Bronchial asthma

Bronchial asthma is a chronic recurrent disease with predominant airway disease. Characterized by the altered reactivity of the bronchi. A mandatory sign of the disease is an attack of suffocation and (or) asthmatic status.

There are two forms of bronchial asthma - immunological and non-immunological - and a number of clinical and pathogenetic variants: atopic, infectious-allergic, autoimmune, dyshormonal, neuropsychic, adrenergic imbalance, primarily altered bronchial reactivity (including "aspirin" asthma and physical effort asthma ), Cholinergic.

Etiology and pathogenesis. The common pathogenetic mechanism inherent in different variants of bronchial asthma is a change in the sensitivity and reactivity of the bronchi, determined by the reaction of bronchial patency in response to the effects of physical and pharmacological factors. It is believed that in 1/3 of patients (mainly in persons suffering from an atonic variant of the disease), asthma is of hereditary origin. In the occurrence of allergic forms of asthma, non-bacterial (house dust, pollen of plants, etc.) and bacterial (bacteria, viruses, fungi) allergens play a role. The most studied allergic mechanisms of asthma origin, based on 1gE or 1lG conditioned reactions. The central place in the pathogenesis of "aspirin" asthma is given to leukotrienes. With an asthma of physical effort, the process of heat transfer from the surface of the respiratory tract is disrupted.

Symptoms, course. The disease often begins with a paroxysmal cough, accompanied by an inspiratory dyspnea with a small amount of vitreous sputum (asthmatic bronchitis). An unfolded picture of bronchial asthma is characterized by the appearance of light, moderate or severe attacks of suffocation. The attack can begin with a harbinger (copious discharge of a watery secret from the nose, sneezing, paroxysmal coughing, etc.). The asthma attack is characterized by a short inhalation and an elongated exhalation, accompanied by audible rattles in the distance. The thorax is in the position of maximum inspiration. In the breath, the muscles of the shoulder girdle, back, abdominal pouch are involved. When percussion over the lungs, a boxed sound is determined, a lot of dry wheezes are heard. The attack, as a rule, ends with the separation of viscous sputum. Severe protracted seizures can go into an asthmatic state - one of the most formidable variants of the course of the disease.

The asthmatic condition is characterized by increasing resistance to bronchodilator therapy and an unproductive cough. There are two forms of asthmatic state - anaphylactic and metabolic. With an anaphylactic form caused by immunological or pseudoallergic reactions with the release of a large number of mediators of an allergic reaction (most often in people with hypersensitivity to medicines), there is an acute severe attack of suffocation. The metabolic form associated with the functional blockade of beta-adrenergic receptors and resulting from an overdose of sympathomimetics in respiratory infections, adverse meteorological factors, due to rapid corticosteroid withdrawal, is formed within a few days. AT ! (Initial) stage, the sputum stops moving, there is pain in the muscles of the shoulder girdle, the chest and in the abdominal area. Hyperventilation, loss of moisture with exhaled air lead to an increase in the viscosity of sputum and obturation of the lumen of the bronchi by a viscous secretion. Education in the posterior sections of the lungs of the "mute lung" indicates a transition of status to the II stage with a clear discrepancy between the severity of remote rales and their absence during auscultation. The condition of the patients is extremely difficult. The thorax is emphysematically swollen. Pulse exceeds 120 in 1 min. Blood pressure tends to increase. On the ECG - signs of an overload of the right heart. Forms respiratory or mixed acidosis. In stage III (hypoxic-hypercapnia coma) dyspnea and cyanosis increase, a sharp excitement is replaced by a loss of consciousness, cramps are possible. Pulse is paradoxical, blood pressure is reduced.

The course of the disease is often cyclic: the phase of exacerbation with the characteristic symptoms and data of laboratory-instrumental studies is replaced by a phase of remission. Complications of bronchial asthma: emphysema of the lungs, often the attachment of infectious bronchitis, with a long and severe course of the disease-the appearance of the pulmonary heart.

