Differential diagnosis of chronic bronchitis. Acute bronchitis: differential diagnosis and rational therapy. Differential diagnosis - signs of bronchitis and pneumonia

The content of the article

Classification of chronic bronchitis

Etiology of chronic bronchitis

The pathogenesis of chronic bronchitis

Pathomorphology of chronic bronchitis

Clinic of chronic bronchitis

Diagnosis of chronic bronchitis

Differential diagnosis of chronic bronchitis

Treatment of chronic bronchitis

Obstructive bronchitis develops after a diffuse pathological change in the bronchi, which occurs as a result of prolonged inflammation or irritation of the airways leading to a decrease in the bronchial lumen and the accumulation of abundant secretions in it. The disease is characterized by the formation of bronchospasm, wheezing, shortness of breath, respiratory failure and other symptoms typical of other diseases in which lung ventilation is impaired.

Therefore, when determining the disease, differential diagnosis of obstructive bronchitis is important, according to which adequate treatment will be prescribed. In order to understand the problem in more detail, it is necessary to dwell in more detail on the causes of obstruction and other features of bronchitis.

Among the reasons leading to narrowing or complete blockage of the bronchi, there are factors that are discussed in detail below.

Medical factors

Medical factors that cause obstruction of small and medium bronchi include:

• the presence of infection in the oral cavity and upper respiratory tract: stomatitis, tonsillitis, ENT diseases, diseases of the teeth, gums and others;
• the presence of pathologies of an infectious nature in the lower respiratory tract: bronchitis,;
• tumor formations in the trachea or bronchial tree;
• hereditary prerequisites;
• allergies, asthma;
• airway hyperreactivity;
• poisoning with toxic fumes, burns or injuries of the bronchi of various kinds.

Social factors

A person's lifestyle plays an important role in the development of respiratory diseases.

Bronchitis can be caused by:

• maintaining an unhealthy lifestyle, alcohol abuse and smoking;
• living in unfavorable conditions;
• age (small children and people of retirement age are more prone to developing diseases).

Environmental factors

The health of his respiratory tract depends on the state of the air masses surrounding a person.

Significantly increases the risk of developing pulmonary diseases the following:

1. Constant or very frequent exposure to mucous membranes of irritating agents: dust, smoke, allergens and others;
2. The impact of chemicals on the respiratory tract: various caustic gases, fumes, fine dust suspended in the air of organic or inorganic origin, etc.

What you need to know about obstructive bronchitis

The classification of bronchitis is quite complicated, which can be seen by watching the video in this article, but if we simplify it to a language more understandable to the average person, then basically the pathology is divided into acute and, and obstruction can occur both in the first and in the second case.

The diagnosis "" in the vast majority is made to children under the age of three due to the characteristics of the young respiratory system; for adults, this form is not typical.

Note. If an adult is diagnosed with acute obstructive pathology, then in this case there is rarely bronchitis, rather it is another disease with similar symptoms.

The main symptoms indicating pathology include the following:

• the first sign is a violation of the full-fledged work of the ciliated epithelium and the development of catarrh of the upper parts of the respiratory system;
• the disease is accompanied by a strong unproductive cough with poorly separated sputum;
• cough is paroxysmal, especially at night or in the morning after sleep;
• the temperature does not rise above subfebrile indicators;
• there are symptoms of respiratory failure, there is shortness of breath, it becomes difficult to breathe;
• when exhaling, wheezing and noises are heard without additional devices.

Violation of the bronchi in this case is completely cured, but with frequent repetitions, the disease becomes chronic, characterized by a constant sluggish process, in which each time after the next exacerbation, the period of remission is reduced. Thus, chronic pathology is characterized by irreversibility.

Important. One of the hallmarks of obstructive bronchitis is the presence of subfebrile temperature, which, as a rule, does not exceed 37.5-37.6 degrees. In the usual acute form, the temperature indicators are much higher.

Chronic form

This disease is typical for adults, developing with constant exposure to the bronchi of harmful agents, less often due to frequent repetitions of acute forms. At the same time, the work of medium and small bronchi is disrupted, which is both reversible and irreversible.

Pay attention to the signs indicating the presence of a chronic form of obstructive bronchitis:

1. The patient coughs throughout the year in general for at least three months;
2. The cough is strong and deep, there is little sputum, it is mucous and difficult to cough up;
3. During the period of remission, coughing attacks are possible in the morning after sleep, usually for a month;
4. It is difficult for the patient to breathe, the exhalation is lengthened, and a characteristic whistle is heard;
5. There are signs of respiratory failure, shortness of breath during physical work, in a neglected state, it can occur even when talking;
6. Often, additional ones in the form of a viral or bacterial infection join the underlying disease. In this case, the sputum becomes completely or partially purulent, usually with a greenish tint.

Differential Diagnosis

The differential diagnosis of obstructive bronchitis is due to the fact that the symptoms of the disease do not have clear signs and may indicate the development of other pathologies with a very similar clinical picture. First of all, asthma, pneumonia and tuberculosis should be excluded. The pathogen can be determined by bacterial examination of sputum or lavage, in which mycobacterium should not be present - Koch's bacillus, which is the cause of tuberculosis.

Pay attention to the importance of sputum collection for bacteriological analysis.

In addition, obstructive bronchitis should be differentiated from:

• heart or lung failure;
• bronchiectasis;
• thromboembolism of pulmonary blood vessels and other diseases.

Differentiation of bronchitis from asthma

Most often, great difficulties arise with the difference between bronchitis and asthma, since the diagnosis is established solely on the basis of the symptoms manifested and there are no other ways to clearly determine the disease, such as pneumonia using x-rays. The presence of obstruction is a characteristic feature for both ailments, and it is one of the main diagnostic syndromes.

More detailed information about the differences is shown in Table 1, and the main ones include the following:

• nature and frequency of cough- constant with bronchitis and in the form of attacks with asthma;
• shortness of breath with an exacerbation of bronchitis and with a chronic neglected form, it is constant, with asthma attacks, it is completely absent if there is no irritating factor;
• the presence of allergies indicates the presence of asthma, bronchitis, as a rule, develops due to infection with infections;
• use of bronchodilators to relieve bronchospasm and obstruction, with asthma the answer is positive, with bronchitis it is partial.

