Recommendations for acute bronchitis. Treatment of acute bronchitis: FDA guidelines. What causes bronchitis

Chronic bronchitis (CB) is a diffuse inflammatory lesion bronchial tree, caused by prolonged irritation of the airways by volatile pollutants and (or) less often by damage by viral and bacterial agents, accompanied by hypersecretion of mucus, a violation of the cleansing function of the bronchi, which is expressed by constant or intermittent cough and sputum production.

Men get sick 6 times more often than women.

Classification

There is currently no generally accepted classification of HB.

Given the nature inflammatory process allocate catarrhal, catarrhal-purulent and purulent HB. The classification also includes rare forms - hemorrhagic and fibrinous CB.

According to the nature of the flow (functional characteristics), CB can be divided into flowing without obstruction and with obstruction respiratory tract. According to the severity of the course, easily flowing CB, CB moderate and heavy flow. The following phases of the disease are known: exacerbation, subsiding exacerbation ( unstable remission) and clinical remission.

Etiology

Exogenous and endogenous factors closely interact in the occurrence and development of CB. Among exogenous factors the main role is played by irritating and damaging household and professional pollutants, as well as non-indifferent dusts that have a harmful chemical and mechanical effect on the bronchial mucosa. Inhalation should take the first place in terms of importance among exogenous factors. tobacco smoke. The importance of air pollution and adverse climatic factors (hypothermia and overheating) is great. Infectious factors in the occurrence of chronic bronchitis play a secondary role. At the same time, viral (influenza viruses, adenoviruses), mycoplasma and bacterial (pneumococcus, Haemophilus influenzae, moraxella) infections are of paramount importance in the development of an exacerbation of chronic bronchitis.

Due to the fact that the disease does not occur in all persons equally exposed to adverse effects, allocate internal causes(endogenous factors) of its development:

Pathological changes in the nasopharynx;

Changes in nasal breathing, accompanied by a violation of the purification, moistening and warming of the inhaled air;

Repeated acute respiratory infections;

Acute bronchitis and focal infectious lesions of the upper respiratory tract;

Violations of local immunity and metabolism (obesity);

Hereditary predisposition (violation of enzyme systems, local immunity).

Pathogenesis

In the pathogenesis of chronic bronchitis, the main role is played by a violation of the secretory, cleansing and protective function bronchial mucosa, leading to a change in mucociliary transport.

Under the influence of exogenous and endogenous factors a series of pathological processes in the tracheobronchial tree (Fig. 1-3).

The structural and functional properties of the mucous membrane and submucosal layer change.

Changes in the structural and functional properties of the mucous membrane and submucosal layer are expressed in hyperplasia and hyperfunction of goblet cells, bronchial glands, hypersecretion of mucus and changes in its properties (the mucous secretion becomes thick, viscous and sucks in the cilia of the ciliated epithelium), which leads to a violation of the mucociliary transport system. The effectiveness of the latter depends on two main factors: the mucociliary escalator, determined by the function of the ciliated mucosal epithelium, and rheological properties bronchial secretion (viscosity and elasticity) - and is due optimal ratio two of its layers - outer (gel) and inner (sol).

Increased mucus formation and changes in the composition of the mucous secretion are also facilitated by hereditary predisposition (deficiency of proteolytic enzymes, clearly manifesting in conditions of increased need for them) and exposure to bacterial and viral pathogens.

Rice. 1-3. The pathogenesis of chronic bronchitis

Mucosal inflammation develops.

Inflammation of the mucous membrane is caused by various irritants in combination with infectious agents(viral and bacterial). The production of secretory IgA decreases, the content of lysozyme and lactoferrin in the mucus decreases. Edema of the mucous membrane develops, and then - atrophy and metaplasia of the epithelium.

Various irritants in the air cause damage to the airways, accompanied by mucosal edema and bronchospasm. This leads to disruption of the evacuation and weakening of the barrier functions of the bronchial mucosa. Catarrhal contents with increased exposure infectious factor is replaced by catarrhal-purulent, and then - purulent.

The spread of the inflammatory process to distal departments bronchial tree disrupts the production of surfactant and reduces the activity of alveolar macrophages, which leads to impaired phagocytosis.

The drainage function of the bronchi is impaired, which is associated with a combination of a number of factors:

Spasm of the smooth muscles of the bronchi, resulting from the direct irritating effect of exogenous factors and inflammatory changes in the mucous membrane;

Hypersecretion of mucus and a change in its rheological properties, leading to disruption of mucociliary transport and blockage of the bronchi with a viscous secret;

Metaplasia of the epithelium from cylindrical to stratified squamous and its hyperplasia;

Violation of the production of surfactant;

Inflammatory edema and mucosal infiltration.

If bronchospasm as a sign of inflammation is pronounced sharply, then they speak of the development of a bronchospastic (non-allergic) component. At the same time, an infectious lesion during an exacerbation of inflammation can contribute to the attachment allergic component, which disappears after the elimination of exacerbation of HB.

If the manifestation of the allergic component is delayed (violation bronchial patency persists beyond the exacerbation of the disease and eosinophils appear in the sputum), then we can assume the debut of the cough variant of bronchial asthma.

Various ratios of changes in the mucous membrane, expressed in its inflammation, determine the formation of one or another clinical form diseases. With catarrhal bronchitis, superficial changes in the structural and functional properties of the mucous membrane predominate, and with mucopurulent (purulent) processes infectious inflammation. The transition of one clinical form of bronchitis to another is possible. So, long-term catarrhal bronchitis due to the addition infection may become mucopurulent, etc.

With the predominant involvement of large-caliber bronchi in the process (proximal bronchitis), bronchial obstruction is not expressed.

The defeat of small bronchi and bronchi of medium caliber often occurs with a violation of bronchial patency, which, as a rule, is expressed during exacerbation of chronic bronchitis.

Ventilation disorders in CB are mostly minor. At the same time, in some patients, the violation of the drainage function of the bronchi is so significant that, according to the nature of the course of chronic bronchitis, it can be regarded as obstructive. Obstructive disorders in CB occur only against the background of an exacerbation of the disease and may be due to inflammatory changes bronchi, hyper- and dyscrinia, as well as bronchospasm (reversible components of obstruction). At severe course CB and persistent inflammatory process, obstructive changes can persist permanently. Developed obstruction of the small bronchi leads to emphysema. There is no direct relationship between the severity of bronchial obstruction and emphysema, since, unlike COPD, emphysema is considered not a symptom of chronic bronchitis, but its complication. In the future, it may lead to respiratory failure with the development of shortness of breath and the formation of pulmonary hypertension.

Clinical painting

Ha first stage of diagnostic search detect the main symptoms of chronic bronchitis - cough and sputum production. Also, pay attention to symptoms. general(sweating, weakness, fast fatiguability, decreased ability to work, increased body temperature, etc.), which may occur during an exacerbation of the disease, be the result of a long chronic intoxication(purulent bronchitis) or act as signs of hypoxia in the development of respiratory failure and other complications.

At the onset of the disease, the cough may be unproductive, often dry. Sputum discharge usually occurs in the morning (when washing). In the phase of stable clinical remission, patients do not complain, their performance for many years can be fully preserved. Patients do not consider themselves sick.

Exacerbations of the disease are quite rare, and in most patients occur no more than 2 times a year. Typical seasonality of exacerbations during the so-called off-season, i.e. in early spring or in late autumn, when the differences in weather factors are most pronounced.

Cough - most typical symptom illness. By the nature of cough and sputum, one or another variant of the course of the disease can be assumed.

With catarrhal bronchitis, cough is accompanied by the release of a small amount of mucous watery sputum, more often in the morning, after exercise. At the beginning of the disease, cough does not bother the patient. If in the future it becomes paroxysmal, then this indicates a violation of bronchial patency. The cough acquires a barking shade and is paroxysmal in nature with severe expiratory collapse (prolapse) of the trachea and large bronchi.

The amount of sputum may increase with exacerbation of bronchitis. With purulent and mucous purulent bronchitis patients are more concerned about not coughing,

a a large number of sputum, because sometimes they do not notice that it is secreted when they cough. Especially a lot of sputum leaves with purulent bronchitis, if its course is complicated by the development of bronchiectasis.

In the acute phase, the patient's well-being determines the ratio of the two main syndromes: cough and intoxication. For intoxication syndrome symptoms of a general nature are characteristic: fever, sweating, weakness, headache and decreased performance. Changes in the upper respiratory tract are noted: rhinitis, sore throat when swallowing, etc. At the same time, chronic diseases nasopharynx (inflammation paranasal sinuses nose, tonsillitis), which often affects patients with chronic bronchitis.

In the event of an exacerbation of the disease, sputum acquires purulent character, and the number may increase. Shortness of breath may occur, which is associated with the addition of obstructive disorders. In this situation, the cough can become unproductive and hacking, and sputum (even purulent) can be secreted into a small amount. In some patients in the exacerbation phase, moderately pronounced bronchospasm usually joins, clinical sign which is difficulty in breathing. It occurs when physical activity, moving into a cold room or at the moment severe cough(sometimes at night).

In typical cases, HB progresses slowly. Shortness of breath usually develops 20-30 years after the onset of the disease, which indicates the occurrence of complications (emphysema, respiratory failure). Such patients almost never fix the onset of the disease (morning cough with sputum is associated with smoking and is not considered a sign of the disease). They consider them the period when these complications or frequent exacerbations occur.

The development of dyspnea during physical exertion in the onset of chronic bronchitis, as a rule, indicates that it is associated with comorbidities(obesity, ischemic heart disease, etc.), as well as detraining and physical inactivity.

History can reveal hypersensitivity to hypothermia and in the vast majority of patients - an indication of prolonged smoking. In a number of patients, the disease is associated with occupational hazards at work.

When analyzing a cough history, it is necessary to make sure that the patient does not have other pathological changes bronchopulmonary apparatus (tuberculosis, tumor, bronchiectasis, pneumoconiosis, systemic diseases connective tissue etc.), accompanied by the same symptoms. This is an indispensable condition for classifying these complaints as signs of CB.

Some patients have a history of hemoptysis, which is usually associated with mild vulnerability of the bronchial mucosa. Recurrent hemoptysis is a symptom hemorrhagic form bronchitis. In addition, hemoptysis in chronic, long-term bronchitis may be the first symptom. lung cancer, which develops in men who smoked for a long time and a lot. Hemoptysis can also manifest bronchiectasis.

