Chuchalin bronchial asthma. Free Download Chuchalin A.G. Approximate word search
Citation:Chuchalin A.G. Heavy bronchial asthma // RMW. 2000. №12. P. 482.
Research Institute of Pulmonology Ministry of Health of the Russian Federation
In modern society, bronchial asthma (BA) applies to the number of the most common diseases. Thus, among the adult population, the disease is registered in more than 5% of cases; Children are ill even more often - up to 10%. In recent years, in the framework of the Society of Pulmonologists in Russia, modern epidemiological studies were conducted, the methodology of which was built on the recommendations of the European respiratory society. The importance of these studies is dictated by the fact that the Ministry of Health of the Russian Federation leads extremely low figures of the morbidity of Ba, not exceeding several pomils. On international scales, the official data of the Ministry of Health of the Russian Federation always cause surprise due to such a low prevalence of the disease among residents of Russia. Conducted epidemiological studies (S.M. Gavalov et al., I.V. Leshchenko et al., T.N. Bilichenko et al.) Allowed the prevalence of the disease, which among children and adolescents in the cities of Novosibirsk and Moscow exceeded 9% and Among the adult population was about 5% in Yekaterinburg. Based on these most confidential epidemiological data, it can be argued that BA is also relevant in Russia, as in other European countries; The total number of patients with asthma in the country is approaching 7 million people. However, as already reported, the Ministry of Health of the Russian Federation takes into account less than 1 million patients. There is a natural question: what kind of patients are we talking about? First of all, in official medical statistics there are information about heavy patients who repeatedly cause ambulance, several times a year come to hospitals and undergo long courses of inpatient treatment, i.e. Predestly are patients with a severe disabled course of the disease. If you interpret official medical statistics, it corresponds to world practice. In this case, it should be postulated that there are about 7 million patients in Russia, from among which about 1 million have severe forms of illness.
At the present stage of medical science, heavy forms of Ba are an urgent problem. Along with the widespread increase in the number of patients suffering from this pathology of respiratory, there is a sustainable trend towards an increase in the number of patients who need emergency care; They are often hospitalized in hospitals due to the severe course of the disease. The aggravation often threatens the life of a sick person. In the United States, the increase in fatal outcomes is marked almost 2 times; In the past three decades, epidemics of deaths in Briting and New Zealand were described.
This article pursues the goal to define a heavy Ba, describe pathological and pathophysiological characteristics, identify the main medical programs in this form of the disease.
Terminology
The term "heavy bronchial asthma" includes a number of clinical syndromes, which unites life-threatening disease. Two terms are most often used in the Russian-language medical literature: aestmatic state and anaphylactic shock, while in English-language literature the following terms are used: Acute Severe Asthma, Status Asthmatecs, Brittle Asthma, Fatal Asthma, Chronic Difficult Asthma, Sudden Onset Attacks, Slow Onset Attacks. Naturally, the question arises: are these synonyms or terms reflect various forms of heavy flow ba? The Russian analogues of the Anglo-Petural Terms could be as follows: Acute heavy asthma, asthma, unstable asthma, fatal asthma, severe chronic asthma, suddenly occurring a heavy asthmatic attack, slowly developing asthmatic attack.
Term "Acute heavy asthma" It implies a sharp beginning of the disease that flows so hard that threatens the life of the patient. Astmatic condition is characterized by a clinical picture of an increasing exacerbation and a sharp decrease in the effectiveness of bronchussessing drugs. In the clinical picture of the exacerbation of BA appears such syndrome as "Silent Easy"; In particularly severe cases, hypoxic coma develops.
Unstable Ba. - relatively new term for Russian medicine. This term describes the patients of BA with allegedly selected treatment, but with suddenly arising severe exacerbations. A striking example is an aspirot form of the disease, when a sudden severe aggravity is provoked by the reception of non-steroidal anti-inflammatory drugs.
Term "Chronic Heavy BA" used in cases where the disease is poorly controlled by inhalation glucocorticosteroids; There is a need to prescribe systemic steroid drugs. Term "Fatal asthma" Used to describe sudden death in a patient suffering from ba. It must be said that this topic is not sufficiently developed in a domestic medical school. Terms "Suddenly or slowly emerged asthmatic attack" Reflect the rate of development of the disease. So, an example is the slow down aggravation of the disease occurring during respiratory viral infection.
Thus, heavy Ba Form is not a homogeneous concept. ; Under this term combined a number of syndromes reflecting the severity of the disease. However, it should be emphasized to emphasize the overall decrease in the effectiveness of armored drugs, up to paradoxical action, and the exacerbation of the patient's life.
Patomorphological features
The definition of the disease is based on an inflammatory concept. In recent years, the question of the morphological features of the severe course of the disease has been discusted; This plan will reach a certain progress. The main morphological changes at BA are damage to epithelial cells and their death; Deskvamated epithelium accumulates in the lumen of the respiratory tract together with the viscous bronchial secret, eosinophils and lymphocytes. Thus, in the lumen of the respiratory tract, the mucous plug is formed, sometimes completely empolving the lumen of the respiratory tract (the "silent lung syndrome"). For heavy forms, Ba is characterized by mass the death of epithelial cells and a large number of mucous traffic jams .
Another morphological feature of the disease is the changes coming in the basal membrane. Basal membrane thickened The scar changes are formed in its reticular part. The described morphological changes of the basement membrane are a pathognomonic feature of Ba, which is distinguished by chronic bronchitis and other chronic respiratory diseases. Heavy forms of the disease are accompanied by more pronounced changes in the basal membrane. It is believed that if morphometric changes detect a significant thickening of the basal membrane, then this is typical for heavy forms of ba.
