedegi
miuTiTebs, rom axalSobilis filtvi umwifaria da hialinuri
membranis daavadebis ganviTarebis riski 60% -s Seadgens.
2. testi gardamavalia, Tu zedapirze buStukebi aris, magram isini
ver faraven siTxis mTels zedapirs. es Sedegi miuTiTebs, rom
hialinuri membranis daavadebis ganviTarebis riski 20%-s
Seadgens.
3. testi dadebiTia, Tu buStukebi faravs siTxis zedapirs. es
Sedegi miuTiTebs, rom axalSobilis filtvi momwifebulia da
hialinuri membranis daavadebis ganviTarebis riski mxolod 4%-
ia.
• hipoqsemia da hiperkapnia arteriul sisxlSi.
diferenciuli diagnozi 5-9:
diferenciuli diagnozi unda gatardes iseT daavadebebTan, rogoricaa:
• pnevmomediastinumi
• pnevmonia
• pnevmoToraqsi
• aspiraciuli sindromi
• gastroezofaguri refluqsi
• hipoglikemia
• hipoTermia
• kardiopulmonuri Sunti
• policitemia
• axalSobilTa tranzitoruli taqipnoe
• gulis manki cianoziT
• filtvis arteriis hipertenzia
• adreuli sefsisi
11
6. gamokvlevis sqema 5-9
laboratoriuli kvlevebi
• sisxlis airebis kvleva klinikuri Cvenebis mixedviT xdeba Wiplaris
arteriidan an sxva arteriis punqciiT. sisxlis airebis monacemebi
gamoavlens respiratorul da metabolur acidozs da hipoqsemias.
instrumentuli kvleva:
• gulmkerdis rentgenogramaze rds–is dros vlindeba fiWisebur-
marcvlovani (WuWyiani minis Sesaxedaobis) suraTi da haerovani
bronqograma filtvis arasruli gaSliT.
⇒ haerovani bronqograma warmoadgens haeriT gadaberili
bronqiolebis zeddebas kolabirebul alveolebze;
⇒ gulis Crdili SeiZleba gadidebuli an normaluri iyos.
kardiomegalia SeiZleba gamoiwvios prenatalurma hipoqsiam, dedis
diabetma, Ria botalis sadinarma, Tandayolilma mankma an
ubralod filtvis arsrulma gaSlam;
⇒ surfaqtantis adreulma gamoyenebam SeiZleba waSalos tipiuri
rentgenologiuri suraTi;
⇒ filtvis rentgenologiuri kvleva yovelTvis ar iZleva rds-is da
pnevmoniis erTmaneTisagan gansxvavebis saSualebas.
axalSobilis mdgomareobidan gamomdinare xSirad saWiroa damatebiTi
laboratoriul-instrumentuli kvlevebi:
• eqokardiografia - Ria botalis sadinris, gulis Tandayolili mankis
gamosaricxad, gulis funqciuri mdgomareobis Sesafaseblad da
pulmonuri hipertenziis dasadgenad;
• hemograma, C reaqtiuli cila, sisxlis baqteriologiuri kvleva -
tardeba infeqciaze eWvis dros;
• neirosonografiuli kvleva, sisxlSi eleqtrolitebis, cilis,
glukozis donis gansazRvra da sxva.
7. mkurnalobis sqema manipulaciebi8
respiratoruli distres sindromis dros mkurnalobis sxvadasxva etapze
SeiZleba saWiro gaxdes Semdegi procedurebisa da manipulaciebis Catareba
• sedacia, analgezia an anesTezia;
• arteriis da venis punqcia; • venis (periferiuli/centraluri) kaTeterizacia;
• Wiplaris arteriis kaTeterizacia;
• Wiplaris venis kaTeterizacia;
• traqeis intubacia an traqeostomia; • bronqoskopia; • Torakocentezi;
12
• kuWis zondireba; • sisxlis da sisxlis preparatebis transfuzia;
• Sardis buStis punqcia da kaTeterizacia.
marTvis ZiriTadi principebi 5-9
respiratoruli distres sindromis mkurnalobis ZiriTadi principebia:
• adekvaturi reanimacia blokSi;
• surfaqtantiT CanacvlebiTi Terapia;
• oqsigenacia da ventilacia mudmivi dadebiTi wneviT sasunTq gzebSi;
• filtvis xelovnuri ventilacia;
• simptomuri Terapia. • adekvaturi reanimacia
naadrev mSobiarobas mizanSewonilia eswrebodes neonatologi da medda,
romlebic pasuxismgebelni arian reanimaciuli RonisZiebebis sruli
sifarTiT Catarebaze, radgan am axalSobilebSi xSiria adaptaciis darRveva,
rac Tavis mxriv aferxebs surfaqtantis produqcias.
araadekvaturi reanimacia auaresebs rds-is mimdinareobas da
gamosavals (rekomendacia B)12.
arasakmarisia mtkicebulebebi imis Taobaze, rom yvela dRenakluls
rutinulad unda Cautardes traqeis intubacia (rekomendacia C)12.
praqtikuli TvalsazrisiT gamarTlebulia 29 kviraze naklebi
gestaciis yvela axalSobilis intubacia (rekomendacia C)12.
• surfaqtantis Canacvlebis Cveneba
intubirebul axalSobilebs rds-iT, romlebic saWiroeben fxv-s
maRali koncentraciis JangbadiT (FiO2 > 0.40) mizanSewonilia CautardeT
surfaqtantiT CanacvlebiTi Terapia (rekomendacia A)12.
surfaqtantiT CanacvlebiTi Terapia saWiroa im dRenaklulebTan,
romelTac aReniSnebaT rds-is ganviTarebis maRali riski
(rekomendacia A)22-25.
• surfaqtantiT CanacvlebiTi Terapia
surfaqtantiT CanacvlebiTi samkurnalo da profilaqtikuri Terapia
aumjobesebs rds-is gamosavals da Sesabamisad amcirebs axalSobilTa
sikvdilobas (mtkicebulebis done I)13-18. surfaqtantiT mkurnalobis
dawyebis Semdeg bolo aTwleulis ganmavlobaSi rds-iT gamowveuli
sikvdiloba 50%-iT Semcirda8.
surfaqtantiT CanacvlebiTi Terapiis dros umjobesdeba oqsigenacia,
mcirdeba pnevmoToraqsisa da intersticiuli emfizemis ganviTarebis
riski, aseve mcirdeba damxmare ventilaciis xangrZlivoba
(mtkicebulebis done I)13.
I
I
B
C
C
A
A
13
surfaqtantiT CanacvlebiTi Terapia amcirebs bpd ganviTarebas da
fsiqomotoruli ganviTarebis Seferxebas (mtkicebulebis done I)13,19-21.
