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

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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

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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 -

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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

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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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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.