Bronchitis chronic

Bronic bronchitis is a diffuse progressive inflammation of the bronchi that is not associated with local or generalized lung damage and manifests itself as a cough. It is customary to talk about the chronic nature of the process if the cough lasts at least 3 months in 1 year for 2 consecutive years. Chronic bronchitis is the most common form of chronic nonspecific lung diseases (CHDF), which tends to become more frequent.

Etiology, pathogenesis. The disease is associated with prolonged irritation of the bronchi with various harmful factors (smoking, inhalation of air polluted with dust, smoke, carbon monoxide, sulfur dioxide, nitrogen oxides and other chemical compounds) and recurrent respiratory infection (respiratory viruses, Pfeiffer's rod, pneumococcus) Rarely occurs with cystic fibrosis, alpha (one) -antitrypsin deficiency. Predisposing factors-chronic inflammatory and suppuration in the lungs, chronic foci of infection in the upper respiratory tract, decreased reactivity of the organism, hereditary factors. The main pathogenetic mechanisms include hypertrophy and hyperfunction of bronchial glands with increased mucus secretion, a relative decrease in serous secretion, a change in the secretion composition, a significant increase in acidic mucopolysaccharides, which increases the viscosity of sputum. Under these conditions, the ciliated epithelium does not provide emptying of the bronchial tree and the usual normal renewal of the entire secretion layer (bronchial emptying occurs only with coughing). Prolonged hyperfunction leads to depletion of the mucociliary apparatus of the bronchi, degeneration and atrophy of the epithelium. Disturbance of the drainage function of the bronchi promotes the appearance of bronchogenic infection, the activity and relapses of which largely depend on the local immunity of the bronchi and the development of secondary immunological failure.

A severe manifestation of the disease is the development of bronchial obstruction due to hyperplasia of the epithelium of the mucous glands, edema and inflammatory infiltration of the bronchial wall, fibrous changes of the wall with stenosis or bronchial obliteration, bronchial obstruction with excess of viscous bronchial secretion, bronchospasm and expiratory collapse of the walls of the trachea and bronchi. Obstruction of small bronchi leads to overstretching of the alveoli on expiration and violation of the elastic structures of the alveolar walls, as well as to the appearance of hypoventilated and completely unventilated zones functioning as an arteriovenous shunt; In connection with the fact that the blood passing through them is not oxygenated, arterial hypoxemia develops. In response to alveolar hypoxia, there is a spasm of pulmonary arterioles with an increase in total pulmonary and pulmonary-arteriolar resistance; There is precapillary pulmonary hypertension. Chronic hypoxemia leads to polycythemia and increased blood viscosity, accompanied by metabolic acidosis, which further strengthens vasoconstriction in the small circulation.

Inflammatory infiltration, in the large bronchi superficial, in the middle and small bronchi, as well as bronchioles can be profound with the development of erosion, ulceration and the formation of meso- and panbronchitis. The phase of remission is characterized by a decrease in inflammation in general, a significant decrease in exudation, proliferation of connective tissue and epithelium, especially in ulceration of the mucosa. The outcome of the chronic bronchial inflammatory process is sclerosis of the bronchial wall, peribronchial sclerosis, atrophy of glands, muscles, elastic fibers, cartilage. Possible stenosis of the bronchus lumen or its expansion with the formation of bronchiectasises.

Symptoms, course. The beginning is gradual. The first symptom is a cough in the morning with the separation of mucous sputum. Gradually cough begins to appear and at night and day, intensifying in cold weather, with the years becomes permanent. The amount of sputum increases, it becomes mucopurulent or purulent. Appears and progresses shortness of breath. There are 4 forms of chronic bronchitis. With a simple, uncomplicated form of bronchitis occurs with the release of mucous sputum without bronchial obstruction. With purulent bronchitis, purulent sputum is constantly or periodically released, but bronchial obstruction is not expressed. Obstructive chronic bronchitis is characterized by persistent obstructive disorders. Purulent-obstructive bronchitis occurs with the release of purulent sputum and obstructive ventilation disorders. During the exacerbation of any form of chronic bronchitis, bronchospastic syndrome may develop.

Typical frequent exacerbations, especially in periods of cold wet weather: cough and dyspnea intensify, sputum increases, malaise, sweat at night, fast fatigue. Body temperature is normal or subfebrile, hard breathing and dry wheezing can be determined over the entire surface of the lungs. The leukocyte formula and ESR are more often normal; A small leukocytosis with a stab-shift in the leukocyte formula is possible. Only with an exacerbation of purulent bronchitis does the biochemical indices of inflammation change insignificantly (C-reactive protein, sialic acids, seromucoid, fibrinogen, etc.). In the diagnosis of the activity of chronic bronchitis, the study of sputum is of great importance: macroscopic, cytological, and biochemical. Thus, with severe exacerbation, purulent sputum character is observed, mainly neutrophilic leukocytes, an increase in the content of acid mucopolysaccharides and DNA fibers enhancing the viscosity of phlegm, a decrease in lysozyme content, etc. Exacerbations of chronic bronchitis are accompanied by increasing respiratory function disorders, and in the presence of pulmonary hypertension - and disorders Blood circulation.

