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CHRONIC Bronchitis and Pulmonary Emphysema

Chronic bronchitis is a disