Treatment of severe bronchial asthma. Bronchial asthma. Symptoms of bronchial asthma

Bronchial asthma is a chronic inflammatory disease of the airways, accompanied by their hyperreactivity, which is manifested by repeated episodes of shortness of breath, difficulty breathing, a feeling of pressure in the chest and cough, occurring mainly at night or in the early morning. These episodes are usually associated with widespread but not permanent airflow obstruction that is reversible, either spontaneously or with treatment.

EPIDEMIOLOGY

The prevalence of bronchial asthma in the general population is 4-10%, and among children - 10-15%. Predominant gender: children under 10 years old - male, adults - female.

CLASSIFICATION

Classifications of bronchial asthma according to etiology, severity of the course and features of the manifestation of bronchial obstruction are of the greatest practical importance.

The most important is the division of bronchial asthma into allergic (atopic) and non-allergic (endogenous) forms, since specific methods that are not used in the non-allergic form are effective in the treatment of allergic bronchial asthma.

International classification of diseases of the tenth revision (ICD-10): J45 - Bronchial asthma (J45.0 - Asthma with a predominance of an allergic component; J45.1 - Non-allergic asthma; J45.8 - Mixed asthma), J46. - Asthmatic status.

The severity of asthma is classified by the presence of clinical signs before starting treatment and/or by the amount of daily therapy required for optimal symptom control.

◊ Severity Criteria:

♦ clinical: the number of night attacks per week and daytime attacks per day and per week, the severity of physical activity and sleep disorders;

♦ objective indicators of bronchial patency: forced expiratory volume in 1 s (FEV 1) or peak expiratory flow rate (PSV), daily fluctuations in PSV;

♦ the therapy received by the patient.

◊ Depending on the severity, four stages of the disease are distinguished (which is especially convenient in treatment).

♦ step 1 : light intermittent (episodic) bronchial asthma. Symptoms (cough, shortness of breath, wheezing) are noted less than once a week. Night attacks no more than 2 times a month. In the interictal period, there are no symptoms, normal lung function (FEV 1 and PSV more than 80% of the expected values), daily fluctuations in PSV less than 20%.

♦ step 2 : light persistent bronchial asthma. Symptoms occur once a week or more often, but not daily. Night attacks more than 2 times a month. Exacerbations can interfere with normal activity and sleep. PSV and FEV 1 outside the attack more than 80% of the proper values, daily fluctuations in PSV 20-30%, indicating an increasing reactivity of the bronchi.

♦ step 3 : persistent bronchial asthma middle degrees gravity. Symptoms occur daily, exacerbations disrupt activity and sleep, reduce quality of life. Night attacks occur more often than once a week. Patients cannot do without daily intake of short-acting β 2 -agonists. PSV and FEV 1 are 60-80% of the proper values, fluctuations in PSV exceed 30%.

♦ step 4 : heavy persistent bronchial asthma. Persistent symptoms throughout the day. Exacerbations and sleep disturbances are frequent. Manifestations of the disease limit physical activity. PSV and FEV 1 are below 60% of the proper values ​​even without an attack, and daily fluctuations in PSV exceed 30%.

It should be noted that it is possible to determine the severity of bronchial asthma by these indicators only before the start of treatment. If the patient is already receiving the necessary therapy, its volume should be taken into account. If a patient has a clinical picture corresponding to stage 2, but at the same time he receives treatment corresponding to stage 4, he is diagnosed with severe bronchial asthma.

Phases of the course of bronchial asthma: exacerbation, subsiding exacerbation and remission.

♦ Asthmatic status (status asthmaticus) - a serious and life-threatening condition - a protracted attack of expiratory suffocation, which is not stopped by conventional anti-asthma drugs for several hours. There are anaphylactic (rapid development) and metabolic (gradual development) forms of status asthmaticus. It is clinically manifested by significant obstructive disorders up to the complete absence of bronchial conduction, unproductive cough, severe hypoxia, and increasing resistance to bronchodilators. In some cases, there may be signs of an overdose of β 2 -agonists and methylxanthines.

According to the mechanism of violation of bronchial patency, the following forms of bronchial obstruction are distinguished.

◊ Acute bronchoconstriction due to smooth muscle spasm.

◊ Subacute bronchial obstruction due to edema of the mucous membrane of the respiratory tract.

◊ Sclerotic bronchial obstruction due to sclerosis of the bronchial wall with a long and severe course of the disease.

◊ Obstructive bronchial obstruction due to impaired discharge and changes in the properties of sputum, the formation of mucous plugs.

ETIOLOGY

There are risk factors (causally significant factors) that predetermine the possibility of developing bronchial asthma, and provocateurs (triggers) that realize this predisposition.

The most significant risk factors are heredity and exposure to allergens.

◊ The likelihood of developing bronchial asthma is associated with a person's genotype. Examples of hereditary diseases accompanied by manifestations of bronchial asthma are increased IgE production, a combination of bronchial asthma, nasal polyposis and intolerance to acetylsalicylic acid (aspirin triad), airway hypersensitivity, hyperbradykininemia. Gene polymorphism in these conditions determines the readiness of the respiratory tract for inadequate inflammatory responses in response to trigger factors that do not cause pathological conditions in people without a hereditary predisposition.

◊ Of the allergens, the most important are the waste products of house dust mites ( Dermatophagoides pteronyssinus and Dermatophagoides farinae), mold spores, plant pollen, dandruff, saliva and urine components of some animals, bird fluff, cockroach allergens, food and drug allergens.

Provoking factors (triggers) can be respiratory tract infections (primarily acute respiratory viral infections), taking β-blockers, air pollutants (sulfur and nitrogen oxides, etc.), cold air, physical activity, acetylsalicylic acid and other NSAIDs in patients with aspirin bronchial asthma, psychological, environmental and professional factors, pungent odors, smoking (active and passive), concomitant diseases (gastroesophageal reflux, sinusitis, thyrotoxicosis, etc.).

PATHOGENESIS

The pathogenesis of asthma is based on chronic inflammation.

Bronchial asthma is characterized by a special form of inflammation of the bronchi, leading to the formation of their hyperreactivity (increased sensitivity to various non-specific stimuli compared to the norm); the leading role in inflammation belongs to eosinophils, mast cells and lymphocytes.

Inflamed hyperreactive bronchi respond to triggers with airway smooth muscle spasm, mucus hypersecretion, edema, and inflammatory cell infiltration of the airway mucosa, leading to the development of an obstructive syndrome, clinically manifested as an attack of shortness of breath or suffocation.

. ◊ Early asthmatic response is mediated by histamine, prostaglandins, leukotrienes and is manifested by contraction of airway smooth muscles, mucus hypersecretion, mucosal edema.

. ◊ Late asthmatic reaction develops in every second adult patient with bronchial asthma. Lymphokines and other humoral factors cause the migration of lymphocytes, neutrophils and eosinophils and lead to the development of a late asthmatic reaction. The mediators produced by these cells can damage the epithelium of the respiratory tract, maintain or activate the inflammation process, and stimulate afferent nerve endings. For example, eosinophils can secrete most of the major proteins, leukotriene C 4 , macrophages are sources of thromboxane B 2 , leukotriene B 4 and platelet activating factor. T-lymphocytes play a central role in the regulation of local eosinophilia and the appearance of excess IgE. In patients with atopic asthma, the number of T-helpers (CD4 + -lymphocytes) is increased in the bronchial lavage fluid.

. ♦ Prophylactic administration of β 2 -adrenergic agonists blocks only an early reaction, and inhaled HA preparations block only a late one. Cromones (eg nedocromil) act on both phases of the asthmatic response.

. ◊ The mechanism of development of atopic bronchial asthma - the interaction of antigen (Ag) with IgE, activating phospholipase A 2 , under the action of which arachidonic acid is cleaved from the phospholipids of the mast cell membrane, from which prostaglandins (E 2 , D 2 , F 2 α) are formed under the action of cyclooxygenase , thromboxane A 2 , prostacyclin, and under the action of lipoxygenase - leukotrienes C 4 , D 4 , E 4 , which through specific receptors increase the tone of smooth muscle cells and lead to inflammation of the respiratory tract. This fact justifies the use of a relatively new class of anti-asthma drugs - leukotriene antagonists.

PATHOMORPHOLOGY

In the bronchi, inflammation, mucous plugs, mucosal edema, smooth muscle hyperplasia, thickening of the basement membrane, and signs of its disorganization are detected. During the attack, the severity of these pathomorphological changes increases significantly. There may be signs of pulmonary emphysema (see Chapter 20 "Emphysema"). Endobronchial biopsy of patients with stable chronic (persisting) bronchial asthma reveals desquamation of the bronchial epithelium, eosinophilic infiltration of the mucous membrane, and thickening of the basement membrane of the epithelium. With bronchoalveolar lavage, a large number of epithelial and mast cells are found in the washing fluid. In patients with nocturnal attacks of bronchial asthma, the highest content of neutrophils, eosinophils and lymphocytes in the bronchial lavage fluid was observed in the early morning hours. Bronchial asthma, unlike other diseases of the lower respiratory tract, is characterized by the absence of bronchiolitis, fibrosis, and granulomatous reaction.

CLINICAL PICTURE AND DIAGNOSIS

Bronchial asthma is characterized by extremely unstable clinical manifestations, so careful history taking and examination of external respiration parameters are necessary. In 3 out of 5 patients, bronchial asthma is diagnosed only in the later stages of the disease, since there may be no clinical manifestations of the disease in the interictal period.

COMPLAINTS AND HISTORY

The most characteristic symptoms are episodic attacks of expiratory dyspnea and / or cough, the appearance of distant wheezing, a feeling of heaviness in the chest. An important diagnostic indicator of the disease is the relief of symptoms spontaneously or after taking drugs (bronchodilators, GCs). When taking the history, attention should be paid to the presence of recurrent exacerbations, usually after exposure to triggers, as well as the seasonal variability of symptoms and the presence of allergic diseases in the patient and his relatives. It is also necessary to carefully collect an allergic history to establish a connection between the occurrence of difficulty in exhaling or coughing with potential allergens (for example, contact with animals, eating citrus fruits, fish, chicken meat, etc.).

PHYSICAL EXAMINATION

Due to the fact that the severity of the symptoms of the disease changes during the day, at the first examination of the patient, the characteristic signs of the disease may be absent. An exacerbation of bronchial asthma is characterized by an attack of suffocation or expiratory dyspnea, swelling of the wings of the nose during inhalation, intermittent speech, agitation, participation in the act of breathing of the auxiliary respiratory muscles, persistent or episodic cough, there may be dry whistling (buzzing) wheezing, aggravated on exhalation and heard on distance (remote wheezing). In a severe course of an attack, the patient sits leaning forward, resting his hands on his knees (or the back of the bed, the edge of the table). With a mild course of the disease, the patient maintains normal activity and sleeps in the usual position.

With the development of pulmonary emphysema, a boxed percussion sound is noted (hyperairiness of the lung tissue). During auscultation, dry rales are most often heard, however, they may be absent even during the period of exacerbation and even in the presence of confirmed significant bronchial obstruction, which is presumably due to the predominant involvement of small bronchi in the process. Prolongation of the expiratory phase is characteristic.

ASSESSMENT OF ALLERGOLOGICAL STATUS

During the initial examination, scarification, intradermal and prick ("prick-test") provocative tests with probable allergens are used. Keep in mind that sometimes skin tests give false negative or false positive results. More reliable detection of specific IgE in blood serum. Based on the assessment of the allergological status, it is possible to distinguish between atopic and non-atopic bronchial asthma with a high probability (Table 19-1).

Table 19-1. Some criteria for the diagnosis of atopic and non-atopic bronchial asthma

LABORATORY RESEARCH

In the general analysis of blood, eosinophilia is characteristic. During the period of exacerbation, leukocytosis and an increase in ESR are detected, while the severity of the changes depends on the severity of the disease. Leukocytosis can also be a consequence of taking prednisolone. The study of the gas composition of arterial blood in the later stages of the disease reveals hypoxemia with hypocapnia, which is replaced by hypercapnia.

Microscopic analysis of sputum reveals a large number of eosinophils, epithelium, Kurschmann's spirals (mucus that forms casts of small airways), Charcot-Leiden crystals (crystallized eosinophil enzymes). During the initial examination and in case of non-allergic asthma, it is advisable to perform a bacteriological examination of sputum for pathogenic microflora and its sensitivity to antibiotics.

INSTRUMENTAL STUDIES

Peak flowmetry (measurement of PSV) is the most important and available technique in the diagnosis and control of bronchial obstruction in patients with bronchial asthma (Fig. 19-1). This study, conducted daily 2 times a day, allows diagnosing bronchial obstruction in the early stages of the development of bronchial asthma, determining the reversibility of bronchial obstruction, assessing the severity of the disease and the degree of bronchial hyperreactivity, predicting exacerbations, determining occupational bronchial asthma, evaluating the effectiveness of treatment and correcting it. . Every patient with bronchial asthma should have a peak flow meter.

Examination of respiratory function: an important diagnostic criterion is a significant increase in FEV 1 by more than 12% and PSV by more than 15% of the proper values ​​after inhalation of short-acting β 2 -agonists (salbutamol, fenoterol). An assessment of bronchial hyperreactivity is also recommended - provocative tests with inhalations of histamine, methacholine (with a mild course of the disease). The standard for measuring bronchial reactivity is the dose or concentration of a provoking agent that causes a decrease in FEV 1 by 20%. Based on the measurement of FEV 1 and PSV, as well as daily fluctuations in PSV, the stages of bronchial asthma are determined.

A chest x-ray is performed primarily to rule out other respiratory diseases. Most often, increased airiness of the lungs is found, sometimes rapidly disappearing infiltrates.

◊ When pleuritic pain occurs in a patient with an attack of bronchial asthma, radiography is necessary to exclude spontaneous pneumothorax and pneumomediastinum, especially when subcutaneous emphysema occurs.

◊ When asthma attacks are combined with elevated body temperature, an X-ray examination is performed to exclude pneumonia.

◊ In the presence of sinusitis, an X-ray examination of the nasal sinuses is advisable to detect polyps.

Bronchoscopy is performed to exclude any other causes of bronchial obstruction. During the initial examination, it is advisable to assess the cellular composition of the fluid obtained during bronchoalveolar lavage. The need for therapeutic bronchoscopy and therapeutic bronchial lavage in this disease is ambiguous.

ECG is informative in severe bronchial asthma and reveals overload or hypertrophy of the right heart, conduction disturbances along the right leg of the His bundle. Sinus tachycardia is also characteristic, decreasing in the interictal period. Supraventricular tachycardia may be a side effect of theophylline.

REQUIRED STUDIES AT DIFFERENT STAGES OF BRONCHIAL ASTHMA

. step 1 . Complete blood count, general urinalysis, respiratory function with a test with β 2 -agonists, provocative skin tests to detect allergies, determination of general and specific IgE, chest x-ray, sputum analysis. Additionally, in a specialized institution to clarify the diagnosis, it is possible to conduct provocative tests with bronchoconstrictors, physical activity and / or allergens.

. step 2 . Complete blood count, urinalysis, FVD study with a sample with β 2 -adrenergic agonists, provocative skin tests, determination of general and specific IgE, chest x-ray, sputum analysis. Daily peak flow is desirable. Additionally, in a specialized institution to clarify the diagnosis, it is possible to conduct provocative tests with bronchoconstrictors, physical activity and / or allergens.

. steps 3 and 4 . Complete blood count, urinalysis, FVD study with a sample with β 2 -agonists, daily peak flow, skin provocative tests, if necessary - determination of general and specific IgE, chest x-ray, sputum analysis; in specialized institutions - a study of the gas composition of the blood.

VARIANTS AND SPECIAL FORMS OF BRONCHIAL ASTHMA

There are several variants (infection-dependent, dyshormonal, disovarian, vagotonic, neuropsychic, a variant with a pronounced adrenergic imbalance, a cough variant, as well as autoimmune and aspirin bronchial asthma) and special forms (occupational, seasonal, bronchial asthma in the elderly) of bronchial asthma .

INFECTION DEPENDENT VARIANT

The infection-dependent variant of bronchial asthma is primarily characteristic of people over 35-40 years old. In patients with this variant of the course, the disease is more severe than in patients with atopic asthma. The cause of exacerbation of bronchial asthma in this clinical and pathogenetic variant is inflammatory diseases of the respiratory organs (acute bronchitis and exacerbation of chronic bronchitis, pneumonia, tonsillitis, sinusitis, acute respiratory viral infections, etc.).

Clinical painting

Attacks of suffocation in such patients are characterized by less acuteness of development, they last longer, they are worse stopped by β 2 -adrenergic agonists. Even after stopping the attack in the lungs, hard breathing with an extended exhalation and dry wheezing remain. Often the symptoms of bronchial asthma are combined with the symptoms of chronic bronchitis. In such patients, there is a constant cough, sometimes with mucopurulent sputum, body temperature rises to subfebrile values. Often in the evening there is a chill, a feeling of chilliness between the shoulder blades, and at night - sweating, mainly in the upper back, neck and neck. In these patients, polyposis-allergic rhinosinusitis is often detected. Attention is drawn to the severity and persistence of obstructive changes in ventilation, which are not fully restored after inhalation of β-adrenergic agonists and relief of an asthma attack. In patients with infectious-dependent bronchial asthma, emphysema, pulmonary heart with CHF develop much faster than in patients with atopic asthma.

Laboratory and instrumental research

Radiologically, as the disease progresses, patients develop and develop signs of increased airiness of the lungs: increased transparency of the lung fields, expansion of retrosternal and retrocardial spaces, flattening of the diaphragm, signs of pneumonia may be detected.

In the presence of an active infectious-inflammatory process in the respiratory organs, leukocytosis is possible against the background of severe blood eosinophilia, an increase in ESR, the appearance of CRP, an increase in the content of α- and γ-globulins in the blood, and an increase in acid phosphatase activity of more than 50 units / ml.

Cytological examination of sputum confirms its purulent nature by the predominance of neutrophils and alveolar macrophages in the smear, although eosinophilia is also observed.

Bronchoscopy reveals signs of inflammation of the mucous membrane, hyperemia, mucopurulent nature of the secret; neutrophils and alveolar macrophages predominate in bronchial swabs during cytological examination.

Required laboratory research

Laboratory studies are needed to establish the presence and identify the role of infection in the pathological process.

Determination in blood serum of antibodies to chlamydia, moraxella, mycoplasma.

Sowing from sputum, urine and feces of fungal microorganisms in diagnostic titers.

Positive skin tests with fungal allergens.

Detection of viral antigens in the epithelium of the nasal mucosa by immunofluorescence.

A four-fold increase in serum titers of antibodies to viruses, bacteria and fungi when observed in dynamics.

DISHORMONAL (HORMONE-DEPENDENT) OPTION

With this option, systemic use of GCs is mandatory for the treatment of patients, and their cancellation or reduction in dosage leads to a deterioration in the condition.

As a rule, patients with a hormone-dependent variant of the course of the disease take GCs, and the formation of hormonal dependence is not significantly related to the duration and dose of these drugs. In patients treated with GC, it is necessary to check for complications of therapy (suppression of the function of the adrenal cortex, Itsenko-Cushing's syndrome, osteoporosis and bone fractures, hypertension, increased blood glucose, gastric and duodenal ulcers, myopathy, mental changes).

Hormonal dependence may result from GC deficiency and/or GC resistance.

Glucocorticoid insufficiency, in turn, can be adrenal and extra-adrenal.

. ◊ Adrenal glucocorticoid insufficiency occurs with a decrease in the synthesis of cortisol by the adrenal cortex, with the predominance of the synthesis of much less biologically active corticosterone by the adrenal cortex.

. ◊ Extra-adrenal glucocorticoid insufficiency occurs with increased binding of cortisol by trascortin, albumin, disturbances in the "hypothalamus-pituitary-adrenal cortex" regulation system, with increased clearance of cortisol, etc.

GC resistance may develop in patients with the most severe course of bronchial asthma; at the same time, the ability of lymphocytes to adequately respond to cortisol decreases.

Required laboratory research

Laboratory studies are needed to identify the mechanisms that form the hormone-dependent variant of bronchial asthma.

Determination of the level of total 11-hydroxycorticosteroids and / or cortisol in blood plasma.

Determination of the concentration of 17-hydroxycorticosteroids and ketosteroids in the urine.

Daily clearance of corticosteroids.

Cortisol uptake by lymphocytes and/or the amount of glucocorticoid receptors in lymphocytes.

Small dexamethasone test.

DISOVARIAL OPTION

The disovarial variant of bronchial asthma, as a rule, is combined with other clinical and pathogenetic variants (most often with atopic) and is diagnosed in cases where exacerbations of bronchial asthma are associated with the phases of the menstrual cycle (usually exacerbations occur in the premenstrual period).