The diagnosis is based on typical attacks of expiratory choking, eosinophilia in the blood and especially in sputum, carefully collected history, allergological examination with dermal and in some cases provocative inhalation tests, studies of immunoglobulins E and G. Careful analysis of anamnestic, clinical, radiological and laboratory data (If necessary, and the results of bronchological research) allows to exclude the syndrome of bronchial obstruction in nonspecific and specific inflammatory diseases of the respiratory system, connective tissue diseases, helminthic invasion, bronchial obstruction (foreign body, tumor), endocrine-humoral pathology (hypoparathyroidism, carcinoid syndrome, ), Hemodynamic disorders in a small circle of blood circulation, affective pathology, etc.

Treatment for bronchial asthma should be strictly individualized, taking into account the variant of the course, the phase of the disease, the presence of complications, concomitant diseases, the tolerability of medicines to patients and their most rational use during the day. Polyclinic - allergological cabinet - a specialized department of the hospital and subsequently constant monitoring in the allergological office - exemplary stages of continuity in the treatment of such patients.

In atonic bronchial asthma, first of all, aliminative therapy is prescribed - the most complete and permanent cessation of contact with the allergen. If the allergen is identified, but the patient can not be isolated from it, a specific hypensensitivity is shown in specialized allergological institutions during the remission phase. Patients with atonic asthma (especially with uncomplicated forms of the disease) are prescribed kromolin sodium (intal) to 20 mg 4 times a day, spraying it with a special inhaler. If asthma is combined with other allergic manifestations, it is preferable that the oral administration is absorbed (ketotifen) 1 mg 2 times a day. The effect of both drugs is gradual (the evaluation of therapeutic efficacy is possible in not less than 3-4 weeks). In the absence of effect, glucocorticoids are prescribed, in mild cases, preferably in the form of inhalations (becotide 50 μg every 6 hours). In severe exacerbations, the intake of glucocorticoids is indicated inside, starting with prednisolone at 15-20 mg / day or triamcinolone at 12-16 mg / day; After achieving a clinical effect, the dose is gradually reduced. With food allergy, the use of unloading and dietary therapy in a hospital is indicated.

Patients with an infectious-allergic form of asthma are recommended treatment with autovaccine, sputum autolysate, heterovaractin, which is currently being prepared using a new technology. Vaccines are treated in a specialized hospital. In case of violations in the immunity system, appropriate immunocorrective therapy (levamisole, pyrogenal and etc.) is prescribed. During the period of remission, foci of chronic infection are sanitized. The question of indications for antibiotic therapy is decided by the nature of the inflammation at the moment. Orientation is the cellular composition of sputum: with eosinophilia antibacterial drugs are not recommended. In this category of patients, glucocorticoids are more often used; Intal and zaditen are less effective.

In case of an infectious-dependent form of asthma, health-improving measures are shown: physical activity, regular exercises in therapeutic gymnastics, and hardening procedures. In connection with the violation of mucociliary clearance, sputum-thinning therapy is needed: abundant warm drink, alkaline warm inhalation, 3% solution of potassium iodide (1 tablespoon 5-6 times a day, subject to tolerance), decoction of herbs - rosemary, mother-and-stepmother And others, mucolytic agents.

Patients with asthma of physical effort are assigned corinfar with a positive pharmacological test with it: a decrease in bronchospasm at the b-10th minute of rest after taking 20 mg of Corinfar sublingually for 1.5 hours before physical exertion. With prolonged use of the drug take 10 mg 3 times a day. In the case of a negative result of a pharmacological test, a long-term treatment with an intralum or zaditenom is performed. Suitable physical training: swimming or quiet running in a warm room; With good tolerability every week increase the load by 1 min (up to 60 min).

With "aspirin" asthma, foods containing acetylsalicylic acid (berries, tomatoes, potatoes, citrus fruits) are excluded from the diet. Categorically prohibited the use of non-steroidal anti-inflammatory drugs. If necessary, appoint intal, zaditen or corticosteroids.

At the expressed emotional frustration the qualified inspection and treatment of the psychotherapist with an individual choice of psychotropic preparations is necessary. Rational psychotherapy, reflex therapy is shown.

