Hobble - treatment. chronic obstructive pulmonary disease: causes, symptoms. Figures and facts. Treatment of COPD with non-pharmacological methods

Yu. E. Veltishcheva, Moscow

Considering the prevalence of electronic cigarettes and steam inhalers among children and adolescents and based on real clinical practice, it should be stated that chronic obstructive bronchitis, which is one of the forms of chronic obstructive pulmonary disease (COPD), can debut in childhood, which previously seemed impossible.

Keywords: children, smoking, electronic cigarettes, vaping, chronic obstructive pulmonary disease (COPD)

Key words: children, smoking, e-cigarettes, vaping, chronic obstructive pulmonary disease (COPD)

To date, COPD is understood as an independent disease, which is characterized by a partially irreversible restriction of airflow in the respiratory tract, which, as a rule, is steadily progressive and provoked by an abnormal inflammatory response of lung tissue to irritation by various pathogenic particles and gases. In response to the impact of external pathogenic factors, the function of the secretory apparatus changes (mucus hypersecretion, changes in the viscosity of the bronchial secretion) and a cascade of reactions develops, leading to damage to the bronchi, bronchioles and adjacent alveoli. Violation of the ratio of proteolytic enzymes and antiproteases, defects in the antioxidant defense of the lungs exacerbate damage.

The prevalence of COPD in the general population is about 1% and increases with age, reaching 10% in people over 40 years of age. According to WHO experts, by 2020 COPD will become the third leading cause of morbidity and mortality in the world. COPD is an urgent problem, since the consequences of the disease are the limitation of physical performance and disability of patients, including modern children and adolescents.

The diagnostic criteria for establishing the diagnosis of COPD in practice include characteristic clinical symptoms (prolonged cough and progressive dyspnea), anamnestic information (presence of risk factors) and functional indicators (progressive decrease in FEV1, and FEV1/FVC ratio).

As an illustration, we give the following clinical example:

Patient Yu., 16 years old, from a family with an uncomplicated allergic history; parents and relatives smoke for a long time, maternal grandfather died of lung cancer. Household history is aggravated by living in a damp apartment where cats are kept. From the age of 3, the girl suffered from recurrent bronchitis with lingering cough, mainly in the cold season, repeatedly received courses of antibiotics and mucolytics on an outpatient basis. At the age of 7 she was on long-term inpatient treatment for a urinary tract infection, in the hospital for the first time she began to smoke cigarettes with other children. Subsequently, due to increased episodes of bronchitis and a long-lasting cough, she was registered with a pulmonologist at the place of residence. The disease was regarded as the onset of bronchial asthma, basic treatment was carried out with inhaled glucocorticosteroids in gradually increasing doses, due to the insufficient effect during the last year before contacting the clinic, she received a combined drug Seretide. She was repeatedly hospitalized in a hospital at the place of residence for relief of exacerbations, inhalations with bronchodilators, mucolytics and antibacterial drugs. Between exacerbations, she suffered from a paroxysmal obsessive cough (in the mornings with scanty sputum), exercise tolerance did not suffer, but the girl often complained of weakness, fatigue and headaches. She was first sent for examination to clarify the diagnosis at the age of 16. Upon admission, the state of moderate severity; complaints of unproductive cough in the morning with mucopurulent sputum; episodes of exacerbations with febrile temperature and increased cough. On examination, there is no dyspnea at rest, physical development is average, harmonious, signs of peripheral osteoarthropathy are not expressed; the chest is not deformed, the percussion sound is boxy, in the lungs, against the background of hard breathing, wet rales of various sizes are heard. When examining deviations from the indicators of general blood tests, urine, biochemical blood tests were not revealed. Immunological study of humoral and cellular immunity, phagocytic activity of neutrophils made it possible to exclude an immunodeficiency state. Allergological examination did not reveal specific sensitization to causative allergens. Morphological analysis of sputum confirmed its mucopurulent character; sputum culture revealed colonies of Staphylococcus aureus and epidermal streptococcus. The radiograph of the lungs showed signs of bronchitis and obstructive syndrome. When conducting spirometry, the volume-velocity parameters were within the proper values, the test with dosed physical activity did not reliably reveal post-exercise bronchospasm. Attention was drawn to the low level of nitric oxide in the exhaled air (FeNO = 3.2 ppb at the norm ppb), as well as sharp increase the content of carbon monoxide in the exhaled air (COex = 20 ppm at a rate of less than 2 ppm), which is pathognomonic for regular active smoking. During body plethysmography, the presence of obstructive disorders detected radiographically was confirmed: a sharp increase in the residual volume of the lungs and its contribution to the total lung capacity. Diaskintest was negative, which ruled out the presence of tuberculosis. The level of sweat chlorides was within the normal range, which disproved the presence of cystic fibrosis.

Markers of persistent viral and bacterial infections were not identified. A carefully collected anamnesis made it possible to clarify that from the age of seven to the present, the girl regularly smoked actively (from ½ to 1 pack of cigarettes per day), i.e. smoking experience by the time of contacting the clinic was 8 years. In her family, parents and close relatives smoked, cigarettes were in the public domain.

At the same time, the girl's parents, knowing about her smoking, did not connect the child's complaints of prolonged cough and repeated bronchitis with smoking and were determined to treat cough with medication. The girl independently made several unsuccessful attempts to quit smoking, but she did not turn to anyone for specialized help. Thus, based on the medical history and the results of the examination, the alleged diagnosis of bronchial asthma was not confirmed, and the patient was diagnosed with Chronic obstructive bronchitis (J 44.8). An explanatory conversation was held with the parents of the teenager and the girl herself, recommendations were given on improving the life, giving up smoking for all family members (including with the help of anti-tuxedo cabinet specialists at the place of residence) and tactics for treating the underlying disease.

In routine clinical practice, portable gas analyzers for determining the level of carbon monoxide in exhaled air (COex) have proven themselves well for detecting active smokers. Thus, in our clinic, 100 patients with bronchial asthma (BA) of varying severity aged 6–18 years (68 boys, 32 girls) were examined for CO2 content using a Smokerlyzer CO analyzer (Bedfont, England).

The simplicity of the breathing maneuver (15-second breath-hold at the height of inhalation followed by exhalation through the mouthpiece of the gas analyzer) makes the non-invasive measurement of COEX available for most children over 6 years of age. Among the surveyed, 14 active smokers aged 13 to 18 years were identified: their average COvy was 7.9 ppm (4-16 ppm) (1 ppm - 1 particle of gas per 106 particles of air); all of them were in the clinic due to the severe course of BA and denied the fact of smoking. Nineteen patients who belonged to the category of passive smokers (in their families, parents or close relatives smoked at home) had an average level of CO-exp = 1.3 ppm (0-2 ppm), which did not significantly distinguish them from the group of children not exposed to tobacco smoke (67 patients, mean COexp = 1.4ppm (0-2ppm)). However, among patients exposed to passive smoking, children with more severe BA prevailed. The results obtained indicate the potential practical significance of using CO analyzers in a children's pulmonology clinic to identify active smokers in order to conduct targeted anti-smoking programs and monitor their effectiveness.

In addition, the most widely used biomarker for human exposure to cigarette smoke is cotinine, the major nicotine metabolite detected by gas chromatography or radioimmunoassay in blood or, preferably, urine, reflecting the level of absorption of nicotine through the lungs. After smoking cessation, cotinine persists in the urine longer than nicotine and is detected within 36 hours after the last cigarette is smoked. In addition, it was found that the level of cotinine in the urine significantly increases in passive smokers. To date, there are special test strips for the determination of cotinine in urine using the immunochromatographic method.

A particular problem is patients who use vaping as an alternative to smoking (from the English vapor - steam, evaporation). This invention is only 14 years old: in 2003, Hong Kong smoker Hong Lik, whose father died of COPD, patented the first electronic vaporizer cigarette designed to quit smoking. However, the further fate of this invention went along the path of improvement various devices and the creation of flavor-aromatic mixtures, the benefits of which raise more and more questions.

The following clinical example is proof of this.

Patient G., 15 years old, from a family with a burdened allergic history: mother and maternal grandmother had allergic rhinitis, her sister had atopic dermatitis.

