Bronchial disease hobl. COPD is a lung disease: treatment and symptoms, a list of drugs. The main causes of chronic obstructive pulmonary disease

Less common causes in non-smokers are α-1-antitrypsin deficiency and various occupational exposures. Symptoms are a productive cough and shortness of breath that develops over the years; common symptoms are weakened breathing, prolongation of the expiratory phase, and wheezing. The severe course of the disease can be complicated by weight loss, pneumothorax, frequent episodes of acute decompensation, and right ventricular failure. Treatment includes bronchodilators, corticosteroids, oxygen therapy as needed, and antibiotics.

COPD includes:

• Chronic obstructive bronchitis (clinically established).
• Emphysema.

Many patients have symptoms of both diseases.

The diagnosis of chronic bronchitis is made in the presence of a productive cough for most days of the week with a total duration of at least 3 months over the next two years. Chronic bronchitis becomes obstructive in the presence of spirometry data indicating airway obstruction.

Emphysema is destruction of the lung parenchyma leading to loss of elastic force and damage to the alveolar septa and radial airway traction, which increases the risk of airway collapse. Following this, hyperair lung development develops, a violation of the passage of air flow and the accumulation of residual air.
The airspace of the lungs increases and bullae may form.

Epidemiology of chronic obstructive pulmonary disease

Approximately 24 million people in the United States have respiratory problems, of which about half are due to COPD. Prevalence, morbidity, and mortality increase with age. Morbidity and mortality are generally higher in Caucasians, factory workers, and people with less education, possibly due to the greater prevalence of smoking in these groups. COPD runs in families regardless of the presence of α 1 -antitrypsin deficiency (an α 1 -antiprotease inhibitor).

The incidence of COPD is increasing around the world due to the increase in smoking in developing countries, the decline in mortality from infectious diseases and the widespread use of biofuels. COPD is responsible for 2.74 million deaths worldwide in 2000 and is projected to become one of the top 5 causes of global burdening diseases by 2020.

Causes of chronic obstructive pulmonary disease

There are several causes of COPD:

• Smoking (and other less common inhalation exposures).
• genetic factors.

Inhalation exposure. Smoke from biofuel combustion in home cooking or home heating is an important trigger in developing countries.

Low body weight, childhood respiratory problems, secondhand exposure to cigarette smoke, air pollution, occupational dust (eg, mineral dust, cotton dust), or inhaled chemicals (eg, cadmium) also contribute to COPD, but to a lesser extent than smoking. cigarettes.

The cause of the development of COPD is associated with smoking, the prevalence of which in Russia among men reaches 60-65%, and among women - 20-30%.

Genetic factors. The most studied genetic disorder that can cause the disease is α 1 -deficiency of α 1 -antitrypsin. It is the main cause of emphysema in non-smokers and also increases susceptibility to the disease in smokers.

The disease also develops under the influence of a genetic factor - a hereditary deficiency of wasps, anti-trypsin, which protects proteins from destruction by proteases elastase, collagenases, blood plasma cathepsins. Its congenital deficiency occurs with a frequency of 1 in 3000-5000 people.

Occupational dust, chemicals and infections contribute to the progression of the disease.

Pathophysiology of chronic obstructive pulmonary disease

Airflow obstruction and other complications of COPD can be caused by a variety of factors.

Inflammation. Inflammation in COPD progresses with an increase in the severity of the disease, and in severe (neglected) forms, inflammation does not completely disappear after smoking is stopped. This inflammation does not appear to respond to corticosteroid therapy.

Infection. Respiratory tract infection in conjunction with cigarette smoking can contribute to the progression of lung destruction.

Airway obstruction is caused by inflammation-induced mucus hypersecretion, mucus obstruction, mucus edema, bronchospasm, peribronchial fibrosis, or a combination of these mechanisms. Alveolar attachment sites and alveolar septa collapse, causing the airways to lose support and close during the expiratory phase.

Increased airway resistance increases breathing, as does hyperair in the lungs. Increased breathing can lead to hypoventilation of the alveoli with the development of hypoxia and hypercapnia, although hypoxia may also be due to a mismatch in the ventilation / perfusion ratio (V / 0).

Complications of chronic obstructive pulmonary disease

Along with airflow restriction and sometimes respiratory failure, the following complications occur:

• Pulmonary hypertension.
• Respiratory tract infection.
• Weight loss and other pathology.

Weight loss may be due to reduced caloric intake or increased levels of tumor necrosis factor-α.

Other concomitant or complicating pathologies that impair the quality of life of patients or affect survival are osteoporosis, depression, lung cancer, muscle atrophy, and gastrointestinal reflux. The extent to which these disorders are associated with COPD, smoking, and associated systemic inflammation remains unclear.

Symptoms and signs of chronic obstructive pulmonary disease

The development and progression of COPD takes years. The initial symptom that develops in smokers in their 40s and 50s is a productive cough. Progressive, persistent, exercise-related dyspnea that worsens during respiratory illness appears by the age of 50-60. Symptoms usually progress rapidly in patients who continue to smoke and in those who have been exposed to tobacco for longer.

Exacerbations of the disease occur sporadically against the background of the course of COPD and are accompanied by an increase in the severity of symptoms. Specific causes of exacerbation in most cases cannot be established, but it is known that ARVI or acute bacterial bronchitis often contribute to exacerbation of the disease. As COPD progresses, exacerbations of the disease become more frequent, averaging 5 episodes per year.

Signs of COPD include wheezing, prolongation of the expiratory phase, lung hyperair, manifested by muffled heart sounds and decreased breathing. Patients with severe emphysema lose weight and experience muscle weakness, which contributes to reduced patient mobility, hypoxia, or the release of mediators of the systemic inflammatory response, such as TNE-α. Signs of severe disease are wrinkled lips breathing, attraction of additional muscles, cyanosis. Signs of cor pulmonale include dilatation of the jugular veins, splitting of the 2nd heart sound with an emphasis on the pulmonary arteries.

As a result of bulla rupture, spontaneous pneumothorax can occur, which should be ruled out in any patient with COPD who suddenly develops breathing problems.

Diagnosis of chronic obstructive pulmonary disease

• X-ray examination of the chest.
• Functional breath tests.

The disease can be suspected on the basis of history, physical examination and x-ray examination, the diagnosis is confirmed by functional respiratory tests.

Systemic diseases in which airflow limitation can be identified may contribute to the development of COPD; these are, for example, HIV infection, intravenous drug abuse (particularly cocaine and amphetamines), sarcoidosis, Sjögren's disease, bronchiolitis obliterans, lymphangioleiomatosis, and eosinophilic granuloma.

Functional breath tests. Patients with suspected COPD should have a complete lung function examination to confirm airflow limitation, determine its severity and reversibility, and differentiate COPD from other diseases.

Functional breath tests are also required to monitor disease progression and monitor response to therapy. The main diagnostic tests are:

• FEV 1 .
• Forced vital capacity (FVC).
• Loop thread.

In middle-aged smokers, whose FEV1 is already low, the decline is even faster. When FEV1 falls below 1 L, patients experience shortness of breath during normal daily activities; when FEV1 drops to 0.8 L, patients are at risk of developing hypoxemia, hypercapnia, and cor pulmonale. FEV1 and FVC are determined simply by office spirometry and reflect disease severity as they correlate with symptom severity and mortality. Normal reference values ​​are determined based on the age, sex and weight of the patient.

Additional functional respiratory tests should be performed only in special cases, for example, before surgery and for lung volume reduction. Other abnormal parameters include increased total lung capacity, functional residual capacity, and residual volume, which may aid in the differential diagnosis between COPD and restrictive lung disease, in which all of these parameters are reduced; reduced vital capacity; reduced diffuse capacity of one breath for carbon monoxide (DLCO). Decreased DLa is nonspecific and decreases in other pathological conditions that affect the lining of the pulmonary vessels, such as interstitial lung disease, but may help to distinguish between emphysema and bronchial asthma, in which DL CO is normal or elevated.

Imaging techniques. Changes in the presence of emphysema may include hyperair of the lungs, manifested as a flattening of the diaphragm, the rapid disappearance of the roots of the lungs and the bulla > 1 cm in a circle with arcuate very thin contours. Other typical features are expansion of the retrosternal airspace and narrowing of the cardiac shadow. Emphysematous changes, found mainly at the base of the lungs, suggest the presence of α 1 -antitrypsin deficiency.

Bulging of the roots of the lungs indicates the expansion of the main pulmonary arteries, which may be a sign of pulmonary hypertension. Right ventricular enlargement due to the presence of cor pulmonale may not be detected due to hyperair of the lungs or manifest as a bulging of the heart shadow into the retrosternal space or expansion of the heart shadow in diameter compared to previous radiographs.

CT may reveal abnormalities that are not visible on chest x-ray and may also indicate the presence of concomitant or complicating pathologies, such as pneumonia, pneumoconiosis, or lung cancer. CT helps to assess the severity and extent of emphysema, either by visual counting or by analyzing the distribution of lung density.

Additional tests. The level of α 1 -antitrypsin should be determined in patients aged<50 лет с клинически выраженным ХОБЛ и у некурящих людей любого возраста ХОБЛ, для того чтобы выявить недостаточность α 1 -антитрипсина. Другие проявления недостаточности α 1 -антитрипсина включают в себя наследственный анамнез преждевременного развития ХОБЛ или билиарный цирроз печени у детей, распределение эмфиземы в основном в нижних долях легкого и ХОБЛ, ассоциированный с ANCA-положительным (антинейтрофильные цитоплазматические антитела) васкулитом. Если уровень α 1 -антитрипсина низкий, диагноз может быть подтвержден при установлении α 1 -антитрипсин фенотипа.

ECG, which is often done in patients to rule out cardiac causes of dyspnoea, usually reveals a decrease in the amplitude of the QRS complex in all leads in combination with the vertical axis of the heart, due to hyperair of the lungs and an increase in the amplitude of the P-wave or shift to the right of the P-wave vector, caused by an increase in the right atrium in patients with severe emphysema.

Echocardiography may be useful in some cases to assess right ventricular function and detect pulmonary hypertension, although air accumulation technically impairs echocardiography in patients with COPD. Echocardiography is most often performed when concomitant valvular heart disease or pathology associated with the left ventricle of the heart is suspected.

Patients with anemia (not caused by COPD) have disproportionately severe dyspnea.