Big changes occur from glass and serous glands which are in the state of hypertrophy and hyperplasia. It is believed that the described changes are expressive than the heavier disease flows. In Lamina Propria, active angiogenesis . However, most of all correlates with the severity of the disease hypertrophy of smooth bronchi sobs . With severe forms, the muscular mass increases by more than 200%.
In recent years, the morphological restructuring process (Remodeling) has been actively discussed. For Remoilding, a pronounced desquamation of epithelial cells is characterized; The latter of the basal membrane, which is thickened, and in its reticular part there is a fibrous process; Hypertrophy of smooth muscles and angiogenesis. The heavy forms of BA are associated with the process of remocioning, in which not only morphological changes occur, but the function of many cells (eosinophils, fat cells, myofibroblasts) is also modified.
The new knowledge of these morphological and biological changes occurring at the progressive forms of BA influence the treatment programs. So, therapeutic approaches to the use of bronighting agents, glucocorticosteroids change significantly; Active scientific search of new drugs for the treatment of heavy forms of BA is underway. Special attention is paid to regulating the process of hypertrophy of smooth muscles. The trophic factors of smooth muscles are histamine, thrombin, thromboxane A 2, endothelin, an epidermal growth factor, tryptase, interleukin-1. It must be emphasized that glucocorticosteroids do not affect this process; They associate the myopathy of respiratory muscles (diaphragm, intercostal muscles and muscles of the upper shoulder belt). Some perspective opened with the introduction of leukotriene receptor inhibitors capable of suspending the increasing hypertrophy of the smooth muscles of bronchi.
Reducing the efficiency of glucocorticosteroids with severe forms of Ba is associated with changes in the spectrum of inflammation cells accumulated in the mucous membranes of the respiratory tract. Eosinophilic infiltration is inferior to the preferential migration of neutrophils, which may affect the biological effects of steroids.
Causes of factors
Of great interest is the study of causal factors capable of leading to the difficult course of exacerbation of BA. Most often lead to the exacerbation of BA infectious viral diseases respiratory tract. A person prone to allergic reactions to a viral respiratory disease corresponds to the increased production of interleukins 4 and 5, which is due to the high polarization of Th 2-cells. The immunological response to the viral disease of a person with normal physiological reactions will manifest an increase in G-interferon products. This process occurs when the TH 1 is activated. Thus, biological patterns underlie the occurrence in patients with exacerbations in viral respiratory diseases. The exacerbation of the disease will be as follows on the 3-5th day of an acute infectious start. In this time, an increase in the number of eosinophils in peripheral blood is occurring and their migration in the mucous respiratory tract increases. Most often lead to the exacerbation of BA coronaviruses, rhinoviruses, respiratory syncitial virus and paragripping virus. Viruses lead to damage to epithelial cells, mucociliary clearance is disturbed, mechanisms for the protection of the mucous respiratory tract are reduced, which contributes to adhesion and invasion of microorganisms. Inflammation caused by viral penetration is accompanied by an increase in the activity of inflammation mediator (cytokines, nitrogen oxide, kinin, arachidonic acid metabolites, active oxygen forms). In the process of inflammatory response induced by viral damage, changing the sensitivity of cholinergic receptors, the disregulation of B-receptors occurs, thus the regulation of the neholinergic - nonadenergic system is disturbed. Sick bars become extremely sensitive to the effects of factors with the construitory properties. If we consider that every person takes a sharp respiratory disease several times during one calendar year, then the role becomes clear and the importance of these diseases in the occurrence of BA exacerbation. Some of the patients suffer severe aggravation of the underlying disease.
Certain Group medicinal preparations may lead to heavy exacerbations of Ba; First of all, this concerns acetylsalicylic acid and analgesics. Patients Ba, having such manifestations, as - swelling of the nasal mucosa, polypose growth, periorubital edema, urctural rash, should always cause alertness when prescribing non-steroidal anti-inflammatory preparations (NSAIDs). Among patients so-called aspirin Asthma The highest percentage of deaths, which is associated with careless appointment by doctors of different specialties NSAIDs. With this form of disease, patients often recommend the reception of systemic steroid drugs. In recent years, inhibitors of leukotriene receptors began to be prescribed, which significantly improved the forecast in the intolerance to aspirin.
In cardiological practice, we found wide application b-blockers and inhibitors of angiotensin glossy enzyme (IAPF). B-receptor blockers refer to the number of bronchokonstrictors, so they are contraindicated with patients ba. In clinical practice there are patients with coronary heart disease, which is successfully treated with this group of drugs for a long time, but often after the transferred viral disease, their reception begins to provoke bronchospasm. Another common group of drugs appointed in patients of the cardiological profile - IAPF. They are in a fairly high percentage of cases (more than 30%) lead to cough and more than 4% cause exacerbation of Ba. It should be noted that angiotensin receptor inhibitors do not provoke the occurrence of cough and exacerbation of Ba.
Factors of the external environment have a major role on the occurrence of severe disease. Among pollutants With a pronounced bronchokonstricative action, sulfur and nitrogen dioxides are labeled, ozone, black smoke. Damaging action allergens Potentiate while simultaneously exposed to the respiratory tract of pollutants. In recent years, data has accumulated on the aggressive impact of tobacco smoke on the respiratory pathways of the person. The multicomponent tobacco smoke has a pronounced violation of mukiciliary clearance, some of its components act as allergens, causing sensitization.