Clinical painting

Exacerbation of bronchial asthma (resumption or increase in asthma attacks, increased shortness of breath, cough with viscous sputum difficult to separate, etc.) before menstruation in such patients is often accompanied by symptoms of premenstrual tension: migraine, mood swings, pastosity of the face and extremities, algomenorrhea. This variant of bronchial asthma is characterized by a more severe and prognostically unfavorable course.

Required laboratory research

Laboratory studies are needed to diagnose ovarian hormonal dysfunction in women with bronchial asthma.

Basal thermometry test in combination with a cytological examination of vaginal smears (colpocytological method).

Determination of the content of estradiol and progesterone in the blood by the radioimmune method on certain days of the menstrual cycle.

PROGRESS ADRENERGIC IMBALANCE

Adrenergic imbalance - violation of the ratio between β - and α -adrenergic reactions. In addition to an overdose of β-agonists, factors contributing to the formation of adrenergic imbalance are hypoxemia and changes in the acid-base state.

Clinical painting

Adrenergic imbalance is most often formed in patients with atopic variant of bronchial asthma and in the presence of viral and bacterial infections in the acute period. Clinical data suggesting the presence of an adrenergic imbalance or a tendency to develop it:

Aggravation or development of bronchial obstruction with the introduction or inhalation of β-agonists;

The absence or progressive decrease in the effect of the introduction or inhalation of β-agonists;

Long-term intake (parenterally, orally, inhalation, intranasally) of β-adrenergic agonists.

Required laboratory research

The simplest and most accessible criteria for diagnosing adrenergic imbalance include a decrease in the bronchodilation reaction [according to FEV 1, inspiratory instantaneous volume velocity (MOS), expiratory MOS, and maximum lung ventilation] in response to inhalation of β-agonists or a paradoxical reaction (increase in bronchial obstruction by more than by 20% after inhalation of β-adrenergic agonist).

CHOLINERGIC (VAGOTONIC) OPTION

This variant of the course of bronchial asthma is associated with impaired acetylcholine metabolism and increased activity of the parasympathetic division of the autonomic nervous system.

Clinical painting

The cholinergic variant is characterized by the following features of the clinical picture.

Occurs predominantly in the elderly.

Formed a few years after the disease of bronchial asthma.

The leading clinical symptom is shortness of breath not only during exercise, but also at rest.

The most striking clinical manifestation of the cholinergic variant of the course of bronchial asthma is a productive cough with the separation of a large amount of mucous, foamy sputum (300-500 ml or more per day), which gave reason to call this variant of bronchial asthma "wet asthma".

Rapid onset of bronchospasm under the influence of physical activity, cold air, strong odors.

Violation of bronchial patency at the level of medium and large bronchi, which is manifested by an abundance of dry rales over the entire surface of the lungs.

Manifestations of hypervagotonia are nocturnal attacks of suffocation and coughing, excessive sweating, hyperhidrosis of the palms, sinus bradycardia, arrhythmias, arterial hypotension, and a frequent combination of bronchial asthma with peptic ulcer.

NEURO-MENTAL OPTION

This clinical and pathogenetic variant of bronchial asthma is diagnosed in cases where neuropsychic factors contribute to the provocation and fixation of asthmatic symptoms, and changes in the functioning of the nervous system become mechanisms of the pathogenesis of bronchial asthma. In some patients, bronchial asthma is a kind of pathological adaptation of the patient to the environment and the solution of social problems.

The following clinical variants of neuropsychic bronchial asthma are known.

A neurasthenic variant develops against the background of low self-esteem, excessive demands on oneself and a painful consciousness of one's insolvency, from which an attack of bronchial asthma "protects".

An hysterical variant may develop against the background of an increased level of the patient's claims to significant persons in the microsocial environment (family, production team, etc.). In this case, with the help of an attack of bronchial asthma, the patient tries to achieve the satisfaction of his desires.

The psychasthenic variant of the course of bronchial asthma is distinguished by increased anxiety, dependence on significant persons in the microsocial environment, and a low ability to make independent decisions. The "conditional pleasantness" of an attack lies in the fact that it "saves" the patient from the need to make a responsible decision.

The shunt mechanism of an attack provides a discharge of neurotic confrontation of family members and receiving attention and care during an attack from a significant environment.

Diagnosis of the neuropsychiatric variant is based on anamnestic and test data obtained when filling out special questionnaires and questionnaires.

AUTOIMMUNE ASTHMA

Autoimmune asthma occurs as a result of sensitization of patients to lung tissue antigen and occurs in 0.5-1% of patients with bronchial asthma. Probably, the development of this clinical and pathogenetic variant is due to allergic reactions of types III and IV according to the classification of Coombs and Gell (1975).

The main diagnostic criteria for autoimmune asthma are:

Severe, continuously relapsing course;

Formation of GC-dependence and GC-resistance in patients;

Detection of antipulmonary antibodies, an increase in the concentration of the CEC and the activity of acid phosphatase in the blood serum.

Autoimmune bronchial asthma is a rare, but the most severe variant of the course of bronchial asthma.

"ASPIRIN" BRONCHIAL ASTHMA

The origin of the aspirin variant of bronchial asthma is associated with a violation of the metabolism of arachidonic acid and an increase in the production of leukotrienes. In this case, the so-called aspirin triad is formed, including bronchial asthma, nasal polyposis (paranasal sinuses), intolerance to acetylsalicylic acid and other NSAIDs. The presence of the aspirin triad is observed in 4.2% of patients with bronchial asthma. In some cases, one of the components of the triad - nasal polyposis - is not detected. There may be sensitization to infectious or non-infectious allergens. Anamnesis data on the development of an asthma attack after taking acetylsalicylic acid and other NSAIDs are important. In the conditions of specialized institutions, these patients undergo a test with acetylsalicylic acid with an assessment of the dynamics of FEV 1.

SPECIAL FORMS OF BRONCHIAL ASTHMA

. Bronchial asthma at elderly. In elderly patients, both the diagnosis of bronchial asthma and the assessment of the severity of its course are difficult due to the large number of comorbidities, such as chronic obstructive bronchitis, emphysema, coronary artery disease with signs of left ventricular failure. In addition, with age, the number of β 2 -adrenergic receptors in the bronchi decreases, so the use of β-agonists in the elderly is less effective.

. professional bronchial asthma accounts for an average of 2% of all cases of this disease. There are more than 200 known substances used in production (from highly active low molecular weight compounds, such as isocyanates, to well-known immunogens, such as platinum salts, plant complexes and animal products) that contribute to the onset of bronchial asthma. Occupational asthma can be either allergic or non-allergic. An important diagnostic criterion is the absence of symptoms of the disease before the start of this professional activity, a confirmed relationship between their appearance at the workplace and disappearance after leaving it. The diagnosis is confirmed by the results of measuring PSV at work and outside the workplace, specific provocative tests. It is necessary to diagnose occupational asthma as early as possible and stop contact with the damaging agent.

. Seasonal bronchial asthma usually associated with seasonal allergic rhinitis. In the period between the seasons, when there is an exacerbation, the manifestations of bronchial asthma may be completely absent.

. Tussive option bronchial asthma: dry paroxysmal cough is the main, and sometimes the only symptom of the disease. It often occurs at night and is usually not accompanied by wheezing.

ASTHMATIC STATUS

Status asthmaticus (life-threatening exacerbation) is an asthma attack of unusual severity for a given patient, resistant to the usual bronchodilator therapy for this patient. Asthmatic status is also understood as a severe exacerbation of bronchial asthma, requiring medical care in a hospital setting. One of the reasons for the development of status asthmaticus may be the blockade of β 2 -adrenergic receptors due to an overdose of β 2 -agonists.

The development of asthmatic status can be facilitated by the unavailability of constant medical care, the lack of objective monitoring of the condition, including peak flowmetry, the patient's inability to self-control, inadequate previous treatment (usually the absence of basic therapy), a severe attack of bronchial asthma aggravated by concomitant diseases.

Clinically, asthmatic status is characterized by pronounced expiratory dyspnea, a sense of anxiety up to the fear of death. The patient takes a forced position with the torso tilted forward and emphasis on the arms (shoulders raised). The muscles of the shoulder girdle, chest and abdominal muscles take part in the act of breathing. The duration of exhalation is sharply prolonged, dry whistling and buzzing rales are heard, with progression, breathing becomes weakened up to "silent lungs" (lack of breath sounds during auscultation), which reflects the extreme degree of bronchial obstruction.

COMPLICATIONS

Pneumothorax, pneumomediastinum, pulmonary emphysema, respiratory failure, cor pulmonale.

DIFFERENTIAL DIAGNOSIS

The diagnosis of bronchial asthma should be excluded if, when monitoring the parameters of external respiration, there are no violations of bronchial patency, there are no daily fluctuations in PSV, bronchial hyperreactivity and coughing fits.

In the presence of broncho-obstructive syndrome, differential diagnosis is carried out between the main nosological forms for which this syndrome is characteristic (Table 19-2).

Table 19-2. Differential diagnostic criteria for bronchial asthma, chronic bronchitis and pulmonary emphysema

When conducting a differential diagnosis of broncho-obstructive conditions, it must be remembered that bronchospasm and cough can cause some chemicals, including drugs: NSAIDs (most often acetylsalicylic acid), sulfites (found, for example, in chips, shrimp, dried fruits, beer, wines, and also in metoclopramide, injectable forms of epinephrine, lidocaine), β-blockers (including eye drops), tartrazine (yellow food coloring), ACE inhibitors. Cough caused by ACE inhibitors, usually dry, poorly controlled by antitussives, β-agonists and inhaled GCs, completely disappears after discontinuation of ACE inhibitors.

Bronchospasm can also be triggered by gastroesophageal reflux. Rational treatment of the latter is accompanied by the elimination of attacks of expiratory dyspnea.

Asthma-like symptoms occur when there is dysfunction of the vocal cords ("pseudo-asthma"). In these cases, it is necessary to consult an otolaryngologist and a phoniatrist.

If chest radiography in patients with bronchial asthma reveals infiltrates, differential diagnosis should be made with typical and atypical infections, allergic bronchopulmonary aspergillosis, pulmonary eosinophilic infiltrates of various etiologies, allergic granulomatosis in combination with angiitis (Churg-Strauss syndrome).

TREATMENT

Bronchial asthma is an incurable disease. The main goal of therapy is to maintain a normal quality of life, including physical activity.

TREATMENT TACTICS

Treatment goals:

Achieving and maintaining control over the symptoms of the disease;

Prevention of exacerbation of the disease;

Maintaining lung function as close to normal as possible;

Maintaining a normal level of activity, including physical;

Exclusion of side effects of anti-asthmatic drugs;

Prevention of the development of irreversible bronchial obstruction;

Prevention of asthma-related mortality.

Asthma control can be achieved in most patients and can be defined as follows:

Minimal severity (ideally absence) of chronic symptoms, including nocturnal ones;

Minimal (infrequent) exacerbations;

No need for emergency and emergency care;

Minimal need (ideally no) for the use of β-adrenergic agonists (as needed);

No restrictions on activity, including physical;

Daily fluctuations in PSV less than 20%;

Normal (close to normal) PSV indicators;

Minimal severity (or absence) of undesirable effects of drugs.

Management of patients with bronchial asthma includes six main components.

1. Teaching patients to form partnerships in their management.

2. Assessment and monitoring of the severity of the disease, both by recording symptoms and, if possible, by measuring lung function; for patients with moderate and severe course, daily peak flowmetry is optimal.

3. Elimination of exposure to risk factors.

4. Development of individual drug therapy plans for long-term management of the patient (taking into account the severity of the disease and the availability of anti-asthma drugs).

5. Development of individual plans for the relief of exacerbations.

6. Ensuring regular dynamic monitoring.

EDUCATIONAL PROGRAMS

The basis of the educational system for patients in pulmonology is asthma schools. According to specially designed programs, patients are explained in an accessible form the essence of the disease, methods of preventing seizures (eliminating the effects of triggers, preventive use of drugs). During the implementation of educational programs, it is considered mandatory to teach the patient to independently manage the course of bronchial asthma in various situations, develop a written plan for him to get out of a severe attack, ensure access to a medical worker is available, teach how to use a peak flow meter at home and keep a daily PSV curve, as well as correctly use metered dose inhalers. The work of asthma schools is most effective among women, non-smokers and patients with a high socioeconomic status.

MEDICAL THERAPY

Based on the pathogenesis of bronchial asthma, bronchodilators (β 2 -agonists, m-anticholinergics, xanthines) and anti-inflammatory anti-asthma drugs (GCs, mast cell membrane stabilizers and leukotriene inhibitors) are used for treatment.

ANTI-INFLAMMATORY ANTI-ASTHMATIC DRUGS (BASIC THERAPY)

. GC: the therapeutic effect of drugs is associated, in particular, with their ability to increase the number of β 2 -adrenergic receptors in the bronchi, inhibit the development of an immediate allergic reaction, reduce the severity of local inflammation, swelling of the bronchial mucosa and secretory activity of bronchial glands, improve mucociliary transport, reduce bronchial reactivity .

. ◊ inhalation GC * (beclomethasone, budesonide, fluticasone), in contrast to the systemic ones, have a predominantly local anti-inflammatory effect and practically do not cause systemic side effects. The dose of the drug depends on the severity of the disease.

* When taking drugs in the form of dosing cartridges, it is recommended to use a spacer (especially with a valve that prevents exhalation into the spacer), which contributes to more effective control of bronchial asthma and reduces the severity of some side effects (for example, those associated with drug settling in the oral cavity, ingestion into the stomach) . A special form of aerosol delivery is the "easy breathing" system, which does not require pressing the can, the aerosol dose is given in response to the patient's negative inspiratory pressure. When using preparations in the form of a powder with the help of a cyclohaler, turbuhaler, etc., a spacer is not used.

. ◊ Systemic GC(prednisolone, methylprednisolone, triamcinolone, dexamethasone, betamethasone) are prescribed for severe bronchial asthma in minimal doses or, if possible, every other day (alternating regimen). They are administered intravenously or orally; the latter route of administration is preferred. Intravenous administration is justified when oral administration is not possible. The appointment of depot drugs is permissible only for seriously ill patients who do not comply with medical recommendations, and / or when the effectiveness of other drugs has been exhausted. In all other cases, their appointment is recommended to be avoided.

. Stabilizers membranes mast cells (cromoglycic acid and nedocromil, as well as drugs combined with short-acting β 2 -agonists) act locally, preventing degranulation of mast cells and the release of histamine from them; suppress both immediate and delayed bronchospastic reaction to inhaled antigen, prevent the development of bronchospasm when inhaling cold air or during exercise. With prolonged use, they reduce bronchial hyperreactivity, reduce the frequency and duration of bronchospasm attacks. They are more effective in childhood and young age. This group of drugs is not used to treat an attack of bronchial asthma.

. Antagonists leukotriene receptors(zafirlukast, montelukast) - a new group of anti-inflammatory anti-asthma drugs. The drugs reduce the need for short-acting β 2 -adrenergic agonists and are effective in preventing bronchospasm attacks. Apply inside. Reduce the need for HA ("sparing effect").

bronchodilators

It should be remembered that all bronchodilators in the treatment of bronchial asthma have a symptomatic effect; the frequency of their use serves as an indicator of the effectiveness of basic anti-inflammatory therapy.

. β 2 - Adrenomimetics short actions(salbutamol, fenoterol) are administered by inhalation, they are considered the means of choice for stopping attacks (more precisely, exacerbations) of bronchial asthma. With inhalation, the action usually begins in the first 4 minutes. The drugs are produced in the form of metered aerosols, dry powder and solutions for inhalers (if necessary, long-term inhalation, the solutions are inhaled through a nebulizer).

◊ Metered dose inhalers, powder inhalers, and spraying through a nebulizer are used to administer drugs. For the correct use of metered dose inhalers, the patient needs certain skills, since otherwise only 10-15% of the aerosol enters the bronchial tree. The correct application technique is as follows.

♦ Remove the cap from the mouthpiece and shake the bottle well.

♦ Exhale completely.

♦ Turn the can upside down.

♦ Position the mouthpiece in front of a wide open mouth.

♦ Start a slow breath, at the same time press the inhaler and continue a deep breath to the end (the breath should not be sharp!).

♦ Hold your breath for at least 10 seconds.

♦ After 1-2 minutes, re-inhalation (for 1 breath on the inhaler you need to press only 1 time).

◊ When using the "easy breathing" system (used in some dosage forms of salbutamol and beclomethasone), the patient should open the mouthpiece cap and take a deep breath. It is not required to press the balloon and coordinate the breath.

◊ If the patient is unable to follow the above recommendations, a spacer (a special plastic flask into which the aerosol is sprayed before inhalation) or a spacer with a valve - an aerosol chamber from which the patient inhales the drug should be used (Fig. 19-2). The correct technique for using a spacer is as follows.

♦ Remove the cap from the inhaler and shake it, then insert the inhaler into the special opening of the device.

♦ Put the mouthpiece in your mouth.

♦ Press the can to receive a dose of the drug.

♦ Take a slow and deep breath.

♦ Hold your breath for 10 seconds and then exhale into the mouthpiece.

♦ Inhale again, but without pressing the can.

♦ Move the device away from your mouth.

♦ Wait 30 seconds before taking the next inhalation dose.

Rice. 19-2. Spacer. 1 - mouthpiece; 2 - inhaler; 3 - hole for the inhaler; 4 - spacer body.

. β 2 - Adrenomimetics long actions used by inhalation (salmeterol, formoterol) or orally (sustained release formulations of salbutamol). The duration of their action is about 12 hours. The drugs cause bronchodilation, increased mucociliary clearance, and also inhibit the release of substances that cause bronchospasm (for example, histamine). β 2 -Adrenergic agonists are effective in preventing asthma attacks, especially at night. They are often used in combination with anti-inflammatory anti-asthma drugs.

M- Anticholinergics(ipratropium bromide) after inhalation act after 20-40 minutes. The method of administration is inhalation from a canister or through a spacer. Specially produced solutions are inhaled through a nebulizer.

. Combined bronchodilators drugs containing β 2 -agonist and m-anticholinergic (spray and solution for a nebulizer).

. Preparations theophyllinea short actions(theophylline, aminophylline) as bronchodilators are less effective than inhaled β 2 -agonists. They often cause pronounced side effects that can be avoided by prescribing the optimal dose and controlling the concentration of theophylline in the blood. If the patient is already taking long-acting theophylline preparations, the administration of aminophylline intravenously is possible only after determining the concentration of theophylline in the blood plasma!

. Preparations theophyllinea prolonged actions applied inside. Methylxanthines cause bronchial dilation, inhibit the release of inflammatory mediators from mast cells, monocytes, eosinophils and neutrophils. Due to the long-term effect, the drugs reduce the frequency of nocturnal attacks, slow down the early and late phase of the asthmatic response to allergen exposure. Theophylline preparations can cause serious side effects, especially in older patients; treatment is recommended to be carried out under the control of the content of theophylline in the blood.

OPTIMIZATION OF ANTI-ASTHMATIC THERAPY

For the rational organization of anti-asthma therapy, methods for its optimization have been developed, which can be described in the form of blocks.

. Block 1 . The first visit by the patient to the doctor, assessment of the severity of bronchial asthma [although it is difficult to establish it exactly at this stage, since accurate information is needed about fluctuations in PSV (according to home peak flow measurements during the week) and the severity of clinical symptoms], determination of patient management tactics. If the patient needs emergency care, it is better to hospitalize him. Be sure to take into account the volume of previous therapy and continue it in accordance with the severity. If the condition worsens during treatment or inadequate previous therapy, an additional intake of short-acting β 2 -adrenergic agonists can be recommended. Assign an introductory weekly period of observation of the patient's condition. If the patient is suspected to have mild or moderate bronchial asthma and there is no need to immediately prescribe treatment in full, the patient should be observed for 2 weeks. Monitoring the patient's condition involves filling in a diary of clinical symptoms by the patient and recording PSV indicators in the evening and morning hours.

. Block 2 . Visiting a doctor 1 week after the first visit. Determining the severity of asthma and choosing the appropriate treatment.

. Block 3 . A two-week monitoring period against the background of ongoing therapy. The patient, as well as during the introductory period, fills out a diary of clinical symptoms and registers PSV values ​​with a peak flow meter.

. Block 4 . Evaluation of the effectiveness of therapy. Visiting a doctor after 2 weeks on the background of ongoing treatment.

DRUG THERAPY ACCORDING TO THE STAGES OF BRONCHIAL ASTHMA

The principles of the treatment of bronchial asthma are based on a stepwise approach, recognized in the world since 1995. The goal of this approach is to achieve the most complete control of the manifestations of bronchial asthma using the least amount of drugs. The number and frequency of taking drugs increase (step up) with the aggravation of the course of the disease and decrease (step down) with the effectiveness of therapy. At the same time, it is necessary to avoid or prevent exposure to trigger factors.