Exacerbation detection. Patients with an exacerbation of the disease are characterized by a combination of increased breathing, low blood oxygen saturation on pulse oximetry, profuse sweating, tachycardia, anxiety, and cyanosis.

Chest x-rays are often done to check for pneumonia or pneumothorax. In rare cases, in patients receiving long-term systemic corticosteroids, infiltrates may indicate Aspergillus pneumonia.

Yellow or green sputum is a reliable indicator of the presence of neutrophils and suggests bacterial colonization or infection. Bacterial culture is often performed on hospitalized patients, but is usually not necessary in an outpatient setting. In outpatient specimens, Gram stains usually show neutrophils with a combination of organisms, most commonly Gram-positive diplococci, Gram-negative rods (H. influenzae), or both. Other commensal organisms that live in the oropharynx, such as Moraxella (Branhamella) catarrhalis, can sometimes also cause an exacerbation. In hospitalized patients, resistant gram-negative organisms or, less commonly, Staphylococcus may be cultured.

Prognosis of chronic obstructive pulmonary disease

The mortality rate in patients with an FEV1 >50% predicted is slightly higher than in the general population.

A more accurate determination of the risk of death is possible by simultaneously measuring body mass index (B), degree of airway obstruction (O, i.e. FEV1 1), dyspnea (D, which is assessed by the MMRC (Modified Medical Research Council) dyspnoea scale) and physical performance, which determines the BODE index.Also, mortality increases in the presence of heart disease, anemia, tachycardia at rest, hypercapnia and hypoxemia, while a significant response to bronchodilators, on the contrary, indicates a favorable prognosis.

The risk of sudden death is high in patients with progressive unexplained weight loss or severe functional impairment (eg, who experience shortness of breath when performing self-care activities such as dressing, washing, or eating). Mortality in COPD in patients who have stopped smoking may be more due to intercurrent diseases than to the progression of the underlying disease.

Treatment of chronic obstructive pulmonary disease

Treatment of stable COPD

• Inhaled bronchodilators, corticosteroids, or a combination.
• supportive therapy.

The management of COPD includes the treatment of chronically current disease and its exacerbations. Treatment of cor pulmonale, the main complication of long-term severe COPD, is discussed in another chapter.

The goal of treating stable COPD is to prevent exacerbations and improve lung and physical parameters through drug therapy, oxygen therapy, smoking cessation, and exercise. Surgical treatment is indicated for certain groups of patients.

Drug therapy. Inhaled bronchodilators are the mainstay of COPD management; medications include:

• β-agonists,
• anticholinergics (muscarinic receptor antagonists).

These two classes are equally effective. Patients with mild disease (stage 1) require treatment only if they are symptomatic. Patients with stage 2 or higher disease require continuous administration of drugs from one or both classes at the same time to improve lung function and increase physical performance. The frequency of exacerbations is reduced by the use of anticholinergic drugs, inhaled corticosteroids, or long-acting β-agonists. However, there is no evidence that regular use of bronchodilators slows the progressive deterioration of lung function. The initial choice among β-adrenergic agonists, long-acting β-agonists, β-anticholinergics (which have a greater bronchodilatory effect), or a combination of β-agonist and anticholinergic drugs is most often based on optimal cost, patient preference, and effect on symptoms.

In the treatment of long-term stable disease, it is preferable to prescribe a metered dose inhaler or powder inhaler than use a nebulizer at home; Home nebulizers tend to get dirty if not properly cleaned and dried. Patients should be taught to exhale to functional residual capacity, inhale the aerosol slowly to full lung capacity, and hold the breath for 3-4 seconds before exhaling. Spacers provide optimal delivery of the drug to the distal respiratory tract and reduce the need to coordinate the inhaler with inspiration. Some spacers cause anxiety to patients if they inhale too quickly. Newer metered dose inhalers using hydrofluoroalkaline (HFA) propellants require slightly different technology than inhalers containing older, environmentally hazardous chlorinated fluorocarbon propellants; when using inhalers containing HFA, 2-3 boosted initial injections are required if they are new or have been used for a long time.

Beta-agonists relax bronchial smooth muscle cells and increase mucociliary clearance. Albuterol is the drug of choice due to its low cost. Long-acting β-adrenergic agonists are preferred in patients with nocturnal symptoms or in those who are not comfortable with frequent use of the drug. There may be options: salmeterol powder and formoterol powder. Dry powders may be more effective in patients who have difficulty coordinating the metered dose inhaler. Patients should be told about the difference between short-acting and long-acting drugs because the use of long-acting drugs more than twice a day increases the risk of cardiac arrhythmias. Side effects often occur with the use of any of the β-agonists and include tremor, anxiety, tachycardia, and slight transient hypokalemia.

Anticholinergic drugs relax bronchial smooth muscle cells by competitively inhibiting muscarinic receptors (M 1 , M 2 , M 3 ). Ipratropium is the most commonly used drug due to its low cost and ease of use. The onset of ipratropium is slow, so β2-adrenergic agonists are often given with ipratropium in combination in the same inhaler or as a separate, release-only drug. Tiotropium, a fourth-generation long-acting anticholinergic in powder form, is M 1 - and M 2 -selective and thus may be preferred over ipratropium, due to the fact that blockade of M 2 receptors (as in the case of ipratropium) can reduce bronchodilation. Side effects of all angiolinergic drugs include pupillary dilation, blurred vision, and dry mouth.

Corticosteroids are often used in the treatment. Inhaled corticosteroids appear to reduce airway inflammation, restore β-adrenergic receptor sensitivity, and inhibit the production of leukotrienes and cytokines. Indicated for patients with recurrent exacerbations or symptoms that persist despite optimal brachiodilator therapy. The dosage depends on the drug; for example, fluticasone 500–1,000 mcg per day or beclamethasone 400–2,000 mcg per day. The long-term risks of inhaled corticosteroid therapy in the elderly have not been proven, but appear to include osteoporosis, cataract formation, and an increased risk of non-fatal pneumonia. Therefore, long-term use should be accompanied by periodic ophthalmic examinations and densitometry, and, if possible, patients should take calcium, vitamin D and bisphosphonates supplements as indicated. Corticosteroid therapy should be discontinued if there is no subjective or objective sign of improvement (eg, after several months of use).

The combination of a long-acting β-adrenergic agonist (eg, salmeterol and inhaled corticosteroids (eg, fluticasone) is most effective compared with the use of only one drug in the treatment of chronic stable COPD.

Oral or systemic corticosteroids are not usually used in the treatment of long-term stable COPD.

Theophylline currently plays a minor role in the treatment of long-term stable COPD, when more effective drugs are available. Theophylline reduces smooth muscle spasm, increases mucociliary clearance, improves right ventricular function, and reduces pulmonary vascular resistance and blood pressure. Its mechanism of action is not fully understood, but apparently differs from the β 2 -action of β-adrenergic agonists and anticholinergic drugs. Theophylline at low doses has an anti-inflammatory effect and may enhance the effect of inhaled corticosteroids.

Theophylline may be used in patients who do not respond adequately to inhaled drugs and in whom its use improves symptoms. There is no need to monitor its serum level, unless the patient does not respond to the drug, he develops signs of intoxication, or the patient's compliance is in doubt; slowly absorbed oral theophylline preparations, which must be taken with less frequency, increase treatment adherence. Intoxication develops frequently, even at low blood levels of the drug, and includes insomnia and disruption of the gastrointestinal tract.

Oxygen therapy. Oxygen therapy leads to an increase in hematocrit to normal values; improves neuropsychological status, possibly due to improved sleep; improves hemodynamic disorders in the pulmonary circulation.

Oxygen saturation should be determined not only at rest, but also during exercise. Similarly to patients with severe COPD who are not eligible for long-term awake oxygen therapy but whose clinical findings suggest pulmonary hypertension in the absence of daytime hypoxemia, the test should be performed during sleep at night, oxygen therapy should be given if the test is during sleep shows episodic desaturation<88%.

Oxygen therapy is carried out through a nasal catheter at a rate sufficient to maintain PaO 2 >60 mm Hg. Art.

Liquid systems. Portable liquid oxygen canisters are easy to carry and have more capacity than compressed gas cylinders. Large compressed air cylinders are the most expensive way to supply oxygen and should only be used when no other source of oxygen is available. All patients should be warned about the dangers of smoking while breathing oxygen.

Various oxygen storage devices reduce the amount of oxygen used by the patient, either by using reservoirs or by allowing oxygen to be delivered only during inhalation.

All patients with COPD with PaO 2<68 мм рт а на уровне моря, выраженной анемией (тематокрит <30) или имеющих сопутствующие сердечные или цереброваскулярные нарушения требуется дополнительный кислород во время длительных перелетов, о чем следует предупредить авиаперевозчика при резервировании места. Авиаперевозчик может обеспечить дополнительный кислород в большинстве случаев требуется предупреждение минимум за 24 ч до полета, справка от врача о состоянии здоровья и рецепт на кислородотерапию. Пациенты должны брать с собой собственные назальные катетеры, потому что в ряде авиакомпаний имеются только маски на лицо. Пациентам не разрешается брать в салон собственный жидкий кислород, но многие авиакомпании допускают применение портативных концентраторов кислорода, которые также являются подходящим источником кислорода во время полета.

To give up smoking. Quitting smoking is very difficult and at the same time very important; it slows down, but does not completely stop the decline in FEV 1. Multiple strategies are most effective at the same time: quit date setting, behavior change techniques, group denial, nicotine replacement therapy, varenicline or bupropion, and physician support. Smoking cessation rates of over 50% per year, however, have not been demonstrated even with the most effective interventions such as bupropion plus nicotine replacement therapy or varenicline alone.

Vaccination. If the patient cannot be vaccinated, or if the predominant strain of the influenza virus is not included in the annual vaccine, prophylactic treatment (amantadine, rimantadine, oseltamivir, or zanamavir) is acceptable during influenza epidemics. Although not proven effective, the pneumococcal polysaccharide vaccine, which causes minimal side effects, can also be used.

Food. Patients with COPD are at risk for weight loss and eating disorders due to an increase in respiratory energy intake by 15-25%; higher energy expenditure during daytime activity; reduced calorie intake relative to needed as a result of dyspnea and the catabolic effect of inflammatory cytokines such as TNF-α. Impaired muscle strength and efficiency of oxygen use. Patients with compromised nutritional status have a worse prognosis, so it is important to recommend a balanced diet with adequate calorie intake combined with exercise to prevent or reverse wasting and muscle wasting. However, overweight should also be avoided, and obese patients should gradually reduce their weight. studies examining the effects of dietary changes alone did not show a significant effect on changes in lung function or exercise tolerance.