The heavy form of BA is characterized by a high degree of respiratory tract hyperreactivity, a high resistance level of respiratory tract airflow and a sharp decrease in the clinical efficacy of bronchus-sewing drugs. The relationship of all three components of heavy flow BA occurs due to the inflammatory process in the respiratory tract. It has been established that the high resistance of the respiratory tract is in a direct correlation dependence on the degree of accumulation of inflammatory cells in the bronchi wall.
Unstable Ba.
The phenomenon of hyperreactivity underlies the allocation of unstable ba. Allocate two forms of unstable ba. The first is characterized by a high degree of variability of the peak feed rate (PSV), although the treatment is selected on the basis of the form. In the clinical picture of such patients prevail symptoms of sudden exacerbation of Ba. The exacerbation of the disease is preceded by a large difference in the indicators of the morning and evening PSV, exceeding 20%. These changes should always be alarmed by the doctor, in such patients, the conductable therapy should be subjected to a thorough audit of inhalation glucocorticosteroids and prolonged B 2 -Gonists, but their state is unstable. It is possible that instability is associated with inhalers that contain freon, therefore, assigning the same drugs in the form of a dry powder, you can significantly improve the condition of the patients. The second clinical form of unstable BA is characterized by the sudden development of severe exacerbation, although the initially sick person received individually selected treatment with a good effect. An example of such a clinical option is patients with intolerance to aspirin and other NSAIDs, in which, with good initial state, the hardest exacerbation may be played after receiving the provoking drug.
Sudden death of patients ba
A little learned problem remains a sudden death of patients ba. In the UK, in the mid-60s, there was an epidemic of deaths in patients with Ba, which was associated with uncontrolled use in high doses of non-selective sympathomimetics. At that time, the sudden deaths of patients of Ba were described, which happened against the background of the peaceful breathing of patients. Experimental data showed that sympathomimetics can have a cardiotoxic effect, especially in hypoxic states; With this adverse action of sympathomimetics, the possibility of the development of ventricular fibrillation and the sudden death of the patient with a satisfactory initial state of the respiratory function are associated.
Astmatic state
A special place in heavy ba is an asthmatic state (Status AsthMaticus). The emergence of a asthmatic state in patients with BA is preceded by the aggravation of the disease; It takes several days and even weeks before the development of such a hard exacerbation, which is an asthmatic state. The most characteristic feature of this exacerbation period is a sharp decrease in the effectiveness of sympathomimetics; Moreover, they begin to act paradoxically. A very important aspect in the conduct of this category of patients is early diagnosis and adequate treatment, which would prevent the development of coma.
Assessment of the state of patients Includes a clinical picture of exacerbation, the scope of consciousness, the degree of total fatigue, the nature of the cyanosis, the fatigue of the respiratory muscles, the data of percussion and auscultation. The clinical picture of an asthmatic state indicates the extreme severity of the patient of Ba. The sick person occupies forced position - Sits in bed, hands fixes the upper shoulder belt, whistling whears are heard at a distance, the speech is extremely difficult, since each word is accompanied by an oppressive deterioration in the state of the patient. Draws attention unproductive cough , it rarely occurs, the wet due to severe viscosity does not leave, with the appearance of cough, the patient's condition becomes even worse; The described clinical picture of the exacerbation of the disease is preceded by the intensive use of dosage inhalation sympathomimetics. It must be remembered that with the help of these drugs, it will not be possible to withdraw a patient from an asthmatic state.
Large prognostic value in the assessment of the patient's condition has sphere of consciousness . With increasing manifestations of hypoxia, patients can be excited, the excitement ends with convulsions and a coma. Excitation and coma precedes progressively increasing treatment of the patient , All the work of breathing is aimed at overcome resistance to exhale: a short breath and without a pause, a long-term painful and difficult exhale. In respiratory act, the auxiliary muscles of the shoulder belt, intercostal muscles and a hard work of the diaphragm participate. The degree of respiratory failure should always be assessed by the fate of the muscles of the neck in the act of breathing, to the population of intercostal intervals and the appearance of thoracoabdominal discordination; The appearance of these features indicates a serious manifestation of an asthmatic state. Another unfavorable sign of the heavy form of Ba is the appearance of blue diffuse cyanosis indicating significant changes in oxygen transport. Percussion and auscultation Allowed to get very important diagnostic information. BA can be complicated by the development of pneumothorax, which is more common in young patients. Percussion allows you to suspect pneumothorax; The final diagnosis is made after the radiography of the chest organs. Auscultation can reveal an important phenomenon "Silent Easy": wheezing are suspended remotely in the bed of the patient and are absent with the lungs auscultation. The appearance of the described syndrome indicates a severe and prognostically unfavorable course of the exacerbation of Ba, which is accompanied by increasing hypoxhemia and hypercapper.
Special attention deserves external respiratory rating. It is recommended to resort to research peak speed of exhalation ; Indicators below 200 l / min indicate a serious exacerbation of BA. Acute respiratory failure is accompanied by the appearance paradoxical pulse . The methodology for determining the paradoxical pulse: the first tone of Korotov is measured at the height of the inhalation and at the depth of the exhalation, if the difference exceeds 12 cm rt, then we can talk about a paradoxical pulse. Syndrome "Silent Light" and a positive paradoxical pulse indicate a serious manifestation of an asthmatic state that requires urgent events.