On the second stage of diagnostic search in initial period disease pathological symptoms may be missing. In the future, auscultatory changes occur: hard breathing(with the development of emphysema,

can become weakened) and dry rales of a diffuse nature, the timbre of which depends on the caliber of the affected bronchi. As a rule, coarse buzzing dry rales are heard, which indicates the involvement of large and medium bronchi in the process. Whistling wheezing, especially audible on expiration, is characteristic of the defeat of small bronchi, which is evidence of the attachment of a bronchospastic syndrome. If there are no wheezing during normal breathing, then auscultation should be performed during forced breathing, as well as in the patient's supine position.

Changes in auscultatory data will be minimal with chronic bronchitis in remission and most pronounced during the exacerbation of the process, when you can listen to even moist rales, which can disappear after a good cough and sputum. Often, with an exacerbation of chronic bronchitis, an obstructive component can join, accompanied by the onset of shortness of breath. When examining a patient, signs of bronchial obstruction are found:

Prolongation of the expiratory phase with calm and especially with forced breathing;

Wheezing wheezes on expiration, which are well audible with forced breathing and in the supine position.

The evolution of bronchitis, as well as the associated complications, change the data of the direct examination of the patient. AT advanced cases diseases show signs of emphysema and respiratory failure. The development of LS in non-obstructive CB is extremely rare.

The addition of an asthmatic (allergic) component significantly changes the picture of chronic bronchitis, which becomes similar to that in asthma, which gives reason to change the diagnosis.

The third stage of diagnostic search depending on the stage of the process, it has a different degree of significance in the diagnosis of CB.

In the initial period of the disease or in the phase of remission, there may be no changes in laboratory and instrumental parameters, but at certain stages of the course of chronic bronchitis, they become essential. They are used to determine the activity of the inflammatory process, clarify the clinical form of the disease, diagnose complications, and differential diagnosis with diseases that have similar clinical symptoms.

X-ray examination of organs chest carried out for all patients with HB. In most of them, there are no changes in the lungs on plain radiographs. In some cases, a mesh deformation of the lung pattern is found, due to the development of pneumosclerosis. With a long course of the process, signs of emphysema are noted.

X-ray examination of the chest organs assists in the diagnosis of complications (pneumonia, bronchiectasis) and differential diagnosis with diseases in which the symptoms of bronchitis may accompany the main process (tuberculosis, bronchial tumor, etc.).

Bronchography, which was previously used to determine bronchiectasis, is now rarely performed, since they can be detected by MSCT results.

Bronchoscopy has great importance in the diagnosis of chronic bronchitis and its differential diagnosis with diseases that have a similar clinical picture.

Bronchoscopy allows:

Confirm the existence of the inflammatory process and assess the degree of its activity;

Clarify the nature of inflammation (the diagnosis of hemorrhagic or fibrinous bronchitis is made only after bronchoscopic examination);

discover functional disorders tracheobronchial tree (plays a leading role in the detection of expiratory prolapse - dyskinesia of the trachea and large bronchi);

discover organic lesions bronchial tree (strictures, tumors, etc.).

Function research external respiration. The simplest and most common method functional diagnostics- spirometry. It is designed to measure lung volumes during various breathing maneuvers (both calm and forced). Spirometry data allows you to determine whether there is a violation of the ventilation function, and to establish the type of violation (obstructive, restrictive or mixed). A schematic representation of the spirogram and the structure of the total lung capacity is shown in fig. 1-4.

According to the spirogram, two relative indicators are calculated: the Tiffno index (the ratio of FEV1 to VC, in percent - the Tiffno coefficient) and the air velocity indicator (the ratio of MVL to VC). In addition, for the purpose of differential diagnosis with COPD, a modified Tiffno coefficient - FEV1 / FVC is calculated. COPD is characterized by an FEV1/FVC value of more than 70%, and in CB this value is always above 70%, even if there is a pronounced broncho-obstructive syndrome.

With the development of obstructive syndrome, a decrease in the absolute speed indicators of external respiration (MVL and FEV1) is noted, exceeding the degree of decrease in VC. The Tiffno index decreases and bronchial resistance on exhalation increases.

An early sign of bronchial obstruction is the predominance of inspiratory power over expiratory power (according to pneumotachometry). At home, for monitoring lung function, it is recommended to determine the peak expiratory flow rate using a pocket device - a peak flow meter.

Diagnosis of violations of bronchial patency on various levels bronchial tree (in large, medium or small bronchi) is possible only with the help of special pneumotachographs equipped with an integrator and a two-coordinate recorder, which makes it possible to obtain a “flow volume” curve (Fig. 1-5).

Studying the expiratory flow at lung volume, equal to 75, 50 and 25% FVC, it is possible to specify the level of bronchial obstruction in the peripheral parts of the bronchial tree: peripheral obstruction is characterized by

Rice. 1-5. Forced expiratory flow-volume curves

a significant decrease in the flow-volume curve in the area of ​​\u200b\u200blow volume, and for proximal obstruction - in the area of ​​​​high volume.

Simultaneous assessment of the magnitude of bronchial resistance and lung volumes also helps to determine the level of obstruction. In the case of the predominance of obstruction at the level of large bronchi, an increase in the residual volume of the lungs is noted, and the total lung capacity does not increase. If peripheral obstruction predominates, then a more significant increase in the residual volume of the lungs (with the same values ​​of bronchial resistance) and an increase in the total lung capacity are recorded.

To determine the proportion of bronchospasm in the total proportion of bronchial obstruction, ventilation and respiratory mechanics are studied after a series of pharmacological tests. After inhalation of bronchodilator aerosols, ventilation rates improve in the presence of a reversible component of airway obstruction.

The study of blood gases and acid-base status is important for diagnosis various degrees respiratory failure. The assessment of the degree of respiratory failure is carried out taking into account the indicator of PaO2 and PaCO2 and data on ventilation indicators (MOD, MVL and VC). The division of respiratory failure by degree is presented in the section "Cor pulmonale".

An ECG is necessary for the diagnosis of hypertrophy of the right ventricle and right atrium developing with PH. The following signs are considered the most significant: pronounced axis deviation QRS right; shift of the transition zone to the left (R/S<1 в V4-V6); S-тип ЭКГ; высокий острый зубец R in leads aVF, III and II.

Clinical analysis of blood during the period of a stable course of the disease is not changed. With severe respiratory failure, erythrocytosis may occur. The general blood test, to a lesser extent than in other diseases, reflects the activity of the inflammatory process. Acute phase indicators are often moderately expressed: ESR may be normal or moderately increased (due to erythrocytosis, a decrease in ESR is sometimes noted); leukocytosis, as well as the shift of the leukocyte formula to the left, is usually small. Eosinophilia is possible, which, as a rule, serves as evidence of an allergic reaction.

A biochemical blood test is carried out to clarify the activity of the inflammatory process. The content of total protein and its fractions, as well as CRP and fibrinogen, are determined. An increase in their concentration is characteristic of the inflammatory process of any localization. The decisive role in assessing the degree of inflammation activity in the bronchi belongs to the data of the bronchoscopic picture, the study of the contents of the bronchi and sputum.

With uncontrolled progression of the process, a study of the immune status and (or) analysis of bronchial contents should be carried out.

The study of sputum and bronchial contents helps to establish the nature and severity of inflammation. With severe inflammation, the content

mine is predominantly purulent or purulent-mucous, contains many neutrophils and single macrophages. In a small amount there are dystrophically altered cells of the ciliated and squamous epithelium.

With moderate inflammation, the contents are close to mucopurulent; the number of neutrophils is slightly increased. The number of macrophages, mucus and bronchial epithelial cells is growing.

With mild inflammation, the bronchial contents are predominantly mucous, desquamated epithelial cells of the bronchi predominate; macrophages and neutrophils are few.

The detection of eosinophils indicates a local allergic reaction. The presence in the sputum of atypical cells, Mycobacterium tuberculosis and elastic fibers plays a significant role in revising the previously existing diagnostic concept, respectively in favor of bronchogenic cancer, tuberculosis or lung abscess.

Bacteriological examination of sputum and bronchial contents is important for establishing the etiology of exacerbation of chronic bronchitis and choosing an antibacterial drug.

The criterion for the etiological significance of the pathogen in a quantitative bacteriological study is:

Determination of the pathogen (pneumococcus or Haemophilus influenzae) in sputum at a concentration of 106 in 1 µl and above in the absence of antibacterial treatment;

Detection in 2-3 studies conducted with an interval of 3-5 days, opportunistic microorganisms at a concentration of 106 in 1 μl and above;

The disappearance or a significant decrease in the number of microorganisms in a dynamic study against the background of clinically effective antibiotic therapy.

Complications

All complications of HB can be divided into two groups:

Directly caused by infection (pneumonia, bronchiectasis, bronchospastic (broncho-obstructive) and allergic (asthmatic) component);

Caused by the evolution of bronchitis (hemoptysis, emphysema, diffuse pneumosclerosis, respiratory failure, drugs (rarely)).

Diagnostics

It is not difficult to recognize CB at the initial stage of the examination according to the anamnesis and the detection of the main symptoms - cough and sputum. In addition, the nature of breathing and the existence of wheezing are taken into account. Nevertheless, to establish a diagnosis, it is necessary to exclude other diseases that can occur with the same symptoms (COPD, tuberculosis, bronchial cancer, bronchiectasis, asthma, etc.).

The results of laboratory and instrumental studies are mainly used to clarify the form of the disease, the phase of the activity of the inflammatory process and differential diagnosis.

The diagnostic significance of various symptoms allows us to identify the diagnostic criteria for CB:

Cough history (at least two years for 3 months in a row, cough dry or with sputum);

The absence of other pathological changes in the bronchopulmonary apparatus (tuberculosis, bronchiectasis, chronic pancreatitis, asthma, lung cancer, etc.), causing a cough history;

Inflammatory changes in the bronchi (according to the study of sputum, bronchial contents, bronchoscopic picture);

Detection of airway obstruction (reversible and irreversible component) in the acute phase of the process.

The formulation of a detailed clinical diagnosis of chronic bronchitis is carried out taking into account the following components:

Clinical variant according to functional characteristics (non-obstructive, obstructive);

The nature of inflammation (catarrhal, catarrhal-purulent, purulent);

Phases of the process (exacerbation, subsiding exacerbation or unstable remission, remission);

Complications.

When formulating the diagnosis of CB, the word "non-obstructive" is usually omitted.

Treatment

The goal of treatment is to reduce the rate of progression of diffuse damage to the bronchi, reduce the frequency of exacerbations, prolong remission, increase exercise tolerance and improve the quality of life.