• surfaqtantiT CanacvlebiT TerapiasTan dakavSirebuli riski
surfaqtantis Canacvlebisas uSualod medikamentis gamoyenebis dros an mis
Semdeg xanmokle periodSi SeiZleba ganviTardes bradikardia, hipoqsemia da
saintubacio milis blokireba26. mogvianebiT SeiZleba ganviTardes filtvidan
sisxldena, Tumca ar matulobs am paTologiiT gamowveuli letaloba13.
• bunebrivi Tu sinTezuri surfaqtanti?
11 randomizebuli kvlevis metaanalizma aCvena27, rom bunebriv
surfaqtants naklebi gverdiTi efeqti da ukeTesi Sedegi aqvs vidre
xelovnurs. bunebrivi surfaqtantis gamoyenebisas naklebad viTardeba
“haeris gaJonvis” sindromi da bpd, umjobesdeba gamosavali (mtkicebulebis
done I)13.
amave dros gaTvaliswinebuli unda iyos is faqti, rom kvlevebi Catarebulia
Zvel sinTezur surfaqtantebze. axal sinTezur surfaqtantebs (lukinaqtanti
anu surfaqsini) aqvT gansxvavebuli Semadgenloba, rac zrdis maT
efeqturobas.
2005 wlis monacemebiT upiratesoba eniWeba bunebriv surfaqtants
(rekomendacia A)12.13.
• profilaqtikuri Tu samkurnalo Terapia
gamomdinare iqidan, rom surfaqtanti icavs umwifar filtvis qsovils, zogi
mkvlevari rekomendacias uwevs mis profilaqtikur gamoyenebas reanimaciis
Semdeg Rrma umwifrobis SemTxvevaSi (27 kviraze naklebi)13.
• dozireba, gamoyenebis gza
surfaqtantis Canacvleba unda Catardes sicocxlis pirveli 2 saaTis
ganmavlobaSi (mtkicebulebis done I)28.
⇒ surfaqtantis rekomendebuli dozaa 25-200 mg/kg. PEEP reJimiTa
(dadebiTi wneva amosunTqvis bolos) da dadebiTi wneviT adekvaturi
ventilaciis (filtvis amuSavebis) Semdeg bolusurad surfaqtantis
micema ganapirobebs mis Tanabar ganawilebas;
⇒ surfaqtanti unda SeTbes oTaxis temperaturamde. saintubacio milSi
misi Seyvana xdeba milSi Cadgmuli zondiT an gverdiTi portidan.
surfaqtantis ganmeorebiTi Seyvana xdeba Tu pirveli dozis gamoyenebis
Semdeg axalSobili ventilaciisTvis saWiroebs 30% an meti
koncentraciis Jangbads. ganmeorebiTi instalacia tardeba I dozis
gamoyenebidan arauadres 2sT-isa, umjobesia 4-6sT-iani Sualedi.
(rekomendacia A)13.
I
I
A
I
A
14
Tu axalSobili surfaqtantis pirveli dozis Seyvanis Semdeg
saWiroebs xelovnur ventilacias 72sT-is ganmavlobaSi, mizanSewonilia
surfaqtantis ganmeorebiTi gamoyeneba.
surfaqtantis 2 doza ufro efeqturia, vidre erTi (rekomendacia
A)13,29-31. surfaqtantis 3 dozaze meti gamoyeneba ar cvlis gamosavals.
(rekomendacia A)13.
Tu pacientis mdgomareoba mcired an saerTod ar gaumjobesda, damatebiTi
dozis gamoyenebamde gamosaricxia Ria botalis sadinari, pnevmonia da
ventilaciis garTulebebi (haeris gaJonva).
Tu axalSobils aReniSneba rds, igi saWiroebs referals maRali donis
klinikaSi. transportirebamde unda moxdes surfaqtantis I dozis
Seyvana (rekomendacia A)13.
• oqsigenacia da CPAP (mudmivi dadebiTi wneva sasunTq gzebSi)
Jangbadi samkurnalo saSualebaa. oqsogenoTerapiis dros Jangbadis Warbi
gamoyenebiT gamowveuli garTulebebis prevenciisTvis aucilebelia
monitoringi da kontroli. Jangbadis toqsiuri zemoqmedeba iwvevs bpd-s da
retinopaTias (gansakuTrebiT Rrma dRenaklulebSi). oqsigenoTerapiis dros
mizanSewonilia aramarto saturaciis, aramed PaO2 kontroli. vinaidan
saturaciis umniSvnelo Secvlis drosac ki PaO2 SeiZleba mniSvnelovnad
Seicvalos. oqsigenaciis pirobebSi sasurvelia SevinarCunoT arteriuli
airebis Semdegi Semadgenloba81:
_ PaO2 50-80 mm vwy sv,
_ SaO2 90-95%.
oqsigenoTerapia da damxmare ventilacia rds-s simZimis Sesabamisad81
rds simZime gestaciuri asaki Carevis done minimaluri distresi drouli
axalSobili
Jangbadis karavi an niRabi (Fi O2– 0,5-0,6, nakadi 3l/wT), Semdeg
nazaluri CPAP zomieri distresi drouli
axalSobili
nazaluri CPAP (Fi O2 – 0,6),
Semdeg intubacia/ventilacia
mZime distresi nebismieri
axalSobili
intubacia/ventilacia
zomieri/mZime
distresi
dRenakluli intubacia/ventilacia
A
A
A
nebismier SemTxvevaSi surfaqtantis doza da Seyvanis teqnika
unda Seesabamebodes mwarmoeblis mier mowodebul
instruqcias.
15
CPAP meTodi mniSvnelovnad amcirebs rds-iT gamowveul sikvdilobas. igi
rds-is mkurnalobis erT-erTi mTavari Terapiuli saSualebaa.
Cveneba
CPAP gamoiyeneba bavSvebSi rds-iT, romelTa PaO2 aris mudmivad 7Kpa (50-60mmHg)-ze naklebi, miuxedavad imisa, rom miwodebuli 02-is
koncentracia 50-60%-ze metia (rekomendacia C)12.
CPAP xels uSlis eqspiraciis bolos alveolebis kolabirebas, riTac
amcirebs marjvena-marcxena Sunts, zrdis sunTqvaSi monawile filtvis
zedapirs da funqciur narCen moculobas.
CPAP–is ganxorcieleba SeiZleba endotraqeuli milis, nazaluri kanulis an
nazofaringuli milis saSualebiT. arsebobs CPAP–is Semdegi doneebi:
CPAP–is done
wneva upiratesoba nakli
dabali <3 sm wy sv ar iwvevs filtvis
dazianebas, ar
viTardeba filtvis
haeriT gadavseba
SeiZleba ar iyos
sakmarisi ateleqtazis
gasaSlelad
zomieri 4-7sm wy sv ateleqtazuri ubnebis
efeqturi gaSla
arsebobs haeris gaJonvis
sindromis ganviTarebis
riski
7sm wy sv meti wnevis gamoyenebis SemTxvevaSi maRalia barotravmis da
filtvis qronikuli paTologiis ganviTarebis riski.