Medical program It is carried out necessarily with a constant participation of the doctor, medical oxygen is provided (2-4 l in 1 min). Medicate funds that are used in the treatment of an asthmatic state are not much different from basic therapy, however the delivery method, the dosage form of these drugs differ significantly from those used to maintain the remission of patients ba. At asthmatic state, short-range preparations are prescribed, i.e. The reception of prolonged sympathomimetics (Salmetterol, Formoterol, Saltos) and Theophyllins (Teofek, etc.) ceases. This principle is dictated by the need to title doses of drugs in a short period of time. Especially it should be drawn to the fact that it is necessary to avoid the appointment of prolonged (depot) steroid drugs - they are contraindicated with bars.
The treatment of an asthmatic state should begin with a solution inhalation salbutamola. At a dose of 2.5 or 5 mg through a nebulizer. This dose can be repeated over the next 40-60 minutes. The question arises regarding the assumption about the negative role of sympathomimetics in the treatment of an asthmatic state. The introduction of salbutamol through the nebulizer allows you to avoid freon inhalations, which is significantly in achieving the desired effect. In these doses, Salbutamol has a stimulating effect on the operation of respiratory muscles, which is very important in the fight against their fatigue. A good effect is achieved when combined salbutamola and Bromide Ipratropium which potentiates brightness.
Glucocorticosteroids Assigned according to life indications in patients with asthmatic state. In the initial manifestations of the asthmatic state, preference is given to the appointment of inhalation forms of steroids (budesonide) in the form of a suspension for nebulizer therapy. However, in Russia, practical doctors are more often prescribed by PER OS prednison at a dose of 30 mg or intravenously 200 mg of hydrocortisone. It is necessary to emphasize that the intravenous administration of the euphilline is not an appointment of the first line. Reducing oxygen voltage up to 60 mm Hg. and an increase in carbon dioxide voltage above 45 mm Hg. indicate severe respiratory failure in a patient with an asthmatic state and should be considered as an absolute indication for the artificial ventilation of the lungs. The big perspective is associated with the appointment. helium In heated form. Helium significantly reduces the level of turbulence of the air flow in the respiratory tract, thereby improving the gas exchange function of the lungs.
Fenoterol -
Berotek N.(tradename)
(Boehringer Ingelheim)
Salbutamol -
Salamole Stherinb (tradename)
(Norton Healthcare)
81 - M.: Medicine, 1985. 160 p., Il. 50 k. - 100,000 copies.
All aspects of bronchial asthma are comprehensively covered in the book. Development factors, immunopathology of asthma, a clinical picture of the disease, medication and climatic treatment of patients, intensive therapy in the seaside period are described. The clinical pharmacology of drugs used in the treatment of bronchial asthma is described in detail.
The book is designed for therapists.
Preface
The last 20-30 years are characterized by increasing the incidence and severity of the flow of bronchial asthma. According to social significance, bronchial asthma comes out on one of the first places among respiratory diseases.
Thanks to active scientific research, medical practice is enriched with new data, which concerns aspects such as epidemiology, immunopathology of bronchial asthma. There are fundamentally new methods for studying the function of external respiration. The study of the clinical picture of bronchial asthma was replenished with new data. Thus, in recent years, there have been issues such as the exchange of prostaglandins in patients with bronchial asthma and intolerance of non-steroidal anti-inflammatory funds, the features of asthma of physical effort, the asthma of food genesis. Therapeutic capabilities expanded. Assessment from the current positions of traditional medication, the role and place of those that have recently appeared are important issues of practical medicine requiring regular lighting. "
In this book, the author, summarizing his many years of experience, the results of scientific observations and research at the Department of Internal Diseases II Molm. N. I. Pirogova and literature data, sought to answer questions arising in everyday clinical practice.
Corresponding Member of the AMN USSR, head. Department of internal diseases
II MOLGMY them. N. I. Pirogova
A. G. Chuchalin
Publishing House "Medicine", 1985
List of abbreviations
Definition and classification
Hell - blood pressure
Balt - Bronchi-Associated Lymphoid Tissue of the VGO - Gas Source
VIP - vasoactive intestinal peptide
Zan - Lung Little Capacity
IgG, IGM - Immunoglobulins CT - Catechol-O-methyltransferase LHF - Lipid Chemotaxic Factor
MVL - maximum lung ventilation
MRC-A - Slowly reacting anaphylaxia substance
NSPP - Nonsteroidal anti-inflammatory drugs
NHF - High Molecular Neutrophil Chemotaxic Factor OCG - General Plethmography
OFV - the volume of forced exhalation
PGE, PGF - Prostaglandins
PSDV - air speed indicator
Fat - platelet activation factor
FVD - Function of External Breath
Fire - Forced Little Life Capacity TSAMF - Cyclic Adenosine Monophosphate TsGMF Cyclic Guanosinmonofosfat
ECP - Eosinophilic Chemotaxic Peptide
Echfa - eosinophilic chemotactic anaphylaxis factor
In most currently currently definitions of bronchial asthma, predominantly clinical signs are used as criteria. Stress out the generalization and reversibility of violations of bronchial patency, increased sensitivity of tracheas and bronchi to physical or chemical stimuli, the presence of night attacks of choking.
In our country, the very proliferation of the disease was obtained, given G. B. Fedoseev (1982). According to this definition, bronchial asthma is an independent chronic, recurrent disease, the main and mandatory pathogenetic mechanism of which is the modified reactivity of bronchi, due to specific immunological (sensitization and allergies) or non-specific mechanisms, and the main (mandatory) clinical sign - the attack of suffocation due to bronchospasm, hypersecretions and swelling of the mucous membrane of the bronchi.
