BRONCHIAL ASTHMA

Bronchial asthma - a chronic inflammatory airway disease in which the bronchial tree become permanently sensitive (hyper-responsiveness); proceeds with attacks of breathlessness. When under the influence of different stimuli is developed bronchial hyperresponsiveness, the result of a complex interaction of inflammatory cells (eosinophils, mast cells), mediators, on the one hand, and of cells of tissues of bronchi - with another developing bronchial obstruction. It is caused by a spasm of airway smooth muscle, edema and swelling of the mucosa and obstruction of small bronchi secret; bronchus obstruction clinically manifested exacerbation of the disease - coughing, shortness of breath and characteristic bouts of breathlessness.

Changes in bronchial reactivity may be primary (congenital or acquired under the effect of chemical, physical, and mechanical factors infection) or secondary (a 'result of the changes in reactivity of the immune, nervous and endocrine systems). Many patients can not identify burdened heredity of allergic diseases (atopy - the ability to increased IgE production in response to exposure to allergens), infectious or allergic pathologies history (eczema, rhinitis , hay fever). In cases where the nature of the allergic disease is not associated with an infectious process, a special role is played aromatics. Among this group of allergens - the smells of cosmetics, flowers, pollen, etc. frequent attacks of asthma triggered by house dust (main allergic component - mites).. And epidermal allergens (dander and animal hair). Cold, nervous stress, exercise, infection can also cause asthma attacks. In patients with "aspirin triad" (bronchial asthma , aspirin intolerance, nasal polyps), any non-steroidal anti-inflammatory drug (aspirin, Analgin, indomethacin, voltaren, etc.) Can cause severe attack of breathlessness.

The clinical picture. The main symptoms of asthma are persistent or recurring cough , wheezing or shortness of breath, feeling of compression of the chest, asthma attacks. Sometimes asthma attacks are preceded by a bad mood, fatigue, feeling of stuffiness, sore along the trachea, dry cough , itchy nose, sneezing, copious watery secretions from the nose, feeling the stillness of the chest. However, as a rule, it occurs suddenly at any time of the day, often at night: the patient wakes up with a feeling of tightness in the chest and acute shortage of air. He was not able to push the air, overflowing chest, and to strengthen the breath, sit in bed, resting his hands on her, or on her knees lowered legs or jumps, throws open the window and standing, leaning on the table, his chair, including a way to act of breathing is not only breathing, but also the supporting muscles of the shoulder girdle and chest. Face cyanotic, swollen veins; characterized by nasal flaring during inspiration (especially in children). Already in the distance could be heard whistling wheezing in the background noise of difficulty exhaling. The rib cage as if frozen in the position of maximum inspiration, with raised edges, increased anteroposterior diameter, protrudes intercostal space. In light percussion box sound is determined, the boundaries of their extended auscultation reveals a dramatic lengthening the exhalation and extremely abundant variety (whistling, rough and music) wheezing . Auscultation of the heart is difficult because of emphysema and wheezing abundance. Pulse normal frequency or speeded up, full, usually lax, rhythmic. Blood pressure can be lowered and raised. Sometimes palpation reveals an apparent increase in the liver can be explained (in the absence of stagnation) ousting her down inflated right lung. Often patients are angry, they feel the fear of death, groaning. There may be a transient increase in body temperature. If the attack is accompanied by cough, hardly leaves a small amount of viscous glassy phlegm.

The current attacks, even in the same patient may be different from "deleted" (a dry cough , whistling wheeze with relatively easy for the patient the feeling of suffocation) and transient (attack lasts 10-15 minutes, and then held their own or through the use of metered dose inhalation beta-agonists) to very severe and prolonged, passing into the asthmatic condition. The pathogenesis of the asthmatic condition lie blockade of beta-adrenergic receptors of the bronchi and sputum mechanical obstruction of the bronchi. Causes asthmatic condition may be uncontrolled receiving sympathomimetic, abrupt termination of long-term corticosteroid therapy, abuse of hypnotics, sedatives, use of narcotic analgesics and beta-blocker, the aggravation of a chronic or an acute inflammatory process in bronchopulmonary apparatus.