Since the beginning of the visit to the kindergarten, he often began to suffer from respiratory infections with a prolonged cough, persistent nasal congestion was often disturbing, and during examination at the place of residence, the allergic genesis of complaints was not confirmed. With the start of school attendance, acute respiratory infections became less common, but nasal congestion persisted, and he received topical steroids with a positive effect in courses. From the age of 12, he began to periodically smoke electronic cigarettes, repeated acute respiratory infections with a prolonged cough resumed. At the age of 15, he began to use a steam inhaler with various flavoring additives. After a month of active "soaring" against the background of subfebrile temperature, a debilitating paroxysmal cough, periodically - to vomiting, aggravated by laughter, deep breathing, when going outside and any physical exertion, nasal congestion increased. The boy stopped attending school. At the place of residence, pertussis-parapertussis and chlamydial-mycoplasma infections were excluded, X-ray examination was performed twice to rule out pneumonia. In therapy for two months, inhalations of berodual, pulmicort in high doses, ascoril, antihistamines, 3 courses of antibiotics, lasolvan, singular, intranasal anti-inflammatory drugs with insufficient effect: excruciating paroxysmal spastic cough and persistent nasal congestion persisted. Upon admission to the clinic, there was a rough paroxysmal cough; there was no dyspnea at rest; physical development above average, disharmonious due to overweight(height 181 cm, weight 88 kg); signs of peripheral osteoarthropathy are not expressed; the chest is not deformed; percussion sound with a box shade; in the lungs against the background of hard breathing during forced exhalation, single wet and dry wheezing rales were heard. When examined in general blood tests, urine, biochemical analysis blood - no pathological changes. Allergological examination revealed a significant sensitization to the mold of the genus Alternariana against the background of a normal level of total IgE. Plain chest x-ray showed signs of obstructive syndrome, bronchitis. When conducting spirometry, a moderate decrease in VC and FVC was noted, forced expiratory rate indicators were within the proper values, a test with dosed physical activity did not reveal significantly post-exercise bronchospasm. drew attention to himself normal level nitric oxide in exhaled air (FeNO = 12.5 ppb at a rate of 10-25ppb), as well as a moderate increase in carbon monoxide in exhaled air (COex = 4ppm at a rate of up to 2ppm), which is pathognomonic for active smoking (although the patient claimed that uses nicotine-free mixtures for vaping (!). During body plethysmography, the presence of obstructive disorders detected radiographically was confirmed: a pronounced increase in the residual volume of the lungs and its contribution to the total lung capacity. Diaskintest was negative, which ruled out tuberculosis. When examined for markers of persistent infections, immunoglobulins of the IgG class to respiratory chlamydia were detected in low titers. An ENT doctor diagnosed allergic rhinitis. When clarifying the anamnesis, it turned out that from 12 to 14 years old, the teenager regularly smoked electronic cigarettes with a low nicotine content; has been vaping since the age of 15, using vapor inhalations of various aromatic mixtures without nicotine. The patient strongly believes that vaping is a safe alternative to active smoking. From the words, he uses only expensive devices and liquids for vaping, spends a lot of time in vaping companies, where he tries different mixtures for vaping. Parents are not informed about the possible consequences of vaping and finance it, while they are set on active drug treatment of cough, as "it interferes with schoolwork."

Thus, based on the history and the results of the examination, the following diagnosis was established: Chronic obstructive bronchitis (J 44.8). allergic rhinitis(J 31.0).

An explanatory conversation was held with parents and a teenager, recommendations were given on the categorical refusal to use steam inhalers and smoking. In order to achieve stabilization of the condition and relief of obsessive cough, it was necessary for another 2 months. use inhaled steroids in high doses in combination with combined bronchodilators through a nebulizer, followed by switching to taking a combined inhaled corticosteroid in high doses (symbicort) while taking an antileukotriene drug (montelukast) for 6 months.

To date, more than 500 brands of devices designed for “soaring” and almost 8,000 types of liquids with and without nicotine are being sold in the world, the vapors of which are inhaled. It has been found that between high school students' fascination with electronic cigarettes and vaporizers has tripled. It is believed that the number of teen vapers already exceeds the number of teens who smoke conventional cigarettes.

Vaping liquids are known to contain glycerin, propylene glycol, distilled water, and various flavors. Propylene glycol and glycerin - two-and trihydric alcohols, viscous, colorless liquids; widely used in household chemicals, cosmetics, are permitted as food additives (E1520 and E422). When heated, propylene glycol (bp.=187°C) and glycerin (b.p.=290°C) evaporate with the formation of a number of carcinogens: formaldehyde, propylene oxide, glycidol, etc. It has been proven that lung tissue cells respond to exposure to water vapor from vaping, as they do to exposure to cigarette smoke, which increases the likelihood of developing lung cancer (compared to non-smokers). To date, some US states equate vapers with smokers, they are prohibited from vaping on board aircraft, in public places and in stores.

According to the FDA (FoodandDrugAdministration, USA - US Food and Drug Administration), liquids for electronic devices may contain 31 toxic Chemical substance, including acrolein, diacetyl, and formaldehyde, which levels increase with temperature and device type. Thus, liquids in these devices can be heated up to 300°C (for example, Tbp. acrolein = 52.7°C), which entails the release of substances hazardous to health. In addition, in experiments on animals after vaping, the development of acute lung failure up to half an hour. In addition, only in 8 months of 2016, 15 people were treated with burns to the face, hands, thighs and groin, which were obtained as a result of the explosion of electronic cigarettes and steam devices; most patients required skin grafting.

In Russia, there are no strict legal restrictions on electronic cigarettes and vaporizers, and statistics of related diseases are not kept; we came across a single report of the death of a 15-year-old teenager from the Leningrad region after using a steam inhaler due to acute respiratory failure. Electronic cigarettes and vaporizers are currently certified as electronic devices - neither their effectiveness in trying to quit smoking, such as nicotine replacement drugs (chewing gum, patches), nor the composition of the contents of cartridges and liquids are tested. Electronic cigarettes and vaping devices are freely available (including in large shopping centers and on the Internet).

Therefore, an important task of modern pediatricians and pulmonologists is to create effective barriers to the "rejuvenation" of COPD. To this end, it is advisable to recommend anonymous surveys of children and adolescents to identify the prevalence of smoking, the use of electronic cigarettes and vaporizers, regular monitoring using portable spirometers, CO analyzers and determining the level of cotinine. An active educational position of the medical community can be facilitated by amendments to existing legislative acts on the mandatory certification of electronic cigarettes and vapor inhalers, as well as liquids for them as medical devices; their free sale to persons under 18 years of age should also be restricted. In addition, it is necessary to involve the media in the discussion of this topic, including through the use of Internet resources and television.

Before it's too late, we must make every effort so that COPD does not have a chance to become a reality in childhood!

The bibliography is under revision.

Therapy-Chronic obstructive pulmonary disease in children

E.V. Klimanskaya

Doctor of Medical Sciences, Professor, Head. Laboratory of Endoscopy in Pediatrics at the Department of Children's Diseases of the Moscow Medical Academy. THEM. Sechenov, Moscow

Chronic obstructive pulmonary disease (COPD) is a heterogeneous group of diseases caused by impaired airway patency. Under the violation of the patency of the respiratory tract is understood such a condition of the bronchi and lungs, which prevents pulmonary ventilation and outflow of bronchial contents. In children of the first years of life, violations of the free patency of the respiratory tract to a greater or lesser extent accompany many bronchopulmonary diseases, manifested by broncho-obstructive syndrome (BOS), which is understood as a symptom complex, including cough, cyanosis, shortness of breath.

In the past two decades, the spectrum of chronic inflammatory pathology lung has undergone significant changes, which decisively affected modern characteristics its structures. The incidence of allergic diseases has increased significantly, while bronchial asthma is gaining more and more weight. Epidemiological studies testify to the negative trend in the increase in the incidence of bronchial asthma, especially in children, according to which currently 4 to 8% of the population suffer from bronchial asthma, and in childhood this figure increases to 10%.

Beginning in childhood, respiratory diseases leading to obstructive syndrome are the most common cause of disability and premature disability. Therefore, the problem of COPD is becoming more and more important every year.

Etiology and pathogenesis

The causes of stenosing lesions of the respiratory tract in children are different. These lesions may be due to malformations, acquired and traumatic injuries, etc. But most often they are the result of inflammatory bronchopulmonary diseases. Bronchial obstruction occurs as a result of exposure to intra- and extra-bronchial factors. The former plays a dominant role in the development of obstructive lesions of the respiratory tract - these are inflammatory changes in the mucous membrane with hypersecretion, dyskrinia and congestion, various mechanical obstacles. Extrabronchial factors - increased The lymph nodes mediastinum, parabronchial cysts and tumors, abnormal vessels - exert pressure on the bronchi from the outside.

The symptomatology of biofeedback is determined by the leading link in pathogenesis, which has its own characteristics in various nosological forms. The basis for biofeedback in case of insufficiency of the muscular-elastic frame of the bronchi are dyskinesia and abrupt changes in the lumen of the lower respiratory tract during breathing and coughing. deep violations in the mucociliary transport system, causing obstruction and shortness of breath, are observed with congenital defects in the structure of the ciliated cells of the respiratory apparatus, with pathological viscosity of the bronchial secretion changed in the physicochemical composition. Developing on the basis of chronic allergic inflammation bronchospasm, hypersecretion, dyskrinia, and mucosal edema are essential pathophysiological components of asthma attacks.

The development of bronchial patency disorders is promoted by age-related anatomical and physiological features of the respiratory organs, among which the most important are the narrowness of the airways, the softness and compliance of their cartilaginous framework, the tendency of the mucous membrane to generalized edema and swelling.