A significant help in the recognition of chronic bronchitis is bronchoscopy, in which the endobronchial manifestations of the inflammatory process (catarrhal, purulent, atrophic, hypertrophic, hemorrhagic, fibrinous-ulcerative endobronchitis) and its severity (but only to the level of subsegmental bronchi) are visually assessed. Bronchoscopy allows to make a biopsy of the mucous membrane and histologically to clarify the nature of the lesion and also to reveal tracheobronchial hypotonic dyskinesia (increase in the mobility of the walls of the trachea and bronchi during breathing up to the expiratory collapse of the tracheal wall and the main bronchi) and static retraction (change in configuration and decrease in the lumen of the trachea and bronchi ), Which can complicate chronic bronchitis and be one of the causes of bronchial obstruction.

However, with chronic bronchitis, the primary lesion is most often localized in the smaller branches of the bronchial tree; Therefore in the diagnosis of chronic bronchitis broncho- and radiography is used. In the early stages of chronic bronchitis, there are no changes in bronchograms in most patients. With long-term chronic bronchitis on bronchograms, there may be breaks in mid-size bronchial tubes and a lack of filling of small branches (due to obstruction), which creates a picture of the "dead tree". In the peripheral areas, bronchiectasis can be detected in the form of small cavities filled with contrast, up to 5 mm in diameter, connected to small bronchial branches. On radiographs, deformity and enhancement of the pulmonary pattern can be detected by the type of diffuse mesh pneumosclerosis often with concomitant emphysema of the lungs.

Signs of violation of bronchial patency (bronchial obstruction) serve as important criteria for the diagnosis, choice of adequate therapy, determination of its effectiveness and prognosis for chronic bronchitis: 1) the appearance of dyspnea in case of physical exertion and exit from a warm room to cold; 2) sputum production after a long tiring cough; 3) presence of wheezing dry wheezes on the forced exhalation; 4) prolongation of the exhalation phase; 5) data of methods of functional diagnostics. Improvement of ventilation and respiratory mechanics with the use of bronchodilators indicates the presence of bronchospasm and the reversibility of bronchial obstruction. In the late period of the disease, violations of ventilation-perfusion ratios, diffusion capacity of the lungs, and gas composition of the blood are added.

Often there is a need to differentiate chronic bronchitis from chronic pneumonia, bronchial asthma, tuberculosis and lung cancer. Unlike chronic pneumonia, chronic bronchitis is always a diffuse disease with the gradual development of widespread bronchial obstruction and often emphysema, respiratory failure and pulmonary hypertension (chronic pulmonary heart); X-ray changes are also diffuse: peribronchial sclerosis, increased transparency of pulmonary fields due to emphysema, expansion of the branches of the pulmonary artery. From bronchial asthma, chronic bronchitis is distinguished by the absence of attacks of suffocation. Differential diagnosis of chronic bronchitis and pulmonary tuberculosis is based on the presence or absence of signs of tuberculosis intoxication, mycobacteria tuberculosis in sputum, data from x-ray and bronchoscopy, tuberculin samples. It is very important early detection of lung cancer against the background of chronic bronchitis. Nasal coughing, hemoptysis, pain in the chest are signs that are suspicious and the attitude of the tumor, and require urgent radiographic and bronchological examination of the patient; The most informative is tomography and bronchography. Cytological examination of sputum and bronchus contents on antipark cells is necessary.

Treatment, prevention. In the phase of exacerbation of chronic bronchitis therapy should be aimed at eliminating the inflammatory process in the bronchi, improving bronchial patency, restoring impaired general and local immunological reactivity. Assign antibiotics and sulfonamides to courses sufficient to suppress the activity of the infection. The duration of antibiotic therapy is individual. Antibiotic is selected taking into account the sensitivity of the microflora of sputum (bronchial secretions), appointed orally, or parenterally, sometimes combined with intratracheal administration. Inhalation of phytoncides of garlic or onions is shown (garlic and onion juice is prepared before inhalation, mixed with 0.25% novocaine solution or isotonic sodium chloride solution in the proportion of 1 part juice to 3 parts of the solvent). Inhalation is carried out 2 times a day; On a course of 20 inhalations. Simultaneously with the therapy of active infection of the bronchi, a conservative sanation of the nasopharyngeal foci is carried out.

