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Bronchial asthma

Cramps and twitching of muscles are rare - arrhythmias. Contraindications: hypersensitivity; with caution in coronary heart disease, tachyarrhythmias, thyrotoxicosis. It is permissible to use a metered dose inhaler of 200-400 mcg (2-4 doses), preferably with a spacer; it is important to follow the technique of inhalation. The most studied? 2 agonist is safer compared to fenoterol.

? Fenoterol - inhalation of 0.5-1.0 mg (with a severe attack of up to 2.0 mg) through a nebulizer for 10-15 minutes. The onset of action after 5 minutes, the maximum effect for 2-3 hours, duration 6-8 hours. If necessary, repeat inhalation every 20 minutes. Side effects and contraindications - see "salbutamol". It is permissible to use a metered dose inhaler of 100-200 mcg (1-2 doses), preferably with a spacer; it is important to follow the technique of inhalation. Fenoterol has a greater effect on the heart than salbutamol, so it is not used for myocardial infarction, WPW syndrome, mitral valve insufficiency and stenosis.

In severe asthma attacks or asthmatic status, anticholinergics are added.

? Ipratropium bromide inhalation of 0.4-2.0 ml (0.1-0.5 mg) through a nebulizer for 10-15 minutes (can be combined in a solution of P2 agonists). The onset of action after 5-20 minutes, the maximum effect after 90 minutes, the duration of 3-4 hours. Possible side effects: cough, dry mouth, unpleasant taste. Contraindications: hypersensitivity, pregnancy (I trimester); with caution in angle-closure glaucoma, prostatic hyperplasia, children under 6 years of age. It is permissible to use a metered dose inhaler of 40–80 mcg (2–4 doses); it is important to follow the technique of inhalation. An additional ipratropium bromide to short-acting? 2 agonists in the treatment of exacerbation of bronchial asthma leads to a statistically significant improvement in pulmonary function.

¦ It is advisable to use combined preparations of selective short-acting? 2 agonists with anticholinergics (for an attack of any severity).

? Fenoterol + ipratropium bromide - inhalation of 1-2 ml (20-40 drops) through a nebulizer for 10-15 minutes. The onset of action after 15 minutes, the maximum effect is achieved after 1-2 hours, the duration is up to 6 hours.

¦ Glucocorticoids - their use depends on the severity of the attack of bronchial asthma. In case of moderate seizure, the use of the following drugs is indicated.

Intravenous prednisolone 60-90 mg, previously diluted in 0.9% sodium chloride solution to 10-20 ml, injected slowly. The clinical effect of glucocorticoids develops 1 hour after administration. T | / in plasma 2.2–3.5 hours, in tissues 18–36 hours. Side effects with intravenous administration: anaphylaxis, redness of the face and cheeks, convulsions. Contraindications: hypersensitivity, peptic ulcer of the stomach and duodenum, severe arterial hypertension, renal failure. Systemic glucocorticoids should be used in patients receiving corticosteroid hormones as a basic therapy and with a weak effect (B2 agonists.

? Or budesonide 1000-2000 mcg through a nebulizer for 5-10 minutes. It is advisable to use in patients who do not use glucocorticoids as a basic therapy.

¦ In severe seizures and asthmatic status, immediate administration of systemic glucocorticoids

? Intravenous prednisone 90-150 mg (up to 300 mg). For health reasons, there are no contraindications.

? Budesonide 1000-2000 mcg through a nebulizer for 5-10 minutes. Used as an adjunct to the systemic administration of glucocorticoids.

¦ In case of deterioration and the threat of respiratory arrest

? Epinephrine 0.1% - 0.3-0.5 ml i / m or s / c, if necessary, repeat after 20 minutes up to three times.

¦ With asthmatic status, oxygen therapy is indicated (caution in cyanosis) at a rate of 2-4 l / min.

¦ Control of NPV, heart rate, blood pressure, and with a severe attack and asthmatic status of the ECG due to possible complications from the heart. Readiness for mechanical ventilation and resuscitation.

Treatment Efficiency Criteria

After stopping the attack, repeat the definition of PSV.