The free patency of the bronchi is directly dependent on the mechanisms of self-purification of the lungs: bronchial peristalsis, the activity of the ciliated epithelium of the mucous membranes of the respiratory tract, cough, which accelerates the movement of mucus through the bronchi and trachea. In young children, due to the weakness of the respiratory muscles and the small amplitude of movement of the ribs and diaphragm, the cough impulse is weak and ineffective, excitability respiratory center reduced, and the lumen of narrow airways with pliable walls decreases even with their slight swelling. Therefore, in children it is much easier than in adults, there may be a violation of the patency of the bronchi.

Pathomorphology

Pathological changes in the lungs are largely determined by the size of the narrowing and the duration of its existence. According to the generally accepted classification of bronchial obstruction disorders (C.Jackson), there are three degrees of bronchial constriction.

At first degree the lumen of the bronchus is narrowed slightly. As a result, during inspiration, less air enters the corresponding segments of the lung than other areas. Coming obstructive hypoventilation.

With the second degree of bronchial obstruction, only a small free space remains for the passage of air, a so-called valve mechanism is created. During inhalation, when the bronchi expand, air partially enters below the obstruction. On exhalation, the bronchi collapse, preventing the reverse flow of air. Repeated respiratory movements under such conditions lead to swelling of the corresponding section of the lung parenchyma. Obstructive emphysema develops. The degree of lung swelling depends on the duration of the valve mechanism and the conditions for air circulation through the narrowed lumen of the bronchus.

In the third degree of violation of bronchial patency, the bronchus is completely obstructed and air does not penetrate into the lung. The air contained in the parenchyma is rapidly absorbed, and obstructive atelectasis develops. In the area of ​​atelectasis are created favorable conditions for the multiplication of microbes and the development of an inflammatory process, the course and outcome of which depend on the duration of the existence of occlusion.

Classification

To date, no unified classification of COPD has been formulated. it not an easy task, since it is necessary to combine diseases that are different in etiology and pathogenesis into a single group. Approaches to diagnosis and subsequent therapy are largely determined by pathogenesis. They are not the same with common types of bronchial obstruction and with limited bronchial lesions, with congenital pathology or acquired diseases. Therefore, when systematizing COPD, it seems important to group them taking into account the localization of pathological changes that cause obstruction, etiology and nosological forms.

Table 1. Classification of COPD in children

Tracheobronchomalacia, tracheobronchomegaly (Mounier-Kuhn syndrome), Williams-Campbell syndrome.

Primary ciliary dyskinesia, immovable cilia syndrome, Kartagener's syndrome.

Anomaly of the aorta (double arch) and pulmonary artery

Recurrent and chronic obstructive bronchitis.

Diagnostics

The negative trend towards irreversible pathoanatomical changes in COPD requires their earliest possible recognition and individual therapy, the purpose of which is to eliminate bronchial obstruction. The BOS symptom complex leading in COPD should not become self-sufficient when making a diagnosis. Diagnosis should be carried out based on the results of a comprehensive examination, highlighting the decisive diagnostic features (see Table 2).

Table 2. Differential diagnosis of COPD in children

At history taking important information about the presence of pulmonary pathology in the family, the frequency of spontaneous abortions and stillbirths, the presence of closely related marriages. Information about the course of pregnancy and childbirth (medication, alcohol, occupational hazards by the mother) is also extremely important. These data contribute to improving the efficiency of diagnosing congenital diseases. Allergological vigilance in the collection of anamnesis will help to avoid errors in the recognition of allergic diseases.

The variety of symptoms and early onset of infectious complications make it difficult to clinically recognize COPD. Along with this, it is possible to identify some diagnostic features due to etiological and pathogenetic factors.

An important role is given to the results of the study of the function external respiration(FVD). For COPD, the most typical obstructive type of violations of respiratory function. The fact of reversibility of functional disorders or their progression can be used in differential diagnosis bronchial asthma and other COPD.

Clinical signs of congenital diseases appear early, in the first year of life, most often against the background of an associated infection. Subsequently, diseases common type violations of bronchial patency are manifested by symptoms of chronic non-specific inflammation, characterized by an undulating course with periods of exacerbation, the presence of a wet productive cough with purulent or purulent-mucous sputum, moist widespread rales in the lungs. Many patients with congenital broncho-obstructive diseases lag behind in physical development, are emaciated, have deformity nail phalanges in the form of drum sticks. An x-ray examination reveals changes characteristic of chronic bronchopulmonary inflammation: deformation of the lung pattern, isolated shadows of compacted lung tissue, mediastinal displacement with a decrease in lung volumes. Plain radiography confirms the reverse arrangement of organs and the diagnosis of Kartagener's syndrome.

Contrasting bronchi - bronchography - with exhaustive completeness provides data on the morphological deformation of the bronchi and allows you to diagnose such nosological forms as Mounier-Kuhn and Williams-Campbell syndromes. During bronchoscopy, along with nonspecific inflammatory changes symptoms typical of some defects are found: excessive mobility and sagging of the posterior membranous wall of the trachea and bronchi in tracheobronchomalacia, pronounced folding of the tracheal walls with prolapse of intercartilaginous spaces, a symptom of "loss of light" in tracheobronchomegaly (Mounier-Kuhn's syndrome).

Anamnesis, characteristic appearance, increased content sweat electrolytes and genetic research allow the diagnosis of cystic fibrosis.

In the clinical picture local types obstruction, respiratory disorders come to the fore. The most important diagnostic symptom is shortness of breath on exhalation, accompanied by noise - expiratory stridor. However, pure expiratory stridor is rare. With high localization of stenosis, both inhalation and exhalation are difficult (mixed stridor). Depending on the degree of narrowing, participation of auxiliary muscles, retraction of compliant chest areas, and cyanosis are noted. With local types of obstruction, X-ray examination, including layer-by-layer, in some cases can help to make not only a symptomatic, but also an etiological diagnosis. With stenosis of the trachea and large bronchi, radiographs show a break or narrowing of the air column, and with neoplasms, the shadow of the tumor and the narrowing of the lumen caused by it.

Bronchoscopy is an objective research method that allows identifying endobronchial causes of stenosis and making a final etiological diagnosis. The endoscopic picture in congenital stenosis is quite typical. The lumen of the trachea looks like a narrow ring bordered by a whitish cartilage without a membranous part. Cystic formations are located eccentrically and cause narrowing of varying degrees. Compression stenoses of the trachea caused by an anomaly large vessels, are characterized by narrowing the lumen of the anterior and lateral walls of the suprabifurcation part of the trachea. In this case, a clear pulsation is determined. Comprehensive data allows you to get aortography.

At acquired local obstructive lesions, the importance of anamnestic information about possible aspiration is undeniable foreign body, traumatic injuries of the respiratory tract (burns), instrumental interventions (intubation), etc. X-ray examination helps to clarify this information. However, the final diagnosis, as with congenital stenosis, is possible only with bronchoscopy.

A special problem is the differential diagnosis of bronchial asthma. As mentioned earlier, bronchial asthma dominates among obstructive diseases, the frequency of which has increased in recent years not only in the population as a whole, but also in children under 5 years of age, in whom its diagnosis is mainly and presents known difficulties, primarily due to the fact that one of the leading criteria for bronchial asthma - recurrent BOS - is clinically indistinguishable at an early age, regardless of whether it develops on the background of atopy (bronchial asthma) or as a result of inflammatory edema mucous membrane caused by a viral infection (obstructive bronchitis). Obstructive conditions against the background of a respiratory viral infection are recorded in 10-30% of infants, and only a third of them are a manifestation of bronchial asthma. At the same time, hiding under the guise of a viral disease, bronchial asthma at this age is often not recognized for a long time. At the same time, BOS polymorphism significantly complicates clinical recognition of etiology and topical diagnosis of the level of bronchial obstruction. It leads to misdiagnosis bronchial asthma, for which patients with various congenital and acquired bronchopulmonary diseases are treated for a long time and unsuccessfully.

Indications for hereditary burden for allergic diseases, allergic reactions on food and medicine, a clear effect of bronchodilator therapy in the exclusion of congenital and acquired obstructive diseases can help clarify the likelihood and make a final diagnosis of bronchial asthma. In children older than 6 years, the results FVD research can provide some assistance in the differential diagnosis of bronchial asthma. An important difference between asthma and other COPD is the reversibility of obstruction and functional parameters. However, in some cases, even the entire complex of modern clinical, radiological and laboratory (determination of the level of general and specific IgE, skin allergic tests) studies is insufficient for a reliable diagnosis of bronchial asthma, and the true nature of the disease can only be clarified by bronchoscopy with a biopsy of the mucous membrane.

