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PULMONOLOGY AND PHYSIOTRY
INVENTION
Patent of the Russian Federation RU2197171

METHOD OF ESTIMATION OF EFFICIENCY OF REHABILITATION ACTIVITIES IN PATIENTS WITH PNEUMONIA

METHOD OF ESTIMATION OF EFFECTIVENESS OF REHABILITATION ACTIVITIES
IN PATIENTS WITH PNEUMONIA

The name of the inventor: Karmanova IV; Nogovitsyn EA; Rupasova T.I.
The name of the patent holder: Ivanovo State Medical Academy; Karmanova Irina Viktorovna
Address for correspondence: 153462, Ivanovo, F. Engels Avenue, 8, IGMA, Patent Department
Date of commencement of the patent: 2000.01.26

The invention relates to medicine, namely, to pulmonology. The method includes a clinical examination of the patient, in which on a particular day of the hospital period, the patient is subjected to a bicycle ergometric test, the physical fitness of the FR is determined x at a submaximal age, and compared with the calculated physical performance of the patient on that day. PC (T) = 625 * exp (- D (T)) + 337, where 625 and 337 are numerical coefficients, T is the day of illness, D (T) = 22 * ​​Sin (0,09 * T) * exp (-0,09 * T) / T, and At the value of the physical performance of the FRS x below the calculated FRS (T), rehabilitation measures are assessed as ineffective, and at higher values ​​- as effective. The method allows timely correction of treatment and rehabilitation schemes, determine the length of the hospital period and the need to continue post-hospital rehabilitation.

DESCRIPTION OF THE INVENTION

The invention relates to medicine, namely to pulmonology for an objective evaluation of the effectiveness of rehabilitation measures for pneumonia, determining the duration of the hospital period, the need to continue posthospital rehabilitation activities, and the readiness of patients to perform occupational and household loads.

The urgency of improving rehabilitation measures for pneumonia forces us to look for new criteria for their effectiveness and more accurate methods for their objective evaluation. Effective correction of therapeutic and rehabilitation measures is based on predicting the course and outcome of the pathological process, i.e. Taking into account the parameters of the system under study in subsequent periods of time. Refinement of the prognosis may have a number of important applications: as a criterion for the severity of the patient; Quantitative measure in choosing the tactics of treatment; Evidence of the need for a set of preventive measures; Evaluation of the effectiveness of rehabilitation. For clinical forecasting, the most important is the prediction of the severity of the course and outcome of the pathological process. At present, in the wide medical practice, the evaluation of the severity of the patient's condition in pneumonia is largely subjective and depends on the intuition and experience of the doctor, and the effectiveness of rehabilitation measures is judged from clinical and laboratory data (nonspecific parameters of peripheral blood, the disappearance of physical symptoms) and restitution of normal X-ray status of lung tissue. Such an approach is based on a unilateral evaluation of the activity of a particular system without taking into account the functional and morphological unity of the respiratory and cardiovascular systems. "The lungs are hurt - the danger is from the heart" (Corvisart, 1807). Moreover, the assessment is conducted without taking into account how the organism of the convalescent will react to the increased demands related to occupational and household loads. According to the literature, a decrease in physical capacity for pneumonia is one of the most persistent symptoms that persists not only in acute and subacute periods of the disease, but also for a long time after discharge of the patient from the hospital (Yachnik AI and Beszaderny YI "Hemodynamics And tolerance to physical activity in persons clinically cured of acute pneumonia. "The main directions of improving the prevention, diagnosis and treatment of lung diseases, Kiev, 1985. - P.261-262, Korovina OV, Kuzyaev AI, Laskin GM "The state of hemodynamics and its response to physical exertion in patients with acute pneumonia." Ter-archive, 1989.- T.61- 3.- P.81-84; Timchenko IS, Yakovlev V. N., Shchegolkov AM, Smosar IB "Modified bicycle ergometry in patients with acute pneumonia in IHD." 3rd National Congress on Respiratory Diseases, St. Petersburg, 1992. - C.117). Interest in the definition of physical performance is due to the fact that the basis for an integrated assessment of the activities of a particular system is to put the level of stress at which patients show signs of a deficiency function. Reaction to physical activity is usually of a systemic nature and, when studied in patients with lung pathology, it is possible to find out how the patient's organism reacts to the increased demands. The main criteria for the adequacy of physical activity are objective tolerance, pulse response, pressure, ECG. According to DM Aronov and A.P. Yurenev ("The use of an electrocardiographic test with physical exertion." Methodological recommendations - M., 1979. - P. 23) The physiological basis of a sample with a measured physical load is an increase in oxygen consumption due to an increase in pulmonary ventilation, minute volume and oxygen extraction by tissues. The highest achievable load level in physical work is determined by the maximum amount of oxygen that can be transported from the lungs to the muscles. Any stress test leads to an increase in the consumption of oxygen by the heart muscle. The relative severity of the load is determined by the increase in heart rate, which is one of the main factors determining myocardial oxygen consumption. The more significant the heart rate is achieved by the subjects, the better the functional capabilities of the cardiovascular system, the higher the oxygen consumption and above the Fed.