Pulmonary rehabilitation. Pulmonary rehabilitation programs serve as an adjunct to drug therapy to improve physical well-being; many hospitals and healthcare organizations have appropriate multidisciplinary rehabilitation programs. Pulmonary rehabilitation includes physical exercises, educational programs and behavioral techniques, treatment should be individualized; Patients and their families should be educated about COPD and its medical management, and patients should be encouraged to take greater responsibility for self-care. Carefully integrated rehabilitation programs help patients with severe COPD overcome psychological limitations and provide real hope of improvement. Patients with severe COPD require a minimum of 3 months of rehabilitation to obtain a beneficial effect, and further maintenance programs are needed.

The exercise program can be done at home, in a hospital, or in a healthcare setting. Gradually increasing exercise can improve skeletal muscle flaccidity caused by physical inactivity or prolonged hospitalization due to respiratory failure. Special exercises for the muscles involved in the breathing process are less effective than aerobic exercise for the whole body.

A standard training program includes walking slowly on a treadmill or pedaling with no load on a bicycle ergometer for several minutes. The duration and magnitude of the load progressively increase after 4-6 weeks until the moment when the patient can perform the load without stopping for 20-30 minutes without experiencing severe shortness of breath. Patients with severe COPD usually become able to perform a load of up to 30 minutes of walking at a speed of 1-2 m/h.

Arm strengthening exercises help the patient perform daily activities (eg, bathing, dressing, cleaning the house).

Patients should be taught how to conserve energy during daily activities and gradually increase their activity. Possible problems in the sexual sphere should be discussed and energy-saving techniques for sexual satisfaction should be advised.

Surgery. Lung volume reduction surgery is a resection of non-functioning emphysematous areas.

Rarely, patients may have bullae so large that they can compress a functioning lung. Such patients may benefit from surgical resection of these bullae, with subsequent improvement in symptoms and improvement in lung function. Most often, the best result is achieved when resection is performed on patients with bullae that affect more than one third or half of the lung, and whose FEV 1 is about half of the expected normal values. It is possible to determine whether the patient's functional status depends on the compression of the lungs with bullae or on widespread emphysema, it is possible on a series of radiographs or on images taken using CT. Significant reduction in DLCO(<40% от предполагаемой) свидетельствует о распространенной эмфиземе и худшем постоперативном прогнозе.

Treatment of exacerbations of COPD

• Addition of oxygen.
• Bronchodilators.
• Corticosteroids.
• Antibiotics.
• Sometimes ventilation support.

The immediate immediate goal of therapy is to ensure adequate oxygenation and normalization of blood pH, elimination of airway obstruction and treatment of causes.

Oxygen therapy. Most patients require oxygen supplementation, even those who have not previously used it for a long time. Hypercapnia may worsen with oxygen therapy. The deterioration occurs, as is commonly believed, due to the weakening of the hypoxic stimulation of respiration. However, increasing the V/Q ratio is probably the more important factor. Prior to the appointment of oxygen therapy, the V / Q ratio is minimized with a decrease in perfusion of poorly ventilated areas of the lungs due to vasoconstriction of the pulmonary vessels. The increase in the V / Q ratio against the background of oxygen therapy is due.

Decreased hypoxic pulmonary vasoconstriction. Hypercapnia may be aggravated by the Haldane effect, but this version is questionable. The Haldane effect is to reduce the affinity of hemoglobin for CO 2 , which leads to an excessive accumulation of CO 2 dissolved in blood plasma. Many patients with COPD can experience both chronic and acute hypercapnia, and therefore severe CNS damage is unlikely unless PaCO 2 is greater than 85 mmHg. The target level for PaO 2 is about 60 mm Hg; higher levels have little effect but increase the risk of hypercapnia. Oxygen is delivered through a venturi mask and must therefore be closely monitored and the patient closely monitored. Patients whose condition worsens on oxygen therapy (eg, in association with severe acidosis or CVD disease) require ventilatory support.

Many patients who require oxygen therapy at home for the first time after being discharged from the hospital due to a COPD exacerbation get better after 50 days and no longer require further oxygen. Therefore, the need for home oxygen therapy should be reassessed 60–90 days after discharge.

ventilation support. Non-invasive supply and exhaust ventilation is an alternative to full mechanical ventilation.

Drug therapy. Together with oxygen therapy (regardless of the form in which oxygen is administered), treatment with β-agonists and anticholinergics with or without the addition of corticosteroids should be initiated to eliminate airway obstruction.

Short-acting β-adrenergic agonists form the basis of drug therapy for exacerbations of COPD. Inhalation via a metered dose inhaler provides rapid bronchodilation: there is no evidence that the administration of the drug through a nebulizer is more effective than the correct administration of the same doses of the drug from a metered dose inhaler. In life-threatening situations, the risk arising from a complication exceeds the risk of a possible overdose of β-adrenergic agonists, so β-adrenergic agonists can be continuously administered through the nebulizer until the situation improves.

Ipratropium is the most commonly used anticholinergic drug, effective in exacerbations of COPD, and can be given together or as an alternative to β-agonists. Ipratropium usually has a bronchodilatory effect similar to that which occurs with the use of the recommended doses of β-adrenergic agonists. The role of the long-acting anticholinergic drug tiotropium in the treatment of exacerbations has not been fully elucidated.

Corticosteroids should be prescribed immediately for all, even mild, exacerbations.

Antibiotics recommended for patients with exacerbation with purulent sputum. Routine sputum culture and Gram stain are not necessary to initiate treatment unless a specific or resistant microorganism is suspected (eg, in hospitalized, warded, or immunosuppressed patients). Showing drugs that affect the microflora of the oral cavity. Tripetoprim/sulfamethoxazole and doxycycline are effective and inexpensive drugs. The choice of the drug is dictated by local characteristics of the sensitivity of bacteria or the patient's history. If the patient is severely ill or there is clinical evidence of resistance to infectious agents, more expensive second-line drugs should be used. These drugs are amoxicillin/clavulanic acid, fluoroquinolones (eg, ciprofloxacin, levofloxacin), 2nd generation cephalosporins (eg, cefuroxime, cefaclor), and extended-spectrum macrolides (eg, azithromycin, clarithromycin). These drugs are effective against β-lactamase-producing strains of H. influenzae and M. catarrhalis, but have not been shown to be more effective than first-line drugs in most patients.

Antitussives such as dextromethorphan and benzonatate play a minor role.

Opioids (eg, codeine, hydrocodone, oxycodone) may be appropriate to relieve symptoms (eg, severe coughing spells, pain), given that these drugs may suppress a productive cough, worsen mental status, and cause constipation.

Care of the terminally ill. In severe stages of the disease, when death is already inevitable, physical activity is undesirable and daily activity is aimed at minimizing energy costs. For example, patients may limit their living space to one floor of the house, eat more often and in small portions rather than infrequently and in large quantities, and avoid tight shoes. The care of the terminally ill should be discussed, including the inevitability of mechanical ventilation, the use of temporary pain relief sedatives, the appointment of a medical decision maker in the event of a patient's disability.

Chronic obstructive pulmonary disease (COPD) is a deadly disease. The number of deaths per year worldwide reaches 6% of the total number of deaths.

This disease, which occurs with long-term damage to the lungs, is currently considered incurable, therapy can only reduce the frequency and severity of exacerbations, and achieve a decrease in the level of deaths.
COPD (Chronic Obstructive Pulmonary Disease) is a disease in which airflow is restricted in the airways, partially reversible. This obstruction is progressively progressive, reducing lung function and leading to chronic respiratory failure.

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Who has COPD

COPD (chronic obstructive pulmonary disease) mainly develops in people with many years of smoking experience. The disease is widespread throughout the world, among men and women. The highest mortality is in countries with a low standard of living.

Origin of the disease

With many years of irritation of the lungs with harmful gases and microorganisms, chronic inflammation gradually develops. The result is a narrowing of the bronchi and the destruction of the alveoli of the lungs. In the future, all respiratory tracts, tissues and vessels of the lungs are affected, leading to irreversible pathologies that cause a lack of oxygen in the body. COPD (chronic obstructive pulmonary disease) develops slowly, progressing steadily over many years.

If left untreated, COPD leads to a person's disability, then death.

The main causes of the disease

• Smoking is the main cause, causing up to 90% of cases of the disease;
• professional factors - work in hazardous production, inhalation of dust containing silicon and cadmium (miners, builders, railway workers, workers in metallurgical, pulp and paper, grain and cotton processing enterprises);
• hereditary factors - rare congenital deficiency of α1-antitrypsin.

• Cough is the earliest and often underestimated symptom. At first, the cough is periodic, then it becomes daily, in rare cases it manifests itself only at night;
• - appears in the early stages of the disease in the form of a small amount of mucus, usually in the morning. With the development of the disease, the sputum becomes purulent and more and more abundant;
• dyspnea- is found only 10 years after the onset of the disease. At first, it manifests itself only with serious physical exertion. Further, the feeling of lack of air develops with minor body movements, later severe progressive respiratory failure appears.

The disease is classified according to severity:

Mild - with mild impairment of lung function. There is a slight cough. At this stage, the disease is very rarely diagnosed.

Moderate severity - obstructive disorders in the lungs increase. Appears shortness of breath with physical. loads. The disease is diagnosed at the address of patients in connection with exacerbations and shortness of breath.

Severe - there is a significant restriction of air intake. Frequent exacerbations begin, shortness of breath increases.

Extremely severe - with severe bronchial obstruction. The state of health deteriorates greatly, exacerbations become threatening, disability develops.

Diagnostic methods

Collection of anamnesis - with an analysis of risk factors. Smokers evaluate the smoker's index (SI): the number of cigarettes smoked daily is multiplied by the number of years of smoking and divided by 20. IC greater than 10 indicates the development of COPD.
Spirometry - to evaluate lung function. Shows the amount of air during inhalation and exhalation and the speed of entry and exit of air.

A test with a bronchodilator - shows the likelihood of reversibility of the process of narrowing of the bronchus.

X-ray examination - establishes the severity of pulmonary changes. The same is being done.

Sputum analysis - to determine the microbes during exacerbation and the selection of antibiotics.

Differential Diagnosis

How to treat the disease

General rules

• Smoking must be stopped forever. If you continue to smoke, no treatment for COPD will be effective;
• the use of personal protective equipment for the respiratory system, reducing, if possible, the number of harmful factors in the working area;
• rational, nutritious nutrition;
• reduction to normal body weight;
• regular physical exercises (breathing exercises, swimming, walking).

Treatment with drugs

Its goal is to reduce the frequency of exacerbations and the severity of symptoms, to prevent the development of complications. As the disease progresses, the amount of treatment only increases. Main drugs in the treatment of COPD:

• Bronchodilators are the main drugs that stimulate the expansion of the bronchi (atrovent, salmeterol, salbutamol, formoterol). It is preferably administered by inhalation. Short-acting drugs are used as needed, long-acting drugs are used constantly;
• glucocorticoids in the form of inhalations - used for severe degrees of the disease, with exacerbations (prednisone). With severe respiratory failure, attacks are stopped by glucocorticoids in the form of tablets and injections;
• Vaccines – Influenza vaccination reduces mortality in half of cases. It is carried out once in October - early November;
• mucolytics - thin the mucus and facilitate its excretion (carbocysteine, ambroxol, trypsin, chymotrypsin). Used only in patients with viscous sputum;
• antibiotics - used only during exacerbation of the disease (penicillins, cephalosporins, it is possible to use fluoroquinolones). Tablets, injections, inhalations are used;
• antioxidants - able to reduce the frequency and duration of exacerbations, are used in courses of up to six months (N-acetylcysteine).

Surgery

• Bullectomy - removal can reduce shortness of breath and improve lung function;
• lung volume reduction by surgery is under study. The operation improves the physical condition of the patient and reduces the mortality rate;
• lung transplantation - effectively improves the quality of life, lung function and physical performance of the patient. Application is hampered by the problem of donor selection and the high cost of the operation.

Oxygen therapy

Oxygen therapy is carried out to correct respiratory failure: short-term - with exacerbations, long-term - with the fourth degree of COPD. With a stable course, constant long-term oxygen therapy is prescribed (at least 15 hours daily).

Oxygen therapy is never prescribed to patients who continue to smoke or suffer from alcoholism.

Treatment with folk remedies

Herbal infusions. They are prepared by brewing a spoonful of the collection with a glass of boiling water, and each is taken for 2 months:

√ 1 part sage, 2 parts chamomile and mallow;

√ 1 part linseeds, 2 parts eucalyptus, linden flowers, chamomile;

√ 1 part chamomile, mallow, sweet clover, anise berries, licorice roots and marshmallow, 3 parts flaxseed.

• Infusion of radish. Grate black radish and medium-sized beets, mix and pour with cooled boiling water. Leave for 3 hours. Use three times a day for a month, 50 ml.
• Nettle. Grind nettle roots into gruel and mix with sugar in a ratio of 2: 3, leave for 6 hours. The syrup removes phlegm, relieves inflammation and relieves cough.
• Milk:

√ Brew a spoonful of cetraria (Icelandic moss) with a glass of milk, drink during the day;

√ Boil 6 chopped onions and a head of garlic for 10 minutes in a liter of milk. Drink half a glass after meals. Every mom should know!

Coughing attacks keeping you awake at night? Perhaps you have tracheitis. You can learn more about this disease

• physical activity, regular and dosed, aimed at the respiratory muscles;
• annual vaccination with influenza and pneumococcal vaccines;
• constant intake of prescribed drugs and regular examinations by a pulmonologist;
• correct use of inhalers.

Forecast

COPD has a conditionally poor prognosis. The disease slowly but constantly progresses, leading to disability. Treatment, even the most active, can only slow down this process, but not eliminate the pathology. In most cases, treatment is lifelong, with ever-increasing doses of medication.

With continued smoking, obstruction progresses much faster, significantly reducing life expectancy.

The incurable and deadly COPD simply urges people to stop smoking forever. And for people at risk, there is only one advice - if you find signs of a disease, immediately contact a pulmonologist. After all, the earlier the disease is detected, the less likely it is to die prematurely.

In contact with

MD, prof. S.I. Ovcharenko, Department of Faculty Therapy No. 1, State Educational Institution of Higher Professional Education MMA named after. THEM. Sechenov

Chronic obstructive pulmonary disease (COPD) is one of the most widespread diseases, which is largely due to the increasing impact of adverse factors (risk factors): environmental pollution, tobacco smoking and recurrent respiratory infections.

COPD is characterized by airflow limitation that is not completely reversible and is steadily progressive.

The diagnosis of COPD should be considered in every person who coughs, produces sputum, and has risk factors. In all these cases, spirometry should be performed. A decrease in the ratio of forced expiratory volume in 1 second to forced vital capacity (FEV 1 / FVC) of less than 70% is an early and reliable sign of airflow limitation, even if FEV 1 > 80% of the proper value is maintained. Moreover, obstruction is considered chronic (and the patient must be considered suffering from COPD) if it is recorded three times within one year. The stage of the disease (its severity) reflects the value of FEV 1 in the post-bronchodilatory test. Chronic cough and excessive sputum production long precede ventilation disorders leading to dyspnoea.

The main goals of treating patients with COPD are clearly formulated in the International Program "Global Strategy: Diagnosis, Treatment and Prevention of COPD", created on the basis of the principles of evidence-based medicine (2003) and in the federal program of the Russian Federation for the diagnosis and treatment of COPD (2004). They are aimed at:

Prevention of disease progression;

Increasing tolerance to physical activity;

Reducing symptoms;

Improving the quality of life;

Prevention and treatment of exacerbations and complications;

Decrease in mortality.

The implementation of these provisions is carried out in the following areas:

Reducing the influence of risk factors;

Implementation of educational programs;

Treatment of COPD in stable condition;

Treatment of an exacerbation of the disease.

Smoking cessation is the first major step in a COPD treatment program to prevent progression of the disease and by far the most effective intervention to reduce the risk of developing COPD. Special programs for the treatment of tobacco dependence have been developed:

Long-term treatment program with the goal of complete smoking cessation;

A short treatment program to reduce the amount of tobacco smoked and increase motivation to quit smoking completely;

Smoking reduction program.

The long-term treatment program is designed for patients with a strong desire to quit smoking. The program lasts from 6 months to 1 year and consists of periodic conversations between the doctor and the patient (more frequent in the first 2 months of quitting smoking), and the patient nicotine-containing preparations(NSP). The duration of taking the drugs is determined individually and depends on the degree of nicotine dependence of the patient.

The short treatment program is intended for patients who do not want to quit smoking, but do not reject this possibility in the future. In addition, this program can be offered to patients who wish to reduce the intensity of smoking. The duration of the short program is from 1 to 3 months. Treatment within 1 month allows to reduce the intensity of smoking by an average of 1.5 times, within 3 months - by 2-3 times. A short treatment program is built on the same principles as a long one: doctor's conversations, development of a patient behavior strategy, nicotine replacement therapy, detection and treatment of chronic bronchitis and prevention of its exacerbation as a result of smoking cessation. For this purpose, acetylcysteine ​​is prescribed - 600 mg 1 time per day in a blister. The difference with this program is that a complete cessation of smoking is not achieved.

The smoking reduction program is designed for patients who do not want to quit smoking, but are willing to reduce the intensity of smoking. The essence of the program is that the patient continues to receive nicotine at the usual level for him, combining cigarette smoking with taking NSP, but at the same time reduces the number of cigarettes smoked per day. Within a month, the intensity of smoking can be reduced by an average of 1.5-2 times, i.e. the patient reduces the intake of harmful substances contained in cigarette smoke, which is undoubtedly a positive result of treatment. This program also uses the doctor's conversations and the development of a strategy for the patient's behavior.

The effectiveness of a combination of two methods has been confirmed - nicotine replacement therapy and conversations between doctors and medical staff with the patient. Even short three-minute smoking cessation consultations are effective and should be used at every medical appointment. Smoking cessation does not lead to the normalization of lung function, but it can slow down the progressive deterioration of FEV 1 (further, the decrease in FEV 1 occurs at the same rate as in non-smoking patients.)

An important role in inducing smoking cessation, in improving the skills of inhalation therapy in patients with COPD and their ability to cope with the disease, is played by educational programs.

For people with COPD, education should cover all aspects of managing the disease and can take many forms: consultations with a doctor or other healthcare professional, home or out-of-home programs, and full-fledged pulmonary rehabilitation programs. For patients with COPD, it is necessary to understand the nature of the disease, risk factors leading to the progression of the disease, clarify their own role and the role of the doctor in order to achieve the optimal result of treatment. Education should be tailored to the needs and environment of the individual patient, be interactive, improve the quality of life, be easy to implement, practical, and appropriate to the intellectual and social level of the patient and those caring for them.

To give up smoking;

Basic information about COPD;

Basic approaches to therapy;

Specific treatment issues (in particular the correct use of inhaled medicines);

Self-management skills (peak flowmetry) and decision-making during an exacerbation. Patient education programs should include the distribution of printed materials and the conduct of educational sessions and workshops aimed at providing information about the disease and teaching patients special skills.

It has been established that training is most effective when it is carried out in small groups.

The choice of drug therapy depends on the severity (stage) of the disease and its phase: a stable state or an exacerbation of the disease.

According to modern ideas about the nature of COPD, the main and universal source of pathological manifestations that develop with the progression of the disease is bronchial obstruction. Hence it follows that bronchodilators should occupy and currently occupy a leading place in the complex therapy of patients with COPD. All other means and methods of treatment should be used only in combination with bronchodilators.

Treatment of COPD in a stable condition of the patient

Treatment of stable COPD patients is necessary to prevent and control symptoms of the disease, reduce the frequency and severity of exacerbations, improve general condition and increase exercise tolerance.

The tactics of managing patients with COPD in a stable state is characterized by a stepwise increase in the amount of therapy, depending on the severity of the disease.

It should be emphasized once again that at present the leading place in the complex therapy of patients with COPD is occupied by bronchodilators. All categories of bronchodilators have been shown to increase exercise tolerance even in the absence of an increase in FEV 1 values. Inhalation therapy is preferred (Evidence level A). The inhalation route of administration of drugs provides direct penetration of the drug into the respiratory tract and, thus, contributes to a more effective drug effect. In addition, the inhalation route of administration reduces the potential risk of systemic side effects.

