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Chronical bronchitis

Chronic bronchitis is a progressive diffuse inflammation of the bronchi that is not associated with a local or generalized pulmonary lesion, manifested by coughing. One can speak about chronic bronchitis if the cough lasts for 3 months in the 1st year - 2 years in a row.

Etiology. The disease is associated with prolonged irritation of the bronchi by various harmful factors (inhalation of air contaminated with dust, smoke, carbon monoxide, sulfur dioxide, nitrogen oxides and other compounds of chemical nature) and recurrent respiratory infections (a large role belongs to respiratory viruses, Pfeiffer rod, pneumococcus), less often occurs when cystic fibrosis. Predisposing factors are chronic inflammatory, suppurative processes in the lungs, chronic foci of infection and chronic diseases localized in the upper respiratory tract, decreased reactivity of the body, hereditary factors.

Pathogenesis. The main pathogenetic mechanism is hypertrophy and hyperfunction of the bronchial glands with increased secretion of mucus, with a decrease in serous secretion and a change in the composition of secretion, as well as an increase in acid mucopolysaccharides, which increases the viscosity of sputum. Under these conditions, the ciliated epithelium does not improve the emptying of the bronchial tree, usually the entire secretion layer is usually updated (partial cleansing of the bronchi is possible only with coughing). Prolonged hyperfunction is characterized by depletion of the mucociliary apparatus of the bronchi, the development of dystrophy and atrophy of the epithelium. When the bronchial drainage function is impaired, there is a bronchogenic infection, the activity and recurrence of which depends on the local bronchial immunity and the onset of secondary immunological insufficiency. With the development of bronchial obstruction due to hyperplasia of the epithelium of the mucous glands, there are swelling and inflammatory thickening of the bronchial wall, obstruction of the bronchi, an excess of viscous bronchial secretions, bronchospasm. With obstruction of the small bronchi, alveolar overdistension develops on exhalation and a violation of the elastic structures of the alveolar walls and the appearance of hypovenous or non-ventilated zones, and therefore the blood passing through them does not oxygenate and arterial hypoxemia develops. In response to alveolar hypoxia, a pulmonary arteriole spasm and an increase in general pulmonary and pulmonary arteriolar resistance develop; developing pericapillary pulmonary hypertension. Chronic hypoxemia leads to an increase in blood viscosity, which is accompanied by metabolic acidosis, which further increases vasoconstriction in the pulmonary circulation. Inflammatory infiltration in the large bronchi is superficial, and in medium and small bronchi, bronchioles - deep with the development of erosion and the formation of meso- and panbronchitis. The remission phase is manifested by a decrease in inflammation and a large decrease in exudation, proliferation of the connective tissue and epithelium, especially with ulceration of the mucous membrane.

Clinical manifestations. The onset of the disease is gradual. The first and main symptom is a cough in the morning with discharge of mucus mucus, gradually cough begins to occur at any time of the day, increases in cold weather and becomes permanent over the years. The amount of sputum increases, the sputum becomes purulent or purulent. Dyspnea appears. With purulent bronchitis, purulent sputum can periodically be released, but bronchial obstruction is not very pronounced. Obstructive chronic bronchitis is manifested persistent obstructive disorders. Purulent obstructive bronchitis is characterized by the release of purulent sputum and obstructive ventilation disorders. Frequent exacerbations during periods of cold, wet weather: cough increases, shortness of breath, sputum increases, malaise, fatigue. Body temperature is normal or subfebrile, can be determined by hard breathing and dry rales over the entire lung surface.

Diagnostics. Possible small leukocytosis with a stab shift in leukocyte formula. When exacerbation of purulent bronchitis, there is a slight change in the biochemical parameters of inflammation (increased C-reactive protein, sialic acids, fibronogen, seromukoid, etc.). Sputum examination: macroscopic, cytological, biochemical. With a pronounced exacerbation of sputum becomes purulent: a large number of neutrophilic leukocytes, elevated levels of acidic mucopolysaccharides and DNA fibers, sputum character, mainly neutrophilic leukocytes, increased levels of acidic mucopolysaccharides and DNA fibers, which increase the viscosity of sputum, reduction of lysozyme, etc. Bronchoscopy, with the help of which the endobronchial manifestations of the inflammatory process are evaluated, the stages of development of the inflammatory process: catarrhal, purulent, atrophic, pertrophic, hemorrhagic and its severity, but mostly to the level of subsegmental bronchi.