Methods of rehabilitation prediction allow to determine the terms of treatment of patients and the degree of their need in post-hospital rehabilitation. Therefore, a comparison of the amount of physical working capacity for each patient on a specific day of the hospital period with the forecasted will allow to evaluate the effectiveness of rehabilitation measures, the need for their continuation in a hospital or polyclinic, and timely correction of treatment and rehabilitation schemes.

Using existing methods of predicting the severity of the course and outcome of pneumonia (Polozhentsev SD, Nazarenko GI, Lebedev MF "Prediction of variants of acute pneumonia." Military Medical Journal, 1987. - 2. - S. 29-32; Semyannikova NM, Kustova NI, Akhmedyanova LG, Minina VM "Immunological characteristics and immune status of patients with various clinical forms of acute pneumonia." 4th National Congress on Organ Diseases - Moscow, 1994. - P. 73, ZK Trushinsky, Vorobyov LP, Soloviev MN et al. "On the application of the mathematical method for predicting the outcomes of acute pneumonia" Soviet Medicine, 1978, - 4. - С. 35-40), it is rather difficult to solve questions of medical and professional rehabilitation. The existing methods do not have objective integral evaluation criteria that allow to determine with high reliability the effectiveness of treatment and rehabilitation schemes at the stage of inpatient treatment, the length of the hospital period, the need for continuation of rehabilitation measures at the post-hospital stage, the readiness of patients for professional and domestic activities.

For the prototype we have a method for predicting the severity of the course and outcome of pneumonia Trushinsky Z.K. Et al. (1978) by the value of the prognostic index of pneumonia (PIP), which is the sum of conventional units for 13 indicators (age, presence of concomitant diseases, clinical form, prevalence of pneumonia, fever, heart rate, blood pressure, leukocyte count in peripheral blood, magnitude Stab shift, proteinuria, disturbance of heart rate and conduction, change in the final part of the ventricular complex). With PIP more than 13 cond. Units With a probability of more than 95%, a favorable outcome of the disease is predicted; With PIP less than -13 conv. Units With the same probability - an unfavorable outcome; With PIP from +13 to -13 conv. Units The forecast remains uncertain. Regardless of the etiology of PIP, more than 25 conv. Units There is a slight current, and with PIP from 14 to 24 conv. Units - Moderate. Patients with an unfavorable and uncertain prognosis made up a group of severe disease (PID less than 13 conventional units).

In the non-epidemics for the flu, 134 patients with pneumonia were examined and 25 were practically healthy (control group). The average age of patients was 43.5 ± 1.1 g. Along with a detailed clinical examination (detailed anamnesis, physical examination), all patients underwent a general analysis of blood and urine, recorded an ECG in 12 leads and studied the function of external respiration. X-ray examination included fluoroscopy, X-ray in the direct and lateral projections, imaging on admission and discharge, and in some patients the study was repeated several times during the treatment.

The severity of the course of pneumonia was determined by the method of mathematical prediction by the PIP value. The level of PIP was determined in the first days of the hospital period. The group with a slight uncomplicated course of pneumonia (97 patients) included those with a PIP> 14 conv. Units Its average value was 24.3 ± 0.7 conv. Units The severe course took place in 37 patients. The value of PIP in them was -1.6 ± 1.7 conv. Units The large value of the error of the arithmetic average for severe flow is explained by the summation of positive to negative values ​​in the determination of M. A preliminary analysis of the material showed no significant differences in clinical manifestations between groups of patients with a mild and moderate course of the disease, as a result of which we combined them into a group of mild disease (Karmanova IV Doctor of medical sciences, Moscow, 1995. - P.53-54).