¦ Good response to ongoing therapy:

? stable condition;

? shortness of breath and dry wheezing in the lungs decreased;

? PSV increased by 60 l / min (in children by 12-15% of the original).

¦ Incomplete response to ongoing therapy:

? unstable condition;

? symptoms are still pronounced;

? areas with poor breathing are preserved;

? no increase in PSV.

¦ Bad response to ongoing therapy:

? Symptoms are expressed in an earlier degree or increase;

? PSV is reduced.

INDICATIONS FOR HOSPITALIZATION

After emergency treatment, urgent hospitalization is required for patients with:

¦ severe attack of bronchial asthma or asthmatic status;

¦ suspected complications;

¦ lack of a quick response to bronchodilation therapy;

¦ further deterioration of the patient's condition against the background of the started treatment;

¦ prolonged use or recently discontinued use of systemic glucocorticoids.

Patients should also be referred to the hospital:

¦ several times hospitalized in the intensive care unit over the past year;

¦ not adhering to a treatment plan for bronchial asthma;

¦ suffering from mental illness.

When stopping a mild / moderate attack of bronchial asthma, stable condition, absence of complications, patients can be left at home.

RECOMMENDATIONS FOR REMAINED HOUSES OF PATIENTS

¦ Avoid contact with causative allergens.

¦ Eliminate (or limit as much as possible) the influence of non-specific irritants: smoking, occupational hazards, pollutants, pungent odors and others. If necessary, limit physical and psycho-emotional stress.

¦ Prohibit taking? -Adrenergic blockers.

¦ Outpatient consultation of the attending physician (pulmonologist, allergist-immunologist) to determine further tactics (examination, treatment of exacerbation of bronchial asthma, selection of basic therapy).

¦ Training in asthma school.

FREQUENTLY MEETING ERRORS

¦ The use of psychotropic drugs, narcotic analgesics, antihistamines of the first generation.

¦ Massive hydration.

¦ Use of acetylsalicylic acid.

¦ The routine use of aminophylline (aminophylline *) iv in case of an attack of bronchial asthma in addition to therapy with? 2 agonists has not been shown. This does not lead to an additional bronchodilating effect, but is accompanied by an increase in the frequency of side effects (tremor, headache, tachycardia, nausea and / or vomiting, increased diuresis, gastroesophageal reflux, dermatitis; because of the small therapeutic latitude, an overdose and the risk of sudden death from arrhythmia are possible or seizures).

? In adults, the appointment of aminophylline as part of complex therapy of asthmatic status (a small additional effect) is acceptable if the patient has not previously taken theophylline orally: 2.4% aminophylline iv - 10-20 ml, previously diluted in 0.9% sodium solution chloride - 10-20 ml and injected for 10-20 minutes.

? In children with a severe attack of bronchial asthma and asthmatic status, the need to use iv aminophylline (6-10 mg / kg) as an addition to systemic gluco-corticoids,? 2 agonists and anticholinergics should be considered. This gives a slight additional bronchodilating effect, but its price is a four-fold increase in the risk of developing vomiting.

METHOD OF APPLICATION AND DOSES OF MEDICINES

Dosage and administration of drugs for exacerbation of bronchial asthma at the stage of the NSR.

¦ Salbutamol (e.g., ventolin *) 2.5 ml nebulized inhalation solution (1 mg / ml).

? Children: 0.5-1 nebula (1.25-2.5 mg) through a nebulizer for 5-15 minutes, evaluate the effect after 20 minutes and, if necessary, repeat inhalation.

? Adults: 1-2 nebula (2.5-5.0 mg) through a nebulizer for 5-15 minutes, evaluate the effect after 20 minutes and, if necessary, repeat inhalation.

¦ Fenoterol (for example, Berotek ") solution for inhalation in 20 ml vials (1 mg / ml).

? Children: 0.5-1.0 mg through a nebulizer for 10-15 minutes, evaluate the effect after 20 minutes and, if necessary, repeat inhalation.

? Adults: 0.5-1.0 mg (up to 2.0 mg) through a nebulizer for 10-15 minutes, evaluate the effect after 20 minutes and, if necessary, repeat inhalation.