Table 1. Differential diagnosis of bronchitis and asthma:

Differentiation of bronchitis from pneumonia

It is not always possible to understand by clinical signs what kind of disease the patient suffers from, since there is no clear line along which one pathology is separated from another. For this purpose, doctors resort to laboratory diagnostic methods.

It is often enough to study an X-ray, and in difficult cases it is necessary to use bronchoscopy, MRI and others, which, with these pathologies, are quite complex research methods. Often neglected bronchitis or just a banal untimely request for medical help leads to the fact that the inflammatory process goes down and causes the development of pneumonia. The main differences are shown in Table 2.

Table 2. Differential diagnosis: bronchitis and pneumonia:

Differential diagnosis with other pathology

Tuberculosis will be indicated by signs such as: fatigue and weakness, increased sweating and temperature. Chronic bronchitis is primarily manifested by coughing, shortness of breath and shortness of breath. There are no purulent formations in the sputum, but there may be blood, with its bacterial examination, Koch's bacillus is detected.

In children, copious sputum production may indicate the development of bronchiectasis, while the chronic form of bronchitis is more characteristic of older people, whose age is over 35 years on average. Bronchoscopy in this case shows local rather than diffuse bronchitis, as is the case with chronic diseases.

Oncological disease is indicated by chest pain, weight loss, fatigue, weakness, while there is no purulent sputum. As a preventive measure for early diagnosis, it is necessary to regularly do fluorography. Table 3 lists possible diseases that have similar symptoms to bronchitis.

Table 3. Highlights of differential diagnosis:

What you need to know about treating bronchitis

Treatment of obstructive and any other bronchitis involves not only medical assistance, but also active assistance from the patient. Both for therapeutic and prophylactic purposes, it is necessary to first eliminate the provoking factors, for example, smoking, the influence of fumes on hazardous production, and so on, be sure to pay attention to strengthening the body's defense mechanisms by adhering to a healthy lifestyle.

In the treatment of obstructive bronchitis, drug treatment plays the first violin. Table 4 presents the main groups of drugs prescribed not only for bronchitis, but also for the treatment of diseases such as pneumonia, emphysema, asthma, tracheitis and the like.

Important. Always read the package leaflet before you start using the medicine. The enclosed instructions will not only tell you how to use the medicine correctly, it contains important information regarding possible contraindications.

Table 4. Drug therapy for bronchitis:

Pay attention to the benefits of therapeutic exercises not only in therapy, but in the prevention of respiratory diseases, especially in chronic forms. There are specially developed methods for this, for example, according to Buteyko, Frolov, Strelnikova and others, which you can learn in more detail from the proposed video in this article.

Indications for hospital treatment

In most cases, bronchitis is treated on an outpatient basis, but it is important to know under what symptoms it is recommended to undergo full-fledged therapy in a hospital setting:

1. If, during an exacerbation of chronic obstructive bronchitis, the disease does not recede, coughing attacks do not stop at home on their own, there are a large number of purulent inclusions in the sputum;
2. Increased shortness of breath and respiratory failure;
3. The disease flows into inflammation of the lungs and thus not only radical pneumonia appears, but also focal forms with localization in the lung tissue;
4. Signs of cardiac pathology begin to appear, the so-called cor pulmonale develops;
5. For a more accurate diagnosis, bronchoscopy is required.

Modern medicine has taken a big step in improving the methods of drug delivery to the foci of inflammation. Recently, nebulizers have been actively used in the treatment of diseases of the respiratory system, which, according to the principle of operation, are similar to inhalers, but have a number of significant advantages.

The most important thing is that the aqueous solution of the drug with the help of ultrasound turns into a cold mist or aerosol, which deeply penetrates the most remote parts of the respiratory tract, which provides a stronger effect and is effective in stopping coughing fits. The device is easy to use, and this is especially beneficial for the treatment of the elderly and young patients, for example, because it is not necessary to monitor the correctness of breathing and deep inspiration, as is the case with inhalations, while the price of the nebulizer is affordable, and the device itself lasts a long time. .

Conclusion

In making a diagnosis for suspected obstructive bronchitis, it is extremely important to take into account all the symptoms that appear, find out the genesis of the disease and conduct a series of specific tests to confirm or refute other pathologies. Chronic obstructive bronchitis has signs similar to many diseases, but first of all, pneumonia, asthma, tuberculosis and oncopathology should be excluded.

If suspected, an X-ray examination is performed, fluorography must be performed annually as a mandatory preventive method to prevent the development of serious pulmonary diseases. The degree of obstruction is determined by spirography, its irreversibility indicates chronic bronchitis.

In infants and young children, bronchitis often has an obstructive character. Although high titer bacilli are also cultured from tracheal aspirate in patients with bronchitis (as well as in children without bronchitis), there is no evidence of their etiological role, and antibiotic treatment does not affect the course of the disease. In 10-15% of children, usually 4-5 years and older, bronchitis is caused by mycoplasma and chlamydia. Complication of bronchitis, incl. in infants, bacterial pneumonia is rare, usually with superinfection.

Pneumonia - inflammation of the alveolar tissue, is observed much less frequently (4-15 per 1000 children) and in most cases is caused by bacterial pathogens. Bronchitis accompanying pneumonia (bronchopneumonia in the old classifications) is diagnosed only if its symptoms significantly affect the picture of the disease.

Symptoms

Signs of an acute lesion of the lower respiratory tract - the presence of wheezing in a feverish child, rapid and / or difficult breathing, chest indrawing and shortening of percussion sound - are given above. The same symptoms in a child without fever are observed with bronchial asthma, chronic lung diseases, and also with a sudden appearance - when a foreign body enters the respiratory tract; these situations that do not require urgent antibiotic therapy are not considered in this section.

Differential diagnosis - signs of bronchitis and pneumonia

The main issue in an acutely ill, feverish child with cough and wheezing in the lungs is an exception.

temperature response. It is characterized by febrile temperature; although this symptom is not very specific, a temperature below 38 ° speaks against (an exception is atypical forms in the first months of life). Without treatment, the temperature lasts 3 days or longer, and with bronchitis, it decreases in 85% of cases within 1-3 days (with the exception of adenovirus infection and influenza); this feature is very specific.