Asthmatic condition lasts from several hours to several days. The attack does not stop, or "lucid intervals" when breathing somewhat easier, are very short, and one seizure follows another. The patient is awake, he greets the new day sitting, exhausted, despairing. Breathing is always noisy, whistling, no sputum, and if it is released, it does not bring relief. Beta-adrenergic agonist, which used to quickly stop an attack, do not work or give a very short and slight improvement. There have tachycardia (usually up to 150 beats per 1 minute, while maintaining the correct rhythm), red-bluish complexion, the skin is covered with drops of sweat. Often there is an increase in blood pressure, which creates an extra burden on the heart. Characteristically mismatch obvious deterioration of the patient and auscultatory data: when listening to a marked decrease or complete disappearance of wheezing due to blockage of small and medium-sized bronchi mucous plugs ( "silent light"). Gradually the patient weaker, breathing becomes shallow, less frequently, a sense of suffocation - less painful, decreases blood pressure, increases heart failure . There is a threat to the development of coma and respiratory arrest. Loss of consciousness may be preceded by the patient's agitation, soporous state, convulsions .

Clinical criteria asthmatic condition is thus a rapid increase in bronchial obstruction, respiratory failure and the growing lack of effect of beta-agonists. There are three stages of an asthmatic condition, based on the following criteria: I stage - a prolonged attack of asthma with the absence of the effect of beta-agonists, II of stage is characterized by the appearance of "dumb" zones during auscultation, in stage III develops coma , blood pressure falls.

Diagnosis. The clinical picture of asthma with a characteristic triad of symptoms (breathlessness, coughing , wheezing) usually does not create diagnostic difficulties. Assess the degree of airflow limitation, its reversibility fluctuations and help to pulmonary function tests - spirometry, pikfluorimetriya the assessment indicators at baseline and after inhalation of beta-agonists. In the blood and sputum eosinophilia detected.

The differential diagnosis is carried out primarily with cardiac asthma (see. Shortness of breath). It is important to remember that the symptoms of asthma - wheezing wheezing on the background of noisy difficulty exhaling - may be due to edema and bronchospasm occurred on the background of acute coronary insufficiency, hypertensive crisis, etc., ie, in cases where.... You can think about the origin of left ventricular failure and cardiac asthma, accompanied by bronchospasm and edema of the mucous membrane.

In chronic lung diseases, such as chronic bronchitis, emphysema, pulmonary heart pnevmoskleroze and often a period of sharp increase in shortness of breath; distinguish them from the attack of asthma helps the absence of its characteristic features (sudden onset, an active part in supporting muscles of the exhalation phase, whistling, "musical" wheezing in the background dramatically hindered exhalation). In these cases there is no eosinophilia in the blood and sputum.

Sometimes it may be necessary to differentiate asthma attack and the so-called stenotic shortness of breath that occurs when cicatricial narrowing of the larynx or bronchial constriction of the lumen due to compression from outside the tumor, aneurysm, getting into the trachea or bronchus foreign body: so dyspnea is inspiratory character (long noisy breath, accompanied by retraction of intercostal spaces, suprasternal and supraclavicular pit), there is an acute pulmonary emphysema, and other characteristic symptoms of asthma. Finally, asthma attacks have neurotic ( "hysterical shortness of breath") proceed without orthopnea (patients may lie), frequent shallow breathing is not accompanied by wheezing and dramatically lengthened exhalation, the general condition of patients is satisfactory.

Treatment of asthma is aimed, on the one hand, to suppress the inflammation of the bronchial tree (basic therapy), on the other - to weaken or eliminate the symptoms of asthma due to improvement of bronchial patency. The major role played by the right, the planned permanent cure of the disease. As a first-line drugs are the inhaled form kromolin- and nedocromil sodium, beta-agonists and corticosteroids. Cromolyn sodium (Intal) and nedocromil sodium (tayled) inhibit mast cell activation and the release of these mediators. Drugs used in the form of metered aerosol inhalation to 2 to 4 times a day. Among the inhaled beta-agonists are preferred sustained drug (Foradil, Serevent). Inhaled corticosteroids (beclomethasone, triamcinolone) administered by inhalation 2 to 4 times a day over 5-10 min after the injection of beta-agonists. After the use of inhaled corticosteroids is necessary to rinse the mouth (prevention of oral candidiasis). Continuous oral corticosteroids is a "therapy of despair" - it should be done only when the frequent severe asthma attacks continue against the backdrop of the maximum therapy. Long-term appointment of hormones in the pills leads to osteoporosis, hypertension, diabetes, cataracts, obesity and other complications. Prolonged drugs theophylline (retafil, teopek et al.) Are second-line agents in the treatment of asthma. These drugs are shown to children, adults with severe symptoms of encephalopathy (when it is impossible to train the patient's technique of using an inhaler), with severe shortness of breath (when you can not take a deep breath), with severe exacerbation (when it is necessary to maintain a constant drug concentration in the blood).