Restoration or improvement of bronchial patency is an important link in the complex therapy of chronic bronchitis in both exacerbation and remission; Apply expectorant, mucolytic and bronchospasmolytic drugs, abundant drink. An expectorant effect is potassium iodide, an infusion of thermopsis, an altite root, leaves of mother-and-stepmother, plantain, as well as mucolytics and cysteine ​​derivatives. Proteolytic enzymes (trypsin, chymotrypsin, chymopsin) reduce the viscosity of sputum, but are now increasingly used in connection with the threat of hemoptysis and the development of allergic reactions. Acetylcysteine ​​(mucomist, mucosolvin, fluimutsil, mistabrene) has the ability to rupture the disulfide bonds of mucus proteins and causes a strong and rapid dilution of sputum. Apply in the form of an aerosol 20% solution of 3-5 ml 2-3 times a day. Bronchial drainage improves with the use of mucoregulators that affect both the secret and the synthesis of glycoproteins in the bronchial epithelium (bromhexine, or bisolvone). Bromhexine (bisolvone) is prescribed 8 mg (2 tablets) 3-4 times a day for 7 days inside, 4 mg (2 ml) 2-3 times a day subcutaneously or in inhalations (2 ml of bromhexine solution is diluted with 2 ml Distilled water) 2-3 times a day. Before inhalation of expectorants in aerosols, bronchodilators are used to prevent bronchospasm and enhance the effect of the drugs used. After inhalation, the positional drainage is performed, mandatory with viscous sputum and cough insolvency (2 times a day with preliminary expectorant intake and 400-600 ml of warm tea).

With bronchial drainage deficiency and bronchial obstruction symptoms, bronchospasmolytic agents are added to the therapy: rectally (or intravenously) euphyllin 2-3 times a day, holinoblockers (atropine, platyphylline inwards, atrovent in aerosols), adrenostimulant ( Ephedrine, isadrin, novorrin, euspyran, alupent, terbutaline, salbutamol, berotek). In a hospital, intra-tracheal lavage with purulent bronchitis is combined with sanation bronchoscopy (3-4 sanation bronchoscopies with a break of 3-7 days). Restoration of the drainage function of the bronchi is also promoted by physical therapy, chest massage, physiotherapy. In case of allergic syndromes, calcium chloride is given inside and / in antihistamines; In the absence of effect, it is possible to conduct a short (before removal of the allergic syndrome) course of glucocorticoids (daily dose should not exceed 30 mg). The danger of activation of infection does not allow to recommend long-term use of glucocorticoids.

When the patient develops a chronic bronchitis syndrome of bronchial obstruction, it is possible to prescribe etazol (0,05-0,1 g 2 times a day for 1 month) and heparin (5,000 units 4 times a day for 3-4 weeks Ned) with a gradual withdrawal of the drug. In addition to the anti-allergic effect, heparin at a dose of 40 000 units / day has a mucolytic effect. In patients with chronic bronchitis, complicated by respiratory failure and chronic pulmonary heart, the use of veroshpiron (up to 150-200 mg / day) is indicated.

The diet of patients should be high-calorie, fortified. Assign ascorbic acid in a daily dose of 1 g, B vitamins, nicotinic acid; If necessary, levamisole, aloe, methyluracil. In connection with the well-known role in the pathogenesis of a number of biologically active substances (histamine, acetylcholine, cyanins, serotonin, prostaglandins), indications are being developed for the inclusion of inhibitors of these systems in complex therapy. When complicating the disease with pulmonary and pulmonary-cardiac failure, oxygene therapy, auxiliary artificial ventilation of the lungs is used. Oxygen therapy involves inhalation of 30-40% oxygen in a mixture with air, it must be intermittent. This provision is based on the fact that with a marked increase in the concentration of carbon dioxide, the respiratory center is stimulated by arterial hypoxemia. Elimination of its intensive and prolonged inhalation of oxygen leads to a decrease in the function of the respiratory center, the growth of alveolar hypoventilation and hypercapnia coma. With stable pulmonary hypertension, long-acting nitrates, calcium ion antagonists (verapamil, phenygidine) are used for a long time. Cardiac glycosides and saluretics are prescribed for congestive heart failure.

Anti-relapse and maintenance therapy begins in the phase of subsiding exacerbation, can be performed in local and climatic sanatoriums, it is also prescribed for clinical examination. It is recommended to allocate 3 groups of dispensary patients. The first group includes patients with severe respiratory failure, pulmonary heart and other complications of the disease, with disability; Patients need systematic maintenance therapy, which is carried out in a hospital or a district doctor. The aim of therapy is to combat the progression of pulmonary-cardiac failure, amyloidosis and other possible complications of the disease. These patients are examined at least once a month. The second group consists of patients with frequent exacerbations of chronic bronchitis and moderate impairment of respiratory function. Patients are monitored pulmonarily 3-4 times a year, anti-relapse courses are prescribed in the spring and autumn, and after acute respiratory infections. A convenient method of drug administration is inhalation; According to the indications, sanation of the bronchial tree is carried out by intracerebral lavage, sanation bronchoscopy. With active infection, antibacterial drugs are used. An important place in the complex of anti-relapse measures is taken by measures aimed at normalizing the reactivity of the organism: referral to a sanatorium, preventoriums, exclusion of occupational hazards, bad habits, etc. The third group consists of patients whose antiretroviral therapy led to the process's stagnation and the absence of relapses For 2 years. He shows seasonal preventive therapy, which includes means to improve bronchial drainage and increase reactivity.