Catarrhal phenomena- frequent (with a disease on the background), although not an obligatory companion. But wet (rarely dry) is constantly detected, its absence testifies against.

physical data. Pneumonia is unlikely in the presence of only dry and mixed moist rales, evenly auscultated in both lungs; dry rales are found only in 10%, and diffuse wet rales - in 25% of patients with pneumonia (mainly in atypical forms). Abundant wheezing on both sides is characteristic of a diffuse lesion of the bronchial tree in bronchitis: moist finely bubbling with viral bronchiolitis in infants and with mycoplasma-induced bronchitis in preschoolers and schoolchildren.

For simple bronchitis, coarse and medium bubbling moist and dry rales are typical, and for obstructive bronchitis - dry wheezing. It is characterized by localization of wheezing over a certain area of ​​the lung; asymmetry of wheezing is also observed in bronchitis caused by mycoplasma, which is an indication for radiography. The diagnosis is facilitated by the identification of hard or weakened breathing and / or shortening of the percussion sound in the area of ​​​​an abundance of wheezing. Unfortunately, these local signs are not determined in all patients with pneumonia.

The nature of the breath. Shortness of breath in bronchitis is a consequence of the obstruction syndrome (expiratory difficulty, wheezing), which is so unusual for community-acquired that this diagnosis can be excluded (obstruction is sometimes observed only with gram-negative nosocomial pneumonia). Obstruction is characteristic of bronchiolitis, obstructive bronchitis.

In the absence of obstruction, shortness of breath is an important symptom, and it is observed more often, the more extensive the lesion of the lungs and the smaller the child. WHO recommends using the following parameters of respiratory rate per minute, which have the highest sensitivity and specificity: 60 and above in children 0-2 months old, 50 and above - 2-12 months, 40 and above - 1-4 years.

Grunting painful breathing with a groaning (grunting) sound at the beginning of exhalation is often taken as a sign of obstruction.

Acute phase proteins. In controversial cases, high (more than 30 mg/l) CRP levels speak in favor of a typical diagnosis, which makes it possible to exclude a purely viral process by 90%. More specific to the typical increase in the level of pro-calcitonin above 2 ng / ml, observed in 3/4 of patients; this level of the indicator has 85% positive and 90% negative predictive value. With mycoplasma infection and bronchitis, this indicator does not increase.

X-ray examination when infiltrative or focal changes are detected, it diagnoses pneumonia. Bronchitis and bronchiolitis, in which only diffuse changes in the lungs, roots of the lungs, swelling of the lung tissue are detected, do not need antibacterial treatment.

About the causes of bronchitis and effective ways to treat it

Professor I.V. Leshchenko, SBEI HPE "Ural State Medical Academy" of the Ministry of Health of the Russian Federation, LLC "Medical Association "New Hospital", Yekaterinburg

Often in the practical work of an internist, there are difficulties in establishing a diagnosis and determining the tactics of managing a patient with a first-time and long-lasting cough or a first-developed broncho-obstructive syndrome. With the most common respiratory symptom - coughing, the doctor needs to determine the optimal amount of examination of the patient as soon as possible and prescribe the appropriate treatment. A significant part of patients who seek medical help for cough are examined on an outpatient basis, which creates additional difficulties for the doctor due to his short-term communication with the patient and the limited possibilities for examining the patient.

One of the causes of cough that appeared for the first time in a patient after an acute respiratory viral infection (ARVI) is acute bronchitis (AB). Despite the apparent simplicity of the clinical symptoms of the disease, many medical errors are made in the diagnosis and treatment of this pathology.

Definition

Acute bronchitis (ICD 10: J20) is an acute / subacute disease of predominantly viral etiology, the leading clinical symptom of which is a cough that lasts no more than 2-3 weeks. and usually accompanied by constitutional symptoms and symptoms of an upper respiratory tract infection.

The Australian Society of General Practitioners guidelines list the following diagnostic criteria for the disease: acute onset cough lasting less than 14 days, in combination with at least one of the following symptoms: sputum production, shortness of breath, wheezing in the lungs or chest discomfort.

Pathogenesis

There are several stages in the pathogenesis of AB. The acute stage is due to the direct effect of the pathogen on the epithelium of the airway mucosa, which leads to the release of cytokines and activation of inflammatory cells. This stage is characterized by the appearance 1-5 days after the "infectious aggression" of such systemic symptoms as fever, malaise and muscle pain. The protracted stage is characterized by the formation of transient hypersensitivity (hyperreactivity) of the epithelium of the tracheobronchial tree. Other mechanisms of the formation of bronchial hypersensitivity are also discussed, for example, an imbalance between the tone of the adrenergic and nervous cholinergic systems. Clinically, bronchial hypersensitivity manifests itself for 1 to 3 weeks. and is manifested by cough syndrome and the presence of dry rales on auscultation.

The following pathophysiological mechanisms play a role in the development of OB:

• decrease in the effectiveness of physical protection factors;
• change in the ability to filter the inhaled air and free it from coarse mechanical particles;
• violation of thermoregulation and air humidification, sneezing and coughing reflexes;
• violation of mucociliary transport in the respiratory tract.

Deviations in the mechanisms of nervous and humoral regulation lead to the following changes in bronchial secretions:

• violation of its viscosity;
• increase in the content of lysozyme, protein and sulfates.

The course of inflammation in the bronchi is also affected by vascular disorders, especially at the level of microcirculation. Viruses and bacteria penetrate the bronchial mucosa more often aerogenically, but hematogenous and lymphogenous routes of infection and toxic substances penetration are possible. It is known that influenza viruses have a bronchotropic effect, manifested by damage to the epithelium and a violation of the trophism of the bronchi due to damage to the nerve conductors. Under the influence of the general toxic effect of the influenza virus, phagocytosis is inhibited, immunological protection is impaired, as a result, favorable conditions are created for the vital activity of the bacterial flora located in the upper respiratory tract and ganglia.

According to the nature of inflammation of the bronchial mucosa, the following forms of OB are distinguished: catarrhal (superficial inflammation), edematous (with swelling of the bronchial mucosa) and purulent (purulent inflammation) (Fig. 1).