. step 1 . Treatment of intermittent bronchial asthma includes prophylactic administration (if necessary) of drugs before exercise (short-acting inhaled β 2 -agonists, nedocromil, their combined drugs). Instead of inhaled β 2 -agonists, m-cholinergic blockers or short-acting theophylline preparations can be prescribed, but their action begins later, and they often cause side effects. With an intermittent course, it is possible to conduct specific immunotherapy with allergens, but only by specialists, allergists.

. step 2 . With a persistent course of bronchial asthma, daily long-term prophylactic administration of drugs is necessary. Assign inhaled GCs at a dose of 200-500 mcg / day (based on beclomethasone), nedocromil or long-acting theophylline preparations. Short-acting inhaled β 2 -adrenergic agonists continue to be used as needed (with proper basic therapy, the need should be reduced until they are canceled).

. ◊ If, during treatment with inhaled GCs (while the doctor is sure that the patient is inhaling correctly), the frequency of symptoms does not decrease, the dose of drugs should be increased to 750-800 mcg / day or, in addition to GCs (at a dose of at least 500 mcg), prescribe long-acting bronchodilators at night (especially to prevent night attacks).

. ◊ If asthma symptoms cannot be achieved with the help of prescribed drugs (the symptoms of the disease occur more often, the need for short-acting bronchodilators increases, or PEF values ​​decrease), treatment should be started according to step 3.

. step 3 . Daily use of anti-asthma anti-inflammatory drugs. Inhaled GCs are prescribed at 800-2000 mcg / day (based on beclomethasone); use of an inhaler with a spacer is recommended. You can additionally prescribe long-acting bronchodilators, especially to prevent nocturnal attacks, for example, oral and inhaled long-acting β 2 -adrenergic agonists, long-acting theophylline preparations (under the control of the concentration of theophylline in the blood; therapeutic concentration is 5-15 μg / ml). You can stop the symptoms with short-acting β 2 -adrenergic agonists. In more severe exacerbations, a course of treatment with oral GCs is carried out. If asthma symptoms cannot be controlled (because symptoms are more frequent, the need for short-acting bronchodilators is increased, or PEF values ​​are reduced), treatment should be initiated according to Step 4.

. step 4 . In severe cases of bronchial asthma, it is not possible to completely control it. The goal of treatment is to achieve the maximum possible results: the least number of symptoms, the minimum need for short-acting β 2 -adrenergic agonists, the best possible PSV values ​​and their minimum dispersion, the least number of side effects of drugs. Usually, several drugs are used: inhaled GCs in high doses (800-2000 mcg / day in terms of beclomethasone), GCs orally continuously or in long courses, long-acting bronchodilators. You can prescribe m-anticholinergics (ipratropium bromide) or their combinations with β 2 -adrenergic agonist. Short-acting inhaled β 2 -agonists can be used if necessary to relieve symptoms, but not more than 3-4 times a day.

. step up(deterioration). They move to the next stage if treatment at this stage is ineffective. However, it should be taken into account whether the patient takes the prescribed drugs correctly, and whether he has contact with allergens and other provoking factors.

. step way down(improvement). A decrease in the intensity of maintenance therapy is possible if the patient's condition is stabilized for at least 3 months. The volume of therapy should be reduced gradually. The transition to the step down is carried out under the control of clinical manifestations and respiratory function.

The basic therapy outlined above should be accompanied by carefully performed elimination measures and supplemented with other drugs and non-drug methods of treatment, taking into account the clinical and pathogenetic variant of the course of asthma.

Patients with infectious-dependent asthma need sanitation of foci of infection, mucolytic therapy, barotherapy, acupuncture.

Patients with autoimmune changes, in addition to GC, can be prescribed cytotoxic drugs.

Patients with hormone-dependent asthma need individual schemes for the use of HA and control over the possibility of developing complications of therapy.

Patients with disovarian changes can be prescribed (after consultation with a gynecologist) synthetic progestins.

Patients with a pronounced neuropsychic variant of the course of bronchial asthma are shown psychotherapeutic methods of treatment.

In the presence of adrenergic imbalance, GCs are effective.

Patients with a pronounced cholinergic variant are shown anticholinergic drug ipratropium bromide.

Patients with bronchial asthma of physical effort need exercise therapy methods, antileukotriene drugs.

Various methods of psychotherapeutic treatment, psychological support are needed for all patients with bronchial asthma. In addition, all patients (in the absence of individual intolerance) are prescribed multivitamin preparations. When the exacerbation subsides and during the remission of bronchial asthma, exercise therapy and massage are recommended.

Particular attention should be paid to teaching patients the rules of elimination therapy, the technique of inhalation, individual peak flowmetry and monitoring their condition.

PRINCIPLES OF TREATMENT OF EXAMERCATIONS OF BRONCHIAL ASTHMA

Exacerbation of bronchial asthma - episodes of a progressive increase in the frequency of attacks of expiratory suffocation, shortness of breath, coughing, the appearance of wheezing, feelings of lack of air and chest compression, or a combination of these symptoms, lasting from several hours to several weeks or more. Severe exacerbations, sometimes fatal, are usually associated with an underestimation by the doctor of the severity of the patient's condition, incorrect tactics at the beginning of an exacerbation. The principles of treatment of exacerbations are as follows.

A patient with bronchial asthma should know the early signs of an exacerbation of the disease and begin to stop them on their own.

The optimal route of drug administration is inhalation using nebulizers.

The drugs of choice for the rapid relief of bronchial obstruction are short-acting inhaled β 2 -adrenergic agonists.

With the ineffectiveness of inhaled β 2 -agonists, as well as with severe exacerbations, systemic GCs are used orally or intravenously.

To reduce hypoxemia, oxygen therapy is carried out.

The effectiveness of therapy is determined using spirometry and / or peak flow by changing the FEV 1 or PSV.

TREATMENT FOR STATUS ASTHMATIC

It is necessary to examine the respiratory function every 15-30 minutes (at least), PSV and oxygen pulse. Hospitalization criteria are given in Table. 19-3. Complete stabilization of the patient's condition can be achieved in 4 hours of intensive care in the emergency department, if during this period it is not achieved, continue observation for 12-24 hours or hospitalize in the general department or intensive care unit (with hypoxemia and hypercapnia, signs fatigue of the respiratory muscles).

Table 19-3. Spirometry criteria for hospitalization of a patient with bronchial asthma

In asthmatic status, as a rule, inhalation of β 2 -adrenergic agonists is first performed (in the absence of data on an overdose in the anamnesis), it is possible in combination with an m-holinobokator and preferably through a nebulizer. Most patients with a severe attack are indicated for additional administration of GC. Inhalation of β 2 -agonists through nebulizers in combination with systemic GCs, as a rule, stops the attack within 1 hour. In a severe attack, oxygen therapy is necessary. The patient remains in the hospital until the night attacks disappear and the subjective need for short-acting bronchodilators decreases to 3-4 inhalations per day.

GC is administered orally or intravenously, for example, methylprednisolone 60-125 mg intravenously every 6-8 hours or prednisolone 30-60 mg orally every 6 hours. The effect of drugs with both methods of administration develops after 4-8 hours; the duration of admission is determined individually.

. Short-acting β 2 -agonists (in the absence of anamnestic data on overdose) are used as repeated inhalations in a serious condition of the patient in the form of dosing cans with spacers or long-term (for 72-96 hours) inhalation through a nebulizer (7 times more effective than inhalations from a can safe for adults and children).

You can use a combination of β 2 -agonists (salbutamol, fenoterol) with m-anticholinergic (ipratropium bromide).

The role of methylxanthines in providing emergency care is limited, since they are less effective than β 2 -agonists, are contraindicated in older patients, and, in addition, control over their concentration in the blood is necessary.

If the condition has not improved, but there is no need for mechanical ventilation, inhalation of an oxygen-helium mixture is indicated (causes a decrease in resistance to gas flows in the respiratory tract, turbulent flows in the small bronchi become laminar), the introduction of magnesium sulfate intravenously, auxiliary non-invasive ventilation. The transfer of a patient with status asthmaticus to mechanical ventilation is carried out for health reasons in any conditions (outside the hospital, in the emergency department, in the general department or intensive care unit). The procedure is performed by an anesthesiologist or resuscitator. The purpose of mechanical ventilation in bronchial asthma is to support oxygenation, normalize blood pH, and prevent iatrogenic complications. In some cases, mechanical ventilation of the lungs requires intravenous infusion of sodium bicarbonate solution.

BRONCHIAL ASTHMA AND PREGNANCY

On average, 1 out of 100 pregnant women suffer from bronchial asthma, and in 1 out of 500 pregnant women it has a severe course with a threat to the life of the woman and the fetus. The course of asthma during pregnancy is highly variable. Pregnancy in patients with a mild course of the disease may improve the condition, while in severe cases it usually aggravates. Increased frequency of seizures is more often noted at the end of the second trimester of pregnancy; during childbirth, severe seizures rarely occur. Within 3 months after birth, the nature of the course of bronchial asthma returns to the original prenatal level. Changes in the course of the disease in repeated pregnancies are the same as in the first. It was previously believed that bronchial asthma is 2 times more likely to cause pregnancy complications (preeclampsia, postpartum hemorrhage), but recently it has been proven that with adequate medical supervision, the likelihood of their development does not increase. However, these women are more likely to give birth to children with reduced body weight, and there is also a need for operative delivery more often. When prescribing anti-asthma drugs to pregnant women, the possibility of their effect on the fetus should always be taken into account, however, most modern inhaled anti-asthmatic drugs are safe in this regard (Table 19-4). In the US FDA * developed a guide according to which all drugs are divided into 5 groups (A-D, X) according to the degree of danger of use during pregnancy * .

* According to the FDA classification (Food and Drug Administration, Committee for the Control of Drugs and Food Additives, USA), drugs are divided into categories A, B, C, D, X according to the degree of danger (teratogenicity) for fetal development. Category A (for example, potassium chloride) and B (eg insulin): adverse effects on the fetus have not been established in animal experiments or in clinical practice; category C (eg, isoniazid): adverse effects on the fetus have been established in animal experiments, but not from clinical practice; category D (eg, diazepam): there is a potential teratogenic risk, but the effect of drugs on a pregnant woman usually outweighs this risk; category X (eg, isotretinoin): the drug is definitely contraindicated in pregnancy and if you want to become pregnant.

Among patients who are indicated for operations with inhalation anesthesia, an average of 3.5% suffer from bronchial asthma. These patients are more likely to have complications during and after surgery, so assessment of the severity and ability to control the course of bronchial asthma, assessment of the risk of anesthesia and this type of surgical intervention, as well as preoperative preparation are extremely important. Consider the following factors.

Acute airway obstruction causes ventilation-perfusion disturbances, exacerbating hypoxemia and hypercapnia.

Endotracheal intubation can cause bronchospasm.

Drugs used during surgery (eg, morphine, trimeperidine) can provoke bronchospasm.

Severe bronchial obstruction in combination with postoperative pain syndrome can disrupt the expectoration process and lead to the development of atelectasis and nosocomial pneumonia.

To prevent exacerbation of bronchial asthma in patients with a stable condition with regular GC inhalations, it is recommended to prescribe prednisone at a dose of 40 mg/day orally 2 days before surgery, and on the day of surgery, give this dose in the morning. In severe cases of bronchial asthma, the patient should be hospitalized a few days before surgery to stabilize the respiratory function (administration of HA intravenously). In addition, it should be borne in mind that patients who received systemic GCs for 6 months or more have a high risk of adrenal-pituitary insufficiency in response to operational stress, so they are shown prophylactic administration of 100 mg of hydrocortisone intravenously before, during and after surgery. .

FORECAST

The prognosis of the course of bronchial asthma depends on the timeliness of its detection, the level of education of the patient and his ability to self-control. The elimination of provoking factors and the timely application for qualified medical help is of decisive importance.

DISPENSERIZATION

Patients need constant monitoring by a therapist at the place of residence (with complete control of symptoms at least 1 time in 3 months). With frequent exacerbations, constant monitoring by a pulmonologist is indicated. According to the indications, an allergological examination is carried out. The patient should know that the Russian Federation provides free (on special prescriptions) provision of anti-asthma drugs in accordance with the lists approved at the federal and local levels.

Factors that determine the need for close and continuous monitoring, which is carried out in a hospital or outpatient setting, depending on the available facilities, include:

Insufficient or declining response to therapy in the first 1-2 hours of treatment;

Persistent severe bronchial obstruction (PSV less than 30% of the due or individual best value);

Anamnestic data on severe bronchial asthma in recent times, especially if hospitalization and stay in the intensive care unit were required;

The presence of high-risk factors for death from bronchial asthma;

Prolonged presence of symptoms before seeking emergency care;

Insufficient availability of medical care and drugs at home;

Poor living conditions;

Difficulty with transportation to hospital in case of further deterioration.

1. Aggravation.

2. Decaying exacerbation.

3. Remission.

VI. Complications

1. Pulmonary: emphysema, pulmonary insufficiency, atelectasis, pneumothorax, etc.

2. Extrapulmonary: myocardial dystrophy, cor pulmonale, heart failure, etc.

However, at present, first of all, bronchial asthma should be classified according to the severity, since this is what determines the tactics of managing the patient. The severity is determined by the following indicators: 1. Number of nocturnal symptoms per week. 2. Number of daytime symptoms per day and per week. 3. Multiplicity of application of b 2 -agonists of short action. 4. The severity of physical activity and sleep disorders. 5. Values ​​​​of PSV and its percentage with the proper or best value. 6. Daily fluctuations in PSV. 7. The volume of therapy. There are 5 degrees of severity of the course of bronchial asthma: mild intermittent, mild persistent; moderate persistent, severe persistent, severe persistent steroid-dependent. (see table). Bronchial asthma of intermittent course. Asthma symptoms less than once a week; short exacerbations from several hours to several days. Night symptoms 2 times a month or less; no symptoms and normal lung function between exacerbations. PSV> 80% of due and fluctuations in PSV less than 20%. Bronchial asthma of mild persistent course. Symptoms 1 time per week or more often, but less than 1 time per day. Exacerbations of the disease can interfere with activity and sleep. Night symptoms occur more often than 2 times a month. PSV more than 80% of due; fluctuations in PSV 20-30% of the due. Bronchial asthma of moderate severity. daily symptoms. Exacerbations disrupt activity and sleep. Nocturnal symptoms occur more than once a week. Daily intake of b 2 short-acting agonists. PSV 60-80% of due. Fluctuations in PSV more than 30%. Bronchial asthma of severe course. Persistent symptoms, frequent flare-ups, frequent nocturnal symptoms, physical activity limited to asthma symptoms; PSV less than 60% of due; fluctuations of more than 30%. It should be noted that the determination of the severity of asthma by these indicators is possible only before the start of treatment. If the patient is already receiving the necessary therapy, then its volume should also be taken into account. Thus, if a patient has mild persistent asthma according to the clinical picture, but at the same time he receives medical treatment corresponding to severe persistent asthma, then this patient is diagnosed with severe bronchial asthma. Severe bronchial asthma is steroid-dependent. Regardless of the clinical picture, a patient receiving long-term treatment with systemic corticosteroids should be regarded as suffering from severe bronchial asthma and assigned to the 5th stage.

Criteria for the diagnosis of bronchial asthma 1. History and assessment of symptoms The most common symptoms of the disease are episodic attacks of breathlessness, shortness of breath, the appearance of wheezing, a feeling of heaviness in the chest, and coughing. An important clinical marker of bronchial asthma is the disappearance of symptoms spontaneously or after the use of bronchodilators and anti-inflammatory drugs. When assessing and taking an anamnesis, one should evaluate the factors that provoke exacerbations, as well as note the seasonal variability of symptoms and the presence of atopic diseases in the patient or his relatives. 2. Clinical examination Due to the variability of obstruction, the characteristic symptoms of the disease are not necessarily detected on physical examination outside of an asthma exacerbation. With an exacerbation of the disease, the patient has the following symptoms: expiratory dyspnea, swelling of the wings of the nose during inspiration, intermittent speech, agitation, activation of the auxiliary respiratory muscles, orthopnea position, persistent or intermittent cough. During auscultation, the doctor most often listens to dry rales. It must be remembered that even during the period of exacerbation during auscultation, wheezing may not be heard, despite significant bronchial obstruction due to the predominant involvement of small airways in the process. 3. Examination of the function of external respiration The study of the function of external respiration greatly facilitates the diagnosis. Measurement of respiratory function provides an objective assessment of bronchial obstruction, and measurement of its fluctuations provides an indirect assessment of airway hyperreactivity. The most widely used is the measurement of forced expiratory volume in 1 s (FEV 1) and the associated measurement of forced vital capacity (FVC), as well as the measurement of forced (peak) expiratory flow (PSV). An important diagnostic criterion is a significant increase in FEV 1 (more than 12%) and PSV (more than 15%) after inhalation of short-acting b 2 agonists. Each patient with bronchial asthma is shown daily peak flowmetry. Asthma monitoring using a peak flow meter gives the doctor the following opportunities: to determine the reversibility of bronchial obstruction; assess the severity of the course of the disease; evaluate bronchial hyperreactivity; predict asthma exacerbations; identify occupational asthma, evaluate the effectiveness of treatment. four. Assessment of allergological status The most commonly used are scarification, intradermal and prick (prick test) tests. However, in some cases, skin tests lead to false-negative or false-positive results. Therefore, a study of specific IgE antibodies in the blood serum is often carried out. Eosinophilia of blood and sputum also indicate an allergic process. Thus, the diagnosis of asthma is based on the analysis of symptoms and anamnesis, as well as the study of the function of external respiration and data on allergy testing. The most important spirometric functional tests are the detection of response to inhaled b 2 -agonists, the change in the variability of bronchial patency by monitoring PSV, provocation by exercise in children. An important criterion in the diagnosis is the determination of the allergic status (although the absence of signs of atopy in the presence of other symptoms does not exclude the diagnosis of asthma). 5. For the purpose of differential diagnosis, they carry out:

radiography of the lungs (to exclude pneumothorax, volumetric processes in the lungs, pleural lesions, bullous changes, interstitial fibrosis, etc.);

ECG (to exclude myocardial damage);

clinical blood test (to detect undiagnosed anemia, detect gross abnormalities);

general sputum analysis (MBT, fungi, atypical cells).

Broncho-obstructive syndrome (BOS) is a symptom complex that occurs in the clinical picture of various congenital and acquired, infectious and non-infectious, allergic and non-allergic diseases of early childhood as one of the manifestations of respiratory failure (DN), which is caused by obstruction of the small bronchi and bronchioles due to hypersecretion, mucosal edema and/or bronchospasm.

Unlike bronchial asthma, chronic obstructive bronchitis, the obstructive syndrome persists steadfastly and does not reverse development even when treated with hormonal drugs, and there is no eosinophilia in the sputum during the analysis.

With left ventricular failure, the development of cardiac asthma is possible, which is manifested by an attack of shortness of breath at night; a feeling of lack of air and tightness in the chest develops into suffocation.

It is combined with arrhythmia and tachycardia (with bronchial asthma, bradycardia is more common). Unlike bronchial asthma, both phases of breathing are difficult. An attack of cardiac asthma can be prolonged (until the use of diuretics or neuroglycerin).

Hysteroid asthma has three forms. The first form is similar to a respiratory cramp. The breath of the "driven dog" - inhalation and exhalation are strengthened. There are no pathological signs on physical examination.

The second form of suffocation is observed in hysteroid people and is caused by a violation of the contraction of the diaphragm. During an attack, breathing is difficult or impossible, in the area of ​​​​the solar plexus - a feeling of pain.

To stop the attack, the patient is offered to inhale hot water vapor or give anesthesia.

Obstructive asthma is a symptom complex of suffocation, which is based on a violation of the patency of the upper respiratory tract.

The cause of obstruction may be tumors, foreign body, stenosis, aortic aneurysm. The highest value in the setting diagnosis belongs to the tomographic examination of the chest and bronchoscopy.

The combination of symptoms of shortness of breath and suffocation also occurs in other conditions (anemic, uremic, cerebral asthma, periarthritis nodosa, carcinoid syndrome).

Pollinosis, or hay fever, is an independent allergic disease in which the body is sensitized to plant pollen.

These diseases are characterized by: bronchospasm, rhinorrhea and conjunctivitis. The disease is characterized by seasonality. Starts with the flowering period of plants and decreases when it ends

The exacerbation stage is characterized by a persistent runny nose, pain in the eyes and lacrimation, coughing until an attack develops. suffocation.

Possible fever, arthralgia. In the general blood test - eosinophilia (up to 20%). During the remission period, it does not manifest itself clinically.