In conclusion, it should be repeated that in recent years the incidence of COPD among children has increased significantly and their etiological structure has changed significantly. Due to the uniformity of clinical symptoms, COPD is often diagnosed with a delay, already with a progressive course of the disease, and is the most common cause of disability in children. Implementation in clinical practice Modern instrumental, laboratory and X-ray methods of research have allowed a new approach to explaining the mechanisms of development of broncho-obstructive diseases and their diagnosis. Timely etiological diagnosis is necessary for targeted therapy and prevention of irreversible changes in the respiratory system.

Literature:

1. Kaganov S.Yu. Modern problems of pediatric pulmonology. Pulmonology 1992; 2:6-12.
2. Sears M R. Descriptive epidemiology of asthma. Lancet 1997; 350 (suppl 11): 1-4.
3. Johansen H, Dutta M, Mao Ychagani K, Sladecek I. An investigation of the increase in preschool-age asthma in Manitoba. Canada Health Rep 1992; four:.
4. Kaganov S.Yu., Rozinova N.N., Sokolova L.V. Difficulties and errors in the diagnosis of bronchial asthma in children. Russian Bulletin of Perinatology and Pediatrics 1993; 4:13-8.
5. Dodge R R, Burrows B: The prevalence and incidence of asthma and asthma-like symptoms in a general population sample. Am Rev Respir Dis 1980; 122(4):.
6. Brandt PL, Hoekstra MO. Diagnosis and treatment of recurrent coughing and wheezing in children younger than 4 years old. Ned Tijdschr Geneeskd 1997; 141:467-7.
7. Foucard T. The wheezy child. Acta Paediatr Scand 1985; 74(2): 172-8.
8. Rabbit E.B., Lukina O.F., Reutova V.S., Dorokhova N.F. Broncho-obstructive syndrome in ARVI in young children. Pediatrics 1990; 3:8-13.
9. Klimanskaya E.V., Sosyura V.Kh. Bronchoscopy under anesthesia in children with bronchial asthma. Pediatrics 1968; 9:39-42.

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Chronic obstructive pulmonary disease (COPD) develops gradually and is characterized by a progressive increase in symptoms of chronic respiratory failure.

COPD can develop as an independent disease, it is characterized by airflow limitation caused by an abnormal inflammatory process, which, in turn, arises as a result of constantly acting annoying factors(smoking, harmful production). Often the diagnosis of COPD combines two diseases at once, for example, Chronical bronchitis and emphysema. This combination is often observed in long-term smokers.

One of the main causes of disability in the population is COPD. Disability, reduced quality of life and, unfortunately, mortality - all this accompanies this disease. According to statistics, about 11 million people suffer from this disease in Russia, and the incidence is increasing every year.

Risk factors

The following factors contribute to the development of COPD:

• smoking, including passive;
• frequent pneumonia;
• unfavorable ecology;
• hazardous industries (work in a mine, exposure to cement dust from builders, metal processing);
• heredity (lack of alpha1-antitrypsin can contribute to the development of bronchiectasis and emphysema);
• prematurity in children;
• low social status, unfavorable living conditions.

COPD: symptoms and treatment

At the initial stage of development, COPD does not manifest itself in any way. The clinical picture of the disease occurs with prolonged exposure to adverse factors, for example, smoking for more than 10 years or working harmful production. The main symptoms of this disease are chronic cough, especially in the morning, a large amount of sputum when coughing and shortness of breath. At first, it appears during physical exertion, and with the development of the disease - even with slight exertion. It becomes difficult for patients to eat, and breathing requires high energy costs, shortness of breath appears even at rest.

Patients lose weight and become physically weak. Symptoms of COPD periodically increase and exacerbate. The disease proceeds with periods of remission and exacerbation. Deterioration of the physical condition of patients during periods of exacerbation can be from minor to life-threatening. Chronic obstructive pulmonary disease lasts for years. The further the disease develops, the more severe the exacerbation.

Four stages of the disease

There are only 4 degrees of severity of this disease. Symptoms do not appear immediately. Often, patients seek medical help late, when an irreversible process develops in the lungs and they are diagnosed with COPD. Disease stages:

1. Mild - usually not manifested by clinical symptoms.
2. Moderate - there may be a cough in the morning with or without sputum, shortness of breath during physical exertion.
3. Severe - cough with a large discharge of sputum, shortness of breath even with slight exertion.
4. Extremely severe - threatens the life of the patient, the patient loses weight, shortness of breath even at rest, cough.

Often patients with early stages do not seek help from a doctor, precious time for treatment has already been lost, this is the insidiousness of COPD. The first and second degrees of severity usually occur without pronounced symptoms. Worries only cough. Severe shortness of breath appears in the patient, as a rule, only at the 3rd stage of COPD. Grades from the first to the last in patients can proceed with minimal symptoms in the remission phase, but it is worth a little hypothermia or a cold, the condition worsens sharply, an exacerbation of the disease occurs.

Diagnosis of the disease

Diagnosis of COPD is carried out on the basis of spirometry - this is the main study for making a diagnosis.

Spirometry is a measurement of respiratory function. The patient is asked to take a deep breath and the same maximum exhalation into the tube. special device. After these steps, the computer connected to the device will evaluate the indicators, and if they differ from the norm, the study is repeated 30 minutes after inhaling the medicine through the inhaler.

This test will help the pulmonologist determine if coughing and shortness of breath are symptoms of COPD or some other disease, such as bronchial asthma.

To clarify the diagnosis, the doctor may prescribe additional methods examinations:

• general blood analysis;
• measurement of blood gases;
• general sputum analysis;
• bronchoscopy;
• bronchography;
• CT (X-ray computed tomography);
• ECG (electrocardiogram);
• X-ray of the lungs or fluorography.

How to stop the progression of the disease?

Smoking cessation is an effective and proven method that can stop the progression of COPD and the decline in lung function. Other methods can alleviate the course of the disease or delay the exacerbation, the progression of the disease is not able to stop. In addition, the ongoing treatment in patients who quit smoking is much more effective than in those who could not give up this habit.

Prevention of influenza and pneumonia will help prevent exacerbation of the disease and further development of the disease. It is necessary to get vaccinated against influenza annually before the winter season, preferably in October.

Revaccination against pneumonia is required every 5 years.

COPD treatment

There are several treatments for COPD. These include:

• drug therapy;
• oxygen therapy;
• pulmonary rehabilitation;
• surgery.

Drug therapy

If drug therapy for COPD is chosen, treatment consists of continuous (lifelong) use of inhalers. Effective drug, helping to relieve shortness of breath and improve the patient's condition, is selected by a pulmonologist or therapist.

Short-acting beta-agonists (rescue inhalers) can quickly relieve shortness of breath, they are used only in emergency cases.

Short-acting anticholinergics can improve lung function, relieve severe symptoms of the disease and improve the general condition of the patient. With mild symptoms, they can not be used constantly, but only as needed.

For patients with severe symptoms, long-acting bronchodilators are prescribed in the last stages of COPD treatment. Preparations:

• Long-acting beta2-agonists (Formoterol, Salmeterol, Arformoterol) can reduce the number of exacerbations, improve the quality of life of the patient and alleviate the symptoms of the course of the disease.
• Long-acting M-anticholinergics (Tiotropium) will help improve lung function, reduce shortness of breath and relieve symptoms of the disease.
• For treatment, a combination of beta 2-agonists and anticholinergics is often used - this is much more effective than using them separately.
• Theophylline (Teo-Dur, Slo-bid) reduces the frequency of exacerbations of COPD, treatment with this drug complements the action of bronchodilators.
• Glucocorticoids, which have powerful anti-inflammatory effects, are widely used to treat COPD in the form of tablets, injections or inhalations. Inhaled drugs such as Fluticasone and Budisonin may reduce the number of exacerbations, increase the period of remission, but will not improve respiratory function. They are often prescribed in combination with bronchodilators. prolonged action. Systemic glucocorticoids in the form of tablets or injections are prescribed only during periods of exacerbation of the disease and for a short time, because. have a number of adverse side effects.
• Mucolytic drugs, such as Carbocestein and Ambroxol, significantly improve sputum discharge in patients and have a positive effect on their general condition.
• Antioxidants are also used to treat this disease. The drug "Acetylcestein" is able to increase periods of remission and reduce the number of exacerbations. This drug used in combination with glucocorticoids and bronchodilators.

Treatment of COPD with non-pharmacological methods

In conjunction with medicines non-pharmacological methods are also widely used to treat the disease. These are oxygen therapy and rehabilitation programs. In addition, patients with COPD should understand that it is necessary to completely stop smoking, because. without this condition, not only recovery is impossible, but the disease will also progress at a faster pace.

Particular attention should be paid to the quality and nutrition of patients with COPD. Treatment and improvement of the quality of life for patients with a similar diagnosis largely depends on themselves.

Oxygen therapy

Patients with a similar diagnosis often suffer from hypoxia - this is a decrease in oxygen in the blood. Therefore, not only the respiratory system suffers, but also all organs, because. they don't get enough oxygen. Patients may develop a range of side effects.