Epidemiology

The incidence of AB is high, but it is extremely difficult to judge its true level, because OB is often nothing more than a component of the infectious process in viral lesions of the upper respiratory tract. Indeed, OB is most often hidden under the guise of SARS or acute respiratory disease (ARI). This is understandable, because OB is most often caused by viruses, which easily “open the door” for bacterial flora.

The epidemiology of AB is related to the epidemiology of the influenza virus. Typical peaks of the increase in the disease and other respiratory viral diseases are more often observed in late December and early March.

Risk factors

Risk factors for the development of AB are:

• allergic diseases (including bronchial asthma (BA), allergic rhinitis, allergic conjunctivitis);
• hypertrophy of the nasopharyngeal and palatine tonsils;
• immunodeficiency states;
• smoking (including passive);
• elderly and children's age;
• air pollutants (dust, chemical agents);
• hypothermia;
• foci of chronic infections of the upper respiratory tract.

Etiology of acute bronchitis

The main role in the etiology of AB belongs to viruses. According to A.S. Monto et al., the development of OB in more than 90% of cases is associated with a respiratory viral infection and in less than 10% of cases with a bacterial one. Influenza A and B viruses, parainfluenza, RS virus, coronavirus, adenovirus, and rhinoviruses play a role among viruses in the etiology of OB. Bacterial agents that cause the development of OB include Bordetella pertussis, Mycoplasma pneumoniae, and Chlamydia pneumoniae. S. pneumoniae, H. influenzae, M. catarrhalis are rare causes of OB. Table 1 gives the characteristics of AB pathogens.

Classification

There is no generally accepted classification of OB, and research is still underway to form it. It is conditionally possible to distinguish the etiological and functional classification signs of the disease:

• viral;
• bacterial.

Other (more rare) etiological variants are also possible:

• toxic;
• burn.

Toxic and burn OB are considered not as independent diseases, but as a systemic lesion syndrome within the framework of the corresponding nosology.

According to ICD-10, depending on the etiology, OB is classified as follows:

• 0 Acute bronchitis due to Mycoplasma pneumoniae
• 1 Acute bronchitis due to Haemophilus influenzae
• 2 Acute bronchitis caused by streptococcus
• 3 Acute bronchitis caused by Coxsackievirus
• 4 Acute bronchitis caused by parainfluenza virus
• 5 Acute bronchitis due to respiratory syncytial virus
• 6 Acute bronchitis due to rhinovirus
• 7 Acute bronchitis due to echovirus
• 8 Acute bronchitis due to other specified agents
• 9 Acute bronchitis, unspecified

Clinic and diagnostics

Clinical manifestations of AB often have similar symptoms with other diseases. The disease can begin with a sore throat, discomfort in the chest, dry painful cough. At the same time, body temperature rises, general malaise appears, appetite disappears. On the 1st and 2nd day, sputum is usually absent. After 2-3 days, the cough begins to be accompanied by sputum discharge.

Diagnosis of AB involves the exclusion of other acute and chronic diseases similar in syndromes. A preliminary diagnosis is made by exclusion and is based on the clinical picture of the disease. Table 2 shows the frequency of clinical signs of AB in adult patients.

The most common clinical symptom in OB is cough. If it lasts more than 3 weeks, it is customary to talk about persistent or chronic cough (which is not equivalent to the term "chronic bronchitis") and requires differential diagnosis.

The diagnosis of AB is made in the presence of an acute cough lasting no more than 3 weeks. (regardless of the presence of sputum), in the absence of signs of pneumonia and chronic lung diseases that may be the cause of coughing. The diagnosis of acute bronchitis is a diagnosis of exclusion.

Laboratory data

When a patient goes to the clinic, they usually do a general blood test, in which there are no specific changes in OB. Leukocytosis with a stab shift to the left is possible. With clinical signs of bacterial etiology of AB, bacterioscopic (Gram stain) and bacteriological (sputum culture) examination of sputum is recommended; if possible, the determination of antibodies to viruses and mycoplasmas. Chest x-rays are only done for differential diagnosis when pneumonia or other lung disease is suspected. Other additional studies, unless there are good reasons, are usually not undertaken. However, reasons sometimes appear, because. cough can be accompanied by a number of conditions completely different from bronchitis. For example, a cough can occur with a runny nose as a result of discharge (mucus) from the nasopharynx flowing down the back of the pharynx. Dry painful cough can develop when taking certain medications (captopril, enalapril, etc.). Cough often accompanies chronic reflux of gastric contents into the esophagus (gastroesophageal reflux disease (GERD)). Cough often accompanies asthma.

Differential Diagnosis

In acute cough, the most important differential diagnosis is between OB and pneumonia, as well as between OB and acute sinusitis. In chronic cough, the differential diagnosis is based on a history of asthma, GERD, postnasal drip, chronic sinusitis, and cough associated with angiotensin-converting enzyme (ACE) inhibitors, etc.

Possible causes of a prolonged cough

• Causes associated with respiratory diseases. Differential diagnosis is carried out using clinical, functional, laboratory, endoscopic methods and methods of radiation diagnostics:
• Chronical bronchitis;
• COPD;
• chronic infectious diseases of the lungs;
• tuberculosis;
• sinusitis;
• postnasal drip syndrome (flowing of nasal mucus along the back of the pharynx into the airways). The diagnosis of postnasal drip may be suspected in patients who describe a sensation of mucus running down the throat from the nasal passages or a frequent need to "clear" the throat by coughing. In most patients, the discharge from the nose is mucous or mucopurulent. With the allergic nature of postnasal drip, eosinophils are usually found in the nasal secretion. Causes of postnasal drip can be general cooling of the body, allergic and vasomotor rhinitis, sinusitis, environmental irritants and drugs (drugs) (eg, ACE inhibitors);
• sarcoidosis;
• lung cancer;
• pleurisy.

Causes associated with heart disease and hypertension:

• taking an ACE inhibitor (an alternative is the selection of another ACE inhibitor or switching to angiotensin II antagonists);
• p-blockers (even selective), especially in patients with atopy or hyperreactivity of the bronchial tree;
• heart failure (cough at night). Chest x-ray and echocardiography help in differential diagnosis.