Therapy during asthma attacks start with a dosage of inhaled short-beta-agonists (salbutamol, berotek); in most cases the effect can be observed after 5-15 min. Beta-blockers relax the smooth muscles of the bronchi, reduces vascular permeability. The inhalation route of administration enhances selectivity of drugs on bronchial, to achieve maximum therapeutic effect with minimal side effects. Tremor - the most common complication of therapy dosage aerosols; excitation and tachycardia are rare. It should be borne in mind that the frequent use of beta-agonists of short action can worsen asthma, these drugs are the drug of choice for the relief of an attack, but not for continuous therapy.

In order that the patient could not heavy on their own to stop asthma attacks, it is necessary to teach the proper technique of using an inhaler. Inhalation is best done sitting or standing, his head thrown back a little to the upper respiratory tract of violence and the drug has reached the bronchi. After vigorous shaking the inhaler should be flip-up balloon. The patient takes a deep breath, his lips tightly covers the mouthpiece and at the beginning of inhalation depresses the cartridge, and then continue to inhale as deeply as possible. At the height of inspiration you need to hold your breath for a few seconds (to cure settled in the bronchial walls), then calmly exhale.

In the absence of inhaled drugs or inability to use the inhaler (for example, a very marked decrease in the patient's intelligence and the inability to teach him the use of an inhaler) have to move to subcutaneous injection of 0.1% solution of epinephrine, which often relieves the attack within a few minutes after injection. Therapy begins with small (0.2 - 0.3 ml of 0.1% solution) doses, if necessary repeated injections over 15 - 20 minutes (up to three times). With repeated injections it is important to change the place of administration, so as epinephrine causes a local vasoconstriction that slows its absorption. It should be borne in mind that sometimes intradermal (method "lemon peel") has the effect of epinephrine in cases when the same dose administered subcutaneously brought no relief. In elderly patients with atherosclerotic vascular brain and heart even a moderate dose of adrenaline as 0.5 ml of 0.1% solution can cause cardiovascular disorders, arrhythmia, so you need to enter only a small dose with careful monitoring of the state of the cardiovascular system. The possibility of paradoxical bronchospasm gain instead of the expected broncho-extending effect with frequent repeated administration of epinephrine, limits its use in cases of protracted nekupiruyuschegosya attack of asthma and asthmatic conditions.

In severe asthma attack, and in the case where the use of high doses of beta-agonists is not possible, it is advisable to start slow intravenous administration of 10 mL of 2.4% aminophylline solution (1-2 ml per minute, or aminophylline intravenously administered). The rapid introduction of the drug may be associated with side effects (palpitations, heart pain, nausea , headache , dizziness , sudden drop in blood pressure, seizures), especially dangerous in elderly patients with severe sclerosis of cerebral vessels. We do not recommend the combined use of aminophylline and beta-agonists as therapeutic effect is not enhanced, and the risk of complications increases.

In cases where the attack is prolonged, it becomes asthmatic condition, and the usual antispasmodic therapy failed, the further use of agonists are contraindicated because of the possibility of "rebound" effect - strengthening of bronchospasm due to the functional blockade of beta-adrenergic receptors. In such a situation requires hormone (hydrocortisone 250-300 mg or prednisolone 90 - 120 mg intravenously in 200 ml of isotonic sodium chloride solution). The introduction of corticosteroids repeated every 2 hours, with no effect added taking hormones orally. Corticosteroids prevent or inhibit the activation and migration of inflammatory cells, reduce bronchial wall edema, mucus production, and increased vascular permeability, increase the sensitivity of the beta-receptor of smooth muscles of the bronchi.

The question of admission is decided taking into account the overall course of the disease, the patient's condition in the interictal period. When nekupiruyuschemsya attacks and asthmatic condition should be immediately hospitalized patient, since only in a hospital full scope of the emergency, including in particularly severe cases, therapeutic bronchoscopy and forced ventilation (translation into hardware breathing) can be applied. transportation method (position of the patient, support) depends on the patient's condition.

Mortality in asthma is of a percent. The immediate cause of death may be a blockage of mucus or phlegm bronchial tubes leading to acute asphyxia; acute right heart failure and circulatory system as a whole; gradually increasing suffocation as a result of lack of oxygen, the accumulation of carbon dioxide in the blood, causing excitement and decrease the sensitivity of the respiratory center. The development of these complications, signs of which can serve the growing cyanosis, the appearance of shallow breathing, easing breathing and reducing the number of wheezes on auscultation, the emergence thready pulse, swelling of the neck veins, swelling and sharp pain of the liver, is especially likely with long-term (the so-called nekupiruyuschemsya) a fit and especially in asthmatic condition.