This definition highlighted the main signs of bronchial asthma: the hyperreactivity of the bronchi, manifested by the spasm of smooth muscles, edema and hypersecretion, and the development of suffocation. G. B. Fedoseev rightly emphasizes that the existing hyperreactivity of the bronchi can be caused by factors with both immunological and non-immunological mechanisms.
The factors provoking the development of asthma are so numerous and diverse, and the flow options are so unlikely, which arises an assumption about the existence of several diseases, various pathogenesis, which are combined with the term "bronchial asthma".
The classification of individual forms of bronchial asthma throughout the history of its study was the subject of a broad discussion. In the middle of the last century, neurogenic mechanisms of asthma were intensively studied intensively, in which the neurogenic factor was dominant. The next important stage was the study of allergic reactions, their role in the emergence and development of bronchial astmg! At the beginning of the century, an anaphylactic theory of bronchial asthma appeared, which in the 20s was transformed into the allocation of an atonic (allergic) form of asthma [co-"Sat A. F. J., Cooke R. A., 1923].
Further study of the mechanisms of the disease, as well as a careful ayaliz of clinical manifestations and features of the flow of asthma, made it possible to establish such a variety of forms that could not be explained from the standpoint of one or another theory. As a result, generalizing work appear, in which they are trying to substantiate the allocation of the hereditary form of the disease, toxic, psychopathic, reflex.
Practical application and the greatest distribution received the classification proposed by Racker (1944), according to which exogenous (extrinsic) and endogenous (intrinsic) forms of bronchial asthma are isolated.
With an exogenous form, it is possible to establish increased sensitivity using an allergological examination, to identify an allergen or group of allergens and thus prove the allergic nature of the disease. If the allergen to identify fails and the nature of the disease remains unclear, asthma can be considered endogenous. SJ In our country, the classification of P. K. Bulatova and A. D. ADO (1968) was more often used, according to which allergic (atonic) and infectious-allergic forms of the disease. In this classification, there was a reflection of an attempt to consider a natural frequent combination of asthma with chronic bacterial bronchius.
In the past 20 years, aspirin (prostaglandin) asthma was studied in more detail, which is based on not allergic reactions, and the perverted reaction of prostaglandins on non-steroidal anti-inflammatory agents (NSPP) was isolated by asthma of physical effort, which in some patients may be a feature of the disease, and Others - the main syndrome. The interest in neurogenic factors, which may cause the occurrence and progression of the disease. Hormonal disorders in patients with bronchial asthma are not sufficiently studied. Clinical observations indicate the non-random combination of some endocrinopathies with asthma.v
The achievements of the last 20-30 years have made it specific to the tire of genetic forms of the disease. Special attention deserves forms in which the balance in the functional activity of adrenergic and choliner receptors is disturbed. The majority of meteorological factors, as well as infectious processes in the respiratory tract .
As a result of numerous observations and a special examination of patients with asthma, it can be considered that the mechanisms of formation of the disease are different, and the same person can observe hypersensitivity to pollen allergens and aggravation of asthma, provoked by viral infection of the respiratory tract, clinical features of asthma of physical effort and hormonal disorders, Increased sensitivity to nonsteroidal anti-inflammatory means and meteorological factors, significant psycho-emotional lability.
It is fundamentally important to recognize the release of bronchial asthma as an independent nosological unit, taking into account the existence of clinical forms with the predominance of various pathogenetic mechanisms /
The classification of bronchial asthma G. B. Fedoseyev (1982) is generally recognized. The author highlights the stages of the development of the disease, the form of bronchial asthma, pathogenetic mechanisms, the severity of the flow of bronchial asthma, the phase of the flow of bronchial asthma and complications.
Classification of bronchial asthma [according to Fedoseyev G. B., 1982] I. Stages of the development of bronchial asthma
1. The state is betrayed. This term denotes states representing the threat of the appearance of bronchial asthma. These include acute and chronic bronchitis, acute and chronic pneumonia with elements of bronchospasm, combined with vasomotor rhinitis, urticule, vasomotor swelling, migraine and neurodermitomit in the presence of eosinophilia in the blood and elevated content of eosinophils in sputum due to immunological or non-immunological mechanisms of pathogenesis.
2. Clinically decorated bronchial asthma - after the first attack or the status of bronchial asthma
P. Bronchial Asthma Forms
1. Immunological form
2. Non-immunological form
III. Pathogenetic mechanisms of bronchial asthma
1. ATONIC - indicating allergenic allergen or allergens
2. Infectious-dependent - indicating infectious agents and the nature of infectious dependence, which can manifest itself to the stimulation of the atopic reaction, infectious allergies and the formation of the primary changed reactivity of bronchi
3. Autimmune
4. Domor monomal - with an indication of the endocrine organ, the function of which is changed, and the nature of the dormriconal changes
5. Neriva-mental with options for neuropsychiatric changes
6. Adrenergic imbalance
7. The primary changed reactivity of bronchi, which is formed without the participation of the changed reactions of immune, endocrine and nervous systems, may be congenital, manifested by chemical, physical and mechanical irritants and infectious agents and is characterized by attacks of choking during exercise, exposure to cold air, medicines and t. d.