Causes associated with connective tissue diseases:

• fibrosing alveolitis, sometimes in combination with rheumatoid arthritis or scleroderma. High-resolution computed tomography, a study of the function of external respiration with the determination of functional residual lung capacity, diffusive capacity of the lungs and restrictive changes are necessary;
• the influence of drugs (drugs taken for rheumatoid arthritis, gold preparations, sulfasalazine, methotrexate).

Reasons related to smoking:

• OB with a prolonged course (more than 3 weeks) or chronic bronchitis;
• special caution in relation to smokers over 50 years of age, especially those who report hemoptysis. In this category of patients, it is necessary to exclude lung cancer.

Causes associated with occupational diseases:

• asbestosis (workers on construction sites, as well as people working in small auto repair shops). It is necessary to conduct radiation diagnostics and spirometry, consultation of an occupational pathologist;
• farmer's lung. May be found in agricultural workers (hypersensitivity pneumonitis due to exposure to moldy hay), possible AD;
• Occupational asthma beginning with a cough can develop in a variety of occupations involving exposure to chemical agents, organic solvents in auto repair shops, dry cleaners, plastics manufacturing, dental laboratories, dental surgeries, etc.

Causes associated with atopy, allergy or hypersensitivity to acetylsalicylic acid:

• the most likely diagnosis is AD. The most common symptoms are transient shortness of breath and mucus sputum. To conduct differential diagnosis, it is necessary to conduct the following studies: measurement of peak expiratory flow at home; spirometry with bronchodilation test; if possible, determination of hyperreactivity of the bronchial tree (provocation with inhaled histamine or methacholine hydrochloride); assessment of the effect of inhaled glucocorticoids.

In the presence of prolonged cough and fever, accompanied by the release of purulent sputum (or without it), it is necessary to exclude:

• pulmonary tuberculosis;
• eosinophilic pneumonia;
• development of vasculitis (eg, periarteritis nodosa, Wegener's granulomatosis).

It is necessary to conduct a chest x-ray or computed tomography, sputum examination for Mycobacterium tuberculosis, smear and sputum culture, blood test, determination of the content of C-reactive protein in the blood serum.

Other causes of persistent cough:

• sarcoidosis (chest x-ray or computed tomography to exclude hyperplasia of the lymph nodes of the respiratory system, infiltrates in the lung parenchyma, morphological examination of biopsies of various organs and systems);
• taking nitrofurans;
• pleurisy (it is necessary to establish the main diagnosis, puncture and biopsy the pleura, study the pleural fluid);
• GERD is one of the common causes of chronic cough, occurring in 40% of people who cough. Many of these patients complain of reflux symptoms (heartburn or a sour taste in the mouth). It is not uncommon for individuals whose cough is caused by gastroesophageal reflux to not report symptoms of reflux.

Indications for specialist consultation

The indication for referral to specialists is the persistence of cough with standard empiric therapy for OB. Consultations needed:

• pulmonologist - to exclude chronic lung pathology;
• gastroenterologist - to exclude gastoesophageal reflux;
• ENT doctor - to exclude ENT pathology as a cause of cough.

Sinusitis, asthma, and gastroesophageal reflux may cause prolonged cough (>3 weeks) in more than 85% of patients with a normal chest x-ray.

Acute bronchitis and pneumonia

Early differential diagnosis of OB and pneumonia is of fundamental importance, since the timely appointment of appropriate therapy depends on the diagnosis (for OB, as a rule, antiviral and symptomatic therapy; for pneumonia, antibacterial therapy). When making a differential diagnosis between OB and pneumonia, a clinical blood test is the standard laboratory test. According to the results of a recently published systematic review, an increase in the number of leukocytes in peripheral blood to 10.4 * 10 9 /l or more is characterized by a 3.7-fold increase in the likelihood of pneumonia, while the absence of this laboratory sign reduces the likelihood of pneumonia by 2 times. Of even greater value is the content of serum C-reactive protein, the concentration of which is above 150 mg / l reliably indicates pneumonia.

Table 3 shows the symptoms in patients with cough and their diagnostic significance in pneumonia.

Out of 9-10 patients with cough and purulent sputum (within 1-3 weeks), pneumonia is diagnosed in 1 patient.

A prolonged cough that first appeared in a patient causes considerable difficulties for the doctor in the differential diagnosis between OB and BA.

In cases where asthma is the cause of the cough, patients usually experience episodes of wheezing. Regardless of the presence or absence of wheezing in patients with asthma, when examining the function of external respiration, reversible bronchial obstruction is detected in tests with β 2 -agonists or methacholine. It must be borne in mind that in 33% of cases, tests with β 2 -agonists and in 22% of cases with methacholine may be false positive. If false-positive results of functional testing are suspected, trial therapy is recommended for 1-3 weeks. inhaled glucocorticosteroids (GCS) - in the presence of BA, the cough should stop or its intensity will significantly decrease, which requires further study.

Differential diagnosis of AB with the most likely diseases in which there is a cough is shown in Table 4.

Treatment

The main goals of the treatment of OB:

• relief of the severity of the cough;
• reducing its duration;
• return to work.

Hospitalization of patients with OB is not indicated.

Non-drug treatment

1. Mode.
2. Relief of mucus secretion:

• instruct the patient to maintain adequate hydration;
• instruct the patient about the benefits of humidified air (especially in dry, hot weather and in winter in any weather);
• pay attention to the need to eliminate the patient's exposure to environmental factors that cause cough (level of evidence C).

Medical treatment

• Drugs that suppress cough (dextromethorphan) are prescribed only for debilitating cough;
• bronchodilators for debilitating cough (level of evidence A). 3 randomized controlled trials showed the effectiveness of bronchodilatory therapy in 50% of patients with OB;
• fixed combination of active substances: salbutamol, guaifenesin and bromhexine (Ascoril ®);
• Antibacterial therapy is not indicated for uncomplicated OB. One of the causes of AB is thought to be the overuse of antibiotics.