CPAP gamoyeneba mizanSewonilia rds-is mqone dRenaklulebSi eqstubaciis
Semdeg, raTa Tavidan aviciloT ateleqtazi da/an apnoe.
CPAP is dros dasaSvebia Semdegi maCveneblebi:
_ pH _ 7.25-7.4-is, _ PaO 2 _ 50-70 mm Hg, _ PCO2 _ 40-65 mm Hg.
Tu zomieri CPAP –is (5 sm wy sv) gamoyenebisas arteriuli sisxlis airebis
normaluri maCveneblebis SesanarCuneblad saWiroa FiO2 – 0,5-1 an gamoxatulia
mZime respiratoruli distresi, aucilebelia intubacia da fxv.
• filtvis xelovnuri ventilacia
fxv rds-is mkurnalobis erT-erT mniSvnelovan meTods warmoadgens. xSirad
fxv-s dawyebamde iyeneben CPAP –s.
Cveneba
xelovnuri ventilacia unda daiwyos im SemTxvevaSi, Tu (rekomendacia
C)12: C
C
16
⇒ PaO2 < 50 mm vswy sv, rodesac Fi O2 > 0,5 (gansakuTrebiT 32
kviraze naklebi gestaciisas) da/an
⇒ PaCO2 > 60 mm vswy sv,
⇒ pH < 7,25.
fxv-s dawyebis klinikuri kriteriumebia:
⇒ apnoe bradikardiasa da cianozTan erTad, romelsac axlavs
desaturacia;
⇒ mkveTri taqipnoe >70, mZime retraqciiT;
⇒ gaxangrZlivebuli mZime bradikardia, hipotonia, mkveTri
sifermkrTale da perfuziis daqveiTeba;
⇒ cianozi, romelic ar ixsneba JangbadiT monoTerapiisas.
fxv-s mizani:
⇒ adekvaturi oqsigenaciis da ventilaciis uzrunvelyofa,
sasunTqi aparaturis maqsimalurad damzogveli reJimis
gamoyenebiT (raTa Semcirdes barotramva da Jangbadis
toqsiuri efeqti).
randomizirebulma kvlevebma aCvena, rom rds-is dros maRali sixSiris
ventilaciis (HFV) gamoyenebisas naklebia pnevmoToraqsis ganviTarebis
riski (rekomendacia B)12,32.
axalSobilebis xelovnuri ventilaciis dros miorelaqsantebis
rutinuli gamoyeneba ar aris rekomendebuli (rekomendacia A/B)12,33.
sinqronuli monacvleobiTi (intermittent) iZulebiTi (mandatory) ventilacia
(SIMV) - randomizebuli kvlevebis mixedviT aseTi reJimiT ventilacia
umjobesia vidre standartuli monacvleobiTi iZulebiTi ventilacia (IMV), radgan mis dros mcirea bronqopulmonuri displaziis (bpd) sixSire,
intubaciis xangrZlivoba da Jangbadze damokidebuloba.
aparatuli sunTqvis dawyebamde mizanSewonilia axalSobilis ventilacia
niRbiT, tomriT da manometriT, rac saSualebas iZleva dadgindes fxv-s
sawyisi parametrebi (wneva, sixSire), romelic saWiroa bavSvis adekvaturi
ventilaciisaTvis. SesaZlebelia gamoyenebuli iyos Semdegi sawyisi
parametrebi:
SIMV ventilaciis sawyisi parametrebi
rds
PIP 12-30 sm H2O
PEEP 3-5 sm H2O sixSire 20-40 wT
CasunTqva/amosunTqvis Sefardeba 1:1 – 1:3
CasunTqvis xangrZlivoba 0,5-0,72 wm
B
A/B
17
nakadis siswrafe:
dabadebis wona < 1000 g – 6-8 l/wT
dabadebis wona > 1000 g – 8-12 l/wT
PIP–is maRali maCveneblebis, gansakuTrebiT ki 30 sm H2O-ze meti CasunTqvis
wnevis gamoyenebis SemTxvevaSi mkveTrad izrdeba barotravmis ganviTarebis
riski. 5sm H2O–ze meti PEEP-is gamoyeneba agreTve zrdis garTulebebis
sixSires.
sasurevlia fxv-s dros gamoyenebuli iyos minimaluri PIP, PEEP da saSualo
wneva, anu damzogveli reJimi, romlis drosac SenarCunebulia sisxlis
klinikurad misaRebi airovani Semadgenloba.
parametrebi SesaZlebelia Seicvalos individualuriad.
filtvis xelovnuri ventilaciis dros unda Sefasdes:
• gulmkerdis eqskursia da Tanabari sunTqviTi xmianobis arseboba;
• vitaluri funqciebi – T, T/A, P, kanis feri, nevrologiuri statusi; • saturacia da arteriuli sisxlis airebi;
• gulmkerdis rentgenograma:
_ endotraqeuli milis mdebareoba
_ filtvis qsovilis gamWvirvaloba (emfizema, ateleqtazi da
sxv)
_ gulis zomebi
sisxlis airebis monitoringi ventilaciis dros:
pH: Tavidan unda iyos acilebuli pH donis daqveiTeba 7.25-ze qvemoT,
radgan irRveva ujreduli metaboluri aqtivoba (rekomendacia C)12.
PaO2: rekomendebuli zRvaria 6-10 kpa (45-70 mmHg). PaO2-isQqveda zRvari gansakuTrebiT mZime rds-is mqone CvilSi SeiZleba iyos kidev ufro
dabali (daaxloebiT 5.6 kpa - 40mmHg) (rekomendacia C)12.
PaCO2: rekomendebuli maCvenebelia 40-65 mmHg. PaCO2-ze ufro
mniSvnelovania pH-is donis SenarCuneba 7.25-ze metad. Tu ar aris
specifiuri Cveneba, PaCO2 ar unda iyos 5 kpa (37.5 mmHg)-ze naklebi
(rekomendacia C)12.
Tu PaCO2 momatebulia (mizezi: hipoventilacia an ventilacia/perfuziis
Seusabamoba) pnevmoToraqsis, ateleqtazis da endotraqeuli milis
obstruqciis gamoricxvis Semdeg mizanSewonilia:
_ PIP - is gazrda _ CasunTqvis sixSiris gazrda
_ nakadis siswrafis gazrda (rac xorcieldeba, orive zemoTmoyvanili
maCveneblis cvlilebiT)
Tu PaO2 daqveiTebulia (mizezi: hipoventilacia, difuziis bloki,
ventilacia/perfuziis Seusabamoba, Sunti), mizanSewonilia respiratoris
maCvenebelebis Secvla:
C
C
C
18
_ FiO2-s gazrda (Tu mizezia hipoventilacia, difuziis bloki,
ventilacia/perfuziis Seusabamoba - mdgomareoba umjobesdeba).