The differential diagnosis is carried out with chronic pneumonia, bronchial asthma, and tuberculosis.
In contrast to chronic pneumonia, chronic bronchitis always develops from a gradual onset, with widespread bronchial obstruction and often emphysema, respiratory failure and pulmonary hypertension with the development of chronic pulmonary heart disease. In X-ray studies, the changes are also diffuse: peribronchial sclerosis, increased transparency of the pulmonary fields due to emphysema, expansion of the branches of the pulmonary artery. Chronic bronchitis differs from bronchial asthma in the absence of suffocation attacks, it is associated with pulmonary tuberculosis by the presence or absence of symptoms of tuberculous intoxication, mycobacterium tuberculosis in sputum, the results of x-ray and bronchoscopic examination, tuberculin tests.

Treatment. In the phase of exacerbation of chronic bronchitis, therapy is directed to the elimination of the inflammatory process, improvement of the bronchial patency, as well as restoration of impaired general and local immunological reactivity. Antibiotics are prescribed, which are selected taking into account the sensitivity of sputum microflora, administered orally or parenterally, sometimes combined with intratracheal administration. Showing inhalation. Apply expectorant, mucolytic and bronchospasmolytic drugs, drink plenty of fluids to restore and improve bronchial patency. Phytotherapy with the use of Altea root, leaves of coltsfoot, plantain. Prescribed proteolytic enzymes (trypsin, chymotrypsin), which reduce the viscosity of sputum, but are rarely used today. Acetylcysteine ​​has the ability to break the disulfide bonds of mucus proteins and contributes to the strong and rapid dilution of sputum. Bronchial drainage improves with the use of mucoregulators, which affect the secret and the production of glycoproteins in the bronchial epithelium (bromhexin). In case of insufficiency of bronchial drainage and existing symptoms of bronchial obstruction, bronchospasmolytic agents are added to treatment: euphylline, holinoblokatory (atropine in aerosols), adrenostimulants (ephedrine, salbutamol, berotok). In a hospital setting intratracheal washing with purulent bronchitis must be combined with a rehabilitation bronchoscopy (3-4 sanation bronchoscopy with a break of 3-7 days). When restoring the drainage function of the bronchi, physiotherapy, chest massage and physiotherapy are also used. With the development of allergic syndromes, calcium chloride and antihistamines are used; in the absence of effect, you can prescribe a short course of glucocorticoids to relieve the allergic syndrome, but the daily dose should not be more than 30 mg. The danger of activation of infectious agents does not allow the use of long-term glucocorticoids. In patients with chronic bronchitis complicated by respiratory failure and chronic pulmonary heart, the use of veroshpiron is shown (up to 150–200 mg / day).

Food of patients must be high-calorie, fortified. Applied ascorbic acid 1 g per day, nicotinic acid, B vitamins; if necessary, aloe, methyluracil. With the development of complications of the disease such as pulmonary and pulmonary heart disease, use oxygen therapy, auxiliary artificial respiration.

Anti-relapse and supportive therapy prescribed in the phase of exacerbation subsiding, is carried out in local and climatic sanatoriums, this therapy is prescribed during clinical examination.

Recommend to allocate 3 groups of dispensary patients.

1st group. It includes patients with a pulmonary heart, with pronounced respiratory failure and other complications, with disability. Patients are prescribed supportive therapy, which is carried out in a hospital or general practitioner. Examination of these patients is carried out at least 1 time per month.

2 nd group. It includes patients with frequent exacerbations of chronic bronchitis, as well as moderate dysfunction of the respiratory organs. Examination of such patients is carried out by a pulmonologist 3-4 times a year, anti-relapse therapy is prescribed in the fall and spring, as well as in acute respiratory diseases. An effective method of administering drugs is the inhalation route; according to indications, it is necessary to carry out a reorganization of the bronchial tree, using intratracheal washes, and reorganization bronchoscopy. With active infection, prescribe antibacterial drugs.

3rd group. It includes patients in whom anti-relapse therapy has led to a decline in the process and the absence of relapses for 2 years. Such patients are shown prophylactic therapy, which includes means aimed at improving bronchial drainage and increasing its reactivity.
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Chronical bronchitis

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