Due to the unique combination of bronchodilators, mucolytics and mucokinetics with different mechanisms of action, special attention in the treatment of patients with OB deserves the use of Ascoril ® as a symptomatic agent. Data from controlled studies and materials from an analytical review of the Cochrane Collaboration indicate the effectiveness of a fixed combination of active substances - salbutamol, guaifenesin and bromhexine that make up Ascoril ® - in the treatment of patients with symptoms of impaired mucoregulation processes, as well as the polyfunctionality and safety of the drug. The pharmacological properties of the main (active) drugs that make up Ascoril are well known.

Salbutamol is a selective short-acting β 2 -agonist with bronchodilator and mucolytic effects. When administered orally, the bioavailability of salbutamol is 50%, food intake reduces the rate of absorption of the drug, but does not affect its bioavailability.

Guaifenesin enhances the secretion of the liquid part of bronchial mucus, reduces the surface tension and adhesive properties of sputum and thereby increases its volume, activates the ciliary apparatus of the bronchi, facilitates the removal of sputum and promotes the transition of an unproductive cough into a productive one.

Bromhexine is a classic mucolytic drug derived from the alkaloid vasicin. The mucolytic effect is associated with the depolymerization of mucoprotein and mucopolysaccharide fibers. The drug stimulates the synthesis of neutral polysaccharides and the release of lysosomal enzymes, increases the serous component of bronchial secretions, activates the cilia of the ciliated epithelium, reduces the viscosity of sputum, increases its volume and improves discharge. One of the unique properties of bromhexine is the stimulation of the synthesis of endogenous surfactant.

Menthol - another component of the drug Ascoril ® contains essential oils that have a calming, mild antispasmodic and antiseptic effect.

According to N.M. Shmeleva and E.I. Shmeleva, the appointment of the drug Ascoril ® in patients with OB of a protracted course leads to a reduction in the symptoms of the disease, an improvement in the general condition and the prevention of secondary bacterial complications.

The clinical efficacy of Ascoril ® compared with double combinations of salbutamol and guaifenesin or salbutamol and bromhexine is shown in a comparative study involving 426 patients with productive cough in acute and chronic bronchitis and amounted to 44%, 14% and 13%, respectively.

Regarding the question of the use of antibiotics for the treatment of patients with OB, the following should be noted. In a randomized study, 46 patients were divided into 4 groups: patients of the 1st group received inhaled salbutamol and placebo capsules; patients of the 2nd group were prescribed inhalations of salbutamol and erythromycin inside; group 3 received erythromycin and placebo inhalations; Group 4 patients received placebo capsules and placebo inhalations.

Cough disappeared in a greater number of patients treated with salbutamol compared with patients treated with erythromycin or placebo (39 and 9%, respectively, p = 0.02). Patients treated with salbutamol were able to start work earlier (p=0.05). When comparing the effectiveness of mixtures with erythromycin and albuterol in 42 patients, the following results were obtained: after 7 days, the cough disappeared in 59% of patients in the group receiving salbutamol and in 12% of patients in the group receiving erythromycin (p = 0.002). In smoking patients, the complete disappearance of cough was noted in 55% of cases in the group of patients who were prescribed salbutamol inhalations; in the group of patients treated with erythromycin, it did not disappear completely in anyone (p=0.03). Antibacterial therapy is indicated for obvious signs of bacterial damage to the bronchi (purulent sputum, fever, signs of intoxication of the body). In case of bacterial etiology of OB, one of the listed antibacterial drugs in general therapeutic doses is recommended: amoxicillin or second-generation macrolides with improved pharmacokinetic properties (clarithromycin, azithromycin).

Prevention of acute bronchitis

Based on the predominantly viral etiology of AB, the prevention of the disease consists primarily in the prevention of SARS. Attention should be paid to the observance of the rules of personal hygiene: frequent hand washing; minimization of contacts "eyes - hands", "nose - hands". Most viruses are transmitted by this contact route. Special studies of the effectiveness of this preventive measure in day hospitals for children and adults have shown its high efficiency.

Annual influenza prophylaxis reduces the incidence of AB (Evidence A).

Indications for annual influenza vaccination:

• age over 50;
• chronic diseases regardless of age;
• being in closed groups;
• long-term aspirin therapy in childhood and adolescence;
• II and III trimesters of pregnancy during the epidemic period of influenza.

In middle-aged people, vaccination reduces the number of flu episodes and disability associated with it. Vaccination of medical personnel leads to a decrease in mortality among elderly patients. In elderly debilitated patients, vaccination reduces mortality by 50% and hospitalization rates by 40%.

Indications for drug prophylaxis: in a proven epidemic period in unimmunized individuals at high risk of influenza, inhaled zanamivir 10 mg/day or oral oseltamivir 75 mg/day are recommended. Antiviral prophylaxis is effective in 70-90% of individuals.

In uncomplicated OB, the prognosis is favorable; in complicated OB, the course of the disease depends on the nature of the complications and may belong to another category of diseases.