To improve the condition of patients and eliminate hypoxia and the consequences of respiratory failure in COPD, treatment is carried out with oxygen therapy. Preliminary, the level of oxygen in the blood is measured in patients. To do this, use such a study as the measurement of blood gases in arterial blood. Blood sampling is carried out only by a doctor, because. blood for research should be taken exclusively arterial, venous will not work. It is also possible to measure the level of oxygen using a pulse oximeter device. It is put on the finger and the measurement is taken.

Patients should receive oxygen therapy not only in a hospital, but also at home.

Food

About 30% of patients with COPD experience difficulty in eating, this is due to severe shortness of breath. Often they simply refuse to eat, and significant weight loss occurs. Patients weaken, immunity decreases, and in this state, infection can be added. You cannot refuse to eat. For such patients, fractional nutrition is recommended.

Patients with COPD should eat often and in small portions. eat food, rich in proteins and carbohydrates. Before eating, it is advisable to rest a little. The diet must include multivitamins and nutritional supplements(they are additional source calories and nutrients).

Rehabilitation

Patients with this disease are recommended annual spa treatment and special lung programs. In the offices physiotherapy exercises they can be taught special breathing exercises to be done at home. Such interventions can significantly improve the quality of life and reduce the need for hospitalization in patients diagnosed with COPD. Symptoms and traditional treatment are discussed. Once again, we emphasize that much depends on the patients themselves, effective treatment is possible only with a complete cessation of smoking.

COPD treatment folk remedies can also bring positive results. This disease existed before, only its name changed over time and traditional medicine coped with it quite successfully. Now that there are evidence-based treatments, folk experience can complement the action of medical drugs.

AT folk medicine for the treatment of COPD, the following herbs are successfully used: sage, mallow, chamomile, eucalyptus, linden flowers, sweet clover, licorice root, marshmallow root, flax seeds, anise berries, etc. Decoctions, infusions are prepared from this medicinal raw material or used for inhalation.

COPD - medical history

Let's turn to the history of this disease. The concept itself - chronic obstructive pulmonary disease - appeared only at the end of the 20th century, and such terms as "bronchitis" and "pneumonia" were first heard only in 1826. Further, 12 years later (1838), the well-known clinician Grigory Ivanovich Sokolsky described another disease - pneumosclerosis. At that time, most medical scientists assumed that pneumosclerosis was the cause of most diseases of the lower respiratory tract. Such damage to the lung tissue is called "chronic interstitial pneumonia".

In the next few decades, scientists around the world studied the course and proposed treatments for COPD. The history of the disease includes dozens of scientific works of physicians. So, for example, the great Soviet scientist, the organizer of the pathological and anatomical service in the USSR, Ippolit Vasilyevich Davydovsky, made invaluable contributions to the study of this disease. He described diseases such as chronic bronchitis, lung abscess, bronchiectasis, and called chronic pneumonia "chronic non-specific pulmonary consumption."

In 2002, Aleksey Nikolaevich Kokosov, Candidate of Medical Sciences, published his work on the history of COPD. In it, he pointed out that in the pre-war period and during the Second World War, the lack of proper and timely treatment, coupled with enormous physical exertion, hypothermia, stress and malnutrition, led to an increase in cardiopulmonary insufficiency among front-line veterans. Many symposiums and works of physicians have been devoted to this issue. At the same time, Professor Vladimir Nikitich Vinogradov proposed the term COPD (chronic nonspecific disease lungs), but this name did not stick.

A little later, the concept of COPD appeared and was interpreted as a collective concept that includes several diseases of the respiratory system. Scientists around the world continue to study the problems associated with COPD and offer new methods of diagnosis and treatment. But regardless of them, doctors agree on one thing: quitting smoking is the main condition for successful treatment.

Chronic obstructive pulmonary disease or COPD refers to chronic lung diseases associated with respiratory failure. Bronchial damage develops with emphysema complications against the background of inflammatory and external stimuli and has a chronic progressive character.

The alternation of latent periods with exacerbations requires a special approach to treatment. The risk of developing serious complications is quite high, which is confirmed by statistical data. Respiratory dysfunction causes disability and even death. Therefore, patients with this diagnosis need to know COPD, what it is and how the disease is treated.

general characteristics

When exposed to the respiratory system of various irritating substances in people with a predisposition to pneumonia, negative processes begin to develop in the bronchi. Amazed, first of all, distal departments- located in close proximity to the alveoli and lung parenchyma.

Against the background of inflammatory reactions, the process of natural discharge of mucus is disrupted, and small bronchi become clogged. When an infection is attached, inflammation spreads to the muscle and submucosal layers. As a result, bronchial remodeling occurs with replacement by connective tissues. In addition, lung tissue and bridges are destroyed, which leads to the development of emphysema. With a decrease in the elasticity of the lung tissues, hyperairiness is observed - the air literally inflates the lungs.

Problems arise precisely with the exhalation of air, since the bronchi cannot fully expand. This leads to a violation of gas exchange and a decrease in the volume of inhalation. A change in the natural process of breathing manifests itself in patients as shortness of breath in COPD, which is greatly enhanced by exertion.

Persistent respiratory failure causes hypoxia - oxygen deficiency. All organs suffer from oxygen starvation. With prolonged hypoxia, the pulmonary vessels narrow even more, which leads to hypertension. As a result, irreversible changes in the heart occur - the right section increases, which causes heart failure.

Why is COPD classified as a separate group of diseases?

Unfortunately, not only patients, but also medical workers little is known about the term chronic obstructive pulmonary disease. Doctors habitually diagnose emphysema or chronic bronchitis. Therefore, the patient does not even realize that his condition is associated with irreversible processes.

Indeed, in COPD, the nature of symptoms and treatment in remission are not much different from the signs and methods of therapy in pulmonary pathologies associated with respiratory failure. What, then, made doctors single out COPD in separate group.

Medicine has determined the basis of such a disease - chronic obstruction. But the narrowing of the gaps in the airways are also found in the course of other pulmonary diseases.

COPD, unlike other diseases such as asthma and bronchitis, cannot be permanently cured. Negative processes in the lungs are irreversible.

So, in asthma, spirometry shows improvement after bronchodilators are used. Moreover, the indicators of PSV, FEV may increase by more than 15%. While COPD does not provide significant improvements.

Bronchitis and COPD are two various diseases. But chronic obstructive pulmonary disease can develop against the background of bronchitis or proceed as an independent pathology, just like bronchitis can not always provoke COPD.

Bronchitis is characterized by a prolonged cough with sputum hypersecretion and the lesion extends exclusively to the bronchi, while obstructive disorders are not always observed. Whereas sputum production in COPD is not increased in all cases, and the lesion extends to structural elements Although auscultatory in both cases, bronchial rales are heard.

Why does COPD develop?

Not so few adults and children suffer from bronchitis, pneumonia. Why, then, chronic obstructive pulmonary disease develops only in a few. In addition to provoking factors, predisposing factors also affect the etiology of the disease. That is, the impetus for the development of COPD can be certain conditions in which people who are prone to pulmonary pathologies find themselves.

Predisposing factors include:

1. hereditary predisposition. It is not uncommon to have a family history of certain enzyme deficiencies. This condition has a genetic origin, which explains why the lungs do not mutate in a heavy smoker, and COPD in children develops for no particular reason.
2. Age and gender. For a long time it was believed that pathology affects men over 40. And the rationale is more related not to age, but to smoking experience. But today the number of women who smoke with experience is no less than that of men. Therefore, the prevalence of COPD among the fair sex is no less. In addition, women who are forced to breathe cigarette smoke also suffer. Passive smoking negatively affects not only the female, but also the children's body.
3. Problems with the development of the respiratory system. Moreover, we are talking about a negative effect on the lungs with intrauterine development, and the birth of premature babies in whom the lungs did not have time to develop for full disclosure. In addition, in early childhood, the lag in physical development negatively affects the state of the respiratory system.
4. Infectious diseases. For frequent respiratory problems infectious origin, both in childhood and at an older age, increases the risk of developing COL at times.
5. Hyperreactivity of the lungs. Initially, this condition is the cause of bronchial asthma. But in the future, the addition of COPD is not ruled out.

But this does not mean that all patients at risk will inevitably develop COPD.

Obstruction develops under certain conditions, which can be:

1. Smoking. Smokers are the main patients diagnosed with COPD. According to statistics, this category of patients is 90%. Therefore, it is smoking that is called the main cause of COPD. And the prevention of COPD is based primarily on smoking cessation.
2. Harmful working conditions. People who, by the nature of their work, are forced to regularly inhale dust of various origins, air saturated with chemicals, and smoke suffer from COPD quite often. Work in mines, construction sites, in the collection and processing of cotton, in metallurgical, pulp, chemical production, in granaries, as well as in enterprises producing cement, other building mixtures leads to the development of respiratory problems to the same extent in smokers and non-smokers .
3. Inhalation of combustion products. We are talking about biofuels: coal, wood, manure, straw. Residents who heat their homes with such fuel, as well as people who are forced to be present during natural fires, inhale combustion products that are carcinogens and irritate the respiratory tract.