_ PEEP -is gazrda (gasaTvaliswinebelia, rom 6 sm H2O-ze maRalma PEEP -is maCvenebelma SeiZleba gamoiwvios venuri ukudinebis daqveiTeba da hemodinamikis darRveva).
_ CasunTqvis drois gazrda xels uwyobs oqsigenaciis gaumjobesebas.
fxv-ze myofi pacientebisaTvis aucilebelia:
• arteriuli airebis kontroli
_ Tu pacientis mdgomareoba arastabiluria da xdeba respiratoris
parametrebis koreqcia, arteriuli airebi unda gakontroldes 15-
30 wT-Si erTxel normaluri maCveneblis miRebamde. airovani
Semadgenlobis gauaresebis dros unda Semowmdes milis
mdebareoba, pacientis pozicia, gamoiricxos garTulebebi (mag.:
pnevmoToraqsi).
_ Tu pacientis mdgomareoba stabiluria arteriuli airebi unda
gakontroldes 4-6sT-Si erTxel.
• endotraqeuli milis sanacia rds-is mqone bavSvebSi minimumamde
unda iyos dayvanili, is tardeba mxolod mas Semdeg, rac
warmoiqmneba sekreti, Cveulebriv sicocxlis 48 saaTis
Semdeg (rekomendacia C)12.
• saintubacio milis sanacia 8 sT-Si (saWirobisas ufro xSirad).
• saturaciis, vitaluri funqciebis monitoringi.
eqstubacia SesaZlebelia Tu pacienti spontanuri sunTqviT inarCunebs
normalur wuTventilacias da oqsigenacias, aqvs xevlis refleqsi da
stabiluri hemodinamika.
ventilatoridan pacientis moxsna xorcieldeba parametrebis TandaTan
daqveiTebiT – pirvelad mcirdeba is parametri, romelTanac asocirdeba
filtvis dazianebis SedarebiT maRali riski81.
eqstubaciis Semdeg SesaZlebelia CPAP –is an Jangbadis karvis gamoyeneba.
maRali sixSiriT ventilacia (HFV) – mcire moculobebis CasunTqva maRali
sixSiriT. Tavdapirvelad es reJimi SemuSavda haeris gaJonvis sindromis
samkurnalod. bevrma kvlevam aCvena, rom maRali sixSiriT ventilaciiT xdeba
filtvis Tanabari gaSla, umjobesdeba filtvis meqanika da gazTa cvla,
mcirdeba alveolis eqsudaciuri SeSupeba, haeris gaJonva da anTebiTi
procesi filtvebSi. maRali sixSiris oscilatoruli ventilaciis adreul
gamoyenebas upiratesoba eniWeba standartul reJimebTan SedarebiT.
sxvadasxva klinikurma kvlevam aCvena, rom maRali sixSiris oscilatoruli
ventilaciis profilaqtikuri gamoyeneba amcirebs filtvis qronikuli
daavadebis ganviTarebis sixSires. Cveulebriv igi gamoiyeneba tradiciuli
ventilaciis uefeqtobis dros, Tumca Rrma dRenaklulebSi SeiZleba
gamoyenebuli iyos Terapiis sawyis etapze (ix. maRali sixSiris ventilaciis
protokoli).
maRali sixSiris ventilaciis gamoyenebis Cvenebaa:
C
19
⇒ PaO2 < 50 mm vswy sv da/an PaCO2
> 65 mm vswy sv, rodesac Fi O2 = 1,0
⇒ ECMO –s potenciuri kandidatebi.
azotis oqsidis inhalacia (iNO) – gamoiyeneba pulmonuri hipertenziis
(krizis) seleqciuri mkurnalobisTvis, amcirebs marjvena-marcxena
eqtrapulmonur Sunts filtvis sisxlZarRvebis rezistentobis daqveiTebis
gziT.
ECMO –eqstrakorporaluri membranuli oqsigenacia gamoiyeneba rds-is
ukiduresad mZime SemTxvevaSi. am dros sisxlis oqsigenacia mimdinareobs
organizmis gareT specialuri aparatis saSualebiT.
• damxmare Terapia
⇒ Termuli kontroli: hipoTermia zrdis Jangbadis moxmarebas.
mniSvnelovania hipoTermiis prevencia mSobiarobis, reanimaciis,
transportirebis dros. rds-is dros mniSvnelovania SevinarCunoT
Termoneitraluri garemo, SesaZlebelia ormagi kedlebis mqone
inkubatoris an sxivuri gamaTboblis gamoyeneba.
⇒ antibiotikoTerapia: septicemiaze eWvis dros unda gakeTdes sisxlis
baqteriologiuri kvleva (kultura), hemograma, leikocituri formula,
C reaqtiuli cilis raodenobrivi gansazRvra da dawyebul iqnas
penicilinis da aminoglikozidis jgufis preparatebis kombinacia (an
cefalosporini), sanam miRebuli iqneba kulturis pasuxi (antibiotikis
arCevisas unda gaTvaliswinebuli iyos SesaZlo hospitaluri Stamebis
arseboba). negatiuri sisxlis kulturis da risk-faqtorebis ar
arsebobis SemTxvevaSi antibiotikis micema wydeba. antibiotikoTerapia
grZeldeba dadebiTi kulturis SemTxvevaSi antibiotikebisadmi
mgrZnobelobis Sesabamisad.
⇒ siTxis, metabolizmis da kvebis uzrunvelyofa – saSualo simZimis da
mZime rds-is dros mizanSewonilia parenteruli kveba. enteralur
kvebaze (nazogatruli zondiT) pacientis gadayvana SesaZlebelia misi
mdgomareobis gaumjobesebis Semdeg, rodesac mas ar esaWiroeba fxv. ZuZuTi kvebis dawyeba rekomendebulia oqsigenoTerapiis Sewyvetis
Semdeg. msubuqi xarisxis rds-s dros naCvenebia gamowvelili dedis
rZis miwodeba nazogastruli zondiT.10
adekvaturi kveba: r.d.s.-is mkurnalobis mniSvnelovani nawilia
adekvaturi kvebis uzrunvelyofa (rekomendacia C)12.
rds-is dros mizanSewonilia sruli parenteruli kveba, Tumca
pacientis mdgomareobis stabilizciisa an gaumjobesebis Semdeg
dasaSvebia minimaluri enteruli kvebac (rekomendacia C)12.
dedis rZe icavs wylulovan - nekrozuli enterokolitisa sxva
garTulebebisgan da saukeTeso sakvebia minimaluri enteruli
kvebisTvis (rekomendacia B)12,34.