Literature

1. Pulmonology. National leadership. Brief edition / Ed. A.G. Chuchalin. M.: GEOTAR-Media, 2013.
2. Falsey A.R., Griddle M.M., Kolassa J.E. et al. Evaluation of a handwashing intervention to reduce respiratory illness rates in senior day-care centers// Infect Control Hosp. epidemiol. 1999 Vol. 20. R. 200-202.
3. Irwin R.S., Curly F.J., French C.I. chronic cough. The spectrum and frequency of causes, key components of diagnostic evaluation, and outcome of specific therapy//Am. Rev. Respir. Dis. 1999 Vol. 141. R. 640-647.
4. Govaert T.M., Sprenger M.J., Dinant G.J. et al. Immune response to influenza vaccination of elderly people. A randomized double-blind placebo-controlled trial// Vaccine. 1994 Vol. 12. R. 11851189.
5. Govaert T. M., Thijs C. T., Masurel N. et al. The efficacy of influenza vaccination in elderly individuals. A randomized double-blind placebo-controlled trial // JAMA. 1994 Vol. 2772. R. 1661-1665.
6. Monto A.S. Zanamivir in the prevention of influenza among healthy adults: a randomized controlled trial // JAMA. 1999 Vol. 282. R. 31-35.
7. Lambert J, Mobassaleh M., Grand R.J. Efficacy of cimetidine for gastric acid suppression in pediatric patients// J. Pediatr. 1999 Vol. 120.R. 474-478.
8. Smucny J.J. Are beta-2-agonists effective treatments for acute bronchitis or acute cough in patients without underlying pulmonary disease? // J. Farm. Pract. 2001 Vol. 50. R. 945-951.
9. Quackenboss J.J., Lebowitz M.D., Kryzanowski M. The normal range of diurnal changes in peak expiratory flow rates. Relationship to symptoms and respiratory disease // Am. Rev. Respir. Dis. 1999 Vol. 143. R. 323-330.
10. Nakagawa N.K., Macchione M., Petrolino H.M. et al. Effects of a heat and moisture exchange and a heated humidifier on respiratory mucus in patients undergoing mechanical ventilation // Crit. Care Med. 2000 Vol. 28. R. 312-317.
11. Gonzales R., Steiner J.F., Lum A., Barrett P.H. Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults // JAMA. 1999 Vol. 281. R. 1512.
12. Canadian guidelines for the management, of acute exacerbations of chronic bronchitis, Can. Resp. J. 2003. Suppl. R. 3-32.
13. Fedoseev G.B., Zinakova M.K., Rovkina E.I. Clinical aspects of the use of Ascoril in the pulmonology clinic / / New St. Petersburg medical records. 2002. No. 2. S. 64-67.
14. Ainapure S.S., Desai A., Korde K. Efficacy and safety of Ascoril in the management of cough — National Study Group report // J. Indian. Med. Assoc. 2001 Vol. 99. R. 111-114.
15. Prabhu Shankar S., Chandrashekharan S., Bolmall C.S., Baliga V. Efficacy, safety and tolerably of salbutamol+guaphenesn+bromhexne (Ascoril) expectorant versus expectorants containing sal-butamol and either guaiphenesin or bromhexine in productive cough: a randomized controlled comparative study // J. Indian. Med. Assoc. 2010 Vol. 108. R. 313-320.
16. Shmeleva N.M., Shmelev E.I. Modern aspects of mucoactive therapy in pulmonological practice // Ter. archive. 2013. No. 3. R. 107-109.
17. Prabhu Shankar S., Chandrashekharan S., Bolmall C.S., Baliga V. Efficacy, safety and tolerability of salbutamol + guaiphenesin + bromhexine (Ascoril) expectorant versus expectorants containing salbutamol and either guaiphenesin or bromhexine in productive cough: a randomized controlled comparative study// J. Indian. Med. Assoc. 2010 Vol. 108. R. 313-314, 316-318, 320.
18. Uhari M., Mottonen M. An open randomized controlled trial of infection prevention in child daycare centers // Pediatr. Infect. Dis. J. 1999. Vol. 18. R. 672-677.
19. Roberts L., Jorm L. Effect of infection control measures on the frequency of diarrhea episodes in child care: a randomized, controlled trial// Pediatrics. 2000 Vol. 105. R. 743-746.
20. Bridges C.B., Thompson W.W., Meltzer M. et al. Effectiveness and cost-benefit of influenza vaccination of healthy working adults: A randomized controlled trial // JAMA. 2000 Vol. 284. R. 16551663.
21. Carman W.F., Eder A.G., Wallace L.A. et al. Effects of influenza vaccination of healthcare workers on mortality of elderly people in long-term care: a randomized controlled trial // Lancet. 2000 Vol. 355. R. 93-97.
22. Nichol K.L., Margolis K.L., Wuorenma J, von Sternberg T. The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community// N. Engl. J. Med. 1994 Vol. 331. R. 778-784.
23. Hayden F.G. Use of the selective oral neuraminidase inhibitor oseltamivir to prevent influenza // N. Engl. J. Med. 1999 Vol. 341. R. 1336-1343.

is a diffuse progressive inflammatory process in the bronchi, leading to a morphological restructuring of the bronchial wall and peribronchial tissue. Exacerbations of chronic bronchitis occur several times a year and occur with increased cough, purulent sputum, shortness of breath, bronchial obstruction, low-grade fever. Examination for chronic bronchitis includes X-ray examination of the lungs, bronchoscopy, microscopic and bacteriological analysis of sputum, respiratory function, etc. In the treatment of chronic bronchitis, drug therapy is combined (antibiotics, mucolytics, bronchodilators, immunomodulators), sanitation bronchoscopy, oxygen therapy, physiotherapy (inhalation, massage, respiratory gymnastics, drug electrophoresis, etc.).

ICD-10

J41 J42

General information

The incidence of chronic bronchitis among the adult population is 3-10%. Chronic bronchitis is 2-3 times more likely to develop in men aged 40 years. In modern pulmonology, chronic bronchitis is said to occur if exacerbations of the disease lasting at least 3 months are noted for two years, which are accompanied by a productive cough with sputum production. With a long-term course of chronic bronchitis, the likelihood of diseases such as COPD, pneumosclerosis, pulmonary emphysema, cor pulmonale, bronchial asthma, bronchiectasis, and lung cancer increases significantly. In chronic bronchitis, the inflammatory lesion of the bronchi is diffuse and eventually leads to structural changes in the bronchial wall with the development of peribronchitis around it.

The reasons

Among the reasons causing the development of chronic bronchitis, the leading role belongs to the long-term inhalation of pollutants - various chemical impurities contained in the air (tobacco smoke, dust, exhaust gases, toxic fumes, etc.). Toxic agents have an irritating effect on the mucous membrane, causing a restructuring of the secretory apparatus of the bronchi, hypersecretion of mucus, inflammatory and sclerotic changes in the bronchial wall. Quite often, an untimely or incompletely cured acute bronchitis is transformed into chronic bronchitis.

The mechanism of development of chronic bronchitis is based on damage to various parts of the system of local bronchopulmonary protection: mucociliary clearance, local cellular and humoral immunity (the drainage function of the bronchi is disturbed; the activity of a1-antitrypsin decreases; the production of interferon, lysozyme, IgA, and pulmonary surfactant decreases; the phagocytic activity of alveolar macrophages is inhibited and neutrophils).

This leads to the development of the classical pathological triad: hypercrinia (hyperfunction of the bronchial glands with the formation of a large amount of mucus), dyscrinia (increased sputum viscosity due to changes in its rheological and physico-chemical properties), mucostasis (stagnation of thick viscous sputum in the bronchi). These disorders contribute to the colonization of the bronchial mucosa by infectious agents and further damage to the bronchial wall.