The main direction of treatment and prevention of progression of CB is the elimination of the effects of harmful impurities contained in the inhaled air (smoking ban, elimination of the effects of passive smoking, rational employment). The actual treatment of CB should be differentiated and depend on the form of the disease and the existence of certain complications.

Treatment of CB consists of a set of measures that differ somewhat during the period of exacerbation and remission of the disease.

There are two main areas of treatment during an exacerbation: etiotropic and pathogenetic.

Etiotropic treatment is aimed at eliminating the inflammatory process in the bronchi and includes the use of antibiotics, antiseptics, phytoncides, etc. Antibiotics are prescribed taking into account the sensitivity of the microflora isolated from sputum or bronchial contents. If it is impossible to determine it, then treatment should begin with the appointment of semi-synthetic and protected penicillins, macrolides. The advantage is given to antibacterial agents taken orally: ampicillin (0.5 g 4 times a day), or amoxicillin (0.5 g 3 times a day), or amoxicillin + clavulanic acid (0.625 g 3 times a day), or clarithromycin (0.5 g 2 times a day), or azithromycin (at a dose of 0.5 g 1 time per day). Treatment is carried out for

nii 7-10 days. Cefixime, a third-generation cephalosporin for oral administration, is highly effective and well tolerated. It is prescribed at a dose of 400 mg 1 time per day and is usually used for five days.

With purulent bronchitis, fluoroquinolones are preferred, since they penetrate best into sputum, and III-IV generation cephalosporins: levofloxacin (orally at a dose of 0.5 g 1 time per day) or moxifloxacin (orally at a dose of 0.4 g 1 time per day). day). With insufficient effectiveness, they switch to parenteral administration of cefepime (intramuscularly and intravenously, 2.0 g 2 times a day) or cefotaxime (intramuscularly and intravenously, 2.0 g 3 times a day).

With simple (catarrhal) chronic bronchitis, especially in cases where the exacerbation is due to a respiratory viral infection, anti-inflammatory treatment is carried out with fenspiride. The drug is taken orally 80 mg 2 times a day for 2-3 weeks.

Pathogenetic treatment is aimed at restoring bronchial patency and improving pulmonary ventilation.

Restoration of bronchial patency is achieved by improving their drainage and eliminating bronchospasm.

The use of mucolytic and expectorant drugs is considered important in the treatment of chronic bronchitis: ambroxol (orally 30 mg 3 times a day), acetylcysteine ​​(orally 200 mg 3-4 times a day), carbocysteine ​​(750 mg 3 times a day), bromhexine ( inside 8-16 mg 3 times a day). Treatment is carried out within 2 weeks. Herbal preparations (thermopsis, ipecac, marshmallow extract) are used as alternative medicines. With the release of purulent sputum, preference is given to a combination of acetylcysteine ​​​​with an antibiotic prescribed in inhalations through a nebulizer for five days.

The previously practiced use of proteolytic enzymes as mucolytics is unacceptable. Therapeutic bronchoscopy is successfully used. The use of low-frequency ultrasonic bronchoscopic sanitation (Ovcharenko S.I. et al., 1985) with aerosol endobronchial spraying of an antibiotic is promising.

In order to eliminate bronchospasm, bronchodilator drugs are used. Anticholinergics (ipratropium bromide), ipratropium bromide + fenoterol and methylxanthines (aminophylline and its derivatives) are used. The most preferred and safest route of administration of medicinal substances. In addition, drugs of prolonged aminophylline (theophylline, etc.), which are administered orally only 2 times a day, are effective.

Improvement (restoration) of impaired pulmonary ventilation, in addition to the elimination of the inflammatory process in the bronchi, is facilitated by exercise therapy and chest massage.

As an additional treatment, appoint:

Drugs that suppress the cough reflex (with an unproductive cough - prenoxdiazine, bromhexine, with a hacking cough - codeine, ethylmorphine, butamirate + guaifenesin);

Medicines that increase the body's resistance (vitamins A, C group B, biogenic stimulants).

Currently, in the treatment of chronic bronchitis (especially protracted exacerbations, often recurrent and purulent forms), immunomodulatory drugs are increasingly being used: thymus extract (subcutaneously at a dose of 100 mg for three days). Inside, bacterial immunocorrectors are successfully used: ribomunil * (ribosomal-proteoglycan complex of the four most common pathogens), bronchomunal (lyophilized lysate of the eight main pathogens) and bronchovacson.

Physiotherapeutic treatment is prescribed: diathermy, calcium chloride electrophoresis, quartz on the chest area, chest massage and breathing exercises.

Outside of exacerbation in mild bronchitis, the foci of infection are eliminated (tonsillectomy, etc.) and hardening of the body begins. Physical therapy (respiratory gymnastics) classes are carried out constantly.

Along with anti-relapse and sanatorium treatment (southern coast of Crimea, dry steppe zone), with moderate and severe bronchitis, many patients are forced to constantly receive supportive medication. In moderate cases of chronic bronchitis, constant breathing exercises are mandatory.

Supportive treatment is aimed at improving bronchial patency, reducing PH and combating right ventricular failure. The same drugs are prescribed as in the period of exacerbation, only in smaller doses, in courses.

Forecast

The least favorable prognosis is for purulent CB complicated by the development of bronchiectasis, as well as for CB with severe bronchial obstruction, leading to the development of pulmonary insufficiency and the formation of LS. The most favorable prognosis is noted with superficial (catarrhal) CB without obstruction.

Prevention

Primary prevention measures include the prohibition of smoking in institutions and enterprises, work in a polluted (dusty and gassed) atmosphere, improvement of the external environment, constant prevention of acute respiratory diseases, treatment of pathological changes in the nasopharynx, etc.

Secondary prevention measures include all actions aimed at preventing the development of exacerbations of the disease.

Bronchitis is one of the most common diseases. Both acute and chronic cases rank high among respiratory pathologies. Therefore, they require high-quality diagnostics and treatment. Summarizing the experience of leading experts, relevant clinical recommendations on bronchitis are created at the regional and international levels. Compliance with the standards of care is an important aspect of evidence-based medicine, which allows you to optimize diagnostic and therapeutic measures.

None of the recommendations can do without considering the causes of the pathology. It is known that bronchitis has an infectious and inflammatory nature. The most common causative agents of the acute process are viral particles (influenza, parainfluenza, respiratory syncytial, adeno-, corona- and rhinoviruses), and not bacteria, as previously thought. Outside of seasonal outbreaks, it is possible to establish a certain role for other microbes: whooping cough, mycoplasmas and chlamydia. But pneumococcus, moraxella and Haemophilus influenzae can cause acute bronchitis only in patients undergoing surgery on the respiratory tract, including tracheostomy.

Infection plays a crucial role in the development of chronic inflammation. But bronchitis at the same time has a secondary origin, arising against the background of a violation of local protective processes. Exacerbations are provoked mainly by the bacterial flora, and the long course of bronchitis is due to the following factors:

1. Smoking.
2. Professional hazards.
3. Air pollution.
4. Frequent colds.

If during acute inflammation there is swelling of the mucous membrane and increased production of mucus, then the central link of the chronic process is the violation of mucociliary clearance, secretory and protective mechanisms. The long course of the pathology often leads to obstructive changes, when due to thickening (infiltration) of the mucosa, sputum stagnation, bronchospasm and tracheobronchial dyskinesia, obstacles are created for the normal passage of air through the respiratory tract. This leads to functional disorders with further development of pulmonary emphysema.

Bronchitis is provoked by infectious agents (viruses and bacteria), and acquires a chronic course under the influence of factors that violate the protective properties of the respiratory epithelium.

Symptoms

Assume pathology at the initial stage will allow the analysis of clinical information. The doctor evaluates the anamnesis (complaints, onset and course of the disease) and conducts a physical examination (examination, auscultation, percussion). So he gets an idea of ​​the symptoms, on the basis of which he makes a preliminary conclusion.

Acute bronchitis occurs on its own or against the background of SARS (most often). In the latter case, it is important to pay attention to the catarrhal syndrome with a runny nose, perspiration, sore throat, as well as fever with intoxication. But pretty soon there are signs of bronchial damage:

• Intense cough.
• Expulsion of scanty mucous sputum.
• Expiratory dyspnea (difficulty exhaling predominantly).

Even chest pains may appear, the nature of which is associated with muscle strain during a hacking cough. Shortness of breath appears only with the defeat of the small bronchi. Percussion sound, as well as voice trembling, are not changed. Auscultation reveals hard breathing and dry rales (buzzing, whistling), which become moist during the resolution of acute inflammation.

If the cough lasts more than 3 months, then there is every reason to suspect chronic bronchitis. It is accompanied by sputum discharge (mucous or purulent), less often it is unproductive. At first this is observed only in the morning, but then any increase in the frequency of breathing leads to expectoration of the accumulated secret. Shortness of breath with prolonged exhalation joins when obstructive disorders appear.

In the acute stage, there is an increase in body temperature, sweating, weakness, the volume of sputum increases and its purulence increases, the intensity of cough increases. The periodicity of chronic bronchitis is quite pronounced, inflammation is especially activated in the autumn-winter period and with sudden changes in weather conditions. The function of external respiration in each patient is individual: in some, it remains at an acceptable level for a long time (non-obstructive bronchitis), while in others, shortness of breath with ventilation disorders appears early, which persists during periods of remission.

On examination, one can notice signs indicating chronic respiratory failure: chest expansion, pallor of the skin with acrocyanosis, thickening of the terminal phalanges of the fingers (“drumsticks”), changes in nails (“watch glasses”). The development of cor pulmonale may indicate swelling of the legs and feet, swelling of the jugular veins. Percussion with simple chronic bronchitis does not give anything, and obstructive changes can be assumed from the box shade of the sound received. The auscultatory picture is characterized by hard breathing and scattered dry rales.

It is possible to assume bronchitis by clinical signs that are revealed during a survey, examination and using other physical methods (percussion, auscultation).

Additional diagnostics

Clinical recommendations contain a list of diagnostic measures that can be used to confirm the doctor's assumption, determine the nature of the pathology and its causative agent, and identify concomitant disorders in the patient's body. On an individual basis, such studies can be prescribed:

• General blood analysis.
• Blood biochemistry (acute phase indicators, gas composition, acid-base balance).
• Serological tests (antibodies to pathogens).
• Analysis of swabs from the nasopharynx and sputum (cytology, culture, PCR).
• Chest X-ray.
• Spirography and pneumotachometry.
• Bronchoscopy and bronchography.
• Electrocardiography.

