Manifestations of Mendelssohn syndrome. Severe respiratory disease

Many complications can develop in patients who are in intensive care. One of these most severe conditions is Mendelssohn's syndrome.

What is this pathology?

Mendelssohn syndrome most often refers to obstructive pulmonary disease with lung tissue damage (pneumonitis), which develops against the background of ingestion of gastric juice in the respiratory tract. This condition was first described in 1946. It is observed in severe patients who have suffered craniocerebral trauma, cavitary operations (especially on the abdominal organs) and childbirth. In most cases, the culprit of this kind of pathology is anesthesia (due to it there is a relaxation of smooth muscles). Against the background of relaxed and lost muscle tone, aspiration occurs (in the respiratory tract) of the contents of the stomach (usually only gastric juice). As a result, both the bronchial tree and the lung tissue are affected. The condition is extremely difficult, it can lead to death if you do not provide appropriate care. It is necessary to understand more in detail, why there is such an unpleasant disease and what should be done with it.

Causes

Several diseases can lead to the development of Mendelssohn's syndrome. These include:

• Pathologies of the nervous system (severe brain trauma, lesion of the glossopharyngeal nerve, strengthening of the nervous regulation of the gastric lining cells and motility of the hollow organs of the gastrointestinal tract).
• Diseases of the digestive tract (hernia of the esophagus of the diaphragm, achalasia of the cardia).
• Diseases of the respiratory tract (short trachea, fistula between esophagus and respiratory throat).

In addition to the listed ailments, severe illness can lead to pneumonitis. A significant influence on the development of aspiration is provided by cavitary operations (due to a decrease in the tone of the musculature of the organs and its reduction in the backward wave of peristalsis direction) and pregnancy (due to the displacement of the diaphragm). For example, surgical interventions account for up to 70% of cases.

However, the most frequent reason for ingestion of gastric juice in the lower respiratory tract is passive leakage due to improper patient position and weakness of the cardiac sphincter.

Pathogenesis of aspiration pneumonitis

The disease develops as a result of damage to the lung and bronchial tissue with hydrochloric acid contained in the stomach. In passing, coagulation necrosis (which, again, is due to the action of acid on the mucous membrane of the bronchi) develops. As a result, the secretory capacity of the bronchi decreases, which leads to their desiccation. In parallel, the acid, penetrated into the lungs, causes the development of pneumonitis - aseptic inflammation of the lung tissue. The respiratory surface of the lungs decreases, the production of surfactant decreases. All this leads to an increase in the airiness of the organ mentioned (because of this, two forms of pathology are distinguished: asthmatic with the predominant bronchial lesion, and obstructive with pulmonary disease and the development of obstruction syndrome). The degree is determined by the pH of the gastric juice (the lower it is, the more concentrated the acid, and the greater the damage). The most severe changes are observed in the alveoli.

Manifestations at the level of the alveoli

Very often, when discussing a disease or accompanying symptoms, readers are offered a photo. Diseases like pneumonitis, as a rule, do not differ in any specific external features. But if you look at the affected area of tissue through a microscope (which is usually done at the autopsy), you can detect certain changes.

As a result of all the above processes and under the influence of gravity, hydrochloric acid descends into the alveoli. There, due to local effects on the alveolar tissue, there is an effusion (usually hemorrhagic). As a result, hemorrhagic pulmonary edema develops. Under the influence of destruction in the alveoli, precipitation of fibrin is observed, as well as penetration of blood cells through the basement membrane (in particular, leukocytes and macrophages). As a result of the development of their enzymes, necrosis of the alveolar septa develops, which is why the structure of the lungs is disrupted. In the place where the vessels are located, endothelial damage and the formation of microthrombi are observed. This all leads to an increase in the bleeding of liquid through the membranes and the formation of atelectasis. They are usually the cause of obstructive pulmonary disease. If slices of undigested food or other foreign bodies get into the lungs with the acid, similar formation of hemorrhagic edema is combined with the development of a slow reaction of formation of the granuloma around the fallen body. This kind of disease progresses more slowly, but it is more severe.