Note. There are various combinations of mechanisms, and by the time of the examination, one of the mechanisms is the main one. The patient may have one pathogenetic mechanism of bronchial asthma. In the process of development of bronchial asthma, a change of basic and secondary mechanisms may occur.
IV. The severity of the flow of bronchial asthma
1. Easy current
2. Middle severity
3. Heavyweight
V. Phase of the flow of bronchial asthma
1. The exacerbation
2. Radiant exacerbation
3. Remissee
Vi. Complications
1. Pulmonary: lung emphysema, pulmonary failure, atelectasis, pneumothorax, etc.
2. Empty: myocardial dystrophy, pulmonary heart, heart failure, etc.
The classification of G. B. Fedoseeva is one of the most complete. Allocation will betray-we have a great practical value. When evaluating this state, not only background diseases can be taken into account, which can be transformed into bronchial asthma, but also an increased reactivity of the bronchi, which should be considered a mandatory feature.
It is important to distinguish not only the immunological forms of the disease, but also clinical. The modern clinic has accumulated a specific experience in keeping patients with an allergic, infectious form of bronchial asthma. The aspirin (prostaglandin) form of the disease, asthma of physical effort, neurogenic and mixed forms of the disease are distinguished. In clinical practice, a steroid-dependent form of the disease is often distinguished.
A.G. Chuchalin: "Asthma is not a reason to refuse even from the career of the soloist of the Bolshoi Theater"
Academician Ramne, Professor, Doctor of Medical Sciences, Director of the Moscow Research Institute of Pulmonology, Alexander Grigorievich Chuchalin - sign figure in modern therapy. It is he who is rightfully considered the founder of the Public School of Pulmolonium. Therefore, when a large number of questions about the treatment of bronchial asthma (BA) came to the editorial board, we thought: "To whom to ask them, if not Alexander Grigorievich?" And they were very pleased that the respected scientist, the world-famous clinician not only agreed to meet with us, but also gave detailed answers and recommendations for our readers.
Alexander Grigorievich, one of the readers of the "Pharmacy Council", an employee of the pharmacy, noticed: for the means to treat bronchial asthma they are treated several times a week. Is this a disease so widespread so widespread?
Bronchial asthma is a very common occurring disease around the world and in our country in particular. The data that I will give, diverge with the figures of official statistics. The reason for the discrepancies is simple: Ministry of Health and Social Development takes into account only those patients who add to the medical institutions about Ba (as a rule, cause ambulance and enroll in the hospital). Recently, the number of such patients is reduced. We also have data from epidemiological studies, according to which in the children's population of BA occurs in 7-8%. In an adult population, asthma is somewhat less common, it is detected only in 4-5% of people. It turns out about 6 million people, and this, you agree, a lot.
I believe that in recent years we have achieved significant success in the fight against asthma due to the fact that modern clinical guidelines have introduced into practice, based on the World Health Organization. They give a clear definition that such a bronchial asthma is what the criteria for diagnosis are very important for the domestic school of pulmonologists. Previously there were disagreements, and even some ambiguity was even in important points. For example, it was not entirely clear what to consider bronchial asthma, but what a different disease. But now we, fortunately, it was overcome and, moreover, achieved good results in control over bronchial asthma.
Speaking about the treatment of bronchial asthma, this term is often used - control. What does he mean? That the disease can not be heal, but can be controlled?
Not certainly in that way. To explain the terminology, I will start from afar. Asthma is treated depending on the degree of severity: light, medium severity or severe. In addition, there are concepts of exacerbation when the attacks happen often, and remission, when the patient's condition remains satisfactory for a long time.
The main symptoms of bronchial asthma are:
Supported cough, the nature of the attack of suffocation (we say "paroxysmal cough", "paroxysm" translated from Greek means "strengthening");
Dyspnea, or how often patients themselves say, choking. Dyspnea can appear both in the daytime and among the night. By the way, the development of attacks at night testifies to the more severe course of asthma;
The appearance of viscous, or, as they write in textbooks, the vitreous secret. After his departing, the patient's condition is dramatically improved.
Those. If a person is drawn to you with such complaints, can you say with confidence that he has bronchial asthma?
Some complaints are certainly not enough. It is necessary that they are supported by the data of the functional studies of the respiratory organs. For example, it is necessary to conduct a study of external respiratory parameters: measure the peak exhalation rate, forced the life capacity of the lungs in 1 second, etc. Those. There must be a functional diagnosis of bronchial asthma. In addition, we attach great importance to the identification of certain biochemical markers of allergies that are associated with increased production of immunoglobulin class E. Our institute is the Moscow Remonstorming Institute of Pulmonology, in which I work and lead, is constantly developing new approaches to the diagnosis of bronchial asthma. One of the recently open areas is to conduct highly sensitive tests for defining biomarkers, which allow to obtain confirmation of the presence of inflammatory processes in the respiratory tract with bronchial asthma. Such a marker, in particular, is nitrogen oxide.
Returning to the examination program, I will say that the doctor should not just listen to the patient, but to ask him targeted issues, clarify what kind of cough, what a sprome looks like and the like. Then explore the function of external respiration and conduct an allergological examination. All this allows you to determine the diagnosis of "bronchial asthma". But it is, as they say in the circles of specialists, still half agencies.
Those. Maybe in fact this patient does not at all bronchial asthma, and some other disease?
No, there are simply there are a lot of causing varieties of asthma. One of the most frequent is asthma associated with the flowering of plants. However, the disease can be associated with home dust, defined food products. Sometimes asthma is induced by viral, bacterial agents. The doctor is faced with the task of identifying risk factors that lead to the development of bronchial asthma, and thus determining its nature. There is, say, asthma, which is caused by the admission of aspirin - aspirin asthma. And there is an asthma associated with sports.