Bronchial asthma, a modern stepwise approach to therapy. Carrying out basic therapy of the disease. Treatment of exacerbations of bronchial asthma. Indications for the appointment of inhaled and systemic glucocorticosteroids. Dispensary observation of patients with bronchial asthma, indications for hospitalization of patients. Definition of temporary and permanent disability. Indications for referral to MSEC.

Treatment of bronchial asthma Treatment of patients with bronchial asthma is complex, it includes drug and non-drug treatment in compliance with the antiallergic regimen. All drugs for drug treatment of the disease are divided into two types: drugs for use as needed and relief of exacerbations and drugs for basic (permanent) therapy. At present, given the persistent nature of inflammation in bronchial asthma, the basis for the treatment of this disease is the appointment of anti-inflammatory anti-asthma therapy. Both the level of obstruction and the degree of its reversibility allow asthma to be subdivided according to severity into intermittent, mild persistent, moderate, and severe. currently used in the treatment of asthma "stepped" approach, in which the intensity of therapy increases as the severity of asthma increases. A stepwise approach to asthma therapy is recommended because there is great variation in asthma severity in different individuals and in the same patient over time. The goal of this approach is to achieve asthma control with the least amount of medication. The number and frequency of medications are increased ( step up) if the course of asthma worsens, and decrease ( step down) if asthma is well controlled. The stepwise approach also implies the need to avoid or control triggers at each step. It should be taken into account whether the patient is taking the medicines of the appropriate stage correctly, and whether there is any contact with allergens or other provoking factors. Control is considered unsatisfactory if the patient:

episodes of coughing, wheezing, or difficulty breathing occur more than 3 times a week;

symptoms appear at night or in the early morning hours;

increased need for the use of short-acting bronchodilators;

the spread of PE values ​​increases.

Step down. A decrease in maintenance therapy is possible if asthma remains under control for at least 3 months. This helps to reduce the risk of side effects and increases the patient's susceptibility to the planned treatment. Reduce therapy should be "stepped", lowering or canceling the last dose or additional drugs. It is necessary to monitor the symptoms, clinical manifestations and indicators of respiratory function. It should be taken into account that the least severity of the course of asthma is presented in stage 1, and the greatest - in stage 5. Stage 1. Patients with mild intermittent (episodic) asthma- these are atopics, in whom asthma symptoms appear only when they come into contact with allergens (for example, pollen or animal hair) or are caused by physical activity, as well as children who have wheezing during a respiratory viral infection of the lower respiratory tract. The possibility of exacerbations should be considered. The severity of exacerbations can vary significantly in different patients at different times. Sometimes exacerbations can even be life-threatening, although this is extremely rare in the intermittent course of the disease. Long-term therapy with anti-inflammatory drugs is usually not indicated in these patients. Treatment includes prophylactic medication before exercise if necessary (inhaled b 2 agonists or cromogycate or nedocromil). As an alternative to short-acting inhaled b 2 -agonists, anticholinergics, oral short-acting b 2 -agonists or short-acting theophyllines can be offered, although these drugs have a later onset of action and / or they have a higher risk of side effects. Stage 2. Patients with mild persistent asthma need daily long-term preventive medication. Daily:

or inhaled corticosteroids 200–500 mcg, or sodium cromoglycate, or nedocromil.

If symptoms persist despite the initial dose of inhaled corticosteroids, and the clinician is confident that the patient is using the drugs correctly, the dose of inhaled drugs should be increased from 400-500 to 750-800 micrograms per day of beclomethasone dipropionate or an equivalent drug. A possible alternative to increasing the dose of inhaled hormones, especially to control nocturnal asthma symptoms, may be the addition (to a dose of at least 500 micrograms of inhaled corticosteroids) of long-acting bronchodilators at night. If asthma control cannot be achieved, as evidenced by more frequent symptoms, increased need for short-acting bronchodilators, or a drop in PEF values, then step 3 treatment should be started. Step 3 Patients with moderate asthma require daily intake of prophylactic anti-inflammatory drugs to establish and maintain asthma control. The dose of inhaled corticosteroids should be at the level of 800-2000 micrograms of beclomethasone dipropionate or its equivalent. It is recommended to use an inhaler with a spacer. Long-acting bronchodilators may also be given in addition to inhaled corticosteroids, especially to control nocturnal symptoms. Long-acting theophyllines, oral and inhaled long-acting b 2 -agonists can be used. Stop symptoms with short-acting b 2 -agonists or alternative drugs. For more severe exacerbations, a course of oral corticosteroids should be given. If asthma control cannot be achieved, as evidenced by more frequent symptoms, an increased need for bronchodilators, or a drop in PEF, then step 4 treatment should be started. Step 4 Patients with severe bronchial asthma Asthma cannot be completely controlled. The goal of treatment is to achieve the best possible results: the minimum number of symptoms, the minimum need for short-acting b 2 -agonists, the best possible PEF values, the minimum variation in PEF, and the minimum side effects from taking drugs. Treatment is usually with a large number of asthma-controlling drugs. Primary treatment includes high-dose inhaled corticosteroids (800 to 2000 micrograms per day of beclomethasone dipropionate or equivalent). Long-acting bronchodilators are recommended in addition to inhaled corticosteroids. You can also use short-acting b 2 -agonists once a day to achieve the effect. You can try to use an anticholinergic drug (ipratropium bromide), especially in patients who report side effects when taking b 2 -agonists. Short-acting inhaled b 2 -agonists can be used if necessary to relieve symptoms, but the frequency of their intake should not exceed 3-4 times a day. A more severe exacerbation may require a course of oral corticosteroids. Step 5 Patients with severe bronchial asthma receiving long-term therapy with systemic steroids, inhalation therapy should be administered as in step 4. Thus, although asthma is an incurable disease, it is reasonable to expect that most patients can and should be controlled for the course of the disease. It should be recalled once again that one of the central places in the treatment of asthma is currently occupied by the educational program of patients and dispensary observation.

The level of BA control is determined by the following parameters:

 minimal severity of chronic symptoms, including nocturnal ones;

 minimal (infrequent) exacerbations;

 lack of need for emergency care;

 minimal (ideally no) use of ß2-agonists “on demand”;

 lack of restrictions on activity, including physical;

 daily fluctuations in PSV less than 20%;

 normal or close to normal indicators of PSV;

 minimal manifestations or absence of undesirable effects of drugs.

Drugs for use on demand and relief of exacerbations:1. Short-acting beta-2 agonists (salbutamol, fenoterol, terbutaline) cause relaxation of the smooth muscles of the bronchi, increased mucociliary clearance, and a decrease in vascular permeability. The preferred route of administration for these drugs is by inhalation. To do this, b 2 -agonists are available in the form of metered aerosols, dry powder and solutions. If long-term inhalation is necessary, salbutamol solutions are used through a nebulizer. 2. Anticholinergic drugs (ipratropium bromide): less potent bronchodilators than b2-agonists and tend to take longer to work. It should be noted that ipratropium bromide enhances the action of b 2 -agonists when they are used together. The method of administration is inhalation (metered-dose aerosol, solution for a nebulizer). 3. Berodual - a combined preparation containing a b 2 -agonist and an anticholinergic drug. The method of administration is inhalation (metered-dose aerosol, solution for a nebulizer). 4. Systemic glucocorticosteroids (prednisolone, methylprednisolone, triamcinalone, dexamethasone, betamethasone). The route of administration is parenteral or oral. Preference is given to oral therapy. 5. Short acting theophyllines - bronchodilators, which are generally less effective than inhaled b 2 agonists. They have significant side effects that can be avoided by properly dosing the drug and monitoring. Do not use without determining the concentration of theophylline in blood plasma if the patient is receiving drugs with a slow release of theophylline.

Preparations of basic therapy

Basic therapy for AD in adults

The basis of the treatment of bronchial asthma are inhaled glucocorticosteroids.1. Inhaled corticosteroids (beclomethasone dipropionate; budesonide; flunisolide; fluticosone propionate) are used as anti-inflammatory drugs for a long time to control the course of bronchial asthma. Doses are determined by the severity of bronchial asthma. Treatment with high-dose aerosolized inhaled corticosteroids is given through a spacer, which improves asthma control and reduces some side effects, or use a "light breathing" inhaler. In severe bronchial asthma, the use of budesonide through a nebulizer may be more effective. Inhaled corticosteroids play an important role in the treatment of AD. They have the following advantages over systemic corticosteroids:

 High affinity for receptors;

 Pronounced local anti-inflammatory activity;

 Lower (about 100 times) therapeutic doses;

 Low bioavailability.

Inhaled corticosteroids are the drug of choice for patients with persistent asthma of any severity.

The undesirable effects of inhaled corticosteroids include: oropharyngeal mycosis, dysphonia, and sometimes cough.

The risk of uncontrolled asthma significantly exceeds the risk of adverse events of inhaled corticosteroids.

2. Systemic glucocorticosteroids (methylprednisolone, prednisolone, triamcinolone, betamethasone) in severe bronchial asthma should be administered at the lowest effective dose. With long-term treatment, the alternating regimen and administration in the morning cause the least amount of side effects. It should be emphasized that in all cases of the appointment of systemic steroids, the patient should be prescribed high doses of inhaled glucocorticoids. 3. Long-acting beta-2 agonists (salmeterol; formoterol; salbutamol hemisuccinate) are widely used in the treatment of severe asthma. The drugs are used both orally and inhalation, as well as parenterally. However, in pulmonological practice, the most common and effective route of drug delivery is inhalation. The advantage of inhaled forms is due to the speed of development of the maximum effect, the local (topical) nature of the action, the absence of a pronounced effect on internal organs when used in therapeutic doses. The drugs are also effective for the prevention of nocturnal asthma attacks. Used in combination with anti-inflammatory anti-asthma drugs. Currently, there are two drugs belonging to the group of long-acting b 2 -agonists: formoterol fumarate and salmeterol xinafoate. Formoterol is the most active long-acting b 2 -agonist and is found in two dosage forms: oxis and foradil. Salmeterol is represented by drugs such as serevent, salmeter. The drugs improve the function of external respiration, reduce the need for short-acting b 2 -agonists, and are effective in preventing bronchospasm provoked by allergens and physical activity. Salmeterol and salbutamol hemisuccinate are used only as basic therapy.

These drugs are not used to treat acute symptoms or flare-ups. Formoterol fumarate is a drug that is characterized by a unique combination of pharmacological properties:

high efficiency combined with high b 2 -selectivity, which provides a unique safety profile of the drug;

rapid onset of action (within 1-3 minutes);

duration of effect within 12 hours;

the absence of antagonistic action against short-acting b 2 -agonists and a significant effect on their effects, which is of great clinical importance in situations involving the combined use of long-term and short-acting adrenomimetics;

lack of cumulation in therapeutic doses.

The high safety record allows formoterol to be used on demand, and its rapid onset of action allows it to be used as a rescue medication. Thus, formoterol may be the only bronchodilator needed by the patient in any situation. The potentiation of long-acting b 2 -agonists, and in particular formoterol and salmeterol, of the effects of glucocorticosteroids should be especially emphasized. With insufficient control of asthma symptoms, it is therapeutically more beneficial to prescribe a combination of low doses of inhaled glucocorticoids and prolonged b 2 -agonists than doubling the dose of steroids.

The presence of one of the indicators of the severity of the course allows the patient to be assigned to one of the categories. When determining the severity of the course, it is necessary to take into account the amount of therapy to control asthma symptoms.

4. Theophyllines of prolonged action. Method of application oral: due to the prolonged action, they reduce the frequency of nocturnal attacks, slow down the early and late phase of the asthmatic response to allergen exposure. The use of theophyllines can cause severe side effects: headache, tremor, nausea, vomiting, tachycardia, heart rhythm disturbances, abdominal pain, loose stools. It is necessary to monitor the content of theophyllines in plasma. 5. Leukotriene receptor antagonists (zafirlukast, montelukast) - a new group of anti-inflammatory anti-asthma drugs. Method of application tableted. The drugs improve the function of external respiration, reduce the need for short-acting b 2 -agonists, and are effective in preventing bronchospasm provoked by allergens and physical activity. In the treatment of severe bronchial asthma, it is especially indicated for those forms of bronchial asthma, the severity of which is associated with an increased metabolism of leukotrienes (aspirin, post-exercise bronchospasm syndrome, reactions to cold air and allergen exposure). 6. M-cholinolytics - anticholinergic drugs (ipratropium bromide) - are not first-line drugs in the treatment of bronchial asthma, as they are inferior in effectiveness to sympathomimetics. However, in some cases, their use in combination with b 2 -agonists can be effective in patients with refractoriness to b 2 -agonists. 7. Combined drugs . Currently, great importance is attached to combined preparations (combinations of b 2 -agonists of prolonged action and inhaled glucocorticoids). There are two dosage forms: Seretide (a combination of salmeterol and fluticasone propionate) and Symbicort (a combination of formoterol and budesonide). It should be noted that these drugs potentiate the action of each other and together have a pronounced anti-inflammatory effect. 8. Sodium cromoglycate and nedocromil: non-steroidal anti-inflammatory drugs for long-term control of bronchial asthma. Effective in preventing bronchospasm triggered by allergens, exercise and cold air.

Treatment of asthma exacerbations in adults

Asthma exacerbations are episodic conditions accompanied by increased coughing, shortness of breath, the appearance of wheezing, suffocation, and a feeling of lack of air. Asthma exacerbation is accompanied by a drop in peak expiratory flow rate and forced expiratory volume in the first second.

There are two options for the development of a severe exacerbation of BA:

 Severe exacerbation of asthma with a slow pace of development, when the increase in respiratory syndromes is observed for several days, despite an increase in the dose of bronchodilators;

 Severe asthma exacerbation with a sudden onset is more rare, and it can take only 1-3 hours from the onset of the first symptoms to respiratory arrest and death.

Risk factors for developing a life-threatening asthma exacerbation

(asthmatic status):

 History of a life-threatening exacerbation of asthma.

 Exacerbation of BA against the background of long-term use of systemic corticosteroids and / or their recent cancellation.

 Hospitalization for exacerbation of BA during the past year in the intensive care unit.

 A history of an episode of artificial lung ventilation due to exacerbation of BA.

 Mental illness or psychosocial problems.

 Patient's non-fulfillment of the asthma treatment plan.

 The presence of persistent symptoms of asthma for a long time (more than 3 hours) before presenting for medical help.

 Unfavorable home conditions.

 Socio-economic factors (low income, lack of access to medicines).

Treatment of an exacerbation involves the exclusion of contact with causally significant allergens, the use of short-acting inhaled bronchodilators (β2-agonists or β2-agonists + m-anticholinergics) for the rapid relief of bronchospasm, inhaled and systemic corticosteroids, short-acting theophyllines.

short-acting β2-agonists are first-line drugs in the treatment of asthma exacerbations, due to their rapid action and relatively high safety profile.

Anticholinergic drugs are referred to as second-line drugs in the treatment of exacerbations of asthma, since they are inferior in effectiveness to β2-agonists, however, they practically do not cause complications, and in combination with β2-agonists they give a greater bronchodilatory effect compared to monotherapy.

If a patient has a aggravated premorbid background in the form of coronary heart disease, cardiac arrhythmias, COPD, then the role of anticholinergic drugs in the symptomatic treatment of BA increases significantly, they become first-line bronchodilators.

Theophylline short acting are classified as second-line drugs for the treatment of asthma exacerbations and are recommended for use no earlier than 4 hours after a β2-agonist. Among bronchodilators, theophylline is the least effective drug. , and its therapeutic dose is almost equal to the toxic one, in addition, it has the greatest number of side effects (nausea, headache, insomnia, electrolyte disorders, arrhythmias, convulsions).

Glucocorticosteroid hormones as the most powerful anti-inflammatory drugs are mandatory for the treatment of asthma exacerbations. It has been proven that the effectiveness of oral and parenteral forms of systemic corticosteroids in the treatment of asthma exacerbations is almost the same. The inhalation method of introducing a nebulized solution or suspension of budesonide (Benacort, Pulmicort) provides a faster onset of anti-inflammatory action than systemic corticosteroids, while a more pronounced improvement in clinical parameters was noted.

Currently, the inhalation route of administration of drugs during exacerbation of BA is the main one at any stage of medical care (outpatient, by the SP team, in the hospital). The rate of development of bronchodilation is comparable with parenteral administration of the drug. The possibility of using a lower dose of the drug and the exclusion of the drug entering the general circulation with this technique reduces the risk of developing side effects of bronchodilators and corticosteroids (table 8).

Table 8

Algorithm for the treatment of asthma exacerbations

(Order No. 300 of the Ministry of Health of the Russian Federation dated 09.10.98)

Oxygen therapy during exacerbation of asthma is of vital importance, since the immediate cause of death in this case is hypoxia. Oxygen therapy is carried out in the form of inhalations, oxygen is used as a carrier gas in nebulizers. With life-threatening attacks, artificial ventilation of the lungs is effective. Non-invasive ventilation of the lungs is recognized as optimal, but the experience of its use in severe exacerbations of BA is still insufficient.

 Antihistamines;

 Sedative drugs;

 Phytopreparations;

 Mustard plasters, banks;

 Calcium preparations, magnesium sulfate;

 Mucolytics;

 Antibacterial agents (may be indicated only in the presence of pneumonia or other bacterial infection);

 Prolonged β2-agonists.

Tactics of management of patients with exacerbation of BA in conditions of SP

To assist a patient with exacerbation of BA, the laying of the SP team should contain:

 Oxygen inhaler, peak flowmeter;

 Nebulizer chamber complete with compressor;

 Disposable syringes;

 A set of medicines (Table 9);

 Venous tourniquet;

 Butterfly needles and/or infusion cannulas

Table 9

Medicines of mandatory and additional assortment for the treatment of asthma exacerbations

Indications for emergency hospitalization:

 Unsatisfactory response to treatment<50% от должного после применения бронходилятаторов);

 Symptoms of exacerbation of BA increase or there is no clear positive dynamics of symptoms within 3 hours from the start of urgent therapeutic measures;

 There is no improvement within 4-6 hours after the start of treatment with systemic corticosteroids.

After the transfer of the patient from the ICU to the pulmonological (therapeutic) department, it is necessary:

 Carry out a 7-10 day course of treatment with corticosteroids, subject to continued treatment with bronchodilators;

 Start or continue treatment with inhaled corticosteroids at a daily dose corresponding to the severity of asthma;

 It is necessary to check the skills of using an inhaler, a peak flow meter for monitoring the condition.

There are no absolute criteria for discharge from the hospital. Before being discharged, the patient should be on the outpatient regimen for 12-24 hours to ensure that it is effective.

The increase in drug consumption, the introduction of new drugs with high biological activity into medical practice, leads to a significant increase in the complications of pharmacotherapy. Any drug, in addition to a direct pharmacological effect, often has a negative effect on both affected and intact organs and tissues, which may cause a change in the nature of the course of the underlying disease, so the pharmacotherapy of asthma should be balanced and justified.

Since bronchial asthma is a chronic disease with periods of exacerbation and remission, patients need constant monitoring. Drug treatment also needs constant correction depending on the severity of the disease. In case of mild and moderate course, it is necessary to be examined by a pulmonologist or therapist 2-3 times a year, and in severe cases - 1 time in 1-2 months. An allergic reaction to infectious and other agents plays an important role in the development of bronchial asthma, therefore, consultations with an allergist (once a year) are indicated for such patients. With bronchial asthma, disorders of the nervous system are noted, so it is advisable to undergo an examination by a psychotherapist once a year. To sanitize foci of chronic infection, you need to regularly (at least once a year) visit an otolaryngologist and a dentist. It is necessary to take a general blood and sputum test 2-3 times a year to detect an inflammatory process in the bronchopulmonary tissue. To determine the functional state of the respiratory system, 2 times a year, it is necessary to perform spirography.

The need to conduct a labor examination and determine the disability group in patients with bronchial asthma occurs with frequent, recurrent or prolonged attacks of suffocation, clinically significant pulmonary or pulmonary heart failure. And also when the course of the underlying disease is complicated by hormonal dependence, asthmatic status or bronchial asthma occurs against the background of a chronic recurrent inflammatory process in the lungs.