Particular attention should be paid to teaching patients the correct technique of inhalation in order to increase the effectiveness of inhalation therapy. m-Cholinolytics and beta 2-agonists are used mainly with the help of metered-dose inhalers. To increase the efficiency of drug delivery to the site of pathological reactions (i.e., to the lower respiratory tract), spacers can be used - devices that increase the flow of the drug into the airways by 20%.

In patients with severe and extremely severe COPD, bronchodilatory therapy is carried out with special solutions through a nebulizer. Nebulizer therapy is also preferred, as is the use of a metered-dose aerosol with a spacer, in the elderly and patients with cognitive impairment.

To reduce bronchial obstruction in patients with COPD, short- and long-acting anticholinergics, short- and long-acting beta2-agonists, methylxanthines, and their combinations are used. Bronchodilators are given "on demand" or on a regular basis to prevent or reduce symptoms of COPD. The sequence of application and the combination of these drugs depends on the severity of the disease and individual tolerance.

For mild COPD, short-acting bronchodilators are used, “on demand”. In moderate, severe and extremely severe disease, long-term and regular treatment with bronchodilators is a priority, which reduces the rate of progression of bronchial obstruction (Evidence A). The most effective combination of bronchodilators with a different mechanism of action, because. the bronchodilator effect is enhanced and the risk of side effects is reduced compared with an increase in the dose of one of the drugs (level of evidence A).

m-Cholinolytics occupy a special place among bronchodilators due to the role of the parasympathetic (cholinergic) autonomic nervous system in the development of the reversible component of bronchial obstruction. The appointment of anticholinergic drugs (ACP) is advisable for any severity of the disease. The best known short-acting AChP is ipratropium bromide, which is usually given at 40 mcg (2 doses) 4 times daily (Evidence B). Due to insignificant absorption through the bronchial mucosa, ipratropium bromide practically does not cause systemic side effects, which allows it to be widely used in patients with cardiovascular diseases. ACPs do not have a negative effect on the secretion of bronchial mucus and the processes of mucociliary transport. Short-acting m-anticholinergics have a longer bronchodilator effect than short-acting beta2-agonists (Evidence A).

A distinctive feature of short-acting beta 2-agonists (salbutamol, fenoterol) is the speed of action on bronchial obstruction. Moreover, the bronchodilating effect is higher, the more pronounced the lesion of the distal bronchi. Patients within a few minutes feel an improvement in breathing and in therapy "on demand" (for mild COPD - stage I) they often give preference to them. However, the regular use of short-acting beta2-agonists as monotherapy for COPD is not recommended (Evidence A). In addition, short-acting beta 2-agonists should be used with caution in elderly patients with concomitant heart disease (with coronary artery disease and hypertension), because. these drugs, especially in combination with diuretics, can cause transient hypokalemia, and, as a result, cardiac arrhythmias.

Many studies have shown that long-term use of ipratropium bromide is more effective for the treatment of COPD than long-term monotherapy with short-acting beta2-agonists (Evidence A). However, the use of ipratropium bromide in combination with short-acting beta2-agonists has a number of advantages, including a reduction in the frequency of exacerbations, and thereby a reduction in the cost of treatment.

Regular treatment with long-acting bronchodilators (tiotropium bromide, salmeterol, formoterol) is recommended for moderate, severe and very severe COPD (Evidence A). They are more effective and convenient to use than short-acting bronchodilators, but they are more expensive to treat (Evidence A). In this regard, patients with severe COPD may be prescribed short-acting bronchodilator drugs in various combinations (see Table 1).

Table 1

The choice of bronchodilators depending on the severity of COPD

Ipratropium bromide is prescribed 40 mcg (2 doses) 4 times a day, tiotropium bromide - 1 time per day at a dose of 18 mcg through "HandiHaler", salbutamol - 100-200 mcg up to 4 times a day, fenoterol - 100-200 mcg up to 4 times a day, salmeterol - 25-50 mcg 2 times a day, formoterol 4.5-12 mcg 2 times a day. When using inhaled short-acting bronchodilators, preference is given to CFC-free dosage forms.

Tiotropium bromide is a representative of a new generation of ACPs, a long-acting drug whose bronchodilating effect persists for 24 hours (Evidence level A), which makes it possible to use this drug once a day. The low frequency of side effects (dry mouth, etc.) indicates a sufficient safety of using this drug in COPD. Early studies have shown that tiotropium bromide not only significantly improves lung volume and peak expiratory flow in patients with COPD, but also reduces the frequency of exacerbations with long-term use.

According to the anticholinergic effect of tiotropium bromide, inhaled by patients with COPD using a metered-dose powder inhaler "HandiHaler", is approximately 10 times greater than ipratropium bromide.

The results of controlled 12-month studies showed a significant superiority of tiotropium bromide over ipratropium bromide in terms of the effect of:

On indicators of bronchial patency;

The severity of shortness of breath;

Need for short-acting bronchodilators;

frequency and severity of exacerbations.

Long-acting beta2-agonists (salmeterol, formoterol) are also recommended for regular use in the treatment of COPD. They, regardless of changes in bronchial patency, can improve clinical symptoms and quality of life of patients, reduce the number of exacerbations (level of evidence B). Salmeterol improves the condition of patients when used at a dose of 50 mcg twice a day (level of evidence B). Formoterol, like salmeterol, acts for 12 hours without loss of effectiveness (level of evidence A), but the effect of formoterol develops faster (after 5-7 minutes) than that of salmeterol (after 30-45 minutes).

Long-acting beta 2-agonists, in addition to the bronchodilator effect, also show other positive qualities in the treatment of patients with COPD:

Reduce hyperinflation of the lungs;

Activate mucociliary transport;

Protect the cells of the mucous membrane of the respiratory tract;

Show antineutrophil activity.

Treatment with a combination of an inhaled beta2-agonist (rapid or long-acting) and an ACP improves airflow better than either agent alone (Evidence A).

Methylxanthines (theophylline) with insufficient efficacy of AHP and beta 2-agonists can be added to regular inhaled bronchodilator therapy for more severe COPD (Evidence level B). All studies that have shown the effectiveness of theophylline in COPD concern long-acting drugs. The use of prolonged forms of theophylline may be indicated for nocturnal symptoms of the disease. The bronchodilating effect of theophylline is inferior to that of beta 2-agonists and ACP, but its oral administration (prolonged forms) or parenteral administration (methylxanthines are not prescribed by inhalation) causes a number of additional effects: reduction of pulmonary hypertension, increased diuresis, stimulation of the central nervous system, improvement of respiratory muscle tone which may be useful in some patients.

Theophylline may be beneficial in the treatment of COPD, but inhaled bronchodilators are preferred due to its potential side effects. Currently, theophylline belongs to the second-line drugs, i.e. is prescribed after ACP and beta 2-agonists or their combinations, or for those patients who cannot use inhaled delivery devices.

In real life, the choice between ACPs, beta2-agonists, theophylline, or a combination of them depends largely on the availability of drugs and the individual's response to treatment in terms of symptom relief and the absence of side effects.

Inhaled glucocorticoids (IGCs) are prescribed in addition to bronchodilator therapy in patients with clinical symptoms of the disease, FEV 1<50% от должного (тяжелое теение ХОБЛ — стадия III и крайне тяжелое течение ХОБЛ — стадия IV) и повторяющимися обострениями (3 раза и более за последние три года) (уровень доказательности А). Предпочтительно применение ИГК длительного действия — флутиказона или будесонида. Эффективность лечения оценивается через 6-12 недель применения ИГК.

The combination with long-acting beta 2-agonists increases the effectiveness of corticosteroid therapy (the effect is superior to the results of separate use). This combination demonstrates the synergism of the action of drugs when exposed to various links in the pathogenesis of COPD: bronchial obstruction, inflammation and structural changes in the airways, mucociliary dysfunction. The combination of long-acting beta2-agonists and ICS (salmeterol/fluticasone and formoterol/budesonide) results in a better risk/benefit ratio than the individual components.

Long-term treatment with systemic glucocorticoids is not recommended due to an unfavorable balance of efficacy and risk of adverse events (Evidence A).

Mucolytic (mucoregulators, mucokinetics) and expectorants shown to a very limited cohort of COPD patients with a stable course in the presence of viscous sputum and do not significantly affect the course of the disease.

For the prevention of exacerbation of COPD, long-term use of the mucolytic acetylcysteine ​​(preferably 600 mg in a blister), which simultaneously has antioxidant activity, seems promising. Taking acetylcysteine ​​for 3-6 months at a dose of 600 mg/day is accompanied by a significant decrease in the frequency and duration of COPD exacerbations.

Application antibacterial agents for prophylactic purposes in patients with COPD should not be a daily practice, tk. According to the results of modern studies, antibiotic prophylaxis of exacerbations of COPD has a low, but statistically significant efficiency, manifested in a decrease in the duration of exacerbations of the disease. However, there is a risk of adverse drug events in patients and the development of pathogen resistance.

In order to prevent exacerbation of COPD during epidemic outbreaks of influenza, it is recommended vaccines, containing killed or inactivated viruses. Vaccines are prescribed to patients once, in October - the first half of November, or twice (in autumn and winter) annually (level of evidence A). Influenza vaccine can reduce the severity and mortality in patients with COPD by 50%. A pneumococcal vaccine containing 23 virulent serotypes is also used, but data on its effectiveness in COPD are insufficient (Evidence level B).

Non-drug treatment with a stable course of COPD includes oxygen therapy. Correction of hypoxemia with oxygen is the most pathophysiologically sound method for the treatment of respiratory failure. Patients with chronic respiratory failure are shown constant many hours of low-flow (more than 15 hours a day) oxygen therapy. Long-term oxygen therapy is currently the only therapy that can reduce mortality in patients with extremely severe COPD (Evidence A).

For patients with COPD at all stages of the course of the process are effective physical training programs increase exercise tolerance and reduce shortness of breath and fatigue. Physical training necessarily includes exercises for the development of strength and endurance of the lower extremities (metered walking, bicycle ergometer). In addition, they may include exercises that increase the strength of the muscles of the upper shoulder girdle (manual ergometer, dumbbells).

Physical exercise is the main component pulmonary rehabilitation. In addition to physical training, rehabilitation activities include: psychosocial support, educational programs, nutritional support. One of the tasks of rehabilitation is to identify and correct the causes of nutritional status disorders in patients with COPD. The most rational diet is the frequent intake of small portions of protein-rich foods. The best way to correct a deficiency in body mass index is to combine supplementary nutrition with physical training, which has a non-specific anabolic effect. The positive effect of rehabilitation programs is also achieved through psychosocial interventions.