C
C
B
20
⇒ adekvaturi cirkulaciis uzrunvelyofa: am mizniT saWiroa Sesabamisad
guliscemis sixSiris, periferiuli perfuziis, arteriuli wnevis
kontroli. saWiroebis SemTxvevaSi gamoiyeneba sisxlis moculobis
Semavseblebis, sisxlis komponentebis gadasxma, inotropebi da
vazopresorebi. U wnevis gazrdis mizniT kristaloiduri xsnari (fiziologiuri
xsnari) iseTive efeqturia, rogorc koloiduri (plazma)12,35.
(rekomendacia A).
sisxlis wnevis gazrdis mizniT dopamini ufro efeqturia, vidre
dobutamini36-37 (rekomendacia A).
rds-is mqone bavSvebSi perfuziis daqveiTebis SemTxvevaSi
mizanSewonilia arteriuli wnevis kontroli da hipotenziis
koreqcia (rekomendacia C)12.
sisxlis Semavseblebis rutinuli gamoyeneba zrdis
intrakraniuli hemoragiis ganviTarebis risksa da sixSires38-40
(rekomendacia A).
⇒ anemia: saWiroa hemogramis monitoringi. hemotransfuziis Cvenebaa
mocirkulire sisxlis moculobis 10%-s dakargva da/ an hematokriti <
40-45%-ze. anemiis samkurnalod gamoiyeneba eriTropoetinebi da rkinis
preparatebi.
⇒ fizioTerapia: rds-is dros rutinuli fizioTerapia ar aris
rekomendebuli (rekomendacia C)12.
⇒ postnataluri steroidebi: zog SemTxvevaSi sicocxlis pirvel TveSi egzogenurad daniSnuli
steroidi (deqsametazoni) amcirebs meqanikuri ventilaciis
xangrZlivobas. am mkurnalobis Soreuli efeqtebi jer ar aris
dadgenili da misi gamoyeneba xdeba im SemTxvevaSi, roca standartuli
mkurnaloba araefeqturia mag.: filtvis paTologiis
persistirebis dros dabadebidan 2 kviris ganmavlobaSi41-42
(rekomendacia A).
deqsametazonis efeqturobis SemTxvevaSi mkurnaloba
mimdinareobs medikamentis dozis SemcirebiT43 (rekomendacia B).
referali
maRali donis klinikaSi pacientis gadayvanis Cvenebaa
• saSualo simZimis da mZime respiratoruli distres sindromi;
• nebismieri simZimis respiratoruli distres sindromi, Tu
samSobiaros ar aqvs adekvaturi oqsigenaciisa da sisxlis airebis
kontrolis saSualeba.
• dRenakluli axalSobili nebismieri simZimis respiratoruli
distresiT.
C
A
A
C
A
A
B
21
msubuqi respiratoruli distresis marTva SeiZleba samSobiaroSi
sadac aris adekvaturi oqsigenaciisa da sisxlis airebis kontrolis
(minimum Jangbadis saturaciis gansazRvra) saSualeba.
rds-is prevencia44 prevenciuli taqtika gulisxmobs:
• naadrevi mSobiarobis Tavidan acilebas.
• antenatalurad steroidebis gamoyenebas, rac aumjobesebs nayofis
filtvebis momwifebas da amcirebs rds-is sixSires.
kortikosteroidebiT antenataluri Terapiis efeqturoba
naadrevi mSobiarobis riskis SemTxvevaSi orsulTan saWiroa
antenatalurad steroidebis gamoyeneba, radgan es ukanaskneli
mniSvnelovnad amcirebs rds-s sixSires, neonatalur sikvdilobas da
intraventrikulur sisxlCaqcevas (rekomendacia A)44.
koxreinis biblioTekis metaanalizebi miuTiTebs, rom kortikosteroidebiT
antenataluri Terapia amcirebs rds-s sixSires, neonatalur sikvdilobas da
intraventrikulur sisxlCaqcevas45, zrdis axalSobilTan surfaqtantiT
Terapiis efeqturobas46. antenatalurad steroidebis gamoyeneba
usafrTxoa47-53. kortikosteroidebiT antenataluri Terapia
gansakuTrebiT efeqturia gestaciis 34 kviramde54 (mtkicebulebis
done I)44.
jandacvis organizaciebSi unda arsebobdes kortikosteroidebiT
antenataluri Terapiis protokolebi, radgan aseTi Terapia amcirebs
danaxarjs axalSobilTa intensiur Terapiaze (mtkicebulebis done III,
rekomendacia B)55-56.
kortikosteroidebis antenatalurad miRebis dawyebasa da mSobiarobas
Soris optimaluri intervali unda iyos 24 sT-ze meti, magram 7 dReze
naklebi (mtkicebulebis done I, rekomendacia A)45.
kortikosteroidebiT antenataluri Terapiis usafrTxoeba
qalebs unda miewodos infromacia, rom kortikosteroidebiT
antenataluri Terapiis erTi kursi ar iwvevs dedasa Tu nayofSi
mniSvnelovan gverdiT efeqtebs (rekomendacia A)44.
xangrZlivma dakvirvebam mozrdilobis asakamde (20 weli) gviCvena, rom
kortikosteroidebiT antenataluri Terapia ar axdens uaryofiT
gavlenas fsiqomotorul ganviTarebaze (mtkicebulebis done I)60-61.
kortikosteroidebiT antenataluri Terapia ar zrdis nayofis Tu dedis
infeqciis ganviTarebis risks, miuxedavad imisa Tu rodis moxda sanayofe
wylis daRvra.