In fact, any external effect on the lungs of an irritating nature can provoke obstructive processes.

Main complaints and symptoms

The primary signs of COPD are associated with coughing. Moreover, cough, to a greater extent, worries patients in daytime. At the same time, sputum separation is insignificant, wheezing may be absent. The pain practically does not bother, sputum leaves in the form of mucus.

Sputum with the presence of pus or a cough that provokes hemoptysis and pain, wheezing - the appearance of a later stage.

The main symptoms of COPD are associated with the presence of shortness of breath, the intensity of which depends on the stage of the disease:

• With mild shortness of breath, breathing is forced against the background brisk walking, as well as when climbing a hill;
• Moderate shortness of breath is indicated by the need to slow down the pace of walking on a flat surface due to breathing problems;
• Severe shortness of breath occurs after several minutes of walking at a free pace or walking a distance of 100 m;
• For shortness of breath of the 4th degree, the appearance of breathing problems during dressing, performing simple actions, immediately after going outside is characteristic.

The occurrence of such syndromes in COPD may accompany not only the stage of exacerbation. Moreover, with the progress of the disease, the symptoms of COPD in the form of shortness of breath, cough become stronger. On auscultation, wheezing is heard.

Breathing problems inevitably provoke systemic changes in the human body:

• The muscles involved in the breathing process, including the intercostal ones, atrophy, which causes muscle pain and neuralgia.
• In the vessels, changes in the lining, atherosclerotic lesions are observed. Increased tendency to form blood clots.
• Man facing heart problems in the form arterial hypertension, ischemic disease and even a heart attack. For COPD, the pattern of cardiac changes is associated with left ventricular hypertrophy and dysfunction.
• Osteoporosis develops, manifested by spontaneous fractures of the tubular bones, as well as the spine. Constant joint pain, bone pain cause a sedentary lifestyle.

The immune defense is also reduced, so any infections are not rebuffed. Frequent colds, at which it is observed heat, headache and other signs infection is not uncommon in COPD.

There are also mental and emotional disorders. Working capacity is significantly reduced, a depressive state, unexplained anxiety develops.

It is problematic to correct emotional disorders that have arisen against the background of COPD. Patients complain of apnea, stable insomnia.

In the later stages, cognitive disorders also appear, manifested by problems with memory, thinking, and the ability to analyze information.

Clinical forms of COPD

In addition to the stages of development of COPD, which are most often used in medical classification,

There are also forms of the disease according to the clinical manifestation:

1. bronchial type. Patients are more likely to cough, wheezing with sputum discharge. In this case, shortness of breath is less common, but heart failure develops more rapidly. Therefore, there are symptoms in the form of swelling and cyanosis of the skin, which gave the name to the patients "blue edema".
2. emphysematous type. The clinical picture is dominated by shortness of breath. The presence of cough and sputum is rare. The development of hypoxemia and pulmonary hypertension is observed only in the later stages. In patients, the weight decreases sharply, and the skin becomes pink-gray, which gave the name - "pink puffers".

However, it is impossible to speak of a clear division, since in practice COPD of a mixed type is more common.

Exacerbation of COPD

The disease can worsen unpredictably under the influence of various factors, including external, annoying, physiological and even emotional. Even after eating in a hurry, choking may occur. At the same time, the condition of a person is deteriorating rapidly. Increasing cough, shortness of breath. The use of the usual basic COPD therapy in such periods does not give results. During the period of exacerbation, it is necessary to adjust not only the methods of COPD treatment, but also the doses of the drugs used.

Usually treatment is carried out in a hospital, where it is possible to provide emergency assistance the patient and conduct the necessary examinations. If exacerbations of COPD occur frequently, the risk of complications increases.

Urgent care

Exacerbations with sudden attacks of suffocation and severe shortness of breath must be stopped immediately. Therefore, emergency assistance comes to the fore.

It is best to use a nebulizer or spacer and provide fresh air. Therefore, a person predisposed to such attacks should always have inhalers with them.

If first aid does not work and suffocation does not stop, it is urgent to call an ambulance.

Video

Chronic obstructive pulmonary disease

Principles of treatment for exacerbations

• Short bronchodilators are used with an increase in the usual dosages and frequency of administration.
• If bronchodilators do not have the desired effect, Eufilin is administered intravenously.
• It can also be prescribed for exacerbation of COPD treatment with beta-stimulants in combination with anticholinergic drugs.
• If pus is present in the sputum, antibiotics are used. It is advisable to use antibiotics with a wide range actions. It makes no sense to use narrowly targeted antibiotics without bakposev.
• The attending physician may decide to prescribe glucocorticoids. Moreover, Prednisolone and other drugs can be prescribed in tablets, injections or used as inhaled glucocorticosteroids (IGCS).
• If oxygen saturation is significantly reduced, oxygen therapy is prescribed. Oxygen therapy is carried out using a mask or nasal catheters to ensure proper oxygen saturation.

In addition, drugs can be used to treat diseases that frolic against the background of COPD.

Basic treatment

To prevent seizures and improve the general condition of the patient, a set of measures is taken, among which behavioral and drug treatment, dispensary observation is not the last.

The main drugs used at this stage are bronchodilators and corticosteroid hormones. Moreover, it is possible to use long-acting bronchodilator drugs.

Together with taking medications, it is necessary to pay attention to the development of pulmonary endurance, for which breathing exercises are used.

As for nutrition, the emphasis is on getting rid of excess weight and saturation with the necessary vitamins.

Treatment of COPD in the elderly, as well as in severe patients, is associated with a number of difficulties due to the presence of comorbidities, complications and reduced immune protection. Often such patients require constant care. Oxygen therapy in such cases is used at home and, at times, is the main way to prevent hypoxia and related complications.

When the damage to the lung tissue is significant, cardinal measures are necessary with resection of a part of the lung.

Modern methods of cardinal treatment include radiofrequency ablation (ablation). It makes sense to do RFA when detecting tumors, when for some reason the operation is not possible.

Prevention

The main methods of primary prevention directly depend on the habits and lifestyle of a person. Smoking cessation, the use of personal protective equipment significantly reduces the risk of developing lung obstruction.

Secondary prevention is aimed at preventing exacerbations. Therefore, the patient must strictly follow the recommendations of doctors for treatment, as well as exclude provoking factors from their lives.

But even cured, operated patients are not fully protected from exacerbations. Therefore, it is relevant tertiary prevention. Regular medical examination allows you to prevent the disease and detect changes in the lungs in the early stages.

Periodic treatment in specialized sanatoriums is recommended for both patients, regardless of the stage of COPD, and cured patients. With such a diagnosis in the anamnesis, vouchers to the sanatorium are provided on a preferential basis.

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Chronic obstructive pulmonary disease in children

Profile: pediatric
Stage: hospital.
Purpose of the stage:
1. establishment of the final diagnosis and development of treatment tactics;
2. liquidation inflammatory manifestations in the lungs;
3. elimination of symptoms of bronchial obstruction, symptoms of intoxication and correction
metabolic disorders;
4. improving the quality of life.
Duration of treatment: 21 day.

ICD codes: J44.0 Chronic obstructive pulmonary disease with acute respiratory infection lower respiratory tract
J44.1 Chronic obstructive pulmonary disease with exacerbation, unspecified
J44.9 Chronic obstructive pulmonary disease, unspecified
J44.8 Chronic obstructive pulmonary disease other specified
J45.8 Mixed asthma
J43.0 McLeod's syndrome
J43.9 Emphysema (lung) (pulmonary).

Definition: Chronic obstructive pulmonary disease (COPD) is a disease of the bronchopulmonary system, characterized by a decrease in airway patency.
paths, which is partially reversible. The decrease in airway patency is progressive and is associated with an inflammatory response of the lungs to dust particles or smoke, smoking, and air pollution.
COPD - disease state characterized by incompletely reversible airflow restriction. This limitation is usually progressive and is associated with pathological reaction lungs for harmful particles and gases.

Tab. 2. Classification:

Receipt: scheduled, emergency.

Indications for hospitalization:
1. progressive cough and shortness of breath;
2. lack of effect from the therapy at the previous stages of treatment;
3. the impossibility of establishing a diagnosis without invasive methods and the need to choose treatment tactics.

The required scope of examination before planned hospitalization:
1. General analysis blood;
2. General analysis of urine;
3. Allergist's consultation.

Diagnostic criteria:
The clinical picture of COPD is characterized by the same type of clinical manifestations - cough and shortness of breath, despite the heterogeneity of the diseases that make it up. The degree of their severity depends on the stage of the disease, the rate of progression of the disease and the predominant level of damage. bronchial tree. The rate of progression and severity of symptoms of COPD depends on the intensity of exposure to etiological factors and their summation.