A characteristic feature of bronchial asthma is complete or partial reversibility spontaneously or under the influence of treatment. Therefore, bronchial asthma initially does not belong to diseases that steadily lead to permanent disability and disability. The combination of modern methods of treatment and measures to limit exposure to provoking factors (primarily tobacco smoke and causally significant allergens) makes it possible to achieve disease control in most patients. However, referral to a medical and social examination (MSE) for asthma is not uncommon. First of all, this is due to the need to change working conditions: in the presence of contraindications in the conditions and nature of work and the impossibility of finding employment in an accessible profession without reducing qualifications or a significant decrease in the volume of production activity. In the presence of a long-term disability, even with a good prognosis, the patient is referred to the MSEC to resolve the issue of aftercare or establishing a disability group. The establishment of a disability group should be accompanied not only by the issuance of a certificate, but also by the preparation of an individual rehabilitation program. The question of establishing a disability group also arises in severe asthma, with hormone dependence (constant hormone intake in tablets), with severe concomitant diseases or complications, with the formation of irreversible bronchial obstruction (developing with a combination of asthma and COPD or with a long uncontrolled course of the disease in the absence of proper treatment ). The list of documents required to be submitted to MSEK for examination for obtaining a disability group: form No. 88; KEK certificate; outpatient card from the clinic; certificate from the place of work; the passport; accident report (if any); referral to % disability; military ID and military medical documents (if any); ITU certificate (during re-examination). The issue of granting a disability group is always decided individually. By itself, the presence of a diagnosis of bronchial asthma is not a basis for establishing a disability group.

Complications of bronchial asthma (asthmatic status). Clinic, diagnostics. Emergency treatment of status asthmaticus.

Complications

BUT.Respiratory tract infections is a common complication of bronchial asthma. They can occur both during exacerbation and during remission of the disease and often provoke attacks of bronchial asthma. Dry wheezing, heard at a distance, during an acute respiratory illness may be the first manifestation of bronchial asthma in children. Bronchial asthma should be excluded in all children with frequent bronchitis and acute respiratory infections.

1. Acute respiratory diseases most commonly cause asthma attacks. The most common infections are caused by respiratory syncytial virus, parainfluenza and influenza viruses, rhino- and adenoviruses. It is assumed that these viruses directly act on the bronchi, increasing their reactivity. It is possible that the occurrence of asthma attacks during acute respiratory infections is due to IgE specific to this virus, or caused by the virus, a decrease in the sensitivity of beta-adrenergic receptors and the release of inflammatory mediators.

2. Bacterial infections rarely provoke attacks of bronchial asthma. The exceptions are chronic sinusitis and mycoplasma infection.

3. Pneumonia usually develops a second time, after prolonged or frequent attacks of bronchial asthma, when a large amount of mucus accumulates in the bronchi. At the age of up to 5 years, viral pneumonia occurs more often, 5-30 years - mycoplasma, after 30 years - pneumococcal and other bacterial pneumonia.

B.Atelectasis- lobar, segmental and subsegmental - can occur during both exacerbation and remission. Usually their appearance is associated with blockage of the bronchi by mucous plugs. Atelectasis is characterized by increased cough, persistent wheezing, shortness of breath, fever, weakened vesicular breathing, and dullness of percussion sound in the area of ​​atelectasis. Most often observed atelectasis of the middle lobe of the right lung. Often they are not diagnosed. If atelectasis is suspected, a chest x-ray is indicated. Atelectasis is characteristic of young children, often recurs, and the same areas of the lung are usually affected.

AT.Pneumothorax and pneumomediastinum

1. Pneumothorax is a rare complication of bronchial asthma. With recurrence of pneumothorax, a cyst, congenital lobar emphysema, and other lung diseases are excluded. Pneumothorax can occur with a strong cough and during mechanical ventilation. This complication should be suspected with the sudden onset of pain in the side, aggravated by breathing and accompanied by shortness of breath, tachypnea, and sometimes cough. The diagnosis is confirmed by chest x-ray. With a small pneumothorax (less than 25% of the volume of the pleural cavity), in the absence of severe shortness of breath and pain, bed rest and observation are indicated. The air in the pleural cavity resolves on its own. In other cases, drainage of the pleural cavity is required.

2. Pneumomediastinum and subcutaneous emphysema more common than pneumothorax. Patients, as a rule, do not complain, so these complications are detected incidentally during chest x-ray, examination and palpation of the neck and chest. Sometimes pneumomediastinum is manifested by pain behind the sternum, less often by shortness of breath, tachypnea, tachycardia, arterial hypotension and cyanosis of the upper half of the body. A characteristic sign of pneumomediastinum is Hamman's symptom (crepitant noise during auscultation of the heart). Pneumomediastinum and subcutaneous emphysema usually occur during severe coughing and mechanical ventilation. Treatment in most cases is not required, in severe cases, the mediastinum is drained.

G.bronchiectasis is a rare complication of bronchial asthma. They usually occur when bronchial asthma is combined with chronic bronchitis, prolonged atelectasis, or allergic bronchopulmonary aspergillosis. With bronchiectasis, a prolonged cough, purulent sputum, hemoptysis, a symptom of drumsticks are observed. It should be noted that with uncomplicated bronchial asthma, the last sign is absent. Sometimes the diagnosis can be made on the basis of a chest x-ray, but in most cases x-ray tomography or CT is required. In rare cases, bronchography is performed.

D.Allergic bronchopulmonary aspergillosis. The causative agent is Aspergillus fumigatus. In the pathogenesis of the disease, allergic reactions caused by the pathogen play a role. It is observed mainly in adult patients with bronchial asthma.

E.Cardiovascular Complications in bronchial asthma, they are most often manifested by arrhythmias - from rare ventricular extrasystoles to ventricular fibrillation. Arrhythmias are more common in patients with cardiovascular disease. The severity of arrhythmias increases with hypoxemia and the abuse of beta-agonists. During an asthma attack, overload of the right heart can occur. Right ventricular failure develops very rarely - only in the case of prolonged severe hypoxemia and volume overload. During an attack of bronchial asthma, pulmonary hypertension is often observed, but cor pulmonale occurs only when bronchial asthma is combined with COPD. To reduce hypoxemia, oxygen inhalations are prescribed. Limit the use of beta-agonists (both inhaled and systemic) and theophylline. In severe arrhythmias and right ventricular failure, cardiac glycosides are prescribed (if the arrhythmia is not caused by these drugs) and other antiarrhythmic drugs. At the same time, it is necessary to take into account whether they cause bronchospasm.

AND.Asthmatic status and respiratory failure .

Asthmatic status (AS) is a syndrome of acute respiratory failure that develops in patients with bronchial asthma due to airway obstruction that is resistant to therapy with aminophylline and sympathomimetics, including selective P2-stimulants.

Persistent asthma is a serious pathology. Symptoms can develop in a person for years, which limits his vital activity. However, some patients experience periods of remission.

Persistent asthma is a chronic disease. Bronchial spasms occur systematically. This is the most common form of AD. Against the background of inflammation of the respiratory tract, exacerbations constantly occur. Mucus secretion (required to protect the body) is produced in large quantities.

In the presence of such a pathology, the patient cannot inhale the air with full breasts. He is also unable to fully exhale it. Some patients experience problems with either inhalation or exhalation.

Classification of persistent asthma

There are four forms of the course of this disease. The severity is set, focusing on the symptoms and condition of the patient. The form of the course of the pathology is established in order to prescribe the most effective therapy. High-quality treatment helps to achieve a long period of time.

Here are the forms of persistent asthma.

• Heavy. Asphyxiants occur systematically, occur both at night and during the day. It is important to limit physical activity. Only special medicines help.
• Average. More often than once or twice a week, seizures occur at night. They happen less during the day. Due to respiratory failure, the quality of life of a person decreases.
• Easy. Attacks occur once or twice a week, mostly during the day. Sleep may be disturbed.

• Timely identify the allergen provocateur and take appropriate measures.
• Keep children vaccinated on time.
• Carefully choose a profession (it is important to reduce the influence of negative external factors to zero).
• Eat right.
• Lead a healthy lifestyle, and regularly.
• Regularly visit the fresh air, take long walks.

Attention! Qualified treatment is of great importance. This will prevent complications.

Bronchial asthma is an allergic disease that leads to asthma attacks caused by spasms of the bronchi and swelling of their mucous membrane. Today, bronchial asthma can be considered one of the most common diseases that affects 4-10% of the world's population. In childhood, 10-15% of children are susceptible to the development of bronchial asthma.

Often, bronchial asthma in the early stages of its development is diagnosed as bronchitis, so its treatment is not adequate and does not lead to effectiveness.

Symptoms of bronchial asthma

- asthma attacks, severe shortness of breath, cough;

- wheezing, wheezing;

- heaviness in the chest area.

Signs of bronchial asthma include the spontaneous disappearance of typical symptoms or their disappearance after taking anti-inflammatory drugs. Be sure to pay attention to repeated exacerbations, which are often caused by various allergens, low temperatures, high humidity, significant physical exertion, viruses, etc. The variability of symptoms may vary depending on the season of the year.

Risk factors

- heredity (the presence in the family of a sick person suffering from bronchial asthma or other allergic diseases);

- climatic factors (low cloudiness, movement of air masses, etc. can provoke an attack of bronchial asthma, in 93.8% of cases asthma is provoked by clay soil, this disease is more common among inhabitants of the plains, especially with a high level of groundwater);

- seasonality (exacerbations can be caused by high and low temperatures, flowering plants, etc.).

The development of bronchial asthma

Bronchial asthma is manifested by attacks of suffocation and coughing, which are based on immune inflammation of the bronchi when allergens or pathogens of an infectious disease enter them. After that, biologically active substances begin to be released, cells are activated, the structure and function of the bronchi are disturbed, mucosal edema develops, bronchial secretion changes, smooth muscle spasms are observed.

During an asthma attack, the bronchial secret becomes thick and clogs the lumen of the bronchus, preventing the passage of air to the outside. This leads to difficulty exhaling - expiratory dyspnea - one of the specific signs of the disease. It is expiratory shortness of breath that causes wheezing, wheezing.

To assess the degree of bronchospasm, various methods are used - spirography, PIR-fluorometry. Spirography allows you to evaluate the volume of expiration in the first second (FEV1), PIC-fluorometry - the volume of peak expiratory flow (PIC).

Bronchial asthma requires mandatory treatment, self-elimination of an attack is possible only with the development of atopic bronchial asthma caused by seasonal flowering of plants.

The course of bronchial asthma

The course of the disease includes periods of exacerbation and remission. The severity of the disease is assessed based on the following criteria:

- the number of seizures during the week at night;

- the number of seizures during the week in the daytime;

- the need to use short-acting agonists;

- sleep disturbances and physical activity;

- changes in FEV1 and POS during an exacerbation of the disease;

- fluctuations of the POS during the day.

According to the severity of the disease, four degrees of bronchial asthma are distinguished:

- intermittent flow (periodic);

- persistent mild course;

— persistent middle current;

- persistent severe course.

Intermittent Bronchial Asthma

- the frequency of night attacks is not more than 2 times a month;

frequency of daytime attacks less than once a week;

- the occurrence of short-term exacerbations, lasting from several hours to several days;

- normal breathing during remission;

— POC fluctuations< 20% в течение суток.

Bronchial asthma of mild persistent course

- night attacks more than twice a month;

- attacks of suffocation in the daytime more than once a week, no more than once a day;

- possible sleep disturbances and physical activity during the day;

- fluctuations of the POS during the day 20 - 30%.

Bronchial asthma of moderate severity of persistent course

- the frequency of nocturnal asthma attacks more than once a week;

- daytime attacks occur daily;

- during exacerbations of the disease, physical activity, working capacity, sleep are disturbed;

- the need to use short-acting agonists daily;

- FEV1, POS 60-80% of the norm;

— fluctuations of POS > 30% during the day.

Bronchial asthma of severe persistent course

- frequent occurrence of asthma attacks at night;

- constant attacks in the daytime;

- frequent exacerbations of the disease;

- significant impairment of physical activity;

- fluctuations of the POS during the day - 20 - 30%.

Survey

A detailed pulmonological and allergological examination of the patient allows to identify the causes of seizures, determine the mechanisms of the development of the disease, as well as the likelihood of concomitant diseases.

Asthma treatment

The method of treating bronchial asthma is determined on the basis of the results of the examination, depending on the mechanism of the development of the disease and its severity. Specific treatment by an allergist is indicated in cases where the exacerbation of the disease is provoked by one or another allergen. In this case, vaccination is chosen as a treatment, carried out in combination with traditional basic therapy with inhaled drugs, symptomatic therapy.

Asthma Prevention

- minimization of exposure to allergens and their entry into the bronchi of the patient;

- prevention of infectious diseases in the lungs and bronchi;

- regular use of the therapy prescribed by the doctor;

- self-control of breathing parameters.

• Asthma symptoms ← Published: 14.Jun.2012
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In children, in most cases, there is an atopic form of bronchial asthma. Typical symptoms of bronchial asthma are manifested by an asthma attack, broncho-obstructive syndrome. The main causes of bronchial obstruction are edema and hypersecretion, spasm of the bronchial muscles.

For bronchospasm clinically more characteristic dry paroxysmal cough, noisy breathing with difficulty exhaling, dry wheezing.

With prevalence and hypersecretion in the bronchi, different-sized moist rales are heard.

It is characteristic that during an attack of bronchial asthma there is shortness of breath, a feeling of lack of air, wheezing, paroxysmal cough with difficult to secrete viscous sputum. Exhalation is difficult. There is swelling of the chest and suffocation in severe bronchial asthma. In children, especially young children, bronchial asthma is often combined with atopic dermatitis or, at an older age (in adolescents), with allergic rhinitis (seasonal or year-round).

Symptoms of bronchial asthma often appear or intensify at night and especially in the morning. A severe attack of bronchial asthma occurs with severe shortness of breath with the participation of auxiliary muscles. Characterized by unwillingness to lie down. The child sits with his hands on his knees. There is swelling of the cervical veins. The skin is pale, there may be cyanosis of the nasolabial triangle and acrocyanosis. With percussion - tympanitis, whistling, buzzing rales and rales of various sizes in all fields of the lungs.

Threatening condition - a silent lung and a sharp decrease in the peak expiratory flow rate of less than 35%.

There is emphysema of the lungs. Difficulty in passing sputum. Sputum is viscous, light, vitreous. Heart sounds are muffled. Tachycardia. There may be an increase in the size of the liver.

To assess the function of external respiration in bronchial asthma, the forced vital capacity of the lungs, the volume of forced expiratory flow in the first second, and the peak volumetric expiratory flow rate determined using portable flowmeters are determined. To assess the degree of violation of the reactivity of the receptor apparatus of the bronchi, inhalation tests with histamine and acetylcholine are performed.

In remission, in the absence of clinical signs of obstruction, a pulmonary function test using spirometry or a forced vital capacity flow-volume curve should be performed.

Clinical and functional criteria for the diagnosis of bronchial asthma

Each degree is characterized by certain changes in clinical and functional parameters. It is important that the presence of at least one sign that corresponds to a higher degree of severity than the other signs makes it possible to identify a child in this category. It should be noted that the criteria for verifying the severity of asthma should only be used if the patient has never received anti-inflammatory treatment or used anti-asthma drugs for more than 1 month ago. This approach to assessing the severity of the disease is used to address the issue of starting therapy and assessing the severity of impairments/limitations of life during the medical and social examination.

Classification of bronchial asthma by severity (GINA, 2006)

1 time per week but 2 times per month

>1 time per week

Disrupt activity and sleep

Disrupt activity and sleep

FEV1 or PSV (from due)

Classification of bronchial asthma

Classifications of bronchial asthma:

• by etiology;
• by severity and level of control;
• according to the period of illness.

Classification of bronchial asthma by etiology

There are allergic and non-allergic forms of the disease. In children, in 90-95% of cases, allergic / atopic bronchial asthma occurs. Non-allergic include non-immune forms of asthma. The search for specific causal environmental factors is important for prescribing elimination measures and, in certain situations (with clear evidence of a link between allergen exposure, disease symptoms, and an IgE-dependent mechanism), allergen-specific immunotherapy.

Symptoms of bronchial asthma depending on the severity

The classification of the severity of bronchial asthma, presented in GINA (2006), is primarily focused on the clinical and functional parameters of the disease; the number of daytime and nighttime symptoms per day / week, the frequency of use of short-acting beta2-agonists, the value of peak expiratory flow (PEF) or volume should be taken into account. forced exhalation in the first second (FEV1) and daily fluctuations in PSV (variability)]. However, it is possible to change the severity of bronchial asthma. In addition to clinical and functional disorders characteristic of this pathology, the volume of current treatment is taken into account when classifying asthma. the degree of control of the disease, as well as its period.

mild bronchial asthma

The frequency of attacks is not more than 1 time per month. Attacks are episodic, mild, quickly disappearing. Night attacks are absent or rare. Sleep, exercise tolerance were not changed. The child is active. Forced expiratory volume and peak expiratory flow rate of 80% of predicted value or more. Daily fluctuations in bronchial patency are not more than 20%.

During the period of remission, there are no symptoms, normal respiratory function. The duration of remission periods is 3 or more months. The physical development of children is not disturbed. The attack is eliminated spontaneously or by a single dose of bronchodilators in inhalation, or by ingestion.

Moderate bronchial asthma

Attacks 3-4 times a month. Occur with distinct violations of respiratory function. Night attacks 2-3 times a week. Reduced exercise tolerance. Forced expiratory volume and peak expiratory flow 60-80% of predicted value. Daily fluctuations in bronchial patency 20-30%. Incomplete clinical and functional remission. The duration of remission periods is less than 3 months. The physical development of children is not disturbed. Attacks are stopped by bronchodilators (in inhalations and parenterally), according to indications, glucocorticosteroids are prescribed parenterally.

severe bronchial asthma

Attacks several times a week or daily. The attacks are severe, asthmatic conditions are possible. Night attacks almost daily. Significantly reduced exercise tolerance. Forced expiratory volume and peak expiratory flow less than 60%. Daily fluctuations in bronchial patency more than 30%. Incomplete clinical and functional remission (respiratory failure of varying severity). The duration of remission is 1-2 months. Perhaps the lag and disharmony of physical development.

Attacks are stopped by the introduction of parenteral bronchospasmolytics in combination with glucocorticosteroids in a hospital, often in the intensive care unit.

Assessment of the spectrum of sensitization and the level of the defect in the receptor apparatus of the smooth muscles of the bronchi is carried out only in the period of remission.

In the period of remission, scarification tests are shown to determine the spectrum of sensitization to dust, pollen and epidermal antigens or prick tests with suspected allergens. Observation and treatment of the patient during the period of exacerbation and remission is carried out by the local pediatrician and pulmonologist. To clarify the cause-significant antigen, skin tests are performed by a district allergist. The allergist decides on the need for specific immunotherapy and conducts it. A pulmonologist and functional diagnostics doctor teaches sick children and their parents how to conduct peak flowmetry and fix the results of the study in a self-observation diary.

Classification according to the period of the disease provides for two periods - exacerbation and remission.

Classification of bronchial asthma depending on the period of the disease

Exacerbation of bronchial asthma - episodes of increasing shortness of breath, coughing, wheezing, chest congestion, or any combination of these clinical manifestations. It is worth noting that the presence of symptoms in patients with asthma in accordance with the criteria is a manifestation of the disease, and not an exacerbation. So, for example, if a patient has daily symptoms, two nocturnal symptoms per week and FEV1 = 80%, the doctor states that the patient has moderate asthma, since all of the above serve as criteria for this form of the disease (and not exacerbation). In the case when a patient has an additional (over the existing) need for short-acting bronchodilators in addition to the existing symptoms, the number of daytime and nighttime symptoms increases, severe shortness of breath occurs, an exacerbation of asthma is noted, which also needs to be classified according to severity.

The control of bronchial asthma is the elimination of the manifestations of the disease against the background of the current basic anti-inflammatory treatment of asthma. Complete control (controlled asthma) is today identified by the GINA experts as the main goal of asthma treatment.

Remission of bronchial asthma is the complete absence of symptoms of the disease against the background of the abolition of basic anti-inflammatory treatment. So, for example, the appointment of a pharmacotherapeutic regimen corresponding to the severity of asthma for some time leads to a decrease (possibly, to complete disappearance) of the clinical manifestations of the disease and the restoration of functional parameters of the lungs. This condition must be perceived as control over the disease. In the event that the lung function remains unchanged, and there are no symptoms of bronchial asthma even after discontinuation of treatment, remission is ascertained. It should be noted that in children in the pubertal period, spontaneous remission of the disease sometimes occurs.

Determining the level of control depending on the response to the treatment of bronchial asthma

Despite the paramount importance (for determining the severity of bronchial asthma) of clinical and functional parameters, as well as the volume of treatment, the above classification of the disease does not reflect the response to the treatment. For example, a patient may see a doctor with moderate asthma symptoms, and as a result, he will be diagnosed with moderate persistent asthma. However, in case of insufficient pharmacotherapy for some time, the clinical manifestations of the disease will correspond to severe persistent asthma. Given this provision, in order to make a decision on changing the volume of current treatment, GINA experts proposed to distinguish not only the severity, but also the level of disease control.