There are no absolute contraindications to pulmonary rehabilitation. Ideal candidates for inclusion in rehabilitation programs are patients with moderate to severe COPD, i.e. patients in whom the disease imposes serious restrictions on the usual level of functional activity.

In recent years, there have been reports of the use of methods surgical treatment in patients with severe COPD. Operative correction of lung volumes by the method bullectomy, resulting in reduced dyspnea and improved lung function. However, this method is a palliative surgical procedure with unproven efficacy. The most radical surgical method is lung transplant in carefully selected patients with very severe COPD. The selection criterion is FEV 1<35% от должной величины, pО 2 <55-60 мм рт. ст., pСО 2 >50 mmHg and evidence of secondary pulmonary hypertension.

Treatment of COPD during an exacerbation

The primary causes of exacerbation of COPD include tracheobronchial infections (often viral etiology) and exposure to aerosolants.

Among the so-called. secondary causes of exacerbation of COPD include: thromboembolism of the branches of the pulmonary artery, pneumothorax, pneumonia, chest trauma, the appointment of beta-blockers and other drugs, heart failure, heart rhythm disturbances, etc.

All exacerbations should be considered as a factor in the progression of COPD, and therefore more intensive therapy is recommended. First of all, this applies to bronchodilator therapy: the doses of drugs are increased and the methods of their delivery are modified (preference is given to nebulizer therapy). For this purpose, special solutions of bronchodilators are used - ipratropium bromide, fenoterol, salbutamol, or a combination of ipratropium bromide with fenoterol.

Depending on the severity of the course and the degree of exacerbation of COPD, treatment can be carried out both on an outpatient basis (mild exacerbation or moderate exacerbation in patients with mild COPD) and on an inpatient basis.

As a bronchodilator in severe COPD exacerbation, it is recommended to prescribe nebulized solutions short-acting beta 2-agonists (level of evidence A). The regimen of high doses of bronchodilators can bring a significant positive effect in acute respiratory failure.

In the treatment of severe patients with the presence of multiple organ pathology, tachycardia, hypoxemia, the role of ACP drugs increases. Ipratropium bromide is prescribed both as monotherapy and in combination with beta 2 agonists.

The generally accepted dosing regimen for inhaled bronchodilators in COPD exacerbations is shown in Table 2.

table 2

Dosing regimens for inhaled bronchodilators in exacerbations of COPD

The appointment of any other bronchodilators or their dosage forms (xanthines, bronchodilators for intravenous administration) should be preceded by the use of the maximum doses of these drugs, administered through a nebulizer or spacer.

The advantages of inhalation through a nebulizer are:

No need to coordinate inspiration with inhalation;

Ease of performing the inhalation technique for the elderly and severely ill;

The possibility of introducing a high dose of a medicinal substance;

The possibility of including a nebulizer in the oxygen supply circuit or the ventilation circuit;

Lack of freon and other propellants;

Ease of use.

Due to the variety of adverse effects of theophylline, its use requires caution. At the same time, if it is impossible, for various reasons, to use inhaled forms of drugs, as well as if other bronchodilators and glucocorticoids are not sufficiently effective, it is possible to prescribe theophylline preparations. The use of theophylline in exacerbations of COPD is debated, since in controlled studies the effectiveness of theophylline in patients with exacerbations of COPD was not high enough, and in some cases, treatment was accompanied by such adverse reactions as hypoxemia. The high risk of adverse reactions necessitates the measurement of the concentration of the drug in the blood, which in the practice of a physician seems to be very difficult.

To stop the exacerbation, along with bronchodilator therapy, antibiotics, glucocorticoids are used, and in a hospital setting - controlled oxygen therapy and non-invasive ventilation of the lungs.

Glucocorticoids. With exacerbation of COPD, accompanied by a decrease in FEV 1<50% от должного, используют глюкокортикоиды параллельно с бронхолитической терапией. Предпочтение отдают системным глюкокортикоидам: например, назначают по 30-40 мг преднизолонав течение 10-14 дней с последующим переводом на ингаляционный путь введения.

Therapy with systemic glucocorticoids (orally or parenterally) contributes to a more rapid increase in FEV 1, a decrease in dyspnea, an improvement in arterial blood oxygenation, and a shortening of hospital stays (Evidence A). They should be prescribed as early as possible, even upon admission to the emergency department. Oral or intravenous administration of glucocorticoids for COPD exacerbations at the hospital stage is carried out in parallel with bronchodilator therapy (if indicated, in combination with antibiotics and oxygen therapy). The recommended dosage has not been definitively determined, but given the serious risk of adverse events with high-dose steroid therapy, prednisolone 30–40 mg for 10–14 days should be considered an acceptable compromise between efficacy and safety (Evidence D). Further continuation of oral administration does not lead to an increase in efficacy, but increases the risk of adverse events.

Antibacterial agents are indicated with increased shortness of breath, an increase in sputum volume and its purulent character. In most cases of exacerbations of COPD, antibiotics can be given by mouth. The duration of antibiotic therapy is from 7 to 14 days (see Table 3).

Table 3

Antibacterial therapy for exacerbations of COPD

For uncomplicated exacerbations, the drug of choice is amoxicillin (alternatively, respiratory fluoroquinolones or amoxicillin / clavulanate, as well as the "new" macrolides - azithromycin, clarithromycin, can be used). In complicated exacerbations, the drugs of choice are respiratory fluoroquinolones (levofloxacin, moxifloxacin) or II-III generation cephalosporins, including those with antipseudomonal activity.

Indications for parenteral use of antibiotics are:

Lack of an oral form of the drug;

Gastrointestinal disorders;

Severe exacerbation of the disease;

Low compliance with the patient.

oxygen therapy is one of the key areas of complex treatment of patients with exacerbation of COPD in a hospital setting. An adequate level of oxygenation, namely pO 2 >8.0 kPa (more than 60 mm Hg. Art.) or pCO 2 >90%, as a rule, is quickly achieved with uncomplicated exacerbations of COPD. After the start of oxygen therapy through nasal catheters (flow rate - 1-2 l / min) or a Venturi mask (oxygen content in the inhaled oxygen-air mixture 24-28%), blood gases should be monitored after 30-45 minutes (adequacy of oxygenation, exclusion of acidosis , hypercapnia).

Auxiliary IVL. If, after a 30-45-minute inhalation of oxygen in a patient with acute respiratory failure, the effectiveness of oxygen therapy is minimal or absent, a decision should be made on assisted ventilation. Recently, special attention has been paid to non-invasive positive pressure ventilation. The effectiveness of this method of treating respiratory failure reaches 80-85% and is accompanied by the normalization of arterial blood gases, a decrease in shortness of breath, and, more importantly, a decrease in the mortality of patients, a decrease in the number of invasive procedures and associated infectious complications, as well as a decrease in the duration of the hospital treatment period. (Evidence level A).

In cases where non-invasive ventilation is ineffective (or unavailable) in a patient suffering from a severe exacerbation of COPD, invasive ventilation is indicated.

A schematic diagram of the treatment of COPD exacerbation is shown in the figure below.

Picture. Schematic diagram of the treatment of exacerbations of COPD

Unfortunately, COPD patients seek medical help, usually in the later stages of the disease, when they already have respiratory failure or develop cor pulmonale. At this stage of the disease, treatment is extremely difficult and does not give the expected effect. In connection with the above, the early diagnosis of COPD and the timely implementation of the developed treatment program remain extremely relevant.

About 6-10% of people over 40 suffer from chronic obstructive pulmonary disease. There are many reasons for the development of the disease. Most often, the impetus for the development of the disease is smoking, heredity and work in harmful conditions. To date, it is impossible to completely cure the disease.

All are aimed at reducing and preventing seizures. The disease often causes complications, which increases the likelihood of death.

Complications and their danger

Pneumonia

It occurs as a result of stagnation of mucus in the respiratory tract and a violation of the mucociliary clearance. The patient begins inflammatory processes with the addition of infection. The cause of pneumonia can also be the regular or long-term use of glucocorticosteroids in the form of inhalations. Also, this type of complication is quite often observed in people who suffer from diabetes.

With the appearance of a secondary, a large percentage of death. Septic shock may occur. Illness accompany severe shortness of breath and the risk of kidney failure.

Respiratory failure

This complication always occurs in a patient with COPD. This is due to the fact that it is difficult for the lungs to maintain the composition of the blood that is necessary for high-quality breathing. This is a pathological syndrome may be acute or chronic. For the development of an acute form, a few minutes or a couple of hours are enough. The course of the chronic form is rather stormy. It can develop for a long time: from several weeks to several months. This complication has three stages:

1. the first is characterized by the presence of shortness of breath only after more serious physical exertion;
2. in the second degree, shortness of breath occurs even at the slightest exertion;
3. Grade 3 is characterized by severe shortness of breath, difficulty breathing even at rest, and a significant decrease in oxygen in the lungs.

Puffiness may also appear, morphological changes in the liver and kidneys may occur, and the normal functioning of these organs will be disrupted.

1. Pulmonary hypertension may appear, which leads to high blood pressure;
2. cor pulmonale may occur.

The functions of cardiac activity are disturbed, the patient develops hypertension. The walls of the organ thicken, the section of the right ventricle expands. The disease can be acute, subacute or chronic. There is a possibility of a collapse. Possible enlargement of the liver. The patient also has tachycardia, shortness of breath, coughing up sputum with blood.

Fact! If this type of complication is chronic, the symptoms may be minor, and shortness of breath worsens over time. Also, the patient may experience swelling and decreased diuresis.

Acute heart failure

There is a violation of the proper functioning of the right ventricle, due to which congestion is observed, and there is a violation of the contractile function of the myocardium. This, in turn, leads to edema, circulatory disorders, tachycardia, decreased performance, and insomnia. If the disease has taken a severe form, a person has severe exhaustion.

Atrial fibrillation

The normal cycle of the heart is disturbed, the muscle fibers of the atrium are chaotically contracted and excited. The ventricles contract less frequently than the atria.

Pneumothorax

Expressed by pain in the chest. If cirrhosis of the lung occurs, it is deformed, the heart and large vessels are also displaced. Appears inflammatory process, and pleurisy begins to develop. Diagnosis of this pathology during x-ray. Most often, men suffer from this pathology.