Objective examination:
Chronic cough (paroxysmal or daily. Often lasts all day; occasionally only at night), chronic sputum production (any episode of chronic sputum production may indicate COPD), acute bronchitis(repeating many times), shortness of breath (progressive. Constant, aggravated by physical exertion, respiratory tract infections).

List of main diagnostic measures:
1. Complete blood count;
2. General analysis of urine;
3. Forced vital capacity lungs (FVC) - (FVC);
4. Forced expiratory volume in 1 second (FEV1) - (FEV1);
5. Sputum examination - cytological, cultural.

List of additional diagnostic measures:
1. Calculation of the ratio FEV1 / FVC (FEV1 / FVC);
2. Bronchodilation tests;
3. Pulse oximetry;
4. Study with physical activity;
5. Immunological methods;
6. X-ray methods;
7. Computed tomography;
8. Bronchological examination.

Treatment tactics:
1. Bronchodilator therapy.
2. Mucolytic therapy.
3. Antibacterial therapy.
4. Chest massage.
5. Anti-inflammatory therapy: selective M-cholinolytics, prolonged sympathomimetics, according to indications - corticosteroids, cromones (inhalation).
6. Immunocorrection (according to indications).
7. Antibiotics (according to indications).
8. Rehabilitation therapy.
9. Bronchodilatory therapy.

The use of bronchodilators is the basic therapy, mandatory in the treatment patients with COPD.
Preference is given to the use of inhaled forms of bronchodilators.
Of the existing bronchodilators in the treatment of COPD, anticholinergics, b2-agonists and methylxanthines are used. The sequence of application and the combination of these drugs depends on the severity of the disease, individual features its progression.

M-cholinolytics are generally recognized as first-line drugs. Their inhalation appointment is mandatory for all degrees of severity of the disease.
Anticholinergic drugs - M-cholinolytics.
The leading pathogenetic mechanism of bronchial obstruction in COPD is cholinergic bronchoconstriction, which can be inhibited by anticholinergic (AChE) drugs.

Currently, inhaled anticholinergic drugs are used - quaternary ammonium derivatives. The best known of these is ipratropium bromide 20 µg, which is used mainly in metered-dose aerosols.
b2-agonists (fenoterol 50 mg, salbutamol 100 mcg, terbutaline 100 mcg) have a rapid effect on bronchial obstruction (with its reversible component preserved).

Combined treatment:
In the treatment of COPD of medium and severe course the use of b2-agonists in combination with anticholinergics allows potentiating the bronchodilatory effect and significantly reducing the total dose of b2-agonists, thereby reducing the risk of side effects of the latter. The advantages of the combination are also the impact on two pathogenetic mechanisms of bronchial obstruction and the rapid onset of bronchodilator action. For this purpose, fixed combinations of drugs in one inhaler are very convenient: (ipratropium bromide 20 mcg + fenoterol 50 mcg).

Methylxanthines:
With insufficient effectiveness of anticholinergics and b2-agonists, methylxanthine preparations (theophylline caps. 100 mg) should be added.
The use of prolonged forms of theophylline is very convenient, especially for nocturnal manifestations of the disease. Switching from one methylxanthine drug to another can also affect blood levels of the drug, even if the doses are the same.

Mucoregulatory agents:
Ambroxol 30 mg stimulates the formation of low viscosity tracheobronchial secretion due to the depolymerization of acid mucopolysaccharides bronchial mucus and production of neutral mucopolysaccharides by goblet cells.
Acetylcysteine ​​100 mg, in 200 mg granules.
Carbocysteine ​​syrup 200 ml normalizes the quantitative ratio of acidic and neutral sialomucins in bronchial secretions.

Glucocorticosteroid therapy.
Indication for corticosteroid (CS) therapy in COPD is ineffectiveness maximum doses means of basic therapy - bronchodilators.
Efficacy of corticosteroids as a means of reducing the severity
bronchial obstruction in patients with COPD is not the same. Only in 10-30% of patients with their use improves bronchial patency. In order to resolve the issue of the advisability of the systematic use of corticosteroids, a trial oral therapy should be carried out: 20-30 mg / day at a rate of 0.4-0.6 mg / kg (prednisolone) for 3 weeks. An increase in response to bronchodilators in a bronchodilator test by 10% of the expected FEV1 values ​​or an increase in FEV1 by at least 200 ml during this time indicates positive influence corticosteroids on bronchial patency and may be the basis for their long-term use.
If the test therapy of the CS improves bronchial patency, which allows you to effectively deliver inhaled forms of drugs to lower divisions respiratory tract, patients are prescribed inhaled forms of CS 100 mcg / dose.
The systemic use of CS entails a wide range of side effects, including special place belongs to the general steroid myopathy (including the respiratory muscles).
With their inhalation use, the list of complications narrows down to fungal and
bacterial superinfection of the respiratory tract, but the therapeutic effect comes more slowly.

Currently, there is no generally accepted point of view on the tactics of using systemic and inhaled CS in COPD.
Correction of respiratory failure Correction of respiratory failure is achieved through the use of oxygen therapy, training of the respiratory muscles. It should be emphasized that the intensity, volume and nature drug treatment depend on the severity of the condition and the ratio of reversible and
irreversible components of bronchial obstruction. With the depletion of the reversible component, the nature of the therapy changes. Methods aimed at correcting respiratory failure come first. At the same time, the volume and intensity of basic therapy are preserved.

An indication for systematic oxygen therapy is a decrease in PaO2 in the blood to 60 mm Hg. Art., decrease in SaO2< 85% при стандартной пробе с 6-минутной ходьбой и < 88% в покое.
Preference is given to long-term (18 hours a day) low-flow (2-5 liters per minute)
oxygen therapy both in stationary conditions and at home. In severe respiratory failure, helium-oxygen mixtures are used. For home oxygen therapy, oxygen concentrators are used, as well as devices for non-invasive ventilation of the lungs with negative and positive pressure on inhalation and exhalation.

Respiratory muscle training is achieved with an individually tailored breathing exercises. Perhaps the use of transcutaneous electrical stimulation of the diaphragm.

In case of severe polycythemic syndrome (Hb > 155 g/l), it is recommended to perform erythrocytepheresis with the removal of 500-600 ml of deplasmated erythrocyte mass. If it is technically impossible to carry out erythrocytepheresis, bloodletting can be performed in a volume of 800 ml with adequate replacement with isotonic sodium chloride solution.

Anti-infective therapy:
During the stable course of COPD, antibiotic therapy is not carried out.
In the cold season, patients with COPD often experience exacerbations of infectious origin. The most common causes are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarralis, and viruses. Antibiotics are prescribed in the presence of clinical signs of intoxication, an increase in the amount of sputum and the appearance of purulent elements in it. Treatment is usually given empirically and lasts 7-14 days. The selection of an antibiotic according to the sensitivity of the flora in vitro is carried out only if empirical antibiotic therapy is ineffective. Do not prescribe antibiotics in inhalation. Antibiotics are not recommended for disease prevention.

List of essential medicines:
1. Fenoterol 5 mg tab.; 0.5 mg/10 ml injection;
2. Salbutamol 100 mcg/dose aerosol; 2 mg, 4 mg tab.; 20 ml solution for nebulizer;
3. Ipratropium bromide 100 ml aerosol;
4. Theophylline 100 mg, 200 mg, 300 mg tab.; 350 mg tablet retard;
5. Ambroxol 30 mg tab.; 15 mg / 2 ml amp.; 15 mg/5 ml, 30 mg/5 ml syrup;
6. Acetylcysteine ​​2% 2 ml amp.; 100 mg, 200 mg tab.;
7. Prednisolone 30 mg/ml amp.; 5 mg tab.

List of additional medicines:
1. Terbutaline 1000 mg tab.
2. Amoxicillin 500 mg, 1000 mg tab.; 250 mg; 500 mg caps.; 250 mg/5 ml oral suspension;
3. Amoxicillin + clavulanic acid 625 mg tab.; 600 mg in vial, solution for injection.

Protocol code: 04-044v

Profile: pediatric

Stage: hospital

Purpose of the stage:

1. establishment of the final diagnosis and development of treatment tactics;

2. elimination of inflammatory manifestations in the lungs;

Elimination of symptoms of bronchial obstruction, symptoms of intoxication and correction of metabolic disorders;

4. improving the quality of life.

Duration of treatment: 21 days

ICD codes:

J44.0 Chronic obstructive pulmonary disease with acute respiratory infection of the lower respiratory tract

J44.1 Chronic obstructive pulmonary disease with exacerbation, unspecified

J44.9 Chronic obstructive pulmonary disease, unspecified

J44.8 Chronic obstructive pulmonary disease other specified

J45.8 Mixed asthma

J43.0 McLeod's syndrome

J43.9 Emphysema (lung) (pulmonary)

Definition: Chronic obstructive pulmonary disease (COPD)

Disease of the bronchopulmonary system, characterized by a decrease in airway patency, which is partially reversible.