The study of the function of external respiration plays a key role in determining violations of bronchial conduction in a chronic process. At the same time, two main indicators are evaluated: the Tiffno index (the ratio of forced expiratory volume in 1 second to the vital capacity of the lungs) and peak expiratory flow rate. Radiologically, with simple bronchitis, only an increase in the pulmonary pattern can be seen, but prolonged obstruction is accompanied by the development of emphysema with an increase in the transparency of the fields and a low standing diaphragm.

Treatment

Having diagnosed bronchitis, the doctor immediately proceeds to therapeutic measures. They are also reflected in the clinical guidelines and standards that guide specialists when prescribing certain methods. Drug therapy is central to acute and chronic inflammation. In the first case, the following drugs are used:

• Antiviral (zanamivir, oseltamivir, rimantadine).
• Expectorants (acetylcysteine, ambroxol).
• Antipyretics (paracetamol, ibuprofen).
• Antitussives (oxeladin, glaucine).

The last group of drugs can be used only with intense hacking cough, which is not stopped by other means. And it should be remembered that they should not inhibit mucociliary clearance and be combined with drugs that increase mucus secretion. Antibiotics are used only in cases where the bacterial origin of the disease is clearly proven or there is a risk of developing pneumonia. In the recommendations after bronchitis there is an indication of vitamin therapy, immunotropic drugs, giving up bad habits and hardening.

Acute bronchitis is treated with medications that affect the infectious agent, disease mechanisms, and individual symptoms.

The treatment of chronic pathology involves various approaches during the period of exacerbation and remission. The first direction is due to the need to sanitize the respiratory tract from infection and involves the appointment of such medications:

1. Antibiotics (penicillins, cephalosporins, fluoroquinolones, macrolides).
2. Mucolytics (bromhexine, acetylcysteine).
3. Antihistamines (loratadine, cetirizine).
4. Bronchodilators (salbutamol, fenoterol, ipratropium bromide, aminophylline).

Drugs that eliminate bronchospasm occupy an important place not only during exacerbation, but also as a basic therapy for chronic inflammation. But in the latter case, preference is given to prolonged forms (salmeterol, formoterol, tiotropium bromide) and combined drugs (Berodual, Spiolto Respimat, Anoro Ellipta). In severe cases of obstructive bronchitis, theophyllines are added. Inhaled corticosteroids, such as fluticasone, beclomethasone, or budesonide, are indicated for the same category of patients. Like bronchodilators, they are used for long-term (basic) therapy.

The presence of respiratory failure requires oxygen therapy. The set of recommended measures also includes influenza vaccination to prevent exacerbations. An important place in the rehabilitation program is occupied by individually selected breathing exercises, high-calorie and fortified diet. And the appearance of single emphysematous bullae may suggest their surgical removal, which favorably affects the ventilation parameters and the condition of patients.

Bronchitis is a very common disease of the respiratory tract. It occurs in acute or chronic form, but each of them has its own characteristics. Methods for diagnosing bronchial inflammation and methods for its treatment are reflected in international and regional recommendations that guide the doctor. The latter were created to improve the quality of medical care, and some have even been put into practice at the legislative level in the form of relevant standards.

This clinical practice guide was created by a working group of the Alberta Medical Association.

Definition and general information about acute bronchitis

Acute bronchitis: acute inflammation of the bronchial tree. Acute bronchitis in adults and children (as well as bronchiolitis in infants) almost always has a viral etiology. Meta-analyses have proven the ineffectiveness of antibiotics in acute bronchitis. Unjustified use of antibiotics in acute bronchitis leads to bacterial resistance.

Sometimes the symptoms of acute bronchitis are falsely mistaken for those of whooping cough, resulting in a misdiagnosis.

Prevention of acute bronchitis

Limiting the possibility of contracting viral infections (for example, through personal hygiene). Stop smoking, including passive.

Diagnosis of acute bronchitis

Acute bronchitis is diagnosed based on the sudden onset of a cough, along with:

Important: yellow/green sputum is an indicator of an inflammatory process and does not necessarily mean bacterial or infection.

Inspection

An elevated body temperature may be present, but the duration of this condition should be no more than 3 days. Auscultation is usually normal, but the presence of breath sounds is mandatory.

Important: evidence of consolidation (localized crackles, bronchial breath sounds, thud on percussion) should alert to possible pneumonia.

Research

Routine tests (eg, sputum flora, lung function test, or serology) are not indicated because do not facilitate diagnosis. A chest x-ray is only indicated if pneumonia is suspected based on physical examination and medical history.

Treatment of acute bronchitis

Antibiotics are NOT indicated for the treatment of acute bronchitis.

These recommendations are systematically supplemented statements designed to help the doctor and the patient make the right decision in a specific clinical setting. They should be used as an adjunct to an objective clinical examination.

Corticosteroids (both sprays and oral) are NOT recommended due to lack of evidence of their effectiveness in acute bronchitis. Expectorants are also generally NOT recommended due to limited efficacy.

Differential diagnosis of acute bronchitis

Observation and practical guidance

Prolonged cough of viral etiology alone does not require antibiotic treatment:

• 45% of patients suffer from cough after 2 weeks;
• 25% of patients suffer from cough after 3 weeks.

Whooping cough causes prolonged coughing and vomiting.

• symptoms worsen or new symptoms appear;
• cough is not cured even after 1 month;
• there are relapses (>3 episodes per year)

Acute bronchitis is diagnosed based on the medical history and clinical examination.

Acute bronchitis continues to be treated with antibiotics, although there is little evidence to support their effectiveness against this disease.

In acute bronchitis, doctors continue to prescribe antibiotics, although they have not been shown to be effective in this case. According to some estimates, in 50-79% of cases of confirmed diagnosis of acute bronchitis, the doctor prescribes antibiotics. In a study of 1398 outpatient consultations of children<14 лет с жалобой на кашель, бронхит был диагностирован в 33% случаев и в 88% из них были назначены антибиотики.

Eight double-blind, randomized, placebo-controlled studies have been published on the efficacy of antibiotics for acute bronchitis in patients over 8 years of age. A meta-analysis of 6 studies found that there is no evidence to justify the use of antibiotics in acute bronchitis.

Four studies evaluating erythromycin, doxycycline, or TMP/SMX demonstrated minimal improvement in symptoms and/or loss of time in the antibiotic group.

An additional 4 trials showed no difference in outcomes between patients taking placebo and those taking erythromycin or doxycycline.

Several pediatric studies have evaluated the feasibility of using antibiotics in the treatment of cough. None of these have been proven to be effective. Antibiotics do not prevent secondary infection of the lower respiratory tract. A meta-analysis of trials evaluating the effectiveness of antibiotics in preventing bacterial infections in SARS showed that antibiotics do not prevent or reduce the severity of bacterial infection.

The results of lung function tests for mild asthma and acute bronchitis are similar. Thus, it has been hypothesized that bronchodilators may provide symptomatic relief to patients with bronchitis.

There is evidence that bronchodilators are effective in acute bronchitis, and their use reduces the duration of the cough to a maximum of 7 days, unlike antibiotics. Hueston studied the efficacy of aerosolized salbutamol against acute bronchitis in patients receiving erythromycin or placebo. After 7 days, the examination showed that patients treated with salbutamol coughed less than patients taking placebo. When the analysis was stratified by erythromycin use, the difference between salbutamol and control patients only increased. Cough suppressants are often used in the treatment of acute bronchitis. They provide symptomatic relief but do not shorten the duration of the illness. A recent review of randomized, double-blind, placebo-controlled trials confirmed the symptomatic use of codeine, dextromethorphan, and diphenhydramine in the treatment of bronchitis. One double-blind study of 108 patients compared the efficacy of the oral dextromethorphan-salbutanol combination with dextromethorphan. The authors did not find a statistically significant difference between the 2 groups in terms of the nature of the cough during the day, as well as the amount of sputum and expectoration.

GENERAL

Bronchitis is a common disease, it ranks first in frequency of occurrence among diseases of the respiratory system. Main risk group - children and the elderly. Men get sick 2-3 times more often than women, because among them there is a higher percentage of workers in hazardous industries and more smokers. The disease is most common in cold climates and regions with high humidity, and among people who are often in damp, drafty, unheated rooms.

Inflammation is provoked by infections and viruses that enter the mucous surface of the bronchi. In addition to them, the global cause of bronchitis is smoking. Smokers, regardless of gender and age, are up to 4 times more likely than others to develop bronchitis. Most of the time, their illness is chronic.

Tobacco smoke and other irritating microscopic elements damage the mucous surface of the upper respiratory tract. Trying to get rid of foreign particles, the bronchi respond with increased sputum production and a strong cough. The disease usually proceeds not severely with timely treatment and elimination of adverse factors that cause the chronic course of the disease.

THE REASONS

The surface of the mucous membranes of the respiratory organs is covered with small cilia. Their main function is to cleanse bacteria and various irritants. If the work of the cilia is disturbed, the airways become vulnerable to infections, allergens and other irritants. The risk of inflammation increases dramatically.

In addition, oxygen saturation of tissues and organs of the body is significantly reduced, which often provokes heart failure, a decrease in general immunity and other serious health problems.

The main factors causing bronchitis:

• viruses and infections, less often - fungi;
• smoking, including passive;
• poor ecology and unsuitable climate;
• unfavorable living and working conditions;
• susceptibility to other respiratory diseases;
• hereditary deficiency of alpha-1 antitrypsin.

Alpha-1 antitrypsin is a special protein produced by the liver and designed to regulate defense mechanisms in the human lungs. It happens that as a result of gene failures, this protein is not produced in the human body, or its quantity is insufficient. In this case, chronic respiratory diseases begin to develop.

CLASSIFICATION

The disease has many variants of the course.

Separate bronchitis primary and secondary:

• Primary arises as an independent disease of the respiratory organs of the upper level.
• Secondary - a consequence of complications after other diseases (flu, tuberculosis, whooping cough and a number of others).

It can be localized in different areas.

Focal bronchitis are divided into:

• Tracheobronchitis - affects only the trachea and large bronchi.
• Bronchitis - affects the bronchi of medium and small size.
• Bronchiolitis - localized only in the bronchioles.

However, this division can be found only at the initial stage of the disease. As a rule, inflammation progresses rapidly and after a short time spreads to all branches of the bronchial tree and acquires a diffuse character.

Clinical forms of bronchitis

• simple;
• obstructive;
• obliterating;
• bronchiolitis.