For relief of asthma attacks, individually selected bronchodilator therapy is prescribed. The optimal dose of bronchodilators is selected empirically (from a small dose to the most effective). Positive effect in most patients have selective stimulators of beta (two) -adrenoceptors (salbutamol, berotek, etc.), produced in the form of metered hand (pocket) inhalers. During an attack 2 aerosol inhalations help. In mild cases, these drugs can be used in the form of tablets. In more severe attacks, injections of bricanil (1 ml of 0.005% solution) or ephedrine (0.5-1 ml of a 5% solution), less often epinephrine (0.3-0.5 ml 0.1% solution) are used. It is necessary to warn patients about the danger of abuse of sympathomimetics, in particular, in the form of dosage inhalers, which can be used no more than 3-4 times a day. Overdose of these drugs (especially with hypoxia) may have cardiotoxic effect; In addition, the frequent use of sympathomimetics causes a blockade of beta receptors. An effective bronchodilator is zuffillin, which is prescribed in severe cases of IV (5-10 ml of a 2.4% solution). The drug is also used in the form of tablets (0.15 grams) and candles (0.3 g each).

Holin blockers (atropine, belladonna, platyphylline) are preferred for infectious-allergic form of the disease, especially with obstruction of large bronchi. Often, these drugs are attached to other bronchodilators. Some patients are helped by solutan (10-30 drops after eating) and antiasthmatic preparations in the form of a powder for smoking or cigarettes (asthmatol, asthmatic). It is necessary to take into account the influence of holinoblokatorov on mucociliary clearance, which leads to thickening of sputum and difficulty in its separation. An effective drug of this group is the atrovent, produced in metered-dose inhalers; It can be used to prevent attacks on 2 breaths 3-4 times a day. The drug has a slight effect on mucociliary clearance. Various mechanisms of bronchial obstruction in each patient determine the appropriateness of a combination of drugs. An effective preparation is Berodual-a combination of berotek and atrovent in the form of a metered-dose inhaler.

Treatment of asthmatic status is carried out differentially depending on its stage, form, cause of occurrence. When anaphylactic form is injected n / k solution of adrenaline and immediately used glucocorticoids, appointing with 100 mg of hydrocortisone intravenously drip. If in the next 15-30 minutes there is no obvious improvement, the effect of hydrocortisone is repeated and intravenous dripping of euphyllin (10-15 ml of a 2.4% solution) begins. At the same time, oxygen therapy is performed through the nasal catheter or mask (2-6 l / min). Treatment should be carried out in the intensive care unit.

Treatment of the metabolic form of asthmatic status is carried out depending on its stage. First, it is necessary to eliminate the unproductive cough, improve sputum discharge by means of warm alkaline inhalations, abundant warm drinking. If the asthmatic condition is due to cancellation or overdose of sympathomimetics, a drip of prednisone 30 mg every 3 hours IV is indicated until the status is relieved. The development of acidosis dictates the need for / in infusion of a 2% solution of sodium hydrogencarbonate. Mandatory rehydration by the introduction of a large amount of fluid. At the II stage of an asthmatic state, the dose of glucocorticoids is increased (prednisolone to 60-90-120 mg every 60-90 min). If the picture of the "mute lung" does not disappear within the next 1.5 h, controlled ventilation with active dilution and sputum absorption is shown. In the III stage, intensive therapy is carried out together with the reanimatologist.

After removal from the asthmatic state, the dose of glucocorticoids is immediately halved, and then gradually reduced to a supporting dose. More than 50% of patients receiving glucocorticoids need long-term admission, often for years. In such cases, it is a steroid-dependent variant of bronchial asthma. Clinical follow-up of such patients, the maximum reduction in the maintenance dose of glucocorticoids, the possible transition to inhalation, the combination with other drugs (zaditen, intal, bronchospasmolytics, etc.), intermittent use of glucocorticoids, the use of psychotropic drugs and physical rehabilitation make it possible to minimize complications Glgoko-corticoid therapy.

In severe patients with no effect or insufficient effect of conventional therapy, as well as a high demand for glucocorticoids and asthmatic status, the use of plasmapheresis is indicated.

In the period of remission, hyposensitizing therapy, sanitation of foci of infection, physical therapy, physical training (walking, swimming), physiotherapy, sanatorium treatment are carried out. The most important is treatment at local resorts, as it became apparent that the processes of adaptation to new climatic conditions and after a short time of re-adaptation do not have a training effect. Significantly improves the effect of complex therapy by qualified psychotherapy.

Forecast. When clinic monitoring (at least 2 times a year), rationally selected treatment is favorable, Lethal outcome can be associated with severe infectious complications, untimely and irrational therapy, progressive pulmonary heart failure in patients with pulmonary heart.