Pneumothorax develops very quickly. The first symptom is severe pain in the region of the heart with shortness of breath, which occurs in the patient even at rest. The patient feels especially severe pain when he takes a breath or coughs. Also, the patient has tachycardia and rapid heart rate. High probability of loss of consciousness.

Polycythemia

This type of complication in COPD leads to erythrocytosis. In humans, the production of red blood cells increases, hemoglobin is elevated. For a long time, polycythemia can occur without symptoms.

blockage of blood vessels

The main vessels are clogged with blood clots, which can lead to terrible consequences.

bronchiectasis

This type of complication is characterized by bronchial dilatation, which most often occurs in the lower lobes. Perhaps the defeat of not one, but two lungs at once. The patient begins hemoptysis, severe pain in the chest. The secreted sputum has an unpleasant odor. Also, a person becomes irritable, his skin turns pale and weight decreases. The phalanges of the fingers on the hands thicken.

pneumosclerosis

There is a replacement of normal tissue with connective tissue, as a result of which the bronchi are deformed, the pleura tissue is compacted, and the mediastinal organs are displaced. Gas exchange is disturbed, respiratory failure develops. This complication refers to the last degree of sclerosis and most often causes death. This pathology is characterized by:

• persistent shortness of breath;
• blue skin;
• frequent cough with mucus.

Important! All these complications are life-threatening, so the patient must be observed by a doctor.

Exacerbation symptoms

In order to start treatment in time or prevent an attack, the patient needs to know the signs of an impending exacerbation. Exacerbations in COPD can occur several times a year Therefore, each patient should be able to control their condition and take the necessary measures to prevent them.

The most common signs are:

1. The appearance of sputum with an admixture of pus in a patient.
2. The amount of secreted mucus is greatly increased.
3. Shortness of breath becomes severe and may occur even at rest.
4. Increasing cough intensity.
5. There are wheezing that can be heard at a distance.
6. There may be severe headaches or dizziness.
7. An unpleasant noise appears in the ears.
8. The extremities become cold.
9. There is insomnia.
10. There is pain in the heart.

Important! Exacerbations in COPD may increase gradually or rapidly.

Treatment for an exacerbation

The doctor selects adequate basic therapy for patients, which includes such drugs:

First-line drugs for adults

• Spiriva;
• Tiotropium-Nativ.

Important! These funds are prohibited for the treatment of children.

• Foradil;
• Oxys;
• Atimos;
• Serevent;
• Theotard;
• Salmeterol.

These drugs can be used in the form of inhalers for moderate and severe forms of the disease. The new drug Spiriva Respimat, which is produced in the form of a solution for inhalation, has proven itself well.

Hormonal drugs

• Flixotide;
• Pulmicort;
• Beclazon-ECO.

Combined preparations from bronchodilators and hormonal agents

• Symbicort;
• Seretide.

The course of antibacterial agents during exacerbation

• Augmentinin;
• Flemoxin;
• Amoxiclav;
• Sumamed;
• Azitrox;
• Klacid;
• Zoflox;
• Sparflo.

Expectorants

• Lasolvana;
• Ambroxol;
• Flavameda.

Mucolytic antioxidant ACC

If the patient does not have severe respiratory failure, treatment can be carried out at home. If an exacerbation of COPD took a heavy form, hospitalization is necessary for the treatment of the patient in the hospital.

If the patient has severe shortness of breath due to chronic hypoxia of the brain, which can lead to disability, the patient is prescribed a course of inhalation with oxygen.

When using inhalation, doctors recommend that patients use a nebulizer, as its use will allow quickly restore the functions of the respiratory tract. If there is no effect from the treatment or suffocation has increased, calling an ambulance is mandatory.

Useful video

Be sure to watch the video about the new methodology for detecting COPD disease and how smoking is involved in the disease:

COPD is a progressive disease that is characterized by chronic inflammation of the bronchial tree and destruction of lung tissue in response to the inhalation of harmful substances. Tobacco smoke, industrial dusts or harmful gaseous substances top this list of substances. Inflammation inside the bronchi leads to a decrease in the lumen of the bronchi - bronchial obstruction. Consequences of obstruction - reduced air flow, impaired pulmonary ventilation. This is a broncho-obstructive lung disease that requires constant treatment and medical supervision, especially during an exacerbation of the disease. Emphysema, bullous emphysema, chronic obstructive bronchitis are manifestations of COPD.

Being in a state of inflammation for a long time, the airways undergo significant pathological changes. Coughing begins to disturb, it is difficult to breathe, shortness of breath occurs.

When damage to the bronchi and bronchioles becomes pronounced from obstruction, a serious problem arises for gas exchange in the body: it becomes more difficult to get enough oxygen and get rid of excess carbon dioxide. These changes lead to shortness of breath and other symptoms.

Causes of chronic obstructive disease

To understand why COPD develops, it is important to understand how the lungs work. Normally, inhaled air travels from the nasopharynx through the airways (bronchi, bronchioles) to tiny air sacs in the lung called alveoli. In the alveoli, the oxygen we breathe in passes through their wall into the bloodstream. Carbon dioxide passes in the opposite direction, from the bloodstream, back to the alveoli, and is eliminated during exhalation (Figure 1).

Inhaling smoke while smoking, or being a passive smoker, inhaling various irritating gaseous substances or small particles, a person has damage to the mucous membrane of the respiratory tract, the occurrence of chronic inflammation, damaging the lung tissue (Figure 2), coughing fits appear.

When the lung is damaged, a situation arises in which normal inspiration is a problem, while the exchange of oxygen and carbon dioxide in the alveoli becomes difficult, which naturally requires therapy.

In most cases, this disease is acquired during life. Contributes to this dubious acquisition, primarily smoking (tobacco, marijuana, etc.). Other factors that increase the risk include hypersensitivity to inhaled substances. This is especially true of inhalation of tobacco smoke in passive smokers, inhalation of organic, inorganic, house dust or polluted air, prolonged exposure to occupational irritants (acid and alkali fumes, industrial dust).

Chronic obstructive disease can be hereditary in nature. Genetic risk factors include severe deficiency of alpha 1 antitrypsin, a protein that protects the lungs. Other hereditary defects also occur. This may also explain the development of COPD in non-smokers. Approximately 20 percent of people who develop the disease have never smoked.

In any of the variants of the development of the disease, this is a progressive disease! All the drama in the word progressive. Having formed, it will irresistibly strive for the death of the patient. And this must be understood by absolutely every patient suffering from diseases of the lungs and bronchi. Death occurs from progressive respiratory failure. In other words, a person slowly dies from a lack of oxygen in the blood.

Question from a patient

Is COPD Bronchitis, Pneumonia or Emphysema?

The term chronic obstructive pulmonary disease is often used along with diseases such as bronchitis and/or emphysema because they are the most common clinical forms of the disease. In addition, the current treatments for COPD, chronic bronchitis, and emphysema are similar. But the outcomes of chronic bronchitis and lung obstruction are different. That is why it is so important to make the correct diagnosis.

Manifestations of COPD

• Dyspnea. Two-thirds of patients with COPD go to the doctor if they experience shortness of breath. Difficulty breathing and shortness of breath interfere with life and work, so the patient comes to see a doctor. Three or five years pass between the first sensation of shortness of breath and a visit to a pulmonologist.
• Cough. The cough is habitual, like a smoker's cough. Cough is not taken seriously. Sputum when coughing is gray, green or brown. Microbes that live and multiply in the bronchi color sputum in such colors.
• Wheezing breath. Shortness of breath and cough are accompanied by wheezing and whistling in the chest. The narrowing of the lumen of the bronchus causes whistling sounds during breathing. Phlegm inside the bronchi enhances or changes these sounds.

Diagnosis of chronic obstructive pulmonary disease

For 10 years, 9.5 thousand patients with COPD have received care at the IntegraMed clinic. The knowledge and experience gained while working at the Research Institute of Pulmonology helps our pulmonologists to choose the right treatment regimen.

During the appointment with the doctor, your complaints will be carefully listened to. Complaints and anamnesis help to correctly assess the development of the disease and the severity. The severity of the disease is assessed according to the international recommendations GOLD 2018. Shortness of breath is measured in points using a patient questionnaire, according to the MRC scale. Evaluation of dyspnea is necessary to monitor treatment. The patient is evaluated by appetite, height and weight, the shape of the chest and skin. The level of oxygen in the blood must be measured.

After the examination, breath tests are performed. Doctors perform spirometry on their own. The test result becomes accurate when the doctor performs a breath test. If necessary, a comprehensive study of respiratory function and diffusion capacity of the lungs will be carried out.

COPD treatment

Treatment of COPD is a long and consistent process under the supervision of doctors. Control is carried out during visits to the doctor or on-line consultations via Skype. The goal of the COPD treatment program is to reduce the number of exacerbations, improve respiratory function, and quickly cope with the exacerbation.

Skype consultations

Online consultations save time and effort for our patients. The patient sends tests, CT scan to the clinic. Then, at a prearranged hour, the pulmonologist who treats you gets in touch via Skype. If during the Skype consultation the doctor understands that an examination is required to correct the treatment, then you will be invited to an appointment.

Calling a doctor at home

For severe patients with COPD, a pulmonologist home call service is offered. Samoylenko Viktor Alexandrovich consults at home, pulmonologist, candidate of medical sciences, nominee for the National Award for the best doctors of Russia "Vocation", student of the academician of the Russian Academy of Sciences, prof. Chuchalina A.G. During an on-site consultation, the doctor adjusts the treatment, changes the regimens of oxygen therapy, and makes new appointments.

Hospitalization

If it turns out that only a pulmonology hospital is required for treatment, then we will organize an URGENT hospitalization in a pulmonology hospital. We will monitor the treatment together with our colleagues in the hospital.

"Day hospital"

In the conditions of the "Day Hospital" we fight COPD exacerbations with intravenous injections in combination with intensive nebulizer therapy. Two to three days of intensive treatment will lead to an improvement in well-being. When breathing is restored, it will be possible to prescribe basic therapy.

Pulmonary rehabilitation in COPD

Our pulmonology department has developed a “Pulmonary Rehabilitation Program for Patients with Chronic Obstructive Pulmonary Disease” .

The course of complex therapy allows replacing bronchoscopic sanitation in patients with bronchiectasis.