Clinical manifestations of pathology

How can I determine if a patient has aspiration pneumonitis? A specific "photo of the disease" can be represented as follows:

• First of all, the clinic will be conditioned by direct exposure of the acid to the mucous membrane. There is a clinical picture of acute and severe respiratory failure - bronchospasm, increasing cyanosis, respiratory failure.
• From the cardiovascular system is observed tachycardia, a drop in blood pressure. In some cases, there is a cardiac arrest or a break in the rhythm. Passively, the cardiac output decreases and pressure builds up in the pulmonary arteries. Due to the violation of gas exchange, development of respiratory and metabolic alkalosis is observed. The larger the volume of pulmonary tissue is affected, the heavier the patient's condition and the more difficult it will be to cure it.
• Usually signs of defeat and respiratory failure appear on the 2nd day, less often later. Sometimes the symptoms can be erased, and functional disorders may not manifest at all.

Diagnostics

The identification of Mendelssohn's syndrome is not an easy task, since the pathology usually develops in weakened patients, and not always, as mentioned above, a clinical picture can take place. First of all, the presence of respiratory failure (dyspnea, wheezing, cyanosis) should be determined. These symptoms can not always be detected in patients who are on ventilator. The most accurate method of diagnosing Mendelssohn syndrome is radiography, or lung fluorography. The picture shows the presence of effusion in the lungs, increasing their airiness. In some cases, bronchial contrast is enhanced (normal in the radiograph in the direct projection of the bronchi are not visible, and you can designate them only if you make side shots). If you go through fluorography to a patient with a suspicion of this syndrome, then, due to the development of necrosis, the tubular branches of the trachea will be visible on a direct radiograph.

Treatment of aspiration syndrome

If there was still aspiration of gastric contents, treatment should be started immediately. First of all, it is necessary to exclude the re-entry of acid into the lower respiratory tract. For this (if the patient's condition permits), it is required to raise the head of his bed. Immediately it is necessary to establish ventilation in the lungs and ensure good oxygenation of the blood. Typically, the appointment of ALV under intermittent positive pressure and hyperbaric oxygen saturation of blood (the use of ventilation systems, control over the gas composition of the blood). All this will prevent the development of acidosis.

Glucocorticosteroids are administered intravenously to reduce the extent of lung tissue damage and a small dose of them is intrabronchial. Hormones allow you to suspend the spread of the process and limit it. For the prevention of antibiotics (usually cephalosporins and macrolides) are prescribed. You should also take sympathomimetics (to reduce the secretion of bronchi and lungs).

Complications of the syndrome

With timely treatment, complications are usually avoided. If you are late, aspiration syndrome can lead to dangerous and undesirable consequences.

Often after a previous illness, if it occurs with a breakdown in the rhythm, there may later be atrial fibrillation or a permanent form of ventricular fibrillation. If it can not be stopped, but the patient does not make complaints, you can leave the patient under supervision only by the local therapist.

Another complication is the development of atelectasis of the lungs, or chronic obstruction. In this case, the process of stabilization of the state will be quite long, and the emphasis, as a rule, is made on the relief of symptoms, since this disease is incurable.

The most severe complication of pneumonitis is death. Especially often it occurs in those cases when aspiration syndrome develops in newborns.

Prophylaxis and prognosis of the disease

To prevent the development of aspiration pneumonia, it is required to conduct a set of some activities. First of all, all patients and women in labor, who are shown to interfere under general anesthesia, should empty their stomach and intestines. This eliminates the main factor in the development of pneumonitis.

Before anesthesia is recommended to undergo a fluorography to exclude the content of gastric juice in the airways. Intubation of the patient should be carried out when the patient is conscious. Lay the person so that the upper part of the trunk is slightly raised. This is achieved by adjusting the head of the bed or the operating table (thus eliminating the possibility of passive flowing of the contents of the digestive system in the respiratory tract).

Subject to compliance with intubation techniques and the patient's correct preparation for surgery, the risk of Mendelssohn syndrome is minimal.

The prognosis for this disease is as follows: usually up to 56 percent of patients with developed pneumonitis of the respiratory tract die. If treatment has been started in a timely manner, the risk of complications and death is reduced to zero.