¦ Ipratropium bromide (atrovent *) solution for inhalation in 20 ml vials (250 μg / ml).

? Children: with caution in children under 6 years of age. Efficiency and safety of use have not been established.

? Adults: 0.4-2.0 ml (0.1-0.5 mg) through a nebulizer for 5-15 minutes.

¦ Fenoterol + ipratropium bromide (berodual *) solution for inhalation in 20 ml vials.

? Children: with caution in children under 6 years of age, at a dose of 0.1-0.4 ml (2-8 drops) through a nebulizer for 10-15 minutes; children over 6 years of age - 0.5-1 ml (10-20 drops).

? Adults: 1-2 ml (20-40 drops) through a nebulizer for 10-15 minutes.

¦ Prednisolone ampoules of 1 ml (30 mg / ml).

? Children: iv, children 2-12 months old - 2-3 mg / kg, 1-14 years old - 1-2 mg / kg body weight.

? Adults: intravenously, 60–90 mg.

¦ Budesonide (pulmicort *) 2 ml suspension for inhalation (250 mcg / ml, 500 mcg / ml).

? Children: inhalation through a nebulizer, children 1-5 years old — 0.25 mg, or 0.5 ml; 6-12 years old - 0.5-1.0 mg, or 1-2 ml.

? Adults: inhalation through a nebulizer, 1-2 mg or 2-4 ml.

¦ Epinephrine (adrenaline-) 0.1% solution in ampoules of 1 ml (1 mg / ml).

? Children: in / m or s / c 0.1% solution - 0.1-0.3 ml (or at the rate of 0.01 mg / kg body weight). If ineffective, repeat after 20 minutes.

? Adults: in / m or s / c 0.1% solution - 0.3-0.5 ml. If ineffective, repeat after 20 minutes.

CLINICAL PHARMACOLOGY OF MEDICINES

Epinephrine, glucocorticoids - see article “Allergic rhinitis, allergic conjunctivitis, urticaria, Quincke's edema”.

An emergency algorithm for an attack of bronchial asthma and asthmatic status at the stage of the NSR. ¦ In all cases - evaluate the result of therapy with bronchodilators after 20 minutes. If the effect is unsatisfactory, repeat the same inhalation of a bronchodilator.

¦ Light attack

? Children: salbutamol 1.25-2.5 mg (1/2 to 1 nebula) through a nebulizer for 5-15 minutes; or fenoterol + ipratropium bromide 0.1-0.4 ml (2-8 drops) for children under 6 years old; 0.5-1 ml (10-20 drops) for children over 6 years old through a nebulizer for 10-15 minutes.

? Adults: salbutamol 2.5 mg (1 nebula) through a nebulizer for 5-15 minutes; or fenoterol + ipratropium bromide 1 ml (20 drops) through a nebulizer for 10-15 minutes.

? Result: stopping the attack.

¦ Moderate seizure

? Children: the same bronchodilators + prednisone 1 mg / kg iv or budesonide 250-500 mcg through a nebulizer for 5-10 minutes.

? Adults: salbutamol 2.5-5.0 mg (1-2 nebulas) through a nebulizer for 5-15 minutes or fenoterol + ipratropium bromide 1-3 ml (20-60 drops) through a nebulizer for 10-15 minutes + prednisone 60–90 mg iv or budesonide through a nebulizer 1000–2000 mcg for 5–10 minutes.

? Result: stopping the attack, hospitalization of children in the hospital.

¦ Severe attack

? Children: fenoterol + ipratropium bromide in the same doses (when using salbutamol, add ipratropium bromide) + prednisolone for children 2-12 months old - 2-3 mg / kg, 1-14 years old - 1-2 mg / kg body weight ± budesonide 250— 500 mcg through a nebulizer for 5-10 minutes.

? Adults: fenoterol + ipratropium bromide in the same doses (when using salbutamol add ipratropium bromide) + prednisolone 90-150 mg iv ± budesonide 1000-2000 mcg through a nebulizer for 5-10 minutes.

? Result: hospitalization in a hospital.

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Bronchial asthma

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