Chronical bronchitis- this is an untreated acute bronchitis that occurs more than three times in 2 years. It happens:

• purulent non-obstructive;
• simple non-obstructive;
• purulent-obstructive;
• obstructive.

According to the severity of the course of bronchitis are:

• catarrhal;
• fibrinous;
• hemorrhagic;
• mucopurulent;
• ulcerative;
• necrotic;
• mixed.

Often there is allergic tracheal bronchitis, the development of which may be accompanied by an asthmatic syndrome or proceed without it.

SYMPTOMS

Bronchitis begins as an acute respiratory disease - with general weakness, runny nose, fever, intoxication, discomfort in the throat. The mucous surfaces of the bronchi are hyperemic, edematous. The disease becomes severe when the bronchial epithelium is affected by erosions and ulcers, often in this pathological process it affects the submucosal layer and muscles of the bronchial walls, as well as the surrounding tissue.

The main external symptom is dry persistent cough. At this stage, the most important task is to achieve the transition of a dry cough into a wet one. A productive wet cough brings relief and promotes the recovery of a person, allowing the bronchi to get rid of mucus. The expectorated sputum has a white, yellow or greenish tint, occasionally with an admixture of blood. Often cough worsens at night or if the patient goes into the supine position.

The lack of adequate timely treatment of the acute form of the disease, as well as the neglect of the rules for the prevention of relapses, contribute to its chronicity with damage to the entire bronchial system and lung tissues.

Symptoms of chronic bronchitis:

• persistent cough, accompanied by the production of thick sputum, which greatly complicates breathing and gas exchange;
• difficulty breathing, which is accompanied by wheezing and shortness of breath even with light physical exertion;
• violation of oxygen metabolism in the body, as a result of which the skin turns pale and acquires a bluish tint;
• increased fatigue, poor sleep.

DIAGNOSTICS

Therapist and pulmonologist are engaged in the diagnosis and treatment of diseases of the respiratory system.

To make a diagnosis, you can prescribe:

• general and biochemical analyzes of urine and blood;
• bacteriological culture of sputum;
• spirogram;
• chest x-ray;
• bronchoscopy.

When conducting a bronchoscopy, the doctor may take a biopsy for research, which will rule out the development of cancer.

TREATMENT

With a confirmed diagnosis, the patient will undergo systematic treatment, including a complex of medications, physiotherapy and auxiliary methods.

In the acute form of the disease, therapy is symptomatic.

Acute bronchitis is treated with:

Physiotherapy for acute bronchitis involves inhalation, therapeutic bronchoscopy, electroprocedures, special breathing exercises, percussion massage.

With adequate treatment and prevention of the transition of the disease into a chronic form, acute bronchitis does not last more than 5-7 days. Full recovery follows in 12-14 days. Chronic bronchitis continues for years even with qualified medical intervention.

Chronic bronchitis is not treatable, but it is categorically impossible to let the disease take its course. Depending on the stage of the disease and the severity of its course, the doctor prescribes a set of measures that allow the patient to maintain the quality of life and performance.

• mandatory smoking cessation, maintaining a healthy lifestyle;
• elimination of the risk of lung infections - elimination of irritants from the air, vaccination against influenza;
• hardening to increase the body's resistance, exercise therapy and sports;
• physiotherapy, oxygen therapy, inhalations, breathing exercises;
• taking bronchodilators or steroid drugs to expand the lumen of the bronchi and facilitate breathing.

Sometimes, with a complex form of the disease or exacerbation, treatment is best done in a hospital setting.

COMPLICATIONS

Chronic bronchitis poses a risk of developing serious complications. Inflammatory reaction and viral intoxication dramatically reduce the drainage function of the bronchi. The discharge of sputum from the lower respiratory tract is difficult, the infection spreads down, causing pneumonia.

At the same time, prerequisites are created for bacterial embolism in the bronchi of a smaller diameter. Scars form on the surface of the mucous membrane of the small respiratory tract, the elasticity and strength of the lung tissue is disturbed, and it becomes difficult for the patient to breathe. In the future, this leads to emphysema and chronic obstructive pulmonary disease. There is a threat to human life.

Spasm and infiltration of the walls of the entire structure of the bronchi affects even the smallest bronchioles, sputum blocks the respiratory lumen - all this disrupts natural ventilation and blood circulation, leading to the development of arterial hypertension. The patient starts experience heart failure, which is accompanied by cyanosis, shortness of breath and cough with intense mucus separation. Cardiac and vascular insufficiency progresses, the liver enlarges, legs swell.

In addition, prolonged chronic bronchitis leads to hyperreactivity of the bronchial mucosa. It thickens, swells, the airway narrows, this entails serious breathing problems, up to suffocation. Developing asthmatic syndrome and subsequently bronchial asthma. The presence of allergies in humans significantly accelerates these processes.

PROGNOSIS FOR RECOVERY

Acute bronchitis with timely access to a medical institution and correctly prescribed therapy, as a rule, responds well to treatment. Full recovery takes up to 10-14 days. Elderly and immunocompromised patients may take 3-4 weeks to recover.

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Bronchiolitis is an inflammatory lesion of the bronchioles - the smallest bronchi. In this case, as a result of a partial or complete decrease in their lumen.

How to treat chronic bronchitis?

Treatment of chronic bronchitis is a long process. Success largely depends on the discipline of the patient, to whom doctors prescribe a long list of drugs. Along with taking medications, breathing exercises are of great importance.

To begin with, the patient is recommended to get rid of the factors that provoke the development of the disease. When smoking - give up bad habits. If you have to work in harmful conditions - change jobs. Otherwise, all treatment will go down the drain.

It is obligatory to follow a high-calorie diet, which helps to strengthen the body's defenses and restore damaged mucous membranes. The patient is advised to enrich the daily diet with protein foods, fruits, nuts, vegetables.

If possible, viral infections should be avoided, which can provoke an exacerbation of the disease. In the cold season, you need to take immunomodulators. After visiting places with a large crowd of people, it is advisable to gargle with salt water.

An important role in the development of chronic bronchitis is played by the quality of home air, so every day it is necessary to do wet cleaning in the apartment. It would be nice to get room air purifiers.

Drug therapy

With an exacerbation of the disease, treatment should be aimed at eliminating the acute inflammatory process in the bronchi. During this period, it is very important to pass sputum for bacteriological analysis, according to the results of which the doctor will be able to prescribe the appropriate antibiotic.

If it is not possible to conduct a study, the remedy is selected empirically. To begin with, the doctor prescribes an antibacterial drug from the penicillin group (Flemoxin, Augmentin). If after three days of therapy no signs of improvement are observed in the patient, the drug is replaced with a cephalosporin (Zinnat) or a macrolide (Azithromycin). Preference is given to tablet forms. In severe cases, injections (Cefatoxime) or droppers (Amoxiclav, Augmentin) may be indicated.

In case of poor sputum discharge, alkaline drink and expectorants (mucolytics) are prescribed. Bromhexine (orally 8 mg 3 times a day), ambroxol (30 mg 3 times a day) or acetylcysteine ​​(200 mg up to 4 times a day) are recommended. The course of treatment with these drugs is 14 days. A good result is also given by ultrasonic inhalations with carbocysten or ambroxol. They are made 2 times a day for 10 days.

In the early stages of the disease, the anti-inflammatory drug Erespal is effective (in tablets or in the form of syrup). It is taken simultaneously with mucolytics (80 mg 3 times a day).

To eliminate spasms of the bronchi, use bronchodilators (bronchodilators). The safest are inhalation (Atrovent, Berotek) and oral (Eufillin) preparations.

With the release of purulent sputum, therapeutic bronchoscopy is done: through thin flexible tubes (endoscopes), the bronchi are washed with a solution of sodium chloride or furacilin. The procedure is performed on an empty stomach under local anesthesia. Sessions are repeated 3-4 times with a break of 3-7 days.

Otherwise, bronchitis is treated during periods of calm:

1. To increase the body's defenses, the patient is prescribed immunomodulators (Ribomunil, Broncho-munal) and vitamins (vitamin C, nicotinic acid, B vitamins).
2. Courses 2 times a year prescribe inhalations with alkaline mineral waters (Borjomi, Bzhni) or mucolytics (Ambroxol).
3. With difficulty breathing in small doses, it is recommended to take bronchodilators (Eufillin) at night.
4. With developed pulmonary heart failure, diuretics (Veroshpiron), agents that improve myocardial metabolism (Riboxin), cardiac glycosides (Digoxin), and oxygen therapy are indicated.

Non-drug measures

From non-drug methods, the doctor may suggest:

1. Massage. Special vibration techniques improve blood circulation in the chest and rid the bronchi of excess phlegm.
2. postural drainage. The patient is placed on a couch, the foot end of which is slightly raised. Under the supervision of a nurse, the patient rolls over several times from back to stomach and from side to side for 20 minutes. This technique helps to facilitate the discharge of sputum. The procedure is repeated 2 times a day for 5-7 days.
3. Halotherapy ("salt cave"). For 30-40 minutes the patient is in a room, the floor and walls of which are lined with salt crystals. Salt vapors actively fight infection and facilitate coughing.
4. Hypoxic therapy ("mountain air"). Breathing with a mixture with a low oxygen content helps to train the immune system and adapt the body to hypoxia conditions. The procedure is carried out in special treatment rooms based on clinics or hospitals.
5. Physiotherapy: ultraviolet or infrared irradiation of the chest, calcium electrophoresis. The procedures are aimed at thinning the sputum in the bronchi.

All of these methods are effective both during exacerbations and during remissions of chronic bronchitis.

In all phases of the disease, it is necessary to perform daily breathing exercises. The simplest of them - according to Kuznetsov - includes the usual exercises with arm swings, which are accompanied by deep breaths and exhalations. More difficult gymnastics according to Strelnikova teaches breathing with the help of the abdominal muscles. It is better to master it under the guidance of an instructor in a medical institution.

During periods of rehabilitation, all patients benefit from:

• Sanatorium-resort rest,
• ski trips,
• swimming,
• hardening.

More about bronchitis (and bronchiectasis) tells the program "Live healthy!":

Prevention of chronic bronchitis: how to prevent the chronicization of the pathological process?

Prevention of chronic bronchitis is essential to maintain normal respiratory health. This pathology is a long-term progressive inflammatory process of the lower respiratory tract with a failure of the cleansing, protective and secretory functions.

Such violations are a factor that predisposes to the development of exacerbations and complications, the addition of infections. According to medical statistics, about 20% of all clinical cases of inflammation of the lower respiratory tract are chronic bronchitis.