Are you talking about novice athletes who, having decided to link their lives with sports, suddenly feel the very attacks of choking?
Rather, professionals are among this category, asthma occurs much more often than in the overall population of the population. The leading number of bronchial asthma patients is detected among athletes. This is also facilitated by high loads on the respiratory system, and contact with allergens, such as chlorinated water pools, and much more. And all this must be considered when diagnosis. One of the first questions that, in my opinion, should ask a doctor to a patient with suspicion of bronchial asthma: "Who do you work?"
Alexander Grigorievich, are Pharmacy Workers in the Group of Increased Risk of Bronchial Asthma?
To this conditionally allocated group, I would include all people in contact with potential allergens, because bronchial asthma has an allergic nature. The smell in pharmacies, of course, specific, but I do not think that the employees of the trading room are so closely contacted precisely with medicinal substances. But employees of the recepting and production departments do relate to the group of potential risk. They would recommend working only in special masks, despite the inconvenience. This will reduce the likelihood of allergens into the respiratory tract.
What other preventive measures can you advise?
Unfortunately, in addition to minimizing contact with allergens - no. Persons with a burdened hereditary factor We can recommend to change the nature of nutrition, lifestyle, abandon smoking, sometimes you need to change the place of residence, but it is not always possible. Preventive reception of some specific drugs is also not prescribed - bronchial asthma is treated, as they say, on the fact of availability.
It is known that there is a treatment of an attack and there is basic therapy. What is more important? Or is it always necessary that both?
The main task is to affect the inflammatory process in the respiratory tract. In other words, it is necessary to treat precisely allergic inflammation - this is the basis anti-inflammatory treatment. If it is not, it is impossible to achieve good results. In 1995, we introduced local anti-inflammatory therapy into practice - these were inhaled glucocorticosteroids. They are used to this day - in a modified form, of course.
But with a light degree of bronchial asthma, especially in pediatrics, we do not begin therapy with inhalation steroids. First, it is advisable to assign, for example, leukotriene inhibitors. Therapy is consisted of several stages, and therefore the doctor sets the timing of determining the effectiveness of treatment. Let's say, prescribes the next visit in 2 weeks, after 1 month, then after 3 months, and then the doctor will be able to determine, "works" this treatment regimen or not.
The average severity of bronchial asthma is characterized by daily attacks of choking. The therapy described above will not be enough, so it is necessary to include in the treatment regimen inhalation glucocorticosteroids in combination with armor-taiters of two classes: short and long-term action. In this case, asthma should not be considered as "a disease of one visit to the doctor."
It is forced to state the fact that our patients are not well treated enough. We have research data by which the frequency of severe bronchial asthma reaches 20%. If asthma proceeds in severe form - say, the symptoms of the disease significantly violate the patient's sleep, lead to a decrease in the quality of life, disabled - we adhere to the treatment of asthma of medium gravity, but we increase the anti-inflammatory component. For example, in the composition of basic therapy, in addition to inhalation glucocorticosteroids, we assign leukotriene inhibitors.
Psychiatrists and psychotherapists consider bronchial asthma by a psychosomatic disease and, in connection with this, they recommend "to treat not the body, but the soul." How do you feel about psychotherapy as a possible method of treating asthma?
All over the world, it is recognized that the psychotherapeutic effect of partly determines the placebo effect for any diseases. However, research confirming the reliable effectiveness of psychotherapy at bronchial asthma is unknown. Of course, we must have a certain reserve of therapeutic effects and use them in certain situations. In my opinion, there are no psychotherapy to such reserve techniques, but the use of monoclonal antibodies to immunoglobulin E. To date, there is only one drug from this group, but I think it will soon have competitors.
Name: Pocket Guide for the treatment and prevention of bronchial asthma.
Chuchalin A.G.
The year of publishing: 2006
The size: 0.47 MB
Format: PDF.
Tongue: Russian
This pocket reference book "Pocket Guidelines for the Treatment and Prevention of Bronchial Asthma" was written on the basis of a global initiative (strategy) on bronchial asthma for doctors and medium medical personnel, issues such as diagnosis, classification and basic components of the treatment of bronchial asthma are considered, special occasions are considered in The treatment of bronchial asthma.
Name: Respiratory medicine. Volume 1.
Chuchalin A.G.
The year of publishing: 2017
The size: 30.42 MB
Format: PDF.
Tongue: Russian
Description: The first volume of the leadership "Respiratory medicine" edited by A.G. Chuchalina examines the anatomy-physiological, genetic and morphofunctional features of the respiratory system, in the book is given ... Download the book for free
Name: Respiratory medicine. Volume 2.
Chuchalin A.G.
The year of publishing: 2017
The size: 22.05 MB
Format: PDF.
Tongue: Russian
Description: The second volume of the leadership "Respiratory medicine" edited by A.G. Chuchalin examines respiratory infections (viral infections, pneumonia, sharp abscess and gangrene of the lungs, tuberculosis breathing ... Download the book for free
Name: Respiratory medicine. Volume 3.
Chuchalin A.G.
The year of publishing: 2017
The size: 15.22 MB
Format: PDF.
Tongue: Russian
Description: The third Tom of the Guide "Respiratory Medicine" edited by A.G. Chuchalina covers such pulmonology issues as infiltrative and interstitial lung diseases (idiopathic interstitial ... download book for free
Name: Chronic obstructive pulmonary disease. Guide for practicing doctors.