Asthma control levels (GINA, 2006)

Controlled AD (all of the above)

Partially controlled asthma (any manifestation within 1 week)

No (2 per week

Yes - any expression

Three or more signs of partially controlled asthma in any week

Night symptoms / awakenings

Yes - any expression

Need for emergency medicines

None (52 episodes per week)

Pulmonary function tests (PEF or FEV1)

>80% predicted (or best for this patient)

1 per year or more

Any week with an aggravation

Diagnosis of allergic and non-allergic asthma in children

It is customary to distinguish between allergic and non-allergic forms of bronchial asthma, they are characterized by specific clinical and immunological signs. The term "allergic asthma" is used as a base term for asthma mediated by immunological mechanisms. When there are indications of IgE-mediated mechanisms (sensitization to environmental allergens, elevated serum IgE levels), one speaks of IgE-mediated asthma. In most patients (typical atopic children with a hereditary predisposition to high production of IgE, with the first manifestation of manifestations at an early age), allergic symptoms can be attributed to atonic asthma. However, IgE-mediated asthma cannot always be called "atopic". In some people who cannot be characterized as atopic, they are not sensitized (at an early age) to common allergens, the development of IgE-mediated allergy occurs later when exposed to high doses of allergens, often in combination with adjuvants such as tobacco smoke. In this regard, the term "allergic asthma" is broader than the term "atopic asthma". In the non-allergic variant, allergen-specific antibodies are not detected during the examination, a low level of serum IgE is characteristic, and there is no other evidence of the involvement of immunological mechanisms in the pathogenesis of the disease.

Medical Expert Editor

Portnov Alexey Alexandrovich

Education: Kyiv National Medical University. A.A. Bogomolets, specialty - "Medicine"

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Bronchial asthma moderate course

Treatment of bronchial asthma is divided into two main aspects. This is the relief of asthma attacks and their prevention with the help of drug therapy. The main tactics of treating bronchial asthma is developed by the attending physician, depending on the stage of the pathology and its form. There are intermittent and persistent, moderate and severe forms of bronchial asthma.

Symptoms of bronchial asthma

Bronchial asthma (BA) is a chronic inflammatory disease of the airways with bronchial hyperreactivity, which is manifested by episodes of shortness of breath, whistling in the chest, coughing and is caused by contact with various substances.

The main symptoms of bronchial asthma and complaints of a pulmonologist patient include coughing and asthma attacks.

Prolonged cough in bronchial asthma

When examined by a doctor of patients who are concerned about chronic cough, in 25% of cases it is possible to establish the presence of several diseases, each of which individually can cause the appearance of this symptom. A prolonged cough in bronchial asthma is a likely sign.

Shortness of breath in bronchial asthma

Shortness of breath in bronchial asthma - a feeling of lack of air or a feeling of greater than usual effort made with each inhalation or exhalation. Shortness of breath is observed both in diseases of the cardiovascular system and in diseases of the respiratory system, however, it has clear distinguishing features. The most common chronic respiratory disease is bronchial asthma.

Causes of bronchial asthma

I distinguish between allergic and inflammatory causes of bronchial asthma. The pathogenesis of bronchial asthma is based on three types of inflammatory reactions:

1. Acute inflammation of the respiratory tract, leading to an attack of bronchial asthma, upon contact with an allergen.

2. Chronic inflammation, due to which bronchial hyperreactivity develops: the patient begins to react pathologically to cold air.

Important! Proper and timely treatment can completely eliminate the manifestations and consequences of both acute and chronic inflammation.

3. In the absence of treatment, over time, the processes of remodeling of the respiratory tract begin to predominate in the patient. The bronchial wall becomes thicker and less elastic due to hypertrophy of the muscle layer and collagen deposits. This process is irreversible and causes the patient to have a persistent (which is not treatable) decrease in airflow.

Treatment of bronchial asthma

Bronchial asthma is a chronic disease, and its complete cure is impossible, but in most patients it is possible to achieve control over the course of the disease. Asthma control is the main goal of treatment. Important! Control over the course of bronchial asthma should be provided with a minimum amount of treatment. There are 5 degrees of severity of the course of bronchial asthma, in accordance with which stepwise treatment of bronchial asthma is carried out.

Intermittent bronchial asthma

What the patient experiences: symptoms of intermittent bronchial asthma gives less than 1 time per week. Short exacerbations from a few hours to a few days. Night symptoms 2 times a month or less. No symptoms and normal lung function between exacerbations.

What does the doctor prescribe

Short-acting β2-agonists on demand (no more than 1 time per week)

Use of short-acting β2-agonists or cromones before exercise or allergen exposure.

Persistent bronchial asthma

What the patient is experiencing: symptoms of persistent bronchial asthma gives from 1 time per week to 1 time per day. Exacerbations of the disease can interfere with activity and sleep. Night symptoms occur more often than 2 times a month.

What does the doctor prescribe

Basic therapy is necessary - daily intake of anti-inflammatory drugs:

• Cromones or standard doses of inhaled glucocorticoids (200-800 mcg);
• Long-acting β2-agonists (especially to control nocturnal symptoms)
• Short-acting β2-agonists on demand.

Bronchial asthma of moderate severity

What the patient experiences: Bronchial asthma of moderate severity gives daily symptoms. Exacerbations disrupt activity and sleep. Nocturnal symptoms occur more than once a week. Daily intake of short-acting β2-agonists.

What does the doctor prescribe

Basic therapy is needed: High doses of inhaled glucocorticoids (800-2000 mcg). Or standard doses in combination with long-acting β2-agonists. β2-Agonists of short action p2o needs.

severe bronchial asthma

What the patient experiences: Severe bronchial asthma has persistent symptoms. Frequent exacerbations. Frequent nocturnal symptoms. Physical activity is limited by the manifestations of asthma.

What does the doctor prescribe

Basic therapy is needed: High doses of inhaled glucocorticoids in combination with regular intake of prolonged bronchodilators.

High dose inhaled glucocorticoids plus one or more of the following:

• inhaled long-acting β2 agonists;
• oral long-acting theophyllines;
• inhaled ipratropium bromide;
• oral long-acting β2 agonists;
• cromones;
• Short-acting β2 agonists on demand.

Rules for the control of bronchial asthma

• Minimal manifestation of symptoms of the disease.
• Maintenance of normal or best functional pulmonary parameters.
• Maintain normal activity levels (including exercise and other physical activities).
• Prevent relapses and minimize the need for emergency hospitalizations.
• Providing optimal pharmacotherapy with minimal or no side effects.

Prevention of asthma attacks

Prevention of asthma attacks is of primary importance in the treatment of the disease. It is necessary to exclude contact with causative allergens: house dust, mite allergens (wet cleaning, special coatings and bedding), pets, certain types of food, professional agents (up to a change of profession). Much attention is paid to non-specific provoking factors - active and passive smoking, taking β-blockers, aspirin and other salicylic acid products (preservatives, dyes).

Drug prevention of asthma attacks

All drugs for the medical prevention of asthma attacks are divided into two types: emergency drugs and drugs for basic (permanent) therapy.

Emergency medicines (for relief of seizures):

1. Fast-acting β2-agonists: salbutamol, fenoterol, terbutaline.

2. Inhaled anticholinergic drugs: ipratropium bromide.

3. Combined preparations of inhaled β2-agonists and ipratropium bromide (Berodual).

It has been proven that the use of a combination of ipratropium with p2-agonists during exacerbation of bronchial asthma leads to a greater bronchodilatory effect compared to monotherapy with β2-agonists and can significantly prolong it.

Preparations of basic (permanent) therapy (must be taken regularly for persistent, moderate and severe course):

1. Inhaled glucocorticosteroids (IGCS): beclomethasone dipropionate, budesonide, fluticasone propionate, mometasone furoate and systemic corticosteroids.

2. Inhalation mast cell membrane stabilizers: sodium cromoglycate, sodium nedocromil.

3. Long-acting β2-agonists: formoterol, salmeterol, in combination with inhaled corticosteroids - salmeterol / fluticasone (Seretide Multidisk), budesonide / formoterol (Symbicort Turbuhaler).

4. Long-acting theophyllines.

5 Leukotriene receptor antagonists and anti-IgE antibodies: montelukast, zofirlukast.

Mistakes in the treatment of bronchial asthma

Error. The visitor too W often uses short-acting β2-agonists (fenoterol, salbutamol, turbutaline).

How to fix. There is no doubt that inhaled short-acting β2-agonists are the drugs of choice for situational symptomatic control of bronchial asthma, as well as for preventing the development of symptoms of exercise-induced asthma. More frequent and prolonged use of inhaled β2-agonists can lead to the loss of adequate control over the course of the disease. For long-term control of the inflammatory process, the basis of therapy is inhaled glucocorticosteroids (beclamethasone dipropionate, budesonide, fluticasone propionate, etc.), which should be used for persistent bronchial asthma of any severity. Inhaled glucocorticosteroids are considered as first-line agents in the treatment of bronchial asthma.

Error. The visitor believes that “hormones” are very harmful, and on the basis of this he is afraid to use inhaled glucocorticosteroids prescribed by his doctor.

How to fix. It should be explained to the visitor that treatment with inhaled glucocorticosteroids is local (topical), which provides pronounced anti-inflammatory effects directly in the bronchi. Inhaled glucocorticosteroids have minimal local side effects with proper selection and inhalation technique (oral and oropharyngeal candidiasis, voice changes, sometimes coughing due to irritation of the upper respiratory tract). The risk of developing local side effects can be significantly reduced by rinsing the mouth with water (followed by spitting) after inhalation. It is also important to draw the visitor's attention to the fact that the use of inhaled glucocorticosteroids is absolutely necessary in the treatment of persistent bronchial asthma, regardless of severity.

Error. A patient with bronchial asthma, while taking the therapy prescribed by the doctor, continues to smoke and wonders why the treatment prescribed by the doctor is “not effective”.

How to fix. It is necessary to explain to the visitor that in the treatment of bronchial asthma it is important not only to comply with all medication measures, according to the doctor's prescriptions, but also to eliminate the factors that can provoke an attack. Quitting smoking is especially important. Smoking is one of the reasons for the "escape" of the control of bronchial asthma. Today it is known that smoking blocks the mechanisms of the anti-inflammatory action of glucocorticosteroids, a necessary component of the basic therapy of bronchial asthma. The consequence of this is an increase in inflammation, and irreversible changes occur in the bronchial wall (loss of elasticity, fibrosis). Over time, the very nature of inflammation changes, which is much more difficult to treat, which ultimately leads to the patient's disability.

Error. The condition of a visitor with bronchial asthma improved markedly while taking inhaled glucocorticosteroids prescribed by a doctor, and he decided that he was cured. And since there are no attacks, then it is not worth continuing the basic treatment.

How to fix. It is known that bronchial asthma cannot be cured, but it can be successfully controlled. Inhaled corticosteroids can achieve complete control of asthma, but discontinuation of their use often leads to the return of symptoms of the disease. Regular and constant intake of inhaled glucocorticosteroids prescribed by a doctor ensures not only the patient's well-being, but also the maximum reduction in the risk of irreversible changes in the respiratory system. In the case of successful control of bronchial asthma, the dose of inhaled glucocorticosteroids can be gradually reduced.

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Bronchial asthma, asthma, choking attacks, suffocation, asphyxia due to illness, shortness of breath

Version: Directory of Diseases MedElement

Asthma (J45)

Pulmonology

general information

Short description

Bronchial asthma* is a chronic inflammatory disease of the respiratory tract, in which many cells and cellular elements are involved. Chronic inflammation causes bronchial hyperreactivity leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing (especially at night or in the early morning). These episodes are usually associated with widespread but variable airway obstruction in the lungs, which is often reversible spontaneously or with treatment.

Bronchial hyperreactivity - increased sensitivity of the lower respiratory tract to various irritating stimuli, which, as a rule, are contained in the inhaled air. These stimuli are indifferent to healthy people. Clinically, bronchial hyperreactivity is most often manifested by episodes of wheezing shortness of breath in response to the action of an irritating stimulus in individuals with a hereditary predisposition.
Latent bronchial hyperreactivity is also distinguished, which is detected only by provocative functional tests with histamine and methacholine.
Bronchial hyperreactivity can be specific and nonspecific.

Specific hyperreactivity occurs in response to exposure to certain allergens, mainly contained in the air (plant pollen, house dust, wool and epidermis of domestic animals, fluff and feathers of poultry, spores and other elements of fungi).

Nonspecific hyperreactivity is formed under the influence of various stimuli of non-allergenic origin (aeropollutants, industrial gases and dust, endocrine disorders, physical activity, neuropsychic factors, respiratory infections, etc.).

Note. Excluded from this subsection are:

Asthmatic status - J46;
- Other chronic obstructive pulmonary disease - J44;
- Lung diseases caused by external agents - J60-J70;
- Pulmonary eosinophilia, not elsewhere classified - J82.

* Definition according to GINA (Global Initiative for Asthma) - Revision 2011.

Classification

Classification of asthma is based on a joint assessment of the symptoms of the clinical picture and indicators of lung function. There is no generally accepted classification of bronchial asthma. Below are examples of the most commonly used classifications.

Classification of bronchial asthma (BA) according to Fedoseev G. B. (1982)

1. Stages of BA development:

1.1The state of betrayal- conditions that threaten the onset of asthma (acute and chronic bronchitis, pneumonia with elements of bronchospasm, combined with vasomotor rhinitis, urticaria, vasomotor edema, migraine and neurodermatitis in the presence of eosinophilia in the blood and an increased content of eosinophils in sputum, due to immunological or non-immunological mechanisms of pathogenesis) .

1.2 Clinically diagnosed BA- after the first attack or asthma status (this term is used mainly in screening studies).

2. BA forms(not included in the formulation of the clinical diagnosis):

immunological form.
- non-immunological form

3. Pathogenetic mechanisms of AD:
3.1 Atonic - indicating the allergenic allergen or allergens.
3.2 Infection-dependent - indicating infectious agents and the nature of infectious dependence, which can be manifested by stimulation of an atopic reaction, infectious allergy and the formation of a primary altered bronchial reactivity (if the infection is an allergen, BA is defined as infectious-allergic).
3.3 Autoimmune.
3.4 Dishormonal - indicating the endocrine organ, the function of which is changed, and the nature of dishormonal changes.
3.5 Neuro-psychic - indicating options for neuro-psychic changes.
3.6 Adrenergic imbalance.
3.7 Primarily altered bronchial reactivity, which is formed without the participation of altered reactions of the immune, endocrine and nervous systems. May be congenital or acquired. Manifested under the influence of chemical, physical and mechanical irritants and infectious agents. Attacks of suffocation are characteristic during physical exertion, exposure to cold air, medicines and other things.

Note to point 3. A patient may have one pathogenetic mechanism of BA or various combinations of mechanisms are possible (by the time of the examination, one of the mechanisms is the main one). During the development of AD, a change in the main and secondary mechanisms is possible.

The separation of BA according to pathogenetic mechanisms and the isolation of the main one are significantly difficult. Nevertheless, this is justified due to the fact that each of the pathogenetic mechanisms involves a certain, unique nature of drug therapy.

4. Severity of BA(in some cases, such a division is conditional; for example, with a mild course, the patient may die from a suddenly developed asthmatic status, and with a rather severe course, a "spontaneous" remission is possible):

4.1 Easy flow: exacerbations are not long, occur 2-3 times a year. Attacks of suffocation are stopped, as a rule, by taking various bronchodilator drugs inside. In the interictal period, signs of bronchospasm, as a rule, are not detected.

4.2 Moderate course: more frequent exacerbations (3-4 times a year). Attacks of suffocation are more severe and are stopped by injections of drugs.

4.3 Severe flow: exacerbations occur frequently (5 or more times a year), differ in duration. The attacks are severe, often turning into an asthmatic state.

5. Phases of the course of bronchial asthma:

1. Aggravation- this phase is characterized by the presence of pronounced signs of the disease, primarily recurring attacks of asthma or an asthmatic condition.

2. fading exacerbation - in this phase, seizures are more rare and not severe. Physical and functional signs of the disease are less pronounced than in the acute phase.

3. Remission - typical manifestations of BA disappear (no asthma attacks occur, bronchial patency is fully or partially restored).

6. Complications:

1. Pulmonary: emphysema, pulmonary insufficiency, atelectasis, pneumothorax and others.

2. Extrapulmonary: myocardial dystrophy, cor pulmonale, heart failure and others.

Classification of asthma according to the severity of the disease and clinical signs before treatment

Step 1 Mild intermittent asthma:
- symptoms less than once a week;
- short exacerbations;
- nocturnal symptoms no more than 2 times a month;
- FEV1 or PSV>= 80% of the expected values;
- variability in FEV1 or PSV< 20%.

Step 2 Mild persistent asthma:

Symptoms more than 1 time per week, but less than 1 time per day;

- nocturnal symptoms more than 2 times a month FEV1 or PEF>= 80% of the expected values;
- variability of FEV1 or PSV = 20-30%.

Step 3 Persistent moderate asthma:

daily symptoms;
- exacerbations can affect physical activity and sleep;
- nocturnal symptoms more than once a week;
- FEV1 or PSV from 60 to 80% of the proper values;
- variability in FEV1 or PSV > 30%.

Step 4 Severe persistent asthma:
- daily symptoms;
- frequent exacerbations;
- frequent nocturnal symptoms;
- restriction of physical activity;
- FEV 1 or PSV<= 60 от должных значений;
- variability in FEV1 or PSV > 30%.

Additionally, the following are BA course phases:
- exacerbation;
- unstable remission;
- remission;
- stable remission (more than 2 years).

Classification according to the Global Asthma Initiative(GINA 2011)
The classification of asthma severity is based on the amount of therapy required to achieve disease control.

1. Mild asthma - disease control can be achieved with a small amount of therapy (low doses of inhaled corticosteroids, antileukotriene drugs or cromones).

2. Severe asthma - A large amount of therapy is needed to control the disease (eg, GINA grade 4) or control cannot be achieved despite a large amount of therapy.

Patients with different AD phenotypes have different responses to conventional treatment. With the advent of specific treatments for each phenotype, AD that was previously considered severe can become mild.
The ambiguity of the terminology associated with the severity of asthma is due to the fact that the term "severity" is also used to describe the severity of bronchial obstruction or symptoms. Severe or frequent symptoms do not necessarily indicate severe asthma, as they may be the result of inadequate treatment.

Classification according to ICD-10

J45.0 Asthma with a predominance of an allergic component (if the disease is associated with an established external allergen) includes the following clinical variants:

allergic bronchitis;

Allergic rhinitis with asthma;

atopic asthma;

Exogenous allergic asthma;

Hay fever with asthma.

J45.1 Non-allergic asthma (when the disease is associated with external factors of a non-allergenic nature or unspecified internal factors) includes the following clinical variants:

Idiosyncratic asthma;

Endogenous non-allergic asthma.

J45.8 Mixed asthma (with signs of the first two forms).

J45.9 Asthma, unspecified, which includes:

asthmatic bronchitis;

Late onset asthma.

J46 Status asthmaticus.

The formulation of the main diagnosis should reflect:
1. The form of the disease (for example, atopic or non-allergic asthma).
2. The severity of the disease (eg, severe persistent asthma).
3. The phase of the course (for example, exacerbation). In remission with steroids, it is reasonable to indicate a maintenance dose of the anti-inflammatory drug (eg, remission at a dose of 800 micrograms of beclomethasone per day).
4. Complications of asthma: respiratory failure and its form (hypoxemic, hypercapnic), especially asthmatic status.

Etiology and pathogenesis

According to GINA-2011, bronchial asthma (BA) is a chronic inflammatory disease of the respiratory tract, which involves a number of inflammatory cells and mediators, which leads to characteristic pathophysiological changes.

1. Inflammatory cells in the airways in asthma.

1.1 Mast cells. Under the action of allergens with the participation of high-affinity IgE receptors and under the influence of osmotic stimuli, mucosal mast cells are activated. Activated mast cells release mediators that cause bronchospasm (histamine, cysteinyl leukotrienes, prostaglandin D2). An increased number of mast cells in airway smooth muscle may be associated with bronchial hyperreactivity.

1.2 Eosinophils. In the airways, the number of eosinophils is increased. These cells secrete the main proteins that can damage the epithelium of the bronchi. Also, eosinophils may be involved in the release of growth factors and airway remodeling.

1.3 T-lymphocytes. In the airways, there is an increased number of T-lymphocytes, which release specific cytokines that regulate the process of eosinophilic inflammation and the production of IgE by B-lymphocytes. The increase in Th2 cell activity may be partly due to a decrease in the number of regulatory T cells that normally inhibit Th2 lymphocytes. It is also possible to increase the number of inKT cells that secrete Th1 and Th2 cytokines in large quantities.

1.4 Dendritic cells capture allergens from the surface of the bronchial mucosa and migrate to regional lymph nodes, where they interact with regulatory T cells and ultimately stimulate the conversion of undifferentiated T lymphocytes into Th2 cells.