• sputum becomes easily coughed up, coughing occurs naturally, drugs are poured into the smallest bronchi, including antimicrobial agents.
• the introduction of drugs into the bronchus and the removal of sputum is not invasive and traumatic.
• Due to the positive effect of drainage techniques and special exercises included in the course, the lymphatic drainage of the bronchi and their blood supply are improved. As a result, the protective properties of the mucous membrane of the damaged bronchi and the surrounding lung tissue are enhanced.
• there are no risks inherent in bronchoscopy: the risk of bleeding, damage and an allergic reaction to anesthesia.

Symptoms

X-ray signs

COPD should be considered if you have:

• Shortness of breath on exertion or at rest.
• Chronic cough with expectoration of sputum and / or shortness of breath;
• The presence of cough long before the onset of shortness of breath;
• Wheezing and wheezing in the chest

If at least one of the above signs is present, a respiratory function test is indicated to detect airflow limitation, even if there is no shortness of breath.

The most common symptoms are: cough without/with expectoration of sputum; shortness of breath on exertion or even at rest; headache; increasing fatigue.

The disease at first usually does not cause or causes very mild clinical manifestations. As they progress, they increase, the patient's condition worsens.

Question from a patient

Is COPD as dangerous as they say?

This is a slow disease. Before the onset of the main symptoms of the disease - usually shortness of breath, cough, it will take 10-15 years. This is due to the peculiarities of inflammation in the airways under the influence of tobacco smoke or dust. As a result of their prolonged exposure and prolonged inflammation, oxygen transport in the alveoli and respiratory bronchioles is hindered. Less oxygen enters the blood and during exercise the patient begins to experience shortness of breath - first from heavy loads, then from habitual ones, and then the patient can hardly get dressed or go to the toilet. Therefore, the answer to the question is COPD dangerous or not, in my opinion, is obvious - DANGEROUS! Deadly DANGEROUS!

Question from a patient

Can asthma develop into chronic obstructive disease?

No. Quite a common misconception. These are two different diseases with the same broncho-obstructive syndrome. In both cases, the pulmonologist is faced with a narrowing of the bronchi - bronchial obstruction. In the case of COPD, it is not reversible; in the case of asthma, it is reversible. Outcomes of diseases are also different. In the treatment of respiratory failure of the lungs, there are common features, but these are different diseases. Very many therapists and pulmonologists immediately prescribe drugs used for asthma to the patient. But this is wrong.
Why? Come and visit us, we will tell you and we will definitely help you.

The following tests are used to diagnose COPD:

• spirometry allows you to quickly and informatively assess the decrease in the lumen of the bronchial tree, as well as assess the degree of reversibility of this process;
• body plethysmography allows diagnosing emphysema and assessing the violation of the diffusion capacity of the lungs;
• peak flowmetry the simplest and fastest evaluation test, but with low sensitivity. Can be effectively used to identify risk groups.

The main functional syndromes are:

• violation of bronchial patency;
• change in the structure of static volumes, diffusion capacity of the lungs;
• decrease in physical performance.

Thus, the diagnosis of chronic obstructive pulmonary disease is based on:

• presence of risk factors;
• cough and shortness of breath;
• steadily progressing violation of bronchial patency;
• exclusion of other diseases leading to similar symptoms.

Probable portrait of the patient:

1. smoker;
2. middle or old age;
3. suffers from shortness of breath;
4. there is a cough with sputum, especially in the morning;
5. complains of frequent exacerbations of bronchitis.

Question from a patient

What is important in the diagnosis of pathology?

Timeliness! The sooner the disease is diagnosed, the more likely it is to get rid of its symptoms. We can help to fully control the disease in the early stages, with full contact with the patient and his relatives.

Stages of disease 4. Treatment at the first and second stages of the disease shows the best results. Control with the third and fourth stages is possible, but these are already disabling phases of COPD. In our clinic "IntegraMedservice", all the necessary studies are carried out according to the standards of ERSATS and the Russian Respiratory Society.

Diagnosis requires careful execution of test methodology. Sometimes it is enough to conduct a respiratory tract to determine the severity of the current condition. But in most clinics, FVD is methodologically incorrect. Our test is carried out by doctors themselves, who have undergone special training, so errors are excluded. If emphysema is suspected, we perform body plethysmography with the measurement of the diffusion capacity of the lungs - this is a painless test performed by our colleagues at the Research Institute of Pulmonology.

Of course, chest CT is indispensable for suspected emphysema and bronchiectasis in patients with COPD. High-resolution CT used in our center completely solves the problem. In difficult cases, we consult with the chief radiologist of Russia, Prof. Tyurina I.E.

Non-pharmacological treatment of COPD

• Categorical and complete refusal of smoking.
• Oxygen therapy.
• Proper nutrition.

Question from a patient

I have COPD and have decided to reduce the number of cigarettes I smoke from 2 packs to 2 cigarettes a day. Will this keep me from progressing the disease?

No. Once diagnosed, it doesn't matter how many cigarettes you smoke. Does the inflammatory process in the bronchi care, since COPD has already formed? If you continue smoking, the progression of the disease will still continue at the same rate.

Question from a patient

I have severe COPD and nothing depends on my quitting smoking! I'll die, I'll die, but I won't quit smoking!

A frequent argument in the practice of our clinic. This is a tragic delusion that has cost many lives. As soon as the patient stops smoking, the rate of inflammation drops sharply and the progression of the disease slows down sharply. Yes, there is no cure for this pathology, but you can win back 10-15 years of life simply by quitting smoking. The lungs will not recover as in youth, but the disease will stop. Then it's up to you and the pulmonologists.

If quitting smoking is a problem for you, you can contact the head of the pulmonology department of IntegraMedservice, Ph.D. Chikina S. Yu. Being a pulmonologist of the highest category, in addition to treating COPD, she can help get rid of the habit of smoking. Techniques generally accepted in the world of respiratory medicine are at your service. And I'm sure together we can tame the beast of obstructive pulmonary disease.

Question from a patient

Does COPD need oxygen?

Prescribing oxygen therapy is no less a difficult issue than prescribing drug treatment of the disease. Not every COPD patient needs oxygen. Incorrectly prescribed oxygen therapy may worsen the prognosis of the disease or not get the desired effect. Many unfortunate pulmonologists, having seen reduced oxygen levels in a patient, rush to prescribe oxygen therapy, without finding out whether it is necessary, is it safe ?!

Patients with advanced obstructive pulmonary disease may have low blood oxygen levels. This condition is called hypoxemia. The oxygen level is measured by a device worn on the finger (pulse oximeter) or in a blood test (arterial blood gas test). In the treatment of people with hypoxemia, long-term oxygen therapy should be carried out, which improves the quality and duration of life.

We use VCT (long-term oxygen therapy) for clear, proven indications. This is always preceded by a serious analysis and testing on modern equipment. The qualification of our pulmonologists allows us to prescribe this therapy on time. We adjust the oxygen supply modes, the duration of the sessions and control the effect.

Food

More than 30% of people with severe chronic pulmonary obstruction are unable to eat enough due to shortness of breath and fatigue. Unintentional weight loss due to dyspnea is common in patients with advanced disease and severe respiratory distress. Irregular eating leads to malnutrition, which will exacerbate the course of obstructive pulmonary disease and increase the risk of developing a respiratory tract infection.

For this reason, the following are indicated in the treatment of COPD:

• Eat small meals and often, with a predominance of nutritious foods;
• Eat food that requires little preparation;
• Rest before eating;
• Introduce multivitamins into your diet.

Dietary supplements are also a good source of extra calories, as they are easy to digest and require no preparation.

COPD treatment with folk remedies

Despite the advanced pharmacotherapy of COPD, the efforts of the world's leading experts, various clinics, people have a craving for alternative methods of treatment. From the point of view of psychology, this is understandable, but just as ineffective. Dear patients, there are no folk remedies that can affect this pathology! This is nonsense!!

There are medicinal herbs that can improve expectoration of sputum. This is true. They are not comparable with the strength and effectiveness of, for example, acetylcysteine, ambraxol. But ... If there is a desire to introduce folk remedies into the treatment regimen, then at least purchase medicinal fees for expectoration of sputum in pharmacies.

Due to the unscientific nature of treatment with folk methods, there is no single recipe for these remedies. There are many thousands of them. Someone helped marshmallow with plantain, someone without elecampane did not clear their throat, etc. If we summarize all the material on the topic of traditional medicine and COPD, we were able to notice that the use of licorice, elecampane, marshmallow root and psyllium are the most common herbs to improve expectoration. Actually, the effectiveness of such an "ancient" drug as Mukaltin is due to the fact that it contains marshmallow root.

Therefore, we want to advise patients - use the modern appointments of pulmonologists for the treatment of COPD. But if you are irresistibly drawn to the use of traditional medicine, do not cancel the appointment of your pulmonologist.

Question from a patient

Is there surgery for COPD?

Yes, surgical treatment of some forms of the disease is carried out. First of all, it is bullous emphysema. This is a variant of the flow of emphysema, in which cysts, bullae (cavities in the form of large blisters) form in the lungs. Surgery is performed using modern endoscopic techniques. Also, according to indications, with extremely severe COPD, a lung transplant is possible - transplantation.

In both cases, operations are dangerous and complex manipulations that require high skill from thoracic surgeons. We have been working with such a specialist for a long time - this is the chief thoracic surgeon of Moscow Tarabrin E.A., and we are ready to refer our patients to him for treatment if necessary.

Question from a patient

What is the difference between the IntegraMedservice Center for Respiratory Medicine and other medical centers?

When prescribing treatment and taking care of a patient with COPD of any severity, we first put the safety and efficacy of therapy at the forefront. We don't treat tests or test results, we treat the patient.

We are the only private center that seriously and purposefully deals only with respiratory problems, and especially with pulmonology. We are not therapists, but real specialists in the field of pulmonology. The experience and knowledge gained while working at the Research Institute of Pulmonology allows us to guarantee the quality of treatment, diagnosis and prevention of COPD.

Diagnosis, diagnosis of its phenotypes, choice of treatment tactics is a multidisciplinary work. Pulmonologists, otolaryngologists, specialists in functional and X-ray diagnostics, specialists in pulmonary rehabilitation and smoking cessation rehabilitation, and sometimes thoracic surgeons should actively take part in it. Moreover, reliable specialists with modern knowledge work at each stage of diagnosis and treatment. Together, this ensures the success of therapy and the quality of life of our patients.