What causes bronchitis?

In chronic bronchitis, in all age categories of patients, an inflammatory process of the bronchopulmonary tract occurs. Usually, residents of large cities with developed infrastructure and industry suffer from the disease.

Important! Chronic bronchitis is diagnosed with the duration of the acute phase of the disease for 3 months or more, subject to the annual occurrence of a severe cough over the past 2 years.

Chronic bronchitis is the main factor that contributes to the occurrence of obstructive lesions of the lung tissues, emphysema, respiratory failure and other complications.

According to the medical classification, the disease differs in the following phases:

• stage of the pathological process;
• modification of the quality index of tissues;
• development of obstructive processes;
• variant of the clinical course.

The pathological process can spread to both large and small bronchi. According to the clinical picture, there may be an inflammatory process that rarely makes itself felt, but there are those that recur often. In some cases, chronic bronchitis occurs with complications (see Complications after various types of bronchitis in adults).

Provoking factors

Etiological factors are quite diverse.

But, there are some risk factors that are more common than others:

• entry into the respiratory tract of various chemical particles from the environment;
• increased harmfulness of production;
• exposure to tobacco;
• chronic tracheitis;
• wrong tactics of therapy of acute type of bronchitis;
• accommodation in the area of ​​large industrial facilities;
• chronic laryngitis;
• difficulty in nasal breathing;
• lack of personal protective equipment in hazardous production.

The reasons that led to the development of pathology, it is not always possible to determine for certain.

Attention! Chronic bronchitis requires a similar definition, since otherwise there are great difficulties with the selection of optimal treatment tactics that will transfer the disease into a phase of stable remission.

For example, if inflammatory processes have arisen as a result of an infectious lesion, tactics will be aimed at eliminating the main pathogen, since bacteria enter the respiratory system from the ENT organs. Also, it is required to take into account that smoking in any form adversely affects the body and provokes the development of pathology.

Important! Smokers experience pathological changes in bronchial secretion, which stagnates and provokes obstructive processes. Nicotine contains a significant number of particles that can potentially lead to the development of inflammatory processes in the mucous membranes.

Inflammatory processes

The pathogenesis of the disease consists in violations that relate to the functionality of the mucous membranes of the lower respiratory organs. At the same time, the function of clearing the bronchi is significantly weakened and the process itself slows down.

In the course of inflammation, other factors also play a role, the main ones being:

• increase in the viscosity of mucus;
• stagnant processes of sputum;
• decreased production of alpha-2 antitrypsin;
• decrease in interferon volumes;
• suppression of phagocytosis;
• disruption of lysozyme production.

Also, violations occur in the immune system of the body.

At the initial stage, with such changes, swelling is formed and there is an admixture of pus in the mucus. A prolonged course provokes atrophy, which later turns into respiratory failure. Prevention of chronic bronchitis in adults is to minimize the impact of harmful factors on the human body.

The video in this article will acquaint the reader with the basic rules for the prevention of bronchitis.

Diagnosis and therapy

With the correct diagnosis, it is not particularly difficult for a specialist to choose the optimal treatment tactics for a specialist.

Diagnostic measures involve the following manipulations:

• auscultation;
• determination of the speed of absorbed air;
• study of external respiration.

The following pathological changes in the patient's respiratory function indicate the progression of the disease:

• a certain boxed sound during listening;
• wheezing of wet and dry nature;
• increase in expiratory duration;
• hard breathing;
• decrease in lung volumes;
• increase in respiratory volume;
• decrease in expiratory duration;
• symptoms associated with emphysema.

It is quite difficult to fully cure the chronic type of bronchitis, but it is quite possible. To do this, you must follow each appointment of the treating specialist exactly. National recommendations imply the use of antibacterial agents in combination with physiotherapy.

1. Quit smoking completely.
2. Protect the respiratory tract from the effects of toxic substances.
3. Review your eating habits and consume quality food.
4. Take all the medicines prescribed by your doctor in the exact dosage and according to the recommended schedule.
5. Do certain breathing exercises.
6. More often to be in the green zone and travel outside the city to ecologically clean regions.
7. Treat all existing concomitant respiratory diseases.

Patients require regular intake of mucolytics and other expectorants. You may also need to take antibiotics. In addition to the above, treatment involves taking medications that expand the bronchi and immunostimulating drugs.

During periods of remission, patients are required to perform all preventive measures that can help get rid of chronic bronchitis not only for a long time, but also to recover from it completely.

Fundamentals of Prevention

With the diagnosis of "chronic bronchitis" it is required to adjust your own rhythm of life to this disease, that is, to perform those actions that can leave the pathology in remission. To do this, the patient must follow these recommendations.

To alleviate the condition, with difficulty breathing, it is possible to periodically exhale with tightly closed lips. As for the main prevention of chronic bronchitis, it is divided into primary and secondary.

Key points for primary prevention

Since the main period of development and exacerbation of respiratory diseases occurs in autumn and spring, during these seasons, it is necessary to carefully carry out preventive measures.

Elementary preventive measures imply compliance with the following rules:

1. Personal hygiene- thorough cleaning of hands, the use of disposable wipes, a contrast shower after sleep. These actions will help strengthen the body and partly prevent the exacerbation of bronchitis.
2. During periods of epidemiological outbreaks, it is required to perform rinsing of the nasopharynx using a solution of sea salt and water.
3. Wet room cleaning when using disinfectants, it can increase humidity and reduce the concentration of pathogenic microorganisms in the air.
4. It is necessary to ventilate the rooms daily(subject to the relative purity of the air in the street).
5. It is required to maintain a healthy microclimate in the living room. This implies a humidity level not exceeding 70% and a room temperature within 20-25̊ C.
6. Taking preventive medicines- means vitamin-mineral complexes, immunomodulatory drugs and other methods of prevention.
7. Avoiding prolonged exposure to large crowds- This will significantly reduce the likelihood of an infectious disease.
8. Vaccination is one of the most important preventive measures, as it helps to prevent the patient from accidentally infecting the patient with any disease that can push bronchitis to the active phase.

In the presence of any chronic diseases, patients are required to be vaccinated annually.

Attention! There are certain contraindications to vaccination. Only a doctor can determine the feasibility of immunization.

Principles of secondary prevention

Chronic bronchitis involves long-term therapy, while secondary prevention measures are aimed at minimizing the likelihood of the transition of the disease to an exacerbated form and a complete revision of the principles and quality of life of the patient. The rehabilitation program is chosen individually by the attending physician.

Basically, secondary prevention involves the implementation of the following measures by the patient:

1. In the chronic form of bronchitis, it is required to undergo a sanatorium-resort rehabilitation. The instruction of generally accepted norms suggests that health procedures be carried out 2 times a year.
2. Hardening allows you to reduce the likelihood of exacerbations, but you need to harden gradually (the water temperature from the usual one drops by 1̊ C every 3 days, not more often) and perform the procedures regularly.
3. With diagnosed chronic bronchitis, it is required to regularly perform breathing exercises.
4. Breathing exercises should be moderate, as excessive fanaticism can lead to negative consequences. The best option is gymnastics according to Strelnikova.
5. Excessively intense physical activity should be avoided, as they can lead to a deterioration in respiratory function in chronic bronchitis.
6. Interaction with any substances that can potentially cause allergic reactions should also be kept to a minimum. You should refuse to work in harmful conditions, because the price is the health and full life of the patient.
7. It is required to abandon activities in enterprises with a high degree of harmfulness, since in this way it is possible to provoke not only chronic bronchitis, but also the development of more severe pathologies of the respiratory tract.

Also, in order to prevent exacerbation of chronic bronchitis, it is required not to forget about the general principles of a healthy lifestyle and adhere to them. Full sleep for 6-8 hours should fall on the dark time of the day, while falling asleep preferably no later than midnight.

It is also desirable to avoid stressful factors and often be in the green urban area, taking walks. It has been proven that moving to regions with favorable environmental conditions is highly desirable for patients suffering from diseases of the upper respiratory tract.

Competent prevention in chronic bronchitis can greatly reduce the likelihood of its exacerbation and lead to a cure for the patient from this pathology.

Bronchitis is one of the most common diseases of the lower respiratory system, which occurs in both children and adults. It can occur due to the action of factors such as allergens, physico-chemical influences, bacterial, fungal or viral infection.

In adults, there are 2 main forms - acute and chronic. On average, acute bronchitis lasts about 3 weeks, and chronic bronchitis lasts at least 3 months during the year and at least 2 years in a row. In children, another form is distinguished - recurrent bronchitis (this is the same acute bronchitis, but repeated 3 or more times throughout the year). If the inflammation is accompanied by a narrowing of the lumen of the bronchi, then they speak of obstructive bronchitis.

If you get sick with acute bronchitis, then for a speedy recovery and to prevent the transition of the disease into a chronic form, you should adhere to the following recommendations of specialists:

1. On days when the temperature rises, observe bed or semi-bed rest.
2. Drink plenty of fluids (at least 2 liters per day). It will facilitate the cleansing of phlegm from the bronchi, because it will make it more liquid, and will also help to remove toxic substances from the body resulting from the disease.
3. If the air in the room is too dry, take care of humidifying it: hang wet sheets, turn on the humidifier. This is especially important in winter during the heating season and in summer when it is hot, as dry air increases coughing.
4. As your condition improves, start doing breathing exercises, ventilate the room more often, and spend more time in the fresh air.
5. In the case of obstructive bronchitis, be sure to exclude contact with allergens, do wet cleaning more often, which will help get rid of dust.
6. If this is not contraindicated by a doctor, then after the temperature has returned to normal, you can do a back massage, especially drainage, put mustard plasters, rub the chest area with warming ointments. Even simple procedures such as a hot foot bath to which you can add mustard powder can help improve blood circulation and speed up recovery.
7. To alleviate a cough, ordinary steam inhalations with soda and decoctions of anti-inflammatory herbs will be useful.
8. To improve sputum discharge, drink milk with honey, tea with raspberries, thyme, oregano, sage, alkaline mineral waters.
9. Make sure that on sick days, the diet is enriched with vitamins and proteins - eat fresh fruits, onions, garlic, lean meat, dairy products, drink fruit and vegetable juices.
10. Take the medicines prescribed by your doctor.