Chuchalin A.G., Ovcharenko S.I., Leshchenko I.V.
The year of publishing: 2016
The size: 3.14 MB
Format: PDF.
Tongue: Russian
Description: The presented book "Chronic obstructive pulmonary disease. Guide for doctors' practitioners" is considering the basic issues of the COPD, necessary in understanding a practice doctor, covering such practical ... Download the book for free
Name: Nosocomial pneumonia in adults. 2nd edition
Gelfand B.R.
The year of publishing: 2016
The size: 0.94 MB
Format: PDF.
Tongue: Russian
Description: Clinical guide "Nosocomial pneumonia in adults" ed., Gelfanda B.R., considers modern data on epidemiology, etiopathogenesis, clinical picture, diagnostic principles, and ... Download the book for free
Name: Bronchial asthma and chronic obstructive pulmonary disease.
Baur K., Passasser A., \u200b\u200bLeshchenko I.V.
The year of publishing: 2010
The size: 11.07 MB.
Format: PDF.
Tongue: Russian
Description: The presented leadership "Bronchial asthma and chronic obstructive pulmonary disease" contains deployed basic questions of the considered pathologies, where the definition of the concept, epidemiologist ... Download the book for free
Name: Bronchial asthma in children
Balabolkin I.I., Bulgakova V.A.
The year of publishing: 2015
The size: 3.11 MB.
Format: PDF.
Tongue: Russian
Description: The practical leadership of the "bronchial asthma in children" ed., Balabolokina I.I., et al., Considers the current state of the problem of bronchial asthma in children of various age groups. Described ... Download the book for free
Name: Functional diagnostics in pulmonology
Chuchalin A.G.
The year of publishing: 2009
The size: 4.16 MB
Format: djvu.
Tongue: Russian
Description: The practical guide "Functional diagnostics in pulmonology" ed., Chuchalin A.G., considers the principles and possibilities of using modern diagnostic techniques in therapy of the broncho-pulmonary ...
A. G. Chuchalin, Professor
asthma is large enough: preparations are created, relaxing the muscles of bronchi, eliminating allergic inflammation, thinning sputum. Doctors a few decades ago could only dream of such an arsenal of anti-asthma funds. Nevertheless, in our days, patients are increasingly becoming even easy to help, even using the newest drugs.
More recently, only twenty years ago, bronchial asthma was considered rare disease. Currently, the situation has changed significantly: it has become one of the most common diseases among people of all ages.
How to explain it? The answer gave an in-depth study of the functions of the lungs. It turns out that they not only provide gas exchanges between the environment and the inner medium of the body, but also along with the spleen, lymph nodes are an immunological body. Studying the immunological status of people suffering from diseases of the respiratory diseases, scientists concluded that the imperfection of the body's immune mechanisms is based on the emergence of bronchial asthma, which makes it difficult to confuse viral and bacterial infections. Suppress protective forces and contamination of the atmosphere, repeated, frequent viral diseases of the respiratory tract. In addition, people are increasingly increasingly sensitive to substances that cause allergic reactions.
In the development of bronchial asthma, the role of the diseases that precedes it, or rather, is preparing its development. This is primarily sinusitis, angry, bronchitis, pneumonia. Often repeating, and even more so acquiring chronic character, they can lead to an increase in the sensitivity of respiratory organs to allergens and thus contribute to the development of bronchial asthma. This is another evidence that all these diseases should be treated in a timely manner, even if there are little painful manifestations.
Along with other methods of treatment of bronchial asthma, reflexotherapy (acupuncture) is also applied.
One of the difficulties of combating bronchial asthma is that it exists, as it is customary to say, a family of bronchial ASTM, which combines several externally similar ailments. Indeed, "bronchial asthma may arise as a result of both hereditary predisposition and developed over the years of the immunodeficiency state or increase the reactivity of the body. Different origins, different stages of the disease dictate and different treatment tactics. One patient requires drugs that eliminate inflammatory phenomena, other medications for Reducing the allergic mood of the body, third-medications for removing bronchospasm, etc.
The doctor chooses the necessary drugs, changes them in a certain sequence, prescribes in various combinations, determines the dose depending on the nature of the disease, the features of its flow from this patient at this time. The patient himself is not to judge this, and should not try to replace the doctor. Such attempts are knowingly doomed to failure.
But confidence in the doctor, the fear of the patient is very important for the success of treatment as well as faith in recovery. The doctor and patient must be in constant contact. This is the key to success. Then there will be less reasons for so dangerous at the bronchial asthma of self-medication.
It is known that respiratory diseases are usually hard to transfer climate change. And it is necessary to take into account the patients with bronchial asthma, solving the question of rest, about a trip to the sea, to a distant resort.
Too often, it is necessary to obey the aggravation of bronchial asthma, which occurs at the stage of adaptation (addictive to the new climate) and redepply (when returning home). Only those who have the opportunity to go on vacation for 2-3 months can take a chance moving to long-range edges, and if the bronchial asthma proceeds not hard. With the overwhelming majority of patients, we recommend relaxing in our usual climate.
I would also like to draw attention to the need for hardening, but necessarily gradual and systematic.
Water-wiping, shower, swimming in the pool, and in summer-in open reservoirs. Swimming contributes to the normalization of breathing, strengthening the protective forces of the body; Especially beneficial swimming with immersion head-style Brass, for example.