Given the radiographic picture, we estimated the outcome of the disease as a complete recovery, where there was a restitution of the normal radiologic status of the lung tissue and an extract with residual changes (focal pneumosclerosis, persistence of infiltration into the lung and enhancement of the lung pattern). Complete recovery with mild pneumonia (68%) was more than 3 times more likely (P <0.001) than in severe (21.6%). Rough morphological changes were preserved in almost half of patients with severe pneumonia, including: infiltration in 27% of cases, focal pneumosclerosis in 21.6% of patients. With easy-flowing pneumonia, these outcomes were 2.1% and 6.2%, respectively. Small morphological changes in the form of intensification of the pulmonary pattern were observed equally often with light (23.7%) and severe (27%) leaking pneumonia. One patient with a severe course of pneumonia had a lethal outcome. Thus, the proposed method for assessing the severity of the course and outcome of pneumonia, having a high predictive accuracy, does not fully satisfy the needs of clinicians in terms of the possibility of assessing the length of stay of patients in the hospital, their need for post-hospital rehabilitation, the readiness of patients to perform the loads associated with professional and domestic Activities. To this end, in addition, all patients underwent bicycle ergometric testing using the method of a continuous step-like increasing load, in dynamics by days of illness, in the post-febrile period, and by healthy ones that formed a control group. The average length of hospital stay was 21 days. Clinical signs of circulatory failure were absent in all patients. The studies were conducted in dynamics by the days of the disease. The sample with the load was carried out on the ergometer KE-11 of the company "Medicor" (Hungary) in the sitting position. Prior to testing, anamnesis was collected, a physical examination was performed, medical records were examined, ECG was recorded at rest in 12 conventional leads and in three in the Sky. The subject was acquainted with the content of the study and possible reactions during the load. The load level was established in accordance with WHO recommendations. For women, the initial load was 25 W (150 kgm / min) and then increased by 25 W on each subsequent stage. For men, the load was started from 50 W (300 kg / min), each next step increased by 25 W. The duration of each next stage was 3 minutes. Control of pulse and pressure was carried out every 1-2 minutes. The reaction of the subjects during the veloergometric test was evaluated in accordance with generally accepted clinical and electrocardiographic criteria. The amount of physical working capacity was assessed by the index of FDH (physical performance at submaximal age heart rate). The amount of FDF in the persons who reached the sub-maximal age heart rate at the last stage of the bicycle ergometric test was determined up to the value of the threshold power, in the opposite cases the FDF calculation was carried out by extrapolation to the age-related heart rate.

The value of heart rate was determined by the formula: HRCC = (220 - age) · 0.75.

In cases of discontinuation of the sample for clinical or electrocardiographic indications, the FRS was determined by tolerance to physical activity (if the sample was stopped at the end of the first or the beginning of the second stage). In the first decade of the onset of the disease, the amount of FDCx was significantly lower in all patients compared to the control group. In patients with mild pneumonia (491.41 ± 45.68 kgm / min, P <0.001), its values ​​were 2.2, and in severe cases 3 times (364.00 ± 68.13 kg / min. ; P <0.01) lower than in healthy (1072.68 ± 55.22 kgm / min). At the time of discharging patients from the hospital in the group of patients with mild course, the value of FDCx was 627.22 ± 32.34 kgm / min, which is 1.3 more than in the 1st decade of the disease (P <0.05), but in 1.7 times lower than in the control group (P <0.001). In severe pneumonia, by the time patients were discharged from the hospital, their magnitude increased 1.4-fold compared with the acute period of the disease (509.93 ± 40.30 kgm / min, P> 0.05), remaining 2.1-fold Below the values ​​of the control group (P <0.001) and 1.2 times lower than the values ​​of the group of patients with mild pneumonia (P <0.05). Thus, in the process of treatment in patients significantly improved the tolerance of physical activity. This indicates a certain relationship between the severity of the process and the level of the Fed. Conducting samples with dosed physical exertion in patients with pneumonia allows to assess their performance and can serve as an additional indicator of the effectiveness of rehabilitation measures and the criterion of recovery. We traced the dynamics of the FRS indicators on the days of illness in patients with mild pneumonia that did not have clinical and radiological changes at the time of discharge; And the indicators of physical performance corresponded to the proper values.

The numerical results of the study were processed by the least squares method using the "Maple V Release 4" program. As a result of the calculations, a mathematical formula was obtained reflecting the dependence of FRS on the day of the disease, being the standard for the dynamics of physical performance of pneumonia patients who, at the time of discharge from the hospital, there was a disappearance of clinical-laboratory, physical symptoms and restitution of the normal pulmonary pattern was determined, Age values.

FR (T) = 625 * exp (-D (T)) + 337,

Where FRS (T) - the physical performance of patients with pneumonia on a particular day of the hospital period,

T is the day of illness,

625 and 337 are numerical coefficients,

D (T) = 22 * ​​Sin (0.09 * T) * exp (-0.09 * T) / T

The formula allows you to predict physical performance in patients with pneumonia on various days of the disease. Comparison of the real values ​​of FRS with the predicted (FRS (T)) will allow in each case to determine the effectiveness of medical and rehabilitation measures, adjust treatment regimens, determine the hospital period, readiness of patients to work (Table 1, drawing).