1.5 macrophages. The number of macrophages in the respiratory tract is increased. Their activation may be associated with the action of allergens with the participation of IgE receptors with low affinity. Due to the activation of macrophages, inflammatory mediators and cytokines are released, which enhance the inflammatory response.

1.6 Neutrophils. In the respiratory tract and sputum of patients with severe asthma and smokers, the number of neutrophils increases. Their pathophysiological role has not been elucidated. It is assumed that an increase in their number may be a consequence of GCS therapy. GCS (glucocorticoids, glucocorticosteroids) - drugs one of the leading properties of which is to inhibit the early stages of the synthesis of the main participants in the formation of inflammatory processes (prostaglandins) in various tissues and organs.
.

2.mediators of inflammation. Currently, more than 100 different mediators are known that are involved in the pathogenesis of asthma and the development of a complex inflammatory response in the airways.

3.Structural changes in the airways - are detected in the airways of patients with asthma and are often considered as a process of bronchial remodeling. Structural changes may be the result of repair processes in response to chronic inflammation. Due to the deposition of collagen fibers and proteoglycans under the basement membrane, subepithelial fibrosis develops, which is observed in all patients with asthma (including children) even before the onset of clinical manifestations of the disease. The severity of fibrosis may decrease with treatment. The development of fibrosis is also observed in other layers of the bronchial wall, in which collagen and proteoglycans are also deposited.

3.1 Smooth muscle of the bronchial wall. due to hypertrophy Hypertrophy - the growth of an organ, part of it or tissue as a result of cell multiplication and an increase in their volume
and hyperplasia Hyperplasia - an increase in the number of cells, intracellular structures, intercellular fibrous formations due to enhanced organ function or as a result of a pathological tissue neoplasm.
there is an increase in the thickness of the smooth muscle layer, which contributes to the overall thickening of the bronchus wall. This process may depend on the severity of the disease.

3.2Blood vessels. Under the influence of growth factors, such as vascular endothelial growth factor (VEGF), there is a proliferation Proliferation - an increase in the number of cells of a tissue due to their reproduction
vessels of the bronchial wall, contributing to the thickening of the bronchial wall.

3.3 Mucus hypersecretion observed as a result of an increase in the number of goblet cells in the epithelium of the respiratory tract and an increase in the size of the submucosal glands.

4. Narrowing of the airways- the universal final stage of the pathogenesis of AD, which leads to the onset of symptoms of the disease and typical physiological changes.

Factors causing narrowing of the airways:

4.1 Contraction of the smooth muscles of the bronchial wall in response to the bronchoconstrictor action of various mediators and neurotransmitters is the main mechanism of airway constriction; almost completely reversible under the action of bronchodilators.

4.2 Airway edema due to increased permeability of the microvascular bed, which is caused by the action of inflammatory mediators. Edema can play a particularly important role in exacerbations.

4.3 Thickening of the bronchus wall as a result of structural changes. This factor may be of great importance in severe asthma. Bronchial wall thickening is not fully reversible with existing drugs.

4.4 Mucus hypersecretion can lead to occlusion Occlusion is a violation of the patency of some hollow formations in the body (blood and lymphatic vessels, subarachnoid spaces and cisterns), due to the persistent closure of their lumen in any area.
bronchial lumen ("mucus plugs") and is the result of increased secretion of mucus and the formation of an inflammatory exudate.

Features of the pathogenesis are described for the following forms of AD:
- exacerbation of BA;
- night BA;
- irreversible bronchial obstruction;
- BA, difficult to treat;
- BA in smokers;
- aspirin triad.

Epidemiology

In the world, bronchial asthma affects about 5% of the adult population (1-18% in different countries). In children, the incidence varies from 0 to 30% in different countries.

The onset of the disease is possible at any age. Approximately half of the patients develop bronchial asthma before the age of 10 years, in a third - up to 40 years.
Among children with bronchial asthma, there are twice as many boys as girls, although the sex ratio levels off by the age of 30.

Factors and risk groups

Factors affecting the risk of developing AD are divided into:
- factors causing the development of the disease - internal factors (primarily genetic);
- factors that provoke the onset of symptoms - external factors.
Some factors belong to both groups.
The mechanisms of influence of factors on the development and manifestations of AD are complex and interdependent.

Internal factors:

1. Genetic (for example, genes predisposing to atopy and genes predisposing to bronchial hyperreactivity).

2. Obesity.

External factors:

1. Allergens:

Room allergens (house dust mites, pet hair, cockroach allergens, fungi, including mold and yeast);

External allergens (pollen, fungi, including molds and yeasts).

2. Infections (mainly viral).

3. Professional sensitizers.

4. Tobacco smoking (passive and active).

5. Air pollution indoors and outdoors.

6. Nutrition.

Elimination of risk factors can significantly improve the course of asthma.

In patients with allergic asthma, elimination of the allergen is of paramount importance. There is evidence that in urban areas in children with atopic asthma, individual complex measures for the removal of allergens in the homes led to a decrease in soreness.

Clinical picture

Clinical Criteria for Diagnosis

Unproductive hacking cough, prolonged expiration, dry, wheezing, usually treble, wheezing in the chest, more at night and in the morning, attacks of expiratory choking, congestion in the chest, dependence of respiratory symptoms on contact with provoking agents.

Symptoms, course

Clinical diagnosis of bronchial asthma(BA) is based on the following data:

1. Identification of bronchial hyperreactivity, as well as reversibility of obstruction spontaneously or under the influence of treatment (decrease in response to appropriate therapy).
2. Unproductive hacking cough; prolonged exhalation; dry, whistling, usually treble, rales in the chest, more marked at night and in the morning; expiratory dyspnea, attacks of expiratory suffocation, congestion (stiffness) of the chest.
3. Dependence of respiratory symptoms on contact with provoking agents.

Also of great importance are the following factors:
- the appearance of symptoms after episodes of contact with the allergen;
- seasonal variability of symptoms;
- a family history of asthma or atopy.

When diagnosing, you need to find out the following questions:
- Does the patient have episodes of wheezing, including recurring ones?

Does the patient have a cough at night?

Does the patient have wheezing or cough after exercise?

Does the patient have episodes of wheezing, chest congestion, or coughing after exposure to aeroallergens or pollutants?

Does the patient report that the cold "goes down to the chest" or continues for more than 10 days?

Does the severity of symptoms decrease after the use of appropriate anti-asthma drugs?

On physical examination, there may be no symptoms of asthma, due to the variability in the manifestations of the disease. The presence of bronchial obstruction is confirmed by wheezing that is detected during auscultation.
In some patients, wheezing may be absent or detected only during forced exhalation, even in the presence of severe bronchial obstruction. In some cases, patients with severe exacerbations of asthma do not wheeze due to severe limitation of airflow and ventilation. In such patients, as a rule, there are other clinical signs indicating the presence and severity of an exacerbation: cyanosis, drowsiness, difficulty in speaking, swollen chest, participation of accessory muscles in the act of breathing and retraction of the intercostal spaces, tachycardia. These clinical symptoms can only be observed when examining the patient during the period of pronounced clinical manifestations.

Variants of clinical manifestations of AD

1.Cough variant of BA. The main (sometimes the only) manifestation of the disease is a cough. Cough asthma is most common in children. The severity of symptoms increases at night, and during the day the manifestations of the disease may be absent.
For such patients, it is important to study the variability of lung function or bronchial hyperreactivity, as well as the determination of eosinophils in sputum.
The cough variant of asthma is differentiated from the so-called eosinophilic bronchitis. In the latter, patients present with cough and sputum eosinophilia, but have normal lung function on spirometry and normal bronchial reactivity.
In addition, cough can occur due to the use of ACE inhibitors, gastroesophageal reflux, postnasal drip syndrome, chronic sinusitis, dysfunction of the vocal cords.

2. Bronchospasm induced by physical activity. Refers to the manifestation of non-allergic forms of asthma, when the phenomena of airway hyperreactivity dominate. In the majority of cases, physical activity is an important or only cause of the onset of symptoms of the disease. Bronchospasm as a result of physical activity, as a rule, develops 5-10 minutes after the cessation of exercise (rarely - during exercise). Patients have typical symptoms of asthma or sometimes a prolonged cough that resolves on its own within 30-45 minutes.
Forms of exercise such as running cause asthma symptoms more frequently.
Exercise-induced bronchospasm often develops when inhaling dry, cold air, more rarely in hot and humid climates.
In favor of asthma is evidenced by the rapid improvement in the symptoms of post-exercise bronchospasm after inhaled β2-agonist, as well as the prevention of the development of symptoms due to inhaled β2-agonist before exercise.
In children, asthma can sometimes manifest itself only during exercise. In this regard, in such patients or in the presence of doubts about the diagnosis, it is advisable to conduct a test with physical activity. Diagnosis is facilitated by a protocol with an 8-minute run.

Clinical picture of an asthma attack quite typical.
In case of allergic etiology of BA, before the development of suffocation, itching (in the nasopharynx, auricles, in the chin area), nasal congestion or rhinorrhea, sensations of the absence of "free breathing", dry cough can be observed. elongated; the duration of the respiratory cycle increases and the respiratory rate decreases (up to 12-14 per minute).
During listening to the lungs in the bulk of cases, against the background of an extended expiration, a large number of scattered dry rales, mostly whistling, are determined. As the asthma attack progresses, wheezing wheezes on expiration are heard at a certain distance from the patient in the form of "wheezing" or "bronchial music".

With a prolonged attack of suffocation, which lasts more than 12-24 hours, there is a blockage of the small bronchi and bronchioles with an inflammatory secret. The general condition of the patient is significantly aggravated, the auscultatory picture changes. Patients experience excruciating shortness of breath, aggravated by the slightest movements. The patient takes a forced position - sitting or half-sitting with fixation of the shoulder girdle. All auxiliary muscles participate in the act of breathing, the chest expands, and the intercostal spaces are drawn in during inspiration, cyanosis of the mucous membranes, acrocyanosis, arises and intensifies. It is difficult for the patient to speak, the sentences are short and jerky.
During auscultation, there is a decrease in the number of dry rales, in some places they are not heard at all, as well as vesicular breathing; so-called silent lung zones appear. Above the surface of the lungs, percussion is determined by a pulmonary sound with a tympanic shade - a box sound. The lower edges of the lungs are lowered, their mobility is limited.
The completion of an asthma attack is accompanied by a cough with a discharge of a small amount of viscous sputum, easier breathing, a decrease in shortness of breath and the number of auscultated wheezing. Even for a long time, a few dry rales can be heard while maintaining an elongated exhalation. After the cessation of the attack, the patient often falls asleep. Signs of asthenia persist for a day or more.

Exacerbation of asthma(attacks of asthma, or acute asthma) according to GINA-2011 is divided into mild, moderate, severe, and such an item as "breathing is inevitable." The severity of the course of BA and the severity of exacerbation of BA are not the same thing. For example, with mild asthma, exacerbations of mild and moderate severity can occur; with asthma of moderate severity and severe, exacerbations of mild, moderate, and severe are possible.

Infant (2-12 months)<160 в минуту;

Younger age (1-2 years old)<120 в минуту;

Preschool and school age (2-8 years)<110 в минуту.
3. Normal respiratory rate in awake children:

Under 2 months< 60 в минуту;

2-12 months< 50 в минуту;

1-5 years< 40 в минуту;

6-8 years old< 30 в минуту.

Diagnostics

Fundamentals of diagnosing bronchial asthma(BA):
1. Analysis of clinical symptoms, which are dominated by periodic attacks of expiratory suffocation (for more details, see the "Clinical picture" section).
2. Determination of indicators of pulmonary ventilation, most often with the help of spirography with registration of the "flow-volume" curve of forced expiration, identification of signs of reversibility of bronchial obstruction.
3. Allergological research.
4. Identification of nonspecific bronchial hyperreactivity.

The study of indicators of the function of external respiration

1. Spirometry Spirometry - measurement of vital capacity of the lungs and other lung volumes using a spirometer
. In patients with BA, signs of bronchial obstruction are often diagnosed: a decrease in indicators - PEF (peak expiratory volumetric velocity), MOS 25 (maximum volumetric velocity at the point of 25% FVC, (FEF75) and FEV1.

To assess the reversibility of bronchial obstruction is used pharmacological bronchodilation test with short-acting β2-agonists (most often salbutamol). Before the test, you should refrain from taking short-acting bronchodilators for at least 6 hours.
Initially, the initial curve "flow-volume" forced breathing of the patient is recorded. Then the patient makes 1-2 inhalations of one of the short and fast acting β2-agonists. After 15-30 minutes, the flow-volume curve is recorded. With an increase in FEV1 or FOS ex by 15% or more, airway obstruction is considered reversible or bronchodilator-reactive, and the test is considered positive.

For asthma, it is diagnostically important to identify a significant daily variability in bronchial obstruction. For this, spirography (when the patient is in the hospital) or peak flowmetry (at home) is used. Scatter (variability) of FEV1 or POS vyd more than 20% during the day is considered to confirm the diagnosis of BA.

2. Peakflowmetry. It is used to evaluate the effectiveness of treatment and to objectify the presence and severity of bronchial obstruction.
Peak expiratory flow rate (PEF) is estimated - the maximum speed at which air can exit the respiratory tract during a forced exhalation after a full breath.
The patient's PSV values ​​are compared with normal values ​​and with the best PSV values ​​observed in this patient. The level of decrease in PSV allows us to draw conclusions about the severity of bronchial obstruction.
The difference between PSV values ​​measured during the day and in the evening is also analyzed. A difference of more than 20% indicates an increase in bronchial reactivity.

2.1 Intermittent asthma (stage I). Daytime attacks of shortness of breath, cough, wheezing occur less than 1 time per week. Duration of exacerbations - from several hours to several days. Night attacks - 2 or less times a month. In the period between exacerbations, lung function is normal; PSV - 80% of normal or less.

2.2 Mild persistent asthma (stage II). Daytime attacks are observed 1 or more times a week (not more than 1 time per day). Night attacks are repeated more often than 2 times a month. During an exacerbation, the activity and sleep of the patient may be disturbed; PSV - 80% of normal or less.

2.3 Persistent asthma of moderate severity (stage III). Daily attacks of suffocation, once a week there are nocturnal attacks. As a result of exacerbations, the patient's activity and sleep are disturbed. The patient is forced to use short-acting inhaled beta-adrenergic agonists daily; PSV - 60 - 80% of the norm.

2.4 Severe course of persistent asthma (stage IV). Daytime and nighttime symptoms are permanent, which limits the patient's physical activity. The PSV index is less than 60% of the norm.

3. Allergological study. Allergological history is analyzed (eczema, hay fever, family history of asthma or other allergic diseases). Positive skin tests with allergens and elevated blood levels of total and specific IgE testify in favor of AD.

4. Provocative Tests with histamine, methacholine, physical activity. They are used to detect nonspecific bronchial hyperreactivity, manifested by latent bronchospasm. Performed in patients with suspected asthma and normal spirography.

In the histamine test, the patient inhales nebulized histamine in progressively increasing concentrations, each of which is capable of causing bronchial obstruction.
The test is assessed as positive if the air flow rate deteriorates by 20% or more as a result of inhalation of histamine at a concentration one or more orders of magnitude lower than that which causes similar changes in healthy people.
Similarly, a test with methacholine is carried out and evaluated.

5. Additional research:
- radiography of the chest in two projections - most often show signs of emphysema (increased transparency of the lung fields, depletion of the lung pattern, low standing of the domes of the diaphragm), while the absence of infiltrative and focal changes in the lungs is important;
- fibrobronchoscopy;

Electrocardiography.
Additional studies are being carried out in atypical asthma and resistance to anti-asthma therapy.

Main diagnostic criteria for AD:

1. The presence in the clinical picture of the disease of periodic attacks of expiratory suffocation, which have their beginning and end, passing spontaneously or under the influence of bronchodilators.
2. Development of asthmatic status.
3. Determination of signs of bronchial obstruction (FEV1 or POS vyd< 80% от должной величины), которая является обратимой (прирост тех же показателей более 15% в фармакологической пробе с β2-агонистами короткого действия) и вариабельной (колебания показателей более 20% на протяжении суток).
4. Identification of signs of bronchial hyperreactivity (hidden bronchospasm) in patients with initial normal indicators of pulmonary ventilation using one of three provocative tests.
5. The presence of a biological marker - a high level of nitric oxide in the exhaled air.

Additional diagnostic criteria:
1. The presence in the clinical picture of symptoms that may be "small equivalents" of an attack of expiratory suffocation:
- unmotivated cough, often at night and after exercise;
- recurring sensations of chest tightness and / or episodes of wheezing;
- the fact of awakening at night from the indicated symptoms strengthens the criterion.
2. Aggravated allergic anamnesis (presence of eczema, hay fever, pollinosis in the patient) or aggravated family history (BA, atopic diseases in the patient's family members).

3. Positive skin tests with allergens.
4. An increase in the patient's blood level of general and specific IgE (reagins).

Professional BA

Bronchial asthma due to professional activity is often not diagnosed. Due to the gradual development of occupational asthma, it is often regarded as chronic bronchitis or COPD. This leads to incorrect treatment or its absence.

Occupational asthma should be suspected when symptoms of rhinitis, cough and/or wheezing appear, especially in nonsmokers. Establishing a diagnosis requires a systematic collection of information about work history and environmental factors in the workplace.

Criteria for the diagnosis of occupational asthma:
- well-established occupational exposure to known or suspected sensitizing agents;
- the absence of symptoms of asthma before employment or a clear worsening of the course of asthma after employment.

Laboratory diagnostics

Non-invasive determination of markers of airway inflammation

1. The study of spontaneously produced or induced by inhalation of hypertonic sputum solution on inflammatory cells - eosinophils or neutrophils. It is used to assess the activity of inflammation in the airways in asthma.

2. Determination of levels of nitric oxide (FeNO) and carbon monoxide (FeCO) in exhaled air. In patients with BA, there is an increase in the level of FeNO (in the absence of inhaled corticosteroids) compared with individuals without BA, however, these results are not specific for this disease. The role of FeNO in the diagnosis of AD has not been evaluated in prospective studies.

3. Skin tests with allergens - are the main method for assessing allergic status. Such samples are highly sensitive, easy to use and do not require much time. It should be borne in mind that incorrect sample performance can lead to false positive or false negative results.

4. The determination of specific IgE in blood serum is a more expensive method than skin tests, which does not surpass them in reliability.
In some patients, specific IgE may be detected in the absence of any symptoms and play no role in the development of AD. Thus, positive test results do not necessarily indicate the allergic nature of the disease and the association of the allergen with the development of asthma.
The presence of allergen exposure and its association with asthma manifestations should be supported by history data. The measurement of total IgE in serum is not a method of diagnosing atopy.

Clinical Tests

1. Complete blood count: during the period of exacerbation, an increase in ESR and eosinophilia are noted. Eosinophilia is not determined in all patients and cannot serve as a diagnostic criterion.

2. General sputum analysis:
- a large number of eosinophils;
- Charcot-Leiden crystals;
- Kurshman's spirals (formed due to small spastic contractions of the bronchi);
- neutral leukocytes - in patients with infectious-dependent BA in the stage of an active inflammatory process;
- release of Creole bodies during an attack.

3. Biochemical analysis of blood: changes are of a general nature. BAC is not the main diagnostic method and is prescribed to monitor the patient's condition during an exacerbation.

Differential Diagnosis

1. Differential diagnosis of BA variants.

The main differential diagnostic features of atopic and infection-dependent variants of BA(according to Fedoseev G. B., 2001)

2. Differential diagnosis of BA is carried out with chronic obstructive pulmonary disease(COPD), which is characterized by more permanent bronchial obstruction. In patients with COPD, there is no spontaneous lability of symptoms typical of BA, there is no or significantly less daily variability in FEV1 and POS exud, complete irreversibility or less reversibility of bronchial obstruction in the test with β2-agonists (increase in FEV1 less than 15%).
Sputum in COPD is dominated by neutrophils and macrophages rather than eosinophils. In patients with COPD, the effectiveness of bronchodilator therapy is lower, more effective bronchodilators are anticholinergics, and not short-acting β2-agonists; pulmonary hypertension and signs of chronic cor pulmonale are more common.

Some features of diagnosis and differential diagnosis (according to GINA 2011)

1.In children aged 5 years and younger wheezing episodes are common.

Types of wheezing in the chest:

1.1 Transient early wheezing, which children often "outgrow" in the first 3 years of life. Such wheezing is often associated with prematurity of children and smoking parents.

1.2 Persistent wheezing with early onset (under 3 years of age). Children usually have recurrent episodes of wheezing associated with acute respiratory viral infections. At the same time, children do not have signs of atopy and there is no family history of atopy (in contrast to children of the next age group with late onset wheezing/bronchial asthma).
Wheezing episodes typically continue into school age and are still detected in a significant proportion of children as young as 12 years of age.
The cause of wheezing episodes in children under 2 years of age is usually a respiratory syncytial virus infection, in children 2-5 years of age - other viruses.