A
I
B
A
A
I
22
kortikosteroidebiT antenataluri Terapiis Cveneba
kortikosteroidebiT antenataluri Terapia unda Cautardes yvela orsuls
gestaciis 24-dan 34 kviramde, romelsac aReniSneba (mtkicebulebis done I,
rekomendacia A)54:
• naadrevi mSobiarobis riski
• sisxldena
• sanayofe siTxis naadrevi daRvra
• nebismieri mdgomareoba, romelic moiTxovs naadrev
mSobiarobas
kortikosteroidebiT antenataluri Terapiis winaaRmdegCveneba
kortikosteroidebiT mkurnaloba winaaRmdegnaCvenebia im qalebSi, romelTac
aqvT sistemuri infeqcia63. sifrTxilea saWiro savaraudo qorioamnionitis
dros64.
kortikosteroidebiT antenataluri Terapiis dros steroidis doza da miRebis gza
betametazoni aris arCevis preparati filtvis momwifebis xelSewyobisTvis.
rekomendebulia betametazonis 2 doza (erTjeradi doza 12 mg)
intramuskulurad 24 saaTis intervaliT (mtkicebulebis done III,
rekomendacia B)48,65,66.
yvelaze metad Seswavlilia steroidebiT mkurnalobis ori reJimi -
betametazonis 2 doza (erTjeradi doza 12 mg) intramuskulurad 24 saaTis
intervaliT da deqsametazonis 4 doza (erTjeradi doza 6 mg)
intramuskulurad 12 saaTis intervaliT. kvlevebis metaanalizis mixedviT
orive kortikosteroidi erTnairad efeqturia rds-s prevenciisaTvis48. Tumca
betametazoni amcirebs periventrikulur malacias 24-31 gestaciuri asakis
dRenaklulebSi46,65, 68.
antenatalurad kotrikosteroidebis ganmeorebiTi kursis gamoyeneba ar aris
rekomendebuli, radgan ar arsebobs sakmarisi mtkicebuleba misi
efeqturobis Sesaxeb (mtkicebulebis done I, rekomendacia A)69-77.
Tireotropuli hormoni
Tireotropuli hormonis antenatalurad gamoyeneba
kortikosteroidebTan erTad rds-s prevenciis mizniT ar aris
rekomendebuli (rekomendacia A)44.
A
I
B
A
A
23
koxreinis biblioTekis metaanalizi gviCvenebs, rom Tireotropinis
gamomyofi hormonis antenatalurad gamoyeneba ar amcirebs rds risks,
JangbadiT Terapiis saWiroebas da sikvdilobas. (mtkicebulebis done
I)78-80.
referali
Tu dedas aReniSneba naadrevi mSobiarobis riski (32 kviramde) unda
moxdes misi referali maRali donis klinikaSi (rekomendacia B)13.
rekomendaciebi warmatebuli klinikuri praqtikisaTvis
rekomendacia xarisxireanimacia araadekvaturi reanimacia auaresebs rds-is mimdinareobas da
gamosavals
B
arasakmarisia mtkicebulebebi imis Taobaze, rom yvela
dRenakluls rutinulad unda Cautardes traqeis intubacia
C
praqtikuli TvalsazrisiT gamarTlebulia 29 kviraze naklebi
gestaciis yvela axalSobilis intubacia
C
surfaqtantiT CanacvlebiTi Terapia intubirebul axalSobilebs rds-iT, romlebic saWiroeben fxv-s
maRali koncentraciis JangbadiT (FiO2 > 0.40) mizanSewonilia
CautardeT surfaqtantiT CanacvlebiTi Terapia
A
surfaqtantiT CanacvlebiTi Terapia saWiroa im dRenaklulebTan,
romlTac aReniSnebaT rds-is ganviTarebis maRali riski
A
2005 wlis monacemebiT upiratesoba eniWeba bunebriv surfaqtants A axalSobilebi rds-Ti, romlebsac esaWiroebaT xelovnuri
ventilacia da Jangbadis miwodeba pirveli 72 sT-is
ganmavlobaSi, saWiroeben surfaqtantis ganmeorebiT Seyvanas.
surfaqtantis 2 dozis gamoyeneba ufro efeqturia vidre erTis
A
surfaqtantis 3 dozaze metad gamoyenebas ar aqvs efeqti A surfaqtantis ganmeorebiTi Seyvana aucilebelia, Tu
ventilaciisTvis 30% an meti koncentraciis Jangbadia saWiro.
ganmeorebiTi instalacia tardeba I dozis gamoyenebidan
arauadres 2sT-isa, umjobesia 4-6 sT-iani Sualedi
A
Tu axalSobils aReniSneba rds igi saWiroebs referals maRali
donis klinikaSi. transportirebamde unda moxdes surfaqtantis I
dozis Seyvana
A
CPAP (mudmivi dadebiTi wneva sasunTq gzebSi) gamoiyeneba bavSvebSi rds-iT, romelTa PaO2 aris mudmivad 7Kpa (50-60mmHg)-ze naklebi, miuxedavad imisa, rom miwodebuli 02-is
koncentracia 50%-ze metia
C
filtvis xelovnuri ventilacia xelovnuri ventilacia unda daiwyos im SemTxvevaSi, roca PaO2
C
I
B
24
naklebia 7 kpa_ze, rodesac FiO2 >0,5-ze (gansakuTrebiT 32 kviraze
naklebi gestaciisas) da/an roca PaCO2 matulobs 7 kpa_mde,
xolo pH 7,25-ze naklebia
randomizirebulma kvlevebma aCvena, rom rds-is dros maRali
sixSiriT oscilatoruli ventilaciis SemTxvevaSi, pnevmoToraqsi
naklebad gvxvdeba
B
xelovnuri ventilaciis dros miorelaqsantebis rutinuli
gamoyeneba ar aris rekomendebuli
A/B
endotraqeuli milis sanacia rds-is mqone bavSvebSi minimumamde
unda iyos dayvanili, is tardeba mxolod mas Semdeg, rac
warmoiqmneba sekreti, Cveulebriv 48 saaTis Semdeg
C
sisxlis airebis monitoringi pH: Tavidan unda iyos acilebuli pH donis vardna 7.25-ze qvemoT,
radgan irRveva ujreduli metaboluri aqtivoba (rekomendacia
C)12.