The decrease in airway patency is progressive and is associated with an inflammatory response of the lungs to dust particles or smoke, smoking, and air pollution.

COPD is a disease state characterized by airflow limitation that is not fully reversible. This limitation is usually progressive and is associated with an abnormal reaction of the lungs to harmful particles and gases.

Classification:

Risk factors:

Admission: planned, emergency

Indications for hospitalization:

1. progressive cough and shortness of breath;

2. lack of effect from the therapy at the previous stages of treatment;

3. the impossibility of establishing a diagnosis without invasive methods and the need to choose treatment tactics.

The required scope of examination before planned hospitalization:

1. Complete blood count;

2. General analysis of urine;

3. Allergist's consultation.

Diagnostic criteria:

The clinical picture of COPD is characterized by the same type of clinical manifestations - cough and shortness of breath, despite the heterogeneity of the diseases that make it up. The degree of their severity depends on the stage of the disease, the rate of progression of the disease and the predominant level of damage to the bronchial tree. The rate of progression and severity of symptoms of COPD depends on the intensity of exposure to etiological factors and their summation.

Objective examination Emphysematous form Bronchitis form

Chronic cough (paroxysmal or daily. Often lasts all day; occasionally only at night), chronic sputum production (any case of chronic sputum production may indicate COPD), acute bronchitis (recurring many times), shortness of breath (progressive. Constant, worse with exertion, respiratory infections)

List of main diagnostic measures:

1. Complete blood count;

2. General analysis of urine;

3. Forced vital capacity (FVC) - (FVC);

4. Forced expiratory volume in 1 second (FEV1) - (FEV1);

5. Sputum examination - cytological, cultural.

List of additional diagnostic measures:

1. Calculation of the ratio FEV1 / FVC (FEV1 / FVC);

2. Bronchodilation tests;

3. Pulse oximetry;

4. Study with physical activity;

5. Immunological methods;

6. X-ray methods;

7. Computed tomography;

8. Bronchological examination.

Treatment tactics:

1. Bronchodilator therapy.

2. Mucolytic therapy.

3. Antibacterial therapy.

4. Chest massage.

5. Anti-inflammatory therapy: selective M-cholinolytics, prolonged sympathomimetics, according to indications - corticosteroids, cromones (inhalation).

6. Immunocorrection (according to indications). Antibiotics:

7. Rehabilitation therapy Bronchodilator therapy

The use of bronchodilator drugs is the basic therapy that is mandatory in the treatment of patients with COPD.

Preference is given to the use of inhaled forms of bronchodilators. Of the existing bronchodilators, anticholinergics, L2-agonists and methylxanthines are used in the treatment of COPD. The sequence of application and the combination of these drugs depends on the severity of the disease, the individual characteristics of its progression. M-cholinolytics are generally recognized as first-line drugs. Their inhalation appointment is mandatory for all degrees of severity of the disease. Anticholinergic drugs - M-cholinolytics The leading pathogenetic mechanism of bronchial obstruction in COPD is cholinergic bronchoconstriction, which can be inhibited by anticholinergic (AChE) drugs.

Algorithm for continuous bronchodilator therapy for COPD.

Currently, inhaled anticholinergic drugs are used - quaternary ammonium derivatives. The best known of these is ipratropium bromide *20 μg, which is used mainly in metered-dose aerosols.

L2-agonists (fenoterol* 50 mg, salbutamol** 100 µg, terbutaline 100 µg) have a rapid effect on bronchial obstruction (with its reversible component preserved).

Combined treatment

In the treatment of moderate and severe COPD, the use of L2-agonists in combination with anticholinergics can potentiate the bronchodilatory effect and significantly reduce the total dose of L2-agonists, thereby reducing the risk of side effects of the latter. The advantages of the combination are also the impact on two pathogenetic mechanisms of bronchial obstruction and the rapid onset of bronchodilator action. For this purpose, fixed combinations of drugs in one inhaler are very convenient: (ipratropium bromide * 20 mcg + fenoterol * 50 mcg).

Methylxanthines

With insufficient effectiveness of anticholinergics and L2-agonists, methylxanthine preparations (theophylline ** caps. 100 mg) should be added.

The use of prolonged forms of theophylline is very convenient, especially for nocturnal manifestations of the disease. Switching from one methylxanthine drug to another can also affect blood levels of the drug, even if the doses are the same.

Mucoregulatory agents

Ambroxol** 30 mg stimulates the formation of low viscosity tracheobronchial secretion due to the depolymerization of acid mucopolysaccharides in bronchial mucus and the production of neutral mucopolysaccharides by goblet cells.

Acetylcysteine ​​* 100 mg, in granules of 200 mg

Carbocysteine ​​syrup 200 ml normalizes the quantitative ratio of acidic and neutral sialomucins in bronchial secretions. Glucocorticosteroid therapy*

The indication for corticosteroid (CS) therapy in COPD is the ineffectiveness of the maximum doses of basic therapy - bronchodilators.

The effectiveness of corticosteroids as a means of reducing the severity of bronchial obstruction in patients with COPD is not the same. Only in 10-30% of patients with their use improves bronchial patency. In order to resolve the issue of the advisability of the systematic use of corticosteroids, a trial oral therapy should be carried out: 20-30 mg / day at a rate of 0.4-0.6 mg / kg (prednisolone) for 3 weeks. An increase in response to bronchodilators in a bronchodilation test by 10% of the expected FEV1 values ​​or an increase in FEV1 by at least 200 ml during this time indicates a positive effect of corticosteroids on bronchial patency and may be the basis for their long-term use.

If the test therapy of CS improves bronchial patency, which makes it possible to effectively deliver inhaled forms of drugs to the lower respiratory tract, patients are prescribed inhaled forms of CS* 100 mcg/dose.

The systemic use of CS entails a wide range of side effects, among which a special place belongs to general steroid myopathy (including the respiratory muscles). With their inhalation use, the list of complications is narrowed down to fungal and bacterial superinfection of the respiratory tract, but the therapeutic effect also occurs more slowly.

Currently, there is no generally accepted point of view on the tactics of using systemic and inhaled CS in COPD.

Correction of respiratory failure

Correction of respiratory failure is achieved through the use of oxygen therapy, training of the respiratory muscles. It should be emphasized that the intensity, volume and nature of drug treatment depend on the severity of the condition and the ratio of reversible and irreversible components of bronchial obstruction. With the depletion of the reversible component, the nature of the therapy changes. Methods aimed at correcting respiratory failure come first. At the same time, the volume and intensity of basic therapy are preserved.

An indication for systematic oxygen therapy is a decrease in PaO2 in the blood to 60 mm Hg. Art., decrease in SaO2 The training of the respiratory muscles is achieved with the help of individually selected breathing exercises. Perhaps the use of transcutaneous electrical stimulation of the diaphragm.

In case of severe polycythemic syndrome (Hb > 155 g/l), it is recommended to perform erythrocytepheresis with the removal of 500-600 ml of deplasmated erythrocyte mass. If it is technically impossible to carry out erythrocytepheresis, bloodletting can be performed in a volume of 800 ml with adequate replacement with isotonic sodium chloride solution. Anti-infective therapy

During the stable course of COPD, antibiotic therapy is not carried out.

In the cold season, patients with COPD often experience exacerbations of infectious origin. The most common causes are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarralis, and viruses. Antibiotics* are prescribed in the presence of clinical signs of intoxication, an increase in the amount of sputum and the appearance of purulent elements in it. Treatment is usually given empirically and lasts 7-14 days. The selection of an antibiotic according to the sensitivity of the flora in vitro is carried out only if empirical antibiotic therapy is ineffective. Do not prescribe antibiotics in inhalation. Antibiotics are not recommended for disease prevention.

List of essential medicines:

1. * Fenoterol 5 mg tab.; 0.5 mg/10 ml injection;

2. **Salbutamol 100 mcg/dose aerosol; 2 mg, 4 mg tab.; 20 ml solution for nebulizer;

3. * Ipratropium bromide 100 ml aerosol;

4. ** Theophylline 100 mg, 200 mg, 300 mg tab.; 350 mg tablet retard;

5. **Ambroxol 30 mg tab.; 15 mg / 2 ml amp.; 15 mg/5 ml, 30 mg/5 ml syrup;

6. * Acetylcysteine ​​2% 2 ml amp.; 100 mg, 200 mg tab.;

7. *Prednisolone 30 mg/ml amp.; 5 mg tab.

List of additional medicines:

1. Terbutaline 1000 mg tab.

2. *Amoxicillin 500 mg, 1000 mg tab.; 250 mg; 500 mg caps.; 250 mg/5 ml oral suspension;

3. * Amoxicillin + clavulanic acid 625 mg tab.; 600 mg in vial, solution for injection.

* - drugs included in the list of essential (vital) drugs

** - is included in the list of types of diseases, in the outpatient treatment of which medicinal

funds are dispensed by prescription free of charge and on preferential terms