1.3 Late-onset wheezing/asthma. Asthma in these children often lasts throughout childhood and continues into adulthood. Such patients are characterized by a history of atopy (often manifested as eczema) and airway pathology typical of asthma.

With repeated episodes of wheezing, it is necessary to exclude other causes of wheezing:

Chronic rhinosinusitis;

Gastroesophageal reflux;

Recurrent viral infections of the lower respiratory tract;

cystic fibrosis;

bronchopulmonary dysplasia;

Tuberculosis;

Aspiration of a foreign body;
- immunodeficiency;

Syndrome of primary ciliary dyskinesia;

Malformations causing narrowing of the lower respiratory tract;
- congenital heart disease.

The possibility of another disease is indicated by the appearance of symptoms in the neonatal period (in combination with insufficient weight gain); wheezing associated with vomiting, signs of focal lung damage or cardiovascular pathology.

2. Patients over 5 years of age and adults. Differential diagnosis should be carried out with the following diseases:

Hyperventilation syndrome and panic attacks;

Obstruction of the upper respiratory tract and aspiration of foreign bodies;

Other obstructive pulmonary diseases, especially COPD;

Non-obstructive lung disease (eg, diffuse lesions of the lung parenchyma);

Non-respiratory diseases (for example, left ventricular failure).

3. Elderly patients. BA should be differentiated from left ventricular failure. In addition, BA is underdiagnosed in the elderly.

Risk Factors for Underdiagnosis of AD in Elderly Patients

3.2 From the doctor's point of view:
- misconception that asthma does not start in old age;
- difficulties in examining lung function;
- perception of asthma symptoms as signs of aging;
- accompanying illnesses;
- underestimation of dyspnea due to a decrease in the patient's physical activity.

Complications

Complications of bronchial asthma are divided into pulmonary and extrapulmonary.

Pulmonary complications: chronic bronchitis, hypoventilation pneumonia, pulmonary emphysema, pneumosclerosis, respiratory failure, bronchiectasis, atelectasis, pneumothorax.

Extrapulmonary complications:"pulmonary" heart, heart failure, myocardial dystrophy, arrhythmia; in patients with a hormone-dependent variant of BA, complications associated with prolonged use of systemic corticosteroids may occur.

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Treatment

Objectives of the treatment of bronchial asthma(BA):

Achieve and maintain control of symptoms;

Maintaining a normal level of activity, including physical activity;

Maintaining lung function at a normal or as close to normal level as possible;

Prevention of asthma exacerbations;

Prevention of unwanted effects of anti-asthma drugs;

Prevention of deaths from AD.

BA control levels(GINA 2006-2011)

1 Pulmonary function testing not reliable in children 5 years of age and younger. Periodic assessment of the level of control over BA in accordance with the criteria indicated in the table will allow individual selection of a pharmacotherapy regimen for the patient.
2 Each exacerbation requires an immediate review of maintenance therapy and an assessment of its adequacy
3 By definition, the development of any exacerbation indicates that asthma is not controlled

Medical therapy

Medications for the treatment of AD:

1. Drugs that control the course of the disease (maintenance therapy):
- inhalation and systemic corticosteroids;
- anti-leukotriene agents;
- long-acting inhaled β2-agonists in combination with inhaled corticosteroids;
- sustained release theophylline;
- cromones and antibodies to IgE.
These drugs provide control over the clinical manifestations of AD; they are taken daily and for a long time. The most effective for maintenance therapy are inhaled corticosteroids.

2. Rescue drugs (to relieve symptoms):
- inhaled β2-rapid agonists;
- anticholinergics;
- short-acting theophylline;
- short-acting oral β2-agonists.
These drugs are taken to relieve symptoms as needed. They have a fast action, eliminate bronchospasm and stop its symptoms.

Drugs for the treatment of asthma can be administered in various ways - inhalation, oral or injection. Advantages of the inhalation route of administration:
- delivers drugs directly to the respiratory tract;
- a locally higher concentration of the medicinal substance is achieved;
- Significantly reduces the risk of systemic side effects.

For maintenance therapy, inhaled corticosteroids are most effective.

The drugs of choice for the relief of bronchospasm and for the prevention of exercise-induced bronchospasm in adults and children of any age are fast-acting inhaled β2-agonists.

Increasing use (especially daily) of rescue drugs indicates worsening asthma control and the need to reconsider therapy.

Inhaled corticosteroids are most effective for the treatment of persistent asthma:
- reduce the severity of asthma symptoms;
- improve quality of life and lung function;
- reduce bronchial hyperreactivity;
- inhibit inflammation in the respiratory tract;
- reduce the frequency and severity of exacerbations, the frequency of deaths in asthma.

Inhaled corticosteroids do not cure BA, and when they are canceled in some patients, a worsening of the condition is observed within weeks or months.
Local undesirable effects of inhaled corticosteroids: oropharyngeal candidiasis, dysphonia, sometimes cough due to irritation of the upper respiratory tract.
Systemic side effects of long-term therapy with high doses of inhaled corticosteroids: a tendency to bruising, suppression of the adrenal cortex, a decrease in bone mineral density.

Calculated equipotent daily doses of inhaled corticosteroids in adults(GINA 2011)

*CFC - chlorofluorocarbon (freon) inhalers
** HFA - hydrofluoroalkane (CFC-free) inhalers

Calculated equipotent daily doses of inhaled corticosteroids for children over 5 years of age(GINA 2011)

Antileukotriene drugs: subtype 1 cysteinyl leukotriene receptor antagonists (montelukast, pranlukast and zafirlukast), as well as a 5-lipoxygenase inhibitor (zileuton).
Action:
- weak and variable bronchodilatory effect;
- reduce the severity of symptoms, including cough;
- improve lung function;
- reduce the activity of inflammation in the respiratory tract;
- reduce the frequency of asthma exacerbations.
Anti-leukotriene drugs can be used as second-line drugs for the treatment of adult patients with mild persistent asthma. Some patients with aspirin asthma also respond well to therapy with these drugs.
Antileukotriene drugs are well tolerated; side effects are few or absent.

Long-acting inhaled β2-agonists: formoterol, salmeterol.
Should not be used as monotherapy for asthma because there is no evidence that these drugs reduce inflammation in asthma.
These drugs are most effective in combination with inhaled corticosteroids. Combination therapy is preferred in the treatment of patients in whom the use of medium doses of inhaled corticosteroids does not achieve control of asthma.
With regular use of β2-agonists, the development of relative refractoriness to them is possible (this applies to both short-acting and long-acting drugs).
Therapy with inhaled long-acting β2-agonists is characterized by a lower incidence of systemic adverse effects (such as stimulation of the cardiovascular system, skeletal muscle tremor and hypokalemia) compared with oral long-acting β2-agonists.

Oral long-acting β2-agonists: sustained-release formulations of salbutamol, terbutaline, and bambuterol (a prodrug that is converted to terbutaline in the body).
Used in rare cases when additional bronchodilator action is required.
Undesirable effects: stimulation of the cardiovascular system (tachycardia), anxiety and skeletal muscle tremor. Undesirable cardiovascular reactions can also occur when oral β2-agonists are used in combination with theophylline.

Rapidly acting inhaled β2-agonists: salbutamol, terbutaline, fenoterol, levalbuterol HFA, reproterol and pirbuterol. Due to its rapid onset of action, formoterol (a long-acting β2-agonist) can also be used to relieve asthma symptoms, but only in patients receiving regular maintenance therapy with inhaled corticosteroids.
Fast-acting inhaled β2-agonists are emergency medicines and are the drugs of choice for the relief of bronchospasm during exacerbation of asthma, as well as for the prevention of exercise-induced bronchospasm. Should be used only as needed, with the lowest possible doses and frequency of inhalations.
The growing, especially daily, use of these drugs indicates a loss of control over asthma and the need to reconsider therapy. In the absence of a rapid and stable improvement after inhalation of a β2-agonist during an exacerbation of asthma, the patient should also continue to be monitored and, possibly, a short course of therapy with oral corticosteroids should be prescribed.
The use of oral β2-agonists in standard doses is accompanied by more pronounced than when using inhaled forms, undesirable systemic effects (tremor, tachycardia).

Short-acting oral β2-agonists(refer to emergency medicines) can be prescribed to only a few patients who are not able to take inhaled drugs. Side effects are observed more often.

Theophylline It is a bronchodilator and, when administered in low doses, has a slight anti-inflammatory effect and increases resistance.
Theophylline is available in sustained-release dosage forms that can be taken once or twice a day.
According to available data, sustained-release theophylline has little efficacy as a first-line agent for the maintenance treatment of bronchial asthma.
The addition of theophylline may improve outcomes in patients in whom inhaled corticosteroid monotherapy does not achieve asthma control.
Theophylline has been shown to be effective as monotherapy and as a supplement to inhaled or oral corticosteroids in children over 5 years of age.
When using theophylline (especially at high doses - 10 mg / kg of body weight per day or more), significant side effects are possible (usually decrease or disappear with prolonged use).
Undesirable effects of theophylline:
- nausea and vomiting - the most common side effects at the beginning of the application;
- disorders of the gastrointestinal tract;
- liquid stool;
- heart rhythm disturbances;
- convulsions;
- death.

Sodium cromoglycate and nedocromil sodium(cromones) are of limited value in the long-term treatment of asthma in adults. There are known examples of the beneficial effects of these drugs in mild persistent asthma and exercise-induced bronchospasm.
Cromones have a weak anti-inflammatory effect and are less effective than low doses of inhaled corticosteroids. Side effects (cough after inhalation and sore throat) are rare.

Anti-IgE(omalizumab) are used in patients with elevated serum IgE levels. Indicated for severe allergic asthma, control over which is not achieved with the help of inhaled corticosteroids.
In a small number of patients, the appearance of an underlying disease (Churg-Strauss syndrome) was observed when glucocorticosteroids were discontinued due to anti-IgE treatment.

Systemic GCS in severe uncontrolled asthma, they are indicated as long-term therapy with oral drugs (recommended use for a longer period than with the usual two-week course of intensive therapy with systemic corticosteroids - standardly from 40 to 50 mg of prednisolone per day).
The duration of the use of systemic corticosteroids is limited by the risk of developing serious adverse effects (osteoporosis, arterial hypertension, depression of the hypothalamic-pituitary-adrenal system, obesity, diabetes mellitus, cataracts, glaucoma, muscle weakness, striae and a tendency to bruise due to thinning of the skin). Patients taking any form of systemic corticosteroids for a long time require the appointment of drugs for the prevention of osteoporosis.

Oral antiallergic drugs(tranilast, repyrinast, tazanolast, pemirolast, ozagrel, celatrodust, amlexanox and ibudilast) are offered for the treatment of mild to moderate allergic asthma in some countries.

Anticholinergic drugs - ipratropium bromide and oxitropium bromide.
Inhaled ipratropium bromide is less effective than inhaled rapid-acting β2-agonists.
Inhaled anticholinergics are not recommended for the long-term treatment of asthma in children.

Comprehensive treatment program BA (according to GINA) includes:

Patient education;
- clinical and functional monitoring;
- elimination of causative factors;
- development of a long-term therapy plan;
- prevention of exacerbations and drawing up a plan for their treatment;
- dynamic observation.

Drug Therapy Options

Treatment for AD is usually lifelong. It should be borne in mind that drug therapy does not replace measures to prevent the patient from coming into contact with allergens and irritants. The approach to the treatment of the patient is determined by his condition and the goal currently facing the doctor.

In practice, it is necessary to distinguish between the following therapy options:

1. Relief of an attack - is carried out with the help of bronchodilators, which can be used by the patient himself situationally (for example, for mild respiratory disorders - salbutamol in the form of a metered aerosol device) or by medical personnel through a nebulizer (for severe disorders of respiratory function).

Basic anti-relapse therapy: a maintenance dose of anti-inflammatory drugs (the most effective are inhaled glucocorticoids).

3. Basic anti-relapse therapy.

4. Treatment of status asthmaticus - is carried out using high doses of systemic intravenous glucocorticoids (SGK) and bronchodilators in the correction of acid-base metabolism and blood gas composition using medications and non-drugs.

Long-term maintenance therapy for asthma:

1. Assessment of the level of control over BA.
2. Treatment aimed at achieving control.
3. Monitoring to maintain control.

Treatment aimed at achieving control is carried out according to step therapy, where each step includes treatment options that can serve as alternatives when choosing maintenance therapy for asthma. The effectiveness of therapy increases from stage 1 to stage 5.

Stage 1
Includes the use of rescue drugs as needed.
It is intended only for patients who have not received maintenance therapy and occasionally experience short-term (up to several hours) symptoms of asthma during the daytime. Patients with more frequent onset of symptoms or episodic worsening of the condition are indicated for regular maintenance therapy (see step 2 or higher) in addition to rescue drugs as needed.

Rescue drugs recommended in step 1: Rapid-acting inhaled β2-agonists.
Alternative drugs: inhaled anticholinergics, short-acting oral β2-agonists, or short-acting theophylline.

Stage 2
Relief drug + one disease control drug.
Drugs recommended as initial maintenance therapy for asthma in patients of any age at stage 2: low-dose inhaled corticosteroids.
Alternative agents for asthma control: antileukotriene drugs.

Step 3

3.1. Emergency drug + one or two drugs to control the course of the disease.
At step 3, children, adolescents and adults are recommended: a combination of a low dose of inhaled corticosteroids with a long-acting inhaled β2-agonist. Reception is carried out using one inhaler with a fixed combination or using different inhalers.
If control over BA has not been achieved after 3-4 months of therapy, an increase in the dose of inhaled corticosteroids is indicated.

3.2. Another treatment option for adults and children (the only one recommended in the management of children) is to increase the doses of inhaled corticosteroids to medium doses.

3.3. Step 3 treatment option: Combination of low dose inhaled corticosteroids with an antileukotriene drug. Low-dose extended-release theophylline may be used instead of an antileukotriene (these options have not been fully investigated in children 5 years of age and younger).

Step 4
Emergency drug + two or more drugs to control the course of the disease.
The choice of drugs in Step 4 depends on prior prescriptions in Steps 2 and 3.
Preferred option: combination of inhaled corticosteroids in a medium or high dose with a long-acting inhaled β2-agonist.

If asthma control is not achieved with a combination of a medium-dose inhaled glucocorticosteroid and a β2-agonist and/or a third maintenance drug (eg, antileukotriene or sustained-release theophylline), high-dose inhaled glucocorticosteroids are recommended, but only as trial therapy. duration 3-6 months.
With prolonged use of high doses of inhaled corticosteroids, the risk of side effects increases.

When using medium or high doses of inhaled corticosteroids, drugs should be prescribed 2 times a day (for most drugs). Budesonide is more effective when the frequency of administration is increased up to 4 times a day.

The effect of treatment increases the addition of a long-acting β2-agonist to medium and low doses of inhaled corticosteroids, as well as the addition of antileukotriene drugs (less compared to a long-acting β2-agonist).
May increase the effectiveness of therapy and the addition of low doses of theophylline sustained release to inhaled corticosteroids in medium and low doses and a long-acting β2-agonist.

Step 5
Emergency drug + additional options for the use of drugs to control the course of the disease.
The addition of oral corticosteroids to other maintenance drugs may increase the effect of treatment, but is accompanied by severe adverse events. Therefore, this option is only considered in patients with severe uncontrolled asthma on treatment at the appropriate stage 4, if the patient has daily symptoms that limit activity, and frequent exacerbations.

The use of anti-IgE in addition to other maintenance drugs improves the control of allergic asthma if it is not achieved during treatment with combinations of other maintenance drugs that include high doses of inhaled or oral corticosteroids.

Well antibiotic therapy indicated in the presence of purulent sputum, high leukocytosis, accelerated ESR. Taking into account antibiograms appoint:
- spiramycin 3,000,000 IU x 2 times, 5-7 days;
- amoxicillin + clavulanic acid 625 mg x 2 times, 7 days;
- clarithromycin 250 mg x 2 times, 5-7 days;
- ceftriaxone 1.0 x 1 time, 5 days;
- Metronidazole 100 ml IV drip.

Forecast

The prognosis is favorable with regular dispensary observation (at least 2 times a year) and rationally selected treatment.
The lethal outcome may be associated with severe infectious complications, progressive pulmonary heart disease in patients with cor pulmonale, untimely and irrational therapy.

The following points should be kept in mind:
- in the presence of bronchial asthma (BA) of any severity, the progression of dysfunctions of the bronchopulmonary system occurs faster than in healthy people;

With a mild course of the disease and adequate therapy, the prognosis is quite favorable;
- in the absence of timely therapy, the disease can go into a more severe form;

In severe and moderate BA, the prognosis depends on the adequacy of treatment and the presence of complications;
- comorbidities can worsen the prognosis of the disease.

X The nature of the disease and long-term prognosis depend on the age of the patient at the time of the onset of the disease.

In asthma that began in childhood, about long-term prognosis is favorable. As a rule, by puberty, children "outgrow" asthma, but they still have impaired lung function, bronchial hyperreactivity, and deviations in the immune status.
With asthma that began in adolescence, an unfavorable course of the disease is possible.
In asthma that began in adulthood and old age, the nature of the development and prognosis of the disease is more predictable.
The severity of the course depends on the form of the disease:
- allergic asthma is easier and prognostically more favorable;
- "pollen" asthma, as a rule, has a milder course compared to "dust";
- in elderly patients, a primary severe course is noted, especially in patients with aspirin BA.

AD is a chronic, slowly progressive disease. With adequate therapy, the symptoms of asthma can be eliminated, but treatment does not affect the cause of their occurrence. Remission periods can last for several years.

Hospitalization

Indications for hospitalization:
- severe attack of bronchial asthma;

There is no rapid response to bronchodilator drugs and the effect lasts less than 3 hours;
- no improvement within 2-6 hours after the start of oral corticosteroid therapy;
- there is a further deterioration - an increase in respiratory and pulmonary heart failure, "silent lung".

Patients at high risk of death:
- having a history of conditions close to lethal;
- requiring intubation, artificial ventilation, which leads to an increase in the risk of intubation during subsequent exacerbations;
- who have already been hospitalized or sought emergency care in the past year due to bronchial asthma;
- taking or recently discontinued oralglucocorticosteroids;
- using inhaled fast-acting β2-agonists in excess, especially more than one pack of salbutamol (or equivalent) per month;
- with mental illness, a history of psychological problems, including the abuse of sedatives;
Poor adherence to the asthma treatment plan.

Prevention

Preventive measures for bronchial asthma (BA) depend on the patient's condition. If necessary, it is possible to increase or decrease the activity of treatment.

Asthma control should begin with a thorough study of the causes of the disease, since the simplest measures can often have a significant impact on the course of the disease (it is possible to save the patient from the clinical manifestations of the atopic variant of asthma by identifying the causative factor and eliminating contact with it later).

Patients should be educated on proper drug administration and proper use of drug delivery devices and peak flow meters to monitor peak expiratory flow (PEF).

The patient must be able to:
- control PSV;
- to understand the difference between drugs of basic and symptomatic therapy;
- avoid asthma triggers;
- identify signs of deterioration of the disease and stop attacks on your own, as well as seek medical help in a timely manner to stop severe attacks.
Asthma control over a long period requires a written treatment plan (algorithm of patient actions).

List of preventive measures:

Termination of contact with cause-dependent allergens;
- termination of contact with non-specific irritating environmental factors (tobacco smoke, exhaust gases, etc.);
- exclusion of occupational hazard;
- with aspirin form of BA - refusal to use aspirin and other NSAIDs, as well as compliance with a specific diet and other restrictions;
- refusal to take beta-blockers, regardless of the form of asthma;
- adequate use of any medicines;
- timely treatment of foci of infection, neuroendocrine disorders and other concomitant diseases;
- timely and adequate therapy of asthma and other allergic diseases;
- timely vaccination against influenza, prevention of respiratory viral infections;
- Carrying out therapeutic and diagnostic measures using allergens only in specialized hospitals and offices under the supervision of an allergist;
- premedication before invasive examination methods and surgical interventions - parenteral administration of drugs: GCS (dexamethosone, prednisolone), methylxanthines (aminophylline) 20-30 minutes before the procedure. The dose should be determined taking into account age, body weight, severity of asthma and the extent of intervention. Before carrying out such an intervention, a consultation with an allergist is indicated.

Information

Sources and literature

1. Global strategy for the treatment and prevention of bronchial asthma (revised 2011) / ed. Belevsky A.S., M.: Russian Respiratory Society, 2012
2. Russian therapeutic reference book / edited by acad.RAMN Chuchalin A.G., 2007
   1. pp 337-341
3. http://lekmed.ru
4. http://pulmonolog.com

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