C
PaO2: rekomendirebuli zRvaria 6-10 kpa. PaO2-isQqveda zRvari rds-is mqone axalSobilSi SeiZleba iyos kidev ufro dabali
(daaxloebiT 5.6 kpa - 40mmHg) (rekomendacia C)12
C
PaCO2: PaCO2-ze ufro mniSvnelovani pH-is donis SenarCuneba 7.25-ze metad, Tu ar aris specifiuri Cveneba PaCO2 ar unda iyos 5 kpa (37.5 mmHg)-ze naklebi
C
kveba rds-is mkurnalobis mniSvnelovani nawilia adekvaturi kvebis
uzrunvelyofa
C
rds-is dros xelmisawvdomi unda sruli parenteraluri kveba,
Tumca pacientis mdgomareobis stabilizciisa an gaumjobesebis
Semdeg dasaSvebia minimaluri enteraluri kvebac
C
dedis rZe icavs wylulovan - nekrozuli enterokolitisa sxva
garTulebebisagan da aris saukeTeso sakvebi minimaluri
enteruli kvebisTvis
B
sisxlis wneva wnevis gazrdis mizniT kristaloiduri xsnari (fiziologiuri
xsnari) iseTive efeqturia, rogorc koloiduri (plazma)
A
sisxlis saSualo wnevis gazrdis mizniT dopamini ufro
efeqturia, vidre dobutamini
A
kargi klinikuri praqtika moicavs rds-is mqone bavSvebSi wnevis
gazomvas da hipotenziis mkurnalobas qsovilebis cudi
perfuziis niSnebis arsebobisas
C
sisxlis moculobis rutinulad gazrda ar aris rekomendebuli
intrakranialuri hemoragiis ganvitarebis riskis gamo
A
fizioTerapia rds-is dros rutinuli fizioTerapia ar aris rekomendirebuli C postnataluri steroidebi sicocxlis pirvel TveSi daniSnuli steroidi (deqsametazoni)
amcirebs meqanikuri ventilaciis xangrZlivobas. am mkurnalobis
Soreuli efeqtebi jer ar aris dadgenili da misi gamoyeneba
xdeba im SemTxvevaSi, roca standartuli mkurnaloba
A
25
araefeqturia mag.: filtvis paTologiis persistireba
dabadebidan 2 kviris ganmavlobaSi
postnataluri steroidis efeqturobis SemTxvevaSi mkurnaloba
mimdinareobs medikamentis dozis SemcirebiT
B
kortikosteroidebiT antenataluri Terapia naadrevi mSobiarobis riskis SemTxvevaSi orsulTan saWiroa
antenatalurad steroidebis gamoyeneba, radgan es ukanaskneli
mniSvnelovnad amcirebs rds-s sixSires, neonatalur sikvdilobas
da intraventrikulur sisxlCaqcevas
A
jandacvis organizaciebSi unda arsebobdes kortikosteroidebiT
antenataluri Terapiis protokolebi, radgan aseTi Terapia
amcirebs danaxarjs axalSobilTa intensiur Terapiaze
B
kortikosteroidebis antenatalurad miRebis dawyebasa da
mSobiarobas Soris optimaluri intervali unda iyos 24 sT-ze
meti, magram 7 dReze naklebi
A
qalebs unda miewodos informacia, rom kortikosteroidebiT
antenataluri Terapiis erTi kursi ar iwvevs dedasa da nayofSi
mniSvnelovan gverdiT efeqtebs
A
kortikosteroidebiT antenataluri Terapia unda Cautardes yvela
orsuls gestaciis 24-dan 34 kviramde, romelsac aReniSneba:
• naadrevi mSobiarobis riski
• sisxldena
• sanayofe siTxis naadrevi daRvra
• nebismieri mdgomareoba, romelic moiTxovs naadrev
mSobiarobas
A
filtvis momwifebis xelSewyobisTvis arCevis preparatia
betametazoni. rekomendebulia betametazonis 2 doza (erTjeradi
doza 12 mg) intramuskulurad 24 saaTis intervaliT
B
antenatalurad kotrikosteroidebis ganmeorebiTi dozebis
gamoyeneba ar aris rekomendebuli, radgan ar arsebobs sakmarisi
mtkicebuleba misi efeqturobis Sesaxeb
A
Tireotropuli hormoni Tireotropuli hormonis antenatalurad gamoyeneba
kortikosteroidebTan erTad ar aris rekomendebuli
A
referali Tu dedas aReniSneba naadrevi mSobiarobis riski (32 kviramde)
unda moxdes misi referali marali donis klinikaSi
B
11. gaidlainis gadasinjvisa da ganaxlebis vada – 2 weli
12. gaidlainis miRebis xerxi/wyaro
gaidlainis SemuSavebis meTodologia
• axalSobilTa respiratoruli distres sindromis prevenciis da
marTvis principebis Sesaxeb arsebobs samecniero mtkicebulebis
safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba.
mocemuli gaidlainis Semqmnis procesSi samuSao jgufis
26
gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli
praqtikuli rekomendaciebi. moxda arsebuli rekomendaciebis
adaptirebuli variantis SemuSaveba, romelic erTis mxriv pasuxebs
saerTaSoriso moTxovnebs, xolo meore mxriv iTvaliswineba
saqarTvelos samedicino dawesebulebaTa rogorc adamianur, ise
teqnikur resursebs.
• rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa
bazis gamoyenebiT.
cxrili 2
qveyana da resursis
dasaxeleba
internet-misamarTi
aSS
US National Guideline Clearinghouse (NGC)
http://www.guideline.gov
Centers for Disease Control and Prevention (CDC)
http://www.phppo.cdc.gov/CDCRecommends/AdvSearchV.asp
Agency for Healthcare Research and Quality (AHRQ)
http://www.ahrq.gov/clinic/cpgsix.htm
Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)
http://hstat.nlm.nih.gov
Institute of Clinical Systems Improvement (ICSI)
http://www.icsi.org
American Medical Association http://www.ama-assn.org
Canadian Medical Association (CMA)
http://mdm.ca/cpgsnew/cpgs/index.asp
Health Canada – Population and Public Health Branch (PPHB)
http://www.hc-sc.gc.ca/pphb-dgspsp/dpg_e.html
didi britaneTi National Institute for Clinical Excellence (NICE)
http://www.nice.org.uk
Sheffield Evidence for Effectiveness and Knowledge (SEEK)
http://www.shef.ac.uk/seek/guidelines.htm
National electronic Library for Health (NeLH)
http://www.nelh.nhs.uk/guidelinesfinder
PRODIGY Clinical Guidance http://www.prodigy.nhs.uk/ClinicalGuidance
Scottish Intercollegiate Guidelines http://www.sign.ac.uk
27
Network (SIGN)
German Guideline Information Service (GERGIS)
http://www.leitlinien.de/english/english/view;
avstralia Australian National Health and Medical Research Council (NHMRC)
http://www.health.gov.au/hfs/nhmrc/publicat/cp-home.htm
axali zelandia
New Zealand Guidelines Group (NZGG)
http://www.nzgg.org.nz/library.cfm
mtkicebiTi medicinis
specialistTa
regionTaSorisi
sazogadoeba
http://www.osdm.org
klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi
da meTodebi
• koxreinis biblioTeka - The Cochrane Library 2006, Issue 2, • amerikis samedicino biblioTekis mier Seqmnil eleqtronul
bibliografiul monacemTa baza - medlaini – MEDLINE • jandacvis msoflio organizaciis reproduqciuli janmrTelobis
biblioTeka
publikaciebis CarTvis/gamoricxvis kriteriumebi
• arCeul iqna kvlevebi Semdegi dizainiT: randomizebuli
kontrolirebadi kvlevebi, sistemuri mimoxilvebi da meta-analizi,
erTmomentiani, kohortuli kvlevebi;
• rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12
wliani SezRudva. Tumca zogjer gamoyenebuli iyo ufro adreuli
publikaciebi, romlebic dResac aqtualuria da safuZvlad udevs
sxva Tanamedrove mtkicebulebebs;
• dadgenili iyo enobrivi SezRudvebi, radganac samuSao jgufs
SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod
inglisur da rusul enebze.
moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi
• samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi.
Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri
meToduri rekomendacia axalSobilTa respiratoruli distres
sindromis marTvis sakiTxebze, romlebic Seicavda jgufis miznis
Sesaferis saWiro informacias. am rekomendaciebis Sefasebisas
gamoyenebuli iyo rekomendaciaTa atestaciisa da eqspertizis kiTxvari
- AGREE (94,96-98). samuSao jgufi xelmZRvanelobda saqarTvelos Sromis,
28
janmrTelobisa da socialuri dacvis saministros mier SemuSavebuli
nacionaluri gaidlainebis gzamkvleviT. Sefasebis Sedegad amorCeuli
iyo qvemoT CamoTvlili organizaciebis gaidlainebi:
⇒ pediatriisa da bavSvTa janmrTelobis samefo koleji
⇒ mean-ginekologTa samefo koleji
⇒ kanadis pediatrTa sazogadoeba
• rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas gamoyenebuli
iyo saqarTvelos Sromis janmrTelobisa da socialuri dacvis
saministros mier mowodebuli mtkicebulebebis donisa da
rekomendaciebis xarisxis sqema.
mtkicebulebaTa doneebisa da rekomendaciebis gradaciebis sqema
done mtkicebulebis siZlieris
done (Muir Gray) xarisxi rekomendaciis xarisxi
(Cook et al) I Zlieri mtkicebuleba,
eyrdnoba minimum erT
sistemur mimoxilvas,
romelic efuZneba swori
dizainis mqone
randomizebul
kontrolirebad kvleva
A eyrdnoba I donis
mtkicebulebas da
Sesabamisad mtkiced
rekomendebulia
II Zlieri mtkicebuleba,
eyrdnoba minimum erTi
swori dizainis mqone
randomizebul
kontrolirebad kvleva
B eyrdnoba II donis
mtkicebulebas da
Sesabamisad mtkiced
rekomendebulia
III klinikuri kvleva
randomizaciis gareSe,
kohortuli da SemTxveva-
kontrolis kvlevebi
C eyrdnoba III donis
mtkicebulebas SeiZleba
CaiTvalos Sesabamisad
IV araeqsperimentuli
multicentruli kvlevebi
D eyrdnoba IV da V donis
mtkicebulebas saWiroebs
konsesuss
Va avtoritetul
profesionalTa mosazreba
Vb klinikuri gamocdileba,
aRwerilobiTi kvlevebi an
eqspertTa angariSi
13. alternatiuli gaidlaini ar arsebobs
14. gamoyenebuli literatura:
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North American Pharmacotherapy 2004 Issue 2, p. 163-167
29
3. American Lung Association - Respiratory Distress Syndrome of the Newborn Fact Sheet - November 2006 - http://www.lungusa.org/
4. National Vital Statistics Reports. Deaths: Final Data for 2003. Vol. 55(13), April 2006. 5. Behrman, Kleigman, Jenson. Nelson Test Book of Pediatrics 17-th edition.2004 – Hyaline
Membran Disease (Respiratory Distress Syndrome) 575-82 6. Respiratory Distress Syndrome (RDS) – UCSF Children’s Hospital, Intensive Care Nursery
House Staff Manual, The rgents of the University of California, 2004 7. Respiratory distress - Newborn Care Manual - Newborn Care Unit - 25. 1/2005 8. Pramanik A.K. - Respiratory Distress Syndrome - Last Updated: October 20, 2006 -
http://www.emedicine.com/ped/topic1993.htm 9. Bowman E., Fraser S. - Neonatal Handbook - http://www.netsvic.org.au/nets/handbook/ Last
Updated 11-Aug-2005. 10. WHO - Managing Newborn Problems – A Guide for doctors, nurses and midwives – 2003 11. PERINATAL EDUCATION PROGRAMME - Newborn Care: Skills 25: 1/2005 2 (shake test) 12. Royal College of Paediatrics and Child Health - Management of Neonatal Respiratory Distress
Syndrome - Guidelines for Good Practice - December 2000 13. Recommendations for neonatal surfactant therapy – Fetus and Newborn committee, Canadian
Paediatric Society – Pediatrics&Child Health 2005; 10 (2):109-116 14. Soll RF. Synthetic surfactant for respiratory distress syndrome in preterm infants (Cochrane
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18. Rodriguez RJ, Martin RJ. Exogenous surfactant therapy in newborns. Respir Care Clin N Am 1999;5:595-616.
19. The Victorian Infant Collaborative Study Group. Economic outcome for intensive care of infants of birthweight 500-999 g born in Victoria in the post surfactant era. J Paediatr Child Health 1997;33:202-8.
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48. Crowley PA. Antenatal corticosteroid therapy: a metaanalysis of the randomized trials, 1972 to 1994. Am J Obstet Gynecol 1995; 173: 322–35.
31
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15. avtorTa jgufi pediatrTa da neontologTa kavSiri `alternativa~
samuSao jgufi:
⇒ dimitri abelaSvili - medicinis doqtori; Tbilisis saxelmwifo
samedicino universitetis diplomis Semdgomi da uwyveti
samedicino ganaTlebis instituti, m. iaSvilis saxelobis bavSvTa
centraluri klinikuri saavadmyofos reanimaciisa da
gadaudebeli daxmarebis samsaxuris ufrosi, axalSobilTa
reanimaciis ganyofilebis gamge. pediatrTa da neontologTa
kavSiri `alternativa~-s wevri;
33
⇒ daviT cibaZe – medicinis doqtori, Tssu g. Jvanias sax.
pediatriuli klinikis kritikuli medicinisa da neonatologiis
departamentis ufrosi;
⇒ maia xerxeuliZe – medicinis doqtori, Tbilisis saxelmwifo
samedicino universitetis pediatriis departamentis asistent-
profesori. pediatrTa da neontologTa kavSiri `alternativa~-s
wevri;
⇒ nani yavlaSvili – medicinis doqtori, Tbilisis saxelmwifo
samedicino universitetis pediatriis departamentis asistent-
profesori. pediatrTa da neontologTa kavSiri `alternativa~-s
wevri.
eqspertebi:
⇒ mamuka CxaiZe – medicinis doqtori, jo enis samedicino centris
bavSvTa da mozrdilTa intensiuri Terapiis samsaxuris ufrosi,
saqarTvelos anesTeziologiisa da kritikuli medicinis
sazogadoebis gamgeobis wevri, saswavlo centris xelmZRvaneli;
⇒ gela mecxvariSvili - medicinis doqtori, q. Tbilisis ss
akademikos o. RuduSauris saxelobis erovnuli samedicno centris
neonatologiis samsaxuris ufrosi;
⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros jandacvis departamenti;
⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros jandacvis departamenti.
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