As a rule, in the treatment of acute bronchitis, the doctor recommends the following groups of drugs:

• Thinning sputum and improving its discharge - for example, Ambroxol, ACC, Mukaltin, licorice root, marshmallow.
• In case of obstruction phenomena - Salbutamol, Eufillin, Teofedrin, antiallergic drugs.
• Strengthening the immune system and helping to fight a viral infection - Groprinosin, vitamins, preparations based on interferon, eleutherococcus, echinacea, etc.
• In the early days, if a dry and unproductive cough is exhausting, antitussives are also prescribed. However, on the days of their intake, expectorant drugs should not be used.
• With a significant increase in temperature, antipyretic and anti-inflammatory drugs are indicated - for example, Paracetamol, Nurofen, Meloxicam.
• If a second wave of temperature occurs or sputum becomes purulent, then antibiotics are added to the treatment. For the treatment of acute bronchitis, amoxicillins protected by clavulanic acid - Augmentin, Amoxiclav, cephalosporins, macrolides (Azithromycin, Clarithromycin) are most often used.
• If the cough lasts more than 3 weeks, then it is necessary to take an x-ray and consult a pulmonologist.

In case of recurrent or chronic bronchitis, the implementation of the recommendations of specialists can reduce the frequency of exacerbations of the disease, and in most cases prevent the occurrence of diseases such as lung cancer, bronchial asthma of an infectious-allergic nature, progression of respiratory failure.

1. Quit smoking completely, including passive inhalation of tobacco smoke.
2. Don't drink alcohol.
3. Annually undergo preventive examinations by a doctor, chest x-ray, ECG, take a general blood test, sputum tests, including for the presence of Mycobacterium tuberculosis, and in case of obstructive bronchitis, also do spirography.
4. Strengthen the immune system by leading a healthy lifestyle, do physiotherapy exercises, breathing exercises, harden, and in the autumn-spring period, take adaptogens - preparations based on echinacea, ginseng, eleutherococcus. If bronchitis is of a bacterial nature, then it is recommended to complete a full course of therapy with Bronchomunal or IRS-19.
5. With obstructive bronchitis, it is very important to avoid work that involves the inhalation of any chemical fumes or dust containing particles of silicon, coal, etc. Also avoid being in stuffy, unventilated areas. Make sure you get enough vitamin C daily.
6. Outside of exacerbation, sanatorium treatment is indicated.

During an exacerbation of chronic or recurrent bronchitis, the recommendations are consistent with those for the treatment of the acute form of the disease. In addition, the introduction of drugs using a nebulizer is widely used, as well as the sanitation of the bronchial tree using a bronchoscope.

Bronchitis is one of the most common diseases. Both acute and chronic cases rank high among respiratory pathologies. Therefore, they require high-quality diagnostics and treatment. Summarizing the experience of leading experts, relevant clinical recommendations on bronchitis are created at the regional and international levels. Compliance with the standards of care is an important aspect of evidence-based medicine, which allows you to optimize diagnostic and therapeutic measures.

Causes and mechanisms

None of the recommendations can do without considering the causes of the pathology. It is known that bronchitis has an infectious and inflammatory nature. The most common causative agents of the acute process are viral particles (influenza, parainfluenza, respiratory syncytial, adeno-, corona- and rhinoviruses), and not bacteria, as previously thought. Outside of seasonal outbreaks, it is possible to establish a certain role for other microbes: whooping cough, mycoplasmas and chlamydia. But pneumococcus, moraxella and Haemophilus influenzae can cause acute bronchitis only in patients who have undergone surgery on the respiratory tract, including tracheostomy.

Infection plays a crucial role in the development of chronic inflammation. But bronchitis at the same time has a secondary origin, arising against the background of a violation of local protective processes. Exacerbations are provoked mainly by the bacterial flora, and the long course of bronchitis is due to the following factors:

1. Smoking.
2. Professional hazards.
3. Air pollution.
4. Frequent colds.

If during acute inflammation there is swelling of the mucous membrane and increased production of mucus, then the central link of the chronic process is the violation of mucociliary clearance, secretory and protective mechanisms. The long course of the pathology often leads to obstructive changes, when due to thickening (infiltration) of the mucosa, sputum stagnation, bronchospasm and tracheobronchial dyskinesia, obstacles are created for the normal passage of air through the respiratory tract. This leads to functional disorders with further development of pulmonary emphysema.

Bronchitis is provoked by infectious agents (viruses and bacteria), and acquires a chronic course under the influence of factors that violate the protective properties of the respiratory epithelium.

Symptoms

Assume pathology at the initial stage will allow the analysis of clinical information. The doctor evaluates the anamnesis (complaints, onset and course of the disease) and conducts a physical examination (examination, auscultation, percussion). So he gets an idea of ​​the symptoms, on the basis of which he makes a preliminary conclusion.

Acute bronchitis occurs on its own or against the background of SARS (most often). In the latter case, it is important to pay attention to the catarrhal syndrome with a runny nose, perspiration, sore throat, as well as fever with intoxication. But pretty soon there are signs of bronchial damage:

• Intense cough.
• Expulsion of scanty mucous sputum.
• Expiratory dyspnea (difficulty exhaling predominantly).

Even chest pains may appear, the nature of which is associated with muscle strain during a hacking cough. Shortness of breath appears only with the defeat of the small bronchi. Percussion sound, as well as voice trembling, are not changed. Auscultation reveals hard breathing and dry rales (buzzing, whistling), which become moist during the resolution of acute inflammation.

If the cough lasts more than 3 months, then there is every reason to suspect chronic bronchitis. It is accompanied by sputum discharge (mucous or purulent), less often it is unproductive. At first this is observed only in the morning, but then any increase in the frequency of breathing leads to expectoration of the accumulated secret. Shortness of breath with prolonged exhalation joins when obstructive disorders appear.

In the acute stage, there is an increase in body temperature, sweating, weakness, the volume of sputum increases and its purulence increases, the intensity of cough increases. The periodicity of chronic bronchitis is quite pronounced, inflammation is especially activated in the autumn-winter period and with sudden changes in weather conditions. The function of external respiration in each patient is individual: in some, it remains at an acceptable level for a long time (non-obstructive bronchitis), while in others, shortness of breath with ventilation disorders appears early, which persists during periods of remission.

On examination, one can notice signs indicating chronic respiratory failure: chest expansion, pallor of the skin with acrocyanosis, thickening of the terminal phalanges of the fingers (“drumsticks”), changes in nails (“watch glasses”). The development of cor pulmonale may indicate swelling of the legs and feet, swelling of the jugular veins. Percussion with simple chronic bronchitis does not give anything, and obstructive changes can be assumed from the box shade of the sound received. The auscultatory picture is characterized by hard breathing and scattered dry rales.

It is possible to assume bronchitis by clinical signs that are revealed during a survey, examination and using other physical methods (percussion, auscultation).

Additional diagnostics

Clinical recommendations contain a list of diagnostic measures that can be used to confirm the doctor's assumption, determine the nature of the pathology and its causative agent, and identify concomitant disorders in the patient's body. On an individual basis, such studies can be prescribed:

• General blood analysis.
• Blood biochemistry (acute phase indicators, gas composition, acid-base balance).
• Serological tests (antibodies to pathogens).
• Analysis of swabs from the nasopharynx and sputum (cytology, culture, PCR).
• Chest X-ray.
• Spirography and pneumotachometry.
• Bronchoscopy and bronchography.
• Electrocardiography.

The study of the function of external respiration plays a key role in determining violations of bronchial conduction in a chronic process. At the same time, two main indicators are evaluated: the Tiffno index (the ratio of forced expiratory volume in 1 second to the vital capacity of the lungs) and peak expiratory flow rate. Radiologically, with simple bronchitis, only an increase in the pulmonary pattern can be seen, but prolonged obstruction is accompanied by the development of emphysema with an increase in the transparency of the fields and a low standing diaphragm.

Treatment

Having diagnosed bronchitis, the doctor immediately proceeds to therapeutic measures. They are also reflected in the clinical guidelines and standards that guide specialists when prescribing certain methods. Drug therapy is central to acute and chronic inflammation. In the first case, the following drugs are used:

• Antiviral (zanamivir, oseltamivir, rimantadine).
• Expectorants (acetylcysteine, ambroxol).
• Antipyretics (paracetamol, ibuprofen).
• Antitussives (oxeladin, glaucine).

The last group of drugs can be used only with intense hacking cough, which is not stopped by other means. And it should be remembered that they should not inhibit mucociliary clearance and be combined with drugs that increase mucus secretion. Antibiotics are used only in cases where the bacterial origin of the disease is clearly proven or there is a risk of developing pneumonia. In the recommendations after bronchitis there is an indication of vitamin therapy, immunotropic drugs, giving up bad habits and hardening.

Acute bronchitis is treated with medications that affect the infectious agent, disease mechanisms, and individual symptoms.

The treatment of chronic pathology involves various approaches during the period of exacerbation and remission. The first direction is due to the need to sanitize the respiratory tract from infection and involves the appointment of such medications:

1. Antibiotics (penicillins, cephalosporins, fluoroquinolones, macrolides).
2. Mucolytics (bromhexine, acetylcysteine).
3. Antihistamines (loratadine, cetirizine).
4. Bronchodilators (salbutamol, fenoterol, ipratropium bromide, aminophylline).

Drugs that eliminate bronchospasm occupy an important place not only during exacerbation, but also as a basic therapy for chronic inflammation. But in the latter case, preference is given to prolonged forms (salmeterol, formoterol, tiotropium bromide) and combined drugs (Berodual, Spiolto Respimat, Anoro Ellipta). In severe cases of obstructive bronchitis, theophyllines are added. Inhaled corticosteroids, such as fluticasone, beclomethasone, or budesonide, are indicated for the same category of patients. Like bronchodilators, they are used for long-term (basic) therapy.

The presence of respiratory failure requires oxygen therapy. The set of recommended measures also includes influenza vaccination to prevent exacerbations. An important place in the rehabilitation program is occupied by individually selected breathing exercises, high-calorie and fortified diet. And the appearance of single emphysematous bullae may suggest their surgical removal, which favorably affects the ventilation parameters and the condition of patients.

Bronchitis is a very common disease of the respiratory tract. It occurs in acute or chronic form, but each of them has its own characteristics. Methods for diagnosing bronchial inflammation and methods for its treatment are reflected in international and regional recommendations that guide the doctor. The latter were created to improve the quality of medical care, and some have even been put into practice at the legislative level in the form of relevant standards.

C In order to select the optimal tactics for managing patients with exacerbation of chronic bronchitis (CB), it is advisable to single out the so-called "infectious" and "non-infectious" exacerbations of chronic bronchitis, requiring an appropriate therapeutic approach. An infectious exacerbation of chronic bronchitis can be defined as an episode of respiratory decompensation that is not associated with objectively documented other causes, and primarily with pneumonia.