The technical result of the proposed method is an increase in the evaluation of the effectiveness of rehabilitation measures for pneumonia on each specific day of illness, the definition of the hospital period, the need for post-hospital rehabilitation of patients, their readiness to perform professional and household tasks.

EXAMPLES:

1. Patient E, 32 years old (case history 647) entered the therapy department with complaints of cough with separation of mucous sputum, pain in the left half of the chest, intensifying with deep inspiration and coughing, general weakness, sweating.

At admission, the skin is pale, the temperature is 37.8, the respiration rate is 18 in 1 min. Above the lungs, a shortening of the percussion sound is noted in the lower sections, and sonorous small bubbling rales were heard here. Heart sounds are sonorous. Pulse is a rhythmic good filling. Blood pressure 130/80 mm Hg. Art. The abdomen is soft and painless. The liver and spleen are not palpable.

The analysis of blood: Нв - 140 g / l, Л - 8,9 · 10 9 / l, п - 0, с - 66, э - 3, lymph - 28, mon - 2, СОЭ - 12 mm per hour.

Urinalysis: Weight 1020, protein is not present, sugar is not present, leucocytes 3-4 in p / sren.

On the ECG, the rhythm is sinusoidal, the electric axis of the heart is not deflected.

With fluoroscopy of the thoracic organs left in the posterior-basal segment, the darkening of the lung tissue was noted. Thus, the patient had focal pneumonia in the lower lobe of the left lung. The degree of severity was regarded as light (PIP 40 conventional units). On the 15th day of the disease, the patient was assigned a chest X-ray, the results of which indicated the disappearance of inflammatory infiltration of the lung tissue. On the same day, the patient underwent a bicycle ergometric test, according to the results of which the physical performance was determined according to the size of the FRS, which was 776.4 kgm / min. The value of the due FRS (15) was obtained using a mathematical formula and amounted to 768.3 kgm / min. Thus, when comparing the results, it turned out that the value of FRF in the given cycloergometric test in the given patient exceeded the predicted values ​​of the FRS (15), which indicated the effectiveness of the ongoing medical measures, the readiness of the patient to perform the usual professional and household tasks and served as an excuse for discharging the patient from Hospital without continuation of post-hospital rehabilitation measures.

2. Patient J., 39 years old (a medical history of 790), received complaints about a cough with mucous sputum, a headache. He got sick acutely, after being undercooled at work. He works as a bricklayer. He was hospitalized on the 2nd day after the onset of the disease. At hospitalization: the temperature is 37.7 degrees, the respiration rate is 20 in 1 min. Above the lungs left below the angle of the scapula, vesicular breathing is weak, crepitus. The heart sounds are loud, the pulse is rhythmic, 120 beats. In minutes, the arterial pressure is 110/70 mm Hg. Art. The abdomen is soft and painless. The liver and spleen are not palpable.

Blood test: HB - 136 g / l, L - 9,6 · 10 9 / l, p - 4, with - 76, e - 1, lymph - 14, mon - 2, ESR - 28 mm per hour.

Urinalysis: Weight 1016, protein 0.033 g / l, L - 2-4 in the field of view.

Sputum analysis: mucopurulent, L - a lot.

On the ECG blockade of the right leg of the bundle of His. Load on the right atrium. Radiographic examination of chest organs revealed intensive darkening in segment S 6 of the right lung. Patient diagnosed: right-sided segmental pneumonia (PIP 32 conventional units). On the 18th day of the disease with control fluoroscopy, inflammatory infiltration in the lung tissue was not detected. Bicycle ergometric testing was performed, according to the results of which the FRF value was calculated, which was 587.65 kgm / min, which is much lower than the predicted Fed value (18), which was 827.9 kgm / min. These results indicated the need to continue rehabilitation activities at the post-hospital stage and served as an excuse for sending the patient after discharge from the hospital to the rehabilitation department.

CLAIM

A method for assessing the effectiveness of rehabilitation measures for pneumonia, including a clinical examination of the patient, characterized by the fact that on a specific day of the hospital period, a patient is bicycle ergometric testing, in which the physical performance of the FR is determined at a submaximal age, and compared with the calculated physical performance of the patient in this Day FPC (T) = 625 * exp (-D (T)) + 337, where 625 and 337 are numerical coefficients, T is the day of illness, D (T) = 22 * ​​Sin (0.09 * T) * exp -0.09 * T) / T, and with the physical performance of the FRF x below the calculated FRS (T), rehabilitation measures are assessed as ineffective, and for higher values ​​- as effective.

print version
Date of publication 06.01.2007gg