The endoscopic picture of chronic bronchitis in the acute phase is characterized by hyperemia of the bronchial mucosa, the presence of a mucopurulent or purulent secret in the lumen of the bronchial tree, in the later stages - atrophy of the mucous membrane, sclerotic changes in the deep layers of the bronchial wall.

Against the background of inflammatory edema and infiltration, hypotonic dyskinesia of large and collapse of small bronchi, hyperplastic changes in the bronchial wall, bronchial obstruction easily joins, which maintains respiratory hypoxia and contributes to an increase in respiratory failure in chronic bronchitis.

Classification

Clinical and functional classification of chronic bronchitis distinguishes the following forms of the disease:

1. By the nature of the changes: catarrhal (simple), purulent, hemorrhagic, fibrinous, atrophic.
2. According to the level of damage: proximal (with predominant inflammation of the large bronchi) and distal (with predominant inflammation of the small bronchi).
3. By the presence of a bronchospastic component: non-obstructive and obstructive bronchitis.
4. According to the clinical course: chronic bronchitis of a latent course; with frequent exacerbations; with rare exacerbations; continuously recurring.
5. According to the phase of the process: remission and exacerbation.
6. According to the presence of complications: chronic bronchitis complicated by pulmonary emphysema, hemoptysis, respiratory failure of varying degrees, chronic pulmonary heart (compensated or decompensated).

Symptoms of chronic bronchitis

Chronic non-obstructive bronchitis is characterized by cough with mucopurulent sputum. The amount of coughed up bronchial secretion without exacerbation reaches 100-150 ml per day. In the phase of exacerbation of chronic bronchitis, the cough intensifies, the sputum becomes purulent, its amount increases; join subfebrile condition, sweating, weakness.

With the development of bronchial obstruction, expiratory dyspnea, swelling of the neck veins on exhalation, wheezing, and whooping cough-like unproductive cough are added to the main clinical manifestations. The long-term course of chronic bronchitis leads to thickening of the terminal phalanges and nails of the fingers (“drumsticks” and “watch glasses”).

The severity of respiratory failure in chronic bronchitis can vary from mild shortness of breath to severe ventilation disorders requiring intensive care and mechanical ventilation. Against the background of an exacerbation of chronic bronchitis, decompensation of concomitant diseases can be noted: coronary artery disease, diabetes mellitus, dyscirculatory encephalopathy, etc. The criteria for the severity of an exacerbation of chronic bronchitis are the severity of the obstructive component, respiratory failure, and decompensation of concomitant pathology.

In catarrhal uncomplicated chronic bronchitis, exacerbations occur up to 4 times a year, bronchial obstruction is not pronounced (FEV1> 50% of the norm). More frequent exacerbations occur with obstructive chronic bronchitis; they are manifested by an increase in the amount of sputum and a change in its nature, significant violations of bronchial patency (FEV1 purulent bronchitis occurs with constant sputum production, a decrease in FEV1

Diagnostics

In the diagnosis of chronic bronchitis, it is essential to determine the anamnesis of the disease and life (complaints, smoking experience, occupational and household hazards). Auscultatory signs of chronic bronchitis are hard breathing, prolonged exhalation, dry rales (whistling, buzzing), wet rales of various sizes. With the development of emphysema, a boxed percussion sound is determined.

Verification of the diagnosis is facilitated by radiography of the lungs. The X-ray picture in chronic bronchitis is characterized by mesh deformation and increased lung pattern, in a third of patients - signs of emphysema. Radiation diagnostics allows to exclude pneumonia, tuberculosis and lung cancer.

Microscopic examination of sputum reveals its increased viscosity, grayish or yellowish-green color, mucopurulent or purulent character, a large number of neutrophilic leukocytes. Bacteriological sputum culture allows to identify microbial pathogens (Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Moraxella catarrhalis, Klebsiella pneumoniae, Pseudomonas spp., Enterobacteriaceae, etc.). With difficulties in collecting sputum, bronchoalveolar lavage and bacteriological examination of bronchial washings are indicated.

The degree of activity and the nature of inflammation in chronic bronchitis is specified in the process of diagnostic bronchoscopy. With the help of bronchography, the architectonics of the bronchial tree is evaluated, the presence of bronchiectasis is excluded.

The severity of violations of the function of external respiration is determined during spirometry. The spirogram in patients with chronic bronchitis demonstrates a decrease in VC of varying degrees, an increase in MOD; with bronchial obstruction - a decrease in FVC and MVL. With pneumotachography, a decrease in the maximum expiratory flow rate is noted.

From laboratory tests for chronic bronchitis, a general analysis of urine and blood is carried out; determination of total protein, protein fractions, fibrin, sialic acids, CRP, immunoglobulins, and other indicators. In case of severe respiratory failure, CBS and blood gas composition are examined.

Treatment of chronic bronchitis

Exacerbation of chronic bronchitis is treated inpatient, under the supervision of a pulmonologist. At the same time, the basic principles of the treatment of acute bronchitis are observed. It is important to exclude contact with toxic factors (tobacco smoke, harmful substances, etc.).

Pharmacotherapy of chronic bronchitis includes the appointment of antimicrobial, mucolytic, bronchodilating, immunomodulatory drugs. For antibiotic therapy, penicillins, macrolides, cephalosporins, fluoroquinolones, tetracyclines orally, parenterally or endobronchially are used. With viscous sputum that is difficult to separate, mucolytic and expectorant agents (ambroxol, acetylcysteine, etc.) are used. In order to stop bronchospasm in chronic bronchitis, bronchodilators (eufillin, theophylline, salbutamol) are indicated. It is mandatory to take immunoregulatory agents (levamisole, methyluracil, etc.).

In severe chronic bronchitis, therapeutic (sanation) bronchoscopy, bronchoalveolar lavage can be performed. To restore the drainage function of the bronchi, auxiliary therapy methods are used: alkaline and pulmonary hypertension. Preventive work to prevent chronic bronchitis is to promote smoking cessation, eliminate adverse chemical and physical factors, treat comorbidities, increase immunity, timely and complete treatment of acute bronchitis.