Diagnosis of infectious exacerbation of CB includes the use of the following clinical, radiological, laboratory, instrumental and other methods of examination of the patient:

Clinical study of the patient;

Study of bronchial patency (according to FEV 1);

X-ray examination of the chest (exclude pneumonia);

Cytological examination of sputum (counting the number of neurophiles, epithelial cells, macrophages);

Sputum Gram stain;

Laboratory studies (leukocytosis, neutrophilic shift, increased ESR);

Bacteriological examination of sputum.

These methods allow, on the one hand, to exclude syndromic-similar diseases (pneumonia, tumors, etc.), and on the other hand, to determine the severity and type of exacerbation of chronic bronchitis.

Clinical symptoms of exacerbations of CB

increased cough;

Increase in the amount of sputum discharge;

Change in the nature of sputum (increase in purulent sputum);

Increased shortness of breath;

Increased clinical signs of bronchial obstruction;

Decompensation of concomitant pathology (heart failure, arterial hypertension, diabetes mellitus, etc.);

Fever.

Each of these signs can be isolated or combined with each other, and also have a different degree of severity, which characterizes the severity of the exacerbation and allows us to tentatively assume the etiological spectrum of pathogens. According to some data, there is a connection between isolated microorganisms and indicators of bronchial patency in patients with exacerbation of chronic bronchitis. As the degree of bronchial obstruction increases, the proportion of gram-negative microorganisms increases with a decrease in gram-positive microorganisms in the sputum of patients with exacerbation of chronic bronchitis.

Depending on the number of symptoms present, different types of exacerbation of chronic bronchitis are distinguished, which acquires important prognostic significance and can determine the tactics of treating patients with exacerbation of chronic bronchitis (Table 1).

In infectious exacerbation of chronic bronchitis, the main method of treatment is empirical antibiotic therapy (AT). It has been proven that AT contributes to a more rapid relief of symptoms of exacerbation of CB, eradication of etiologically significant microorganisms, an increase in the duration of remission, and a reduction in costs associated with subsequent exacerbations of CB.

The choice of antibacterial drug for exacerbation of chronic bronchitis

When choosing an antibacterial drug, it is necessary to consider:

clinical situation;

The activity of the drug against the main (most likely in this situation) pathogens of an infectious exacerbation of the disease;

Accounting for the likelihood of antibiotic resistance in this situation;

Pharmacokinetics of the drug (penetration into sputum and bronchial secretions, half-life, etc.);

Lack of interaction with other medicines;

Optimal dosing regimen;

Minimal side effects;

Cost indicators.

One of the guidelines for empiric antibiotic therapy (AT) of CB is the clinical situation, i.e. variant of exacerbation of CB, severity of exacerbation, presence and severity of bronchial obstruction, various factors of poor response to AT, etc. Taking into account the above factors allows us to tentatively assume the etiological significance of a particular microorganism in the development of an exacerbation of CB.

The clinical situation also makes it possible to assess the likelihood of antibiotic resistance of microorganisms in a particular patient (penicillin resistance of pneumococci, products H. influenzae(lactamase), which may be one of the guidelines when choosing the initial antibiotic.

Risk factors for penicillin resistance in pneumococci

Age up to 7 years and over 60 years;

Clinically significant comorbidities (heart failure, diabetes mellitus, chronic alcoholism, liver and kidney disease);

Frequent and prolonged prior antibiotic therapy;

Frequent hospitalizations and stay in places of charity (boarding schools).

Optimal pharmacokinetic properties of the antibiotic

Good penetration into sputum and bronchial secretions;

Good bioavailability of the drug;

Long half-life of the drug;

No interaction with other medicines.

Among the most commonly prescribed aminopenicillins for exacerbations of chronic bronchitis, amoxicillin, produced by Sintez OJSC under the brand name, has optimal bioavailability. Amosin® , JSC "Synthesis", Kurgan, which therefore has advantages over ampicillin, which has a rather low bioavailability. When taken orally, amoxicillin ( Amosin® ) has a high activity against the main microorganisms etiologically associated with exacerbation of CB ( Str. Pneumoniae, H. influenzae, M. cattharalis). The drug is available in 0.25, 0.5 g No. 10 and in capsules 0.25 No. 20.

A randomized, double-blind and double-placebo-controlled study compared the efficacy and safety of amoxicillin at a dose of 1 g 2 times a day (Group 1) and 0.5 g 3 times a day (Group 2) in 395 patients with exacerbation of chronic bronchitis. The duration of treatment was 10 days. Clinical efficacy was assessed at 3-5 days, 12-15 days and 28-35 days after the end of treatment. Among the ITT population (who did not complete the study), the clinical efficacy in patients in groups 1 and 2 was 86.6% and 85.6%, respectively. At the same time, in the RR population (completion of the study according to the protocol) - 89.1% and 92.6%, respectively. Clinical recurrence in the ITT and RR populations was observed in 14.2% and 13.4% in group 1 and 12.6% and 13.7% in group 2. Statistical data processing confirmed the comparable efficacy of both regimens. Bacteriological efficacy in groups 1 and 2 among the ITT population was noted in 76.2% and 73.7%.

Amoxicillin ( Amosin® ) is well tolerated, except in cases of hypersensitivity to beta-lactam antibiotics. In addition, it has practically no clinically significant interaction with other drugs prescribed to patients with chronic bronchitis, both in connection with an exacerbation and for comorbidities.

Risk factors for poor response to antigens in exacerbation of CB

Elderly and senile age;

Severe violations of bronchial patency;

Development of acute respiratory failure;

Concomitant pathology;

Frequent previous exacerbations of HB (more than 4 times a year);

The nature of the pathogen (antibiotic-resistant strains, Ps. aeruginosa).

The main options for exacerbation of CB and AT tactics

Simple chronic bronchitis:

The age of patients is less than 65 years;

The frequency of exacerbations is less than 4 per year;

FEV 1 more than 50% of due;

The main etiologically significant microorganisms: St. pneumoniae H. influenzae M. cattarhalis(possible resistance to b-lactams).

First line antibiotics:

Aminopenicillins (amoxicillin) Amosin® )) 0.5 g x 3 times inside, ampicillin 1.0 g x 4 times a day inside). Comparative characteristics of ampicillin and amoxicillin ( Amosin® ) is presented in Table 2.

Macrolides (azithromycin (Azithromycin - AKOS, JSC Sintez, Kurgan) 0.5 g per day on the first day, then 0.25 g per day for 5 days, clarithromycin 0.5 g x 2 times a day inside .

Tetracyclines (doxycycline 0.1 g twice daily) may be used in regions with low pneumococcal resistance.

Alternative antibiotics:

Protected penicillins (amoxicillin / clavulanic acid 0.625 g every 8 hours orally, ampicillin / sulbactam (Sultasin®, Sintez OJSC, Kurgan) 3 g x 4 times a day),

Respiratory fluoroquinolones (sparfloxacin 0.4 g once daily, levofloxacin 0.5 g once daily, moxifloxacin 0.4 g once daily).

Complicated chronic bronchitis:

Age over 65;

Frequency of exacerbations more than 4 times a year;

An increase in the volume and purulence of sputum during exacerbations;

FEV 1 less than 50% of due;

More pronounced symptoms of exacerbation;

The main etiologically significant microorganisms: the same as in group 1 + St. aureus+ Gram-negative flora ( K. pneumoniae), frequent resistance to b-lactams.

First line antibiotics:

• Protected penicillins (amoxicillin/clavulanic acid 0.625 g every 8 hours orally, ampicillin/sulbactam 3 g x 4 times a day IV);
• Cephalosporins 1-2 generations (cefazolin 2 g x 3 times a day IV, cefuroxime 0.75 g x 3 times a day IV;
• "Respiratory" fluoroquinolones with antipneumococcal activity (sparfloxacin 0.4 g once a day, moxifloxacin 0.4 g per day orally, levofloxacin 0.5 g per day orally).

Alternative antibiotics:

3rd generation cephalosporins (cefotaxime 2 g x 3 times a day IV, ceftriaxone 2 g once a day IV).

Chronic purulent bronchitis:

Any age;

Constant discharge of purulent sputum;

Frequent comorbidities;

Frequent presence of bronchiectasis;

FEV 1 less than 50%;

Severe symptoms of exacerbation, often with the development of acute respiratory failure;

The main etiologically significant microoraginisms: the same as in group 2 + Enterobactericae, P. aeruginosa.

First line antibiotics:

• 3rd generation cephalosporins (cefotaxime 2 g x 3 times a day IV, ceftazidime 2 g x 2-3 times a day IV, ceftriaxone 2 g once a day IV);
• Respiratory fluoroquinolones (levofloxacin 0.5 g once daily, moxifloxacin 0.4 g once daily).

Alternative antibiotics:

"Gram-negative" fluoroquinolones (ciprofloxacin 0.5 g x 2 times orally or 400 mg IV x 2 times a day);

4th generation cephalosporins (cefepime 2 g x 2 times a day IV);

Antipseudomonal penicillins (piperacillin 2.5 g x 3 times a day IV, ticarcillin / clavulanic acid 3.2 g x 3 times a day IV);

Meropenem 0.5 g x 3 times a day IV.

In most cases of exacerbations of chronic bronchitis, antibiotics should be given by mouth. Indications for parenteral antibiotic use are :

Gastrointestinal disorders;

Severe exacerbation of HB disease;

The need for IVL;

Poor oral antibiotic bioavailability;

Patient incompatibility.

The duration of AT during exacerbations of HB is 5-7 days. It has been proven that 5-day courses of treatment are no less effective than longer use of antibiotics.

In cases where there is no effect from the use of first-line antibiotics, a bacteriological examination of sputum or BALF is performed and alternative drugs are prescribed, taking into account the sensitivity of the identified pathogen.

When evaluating the effectiveness of AT exacerbations of chronic bronchitis, the main criteria are :

Immediate clinical effect (rate of regression of clinical symptoms of exacerbation, dynamics of bronchial patency;

Bacteriological efficacy (achievement and timing of eradication of an etiologically significant microorganism);

Long-term effect (duration of remission, frequency and severity of subsequent exacerbations, hospitalization, need for antibiotics);

Pharmacoeconomic effect, taking into account the cost of the drug / treatment efficacy.

Table 3 summarizes the main characteristics of oral antibiotics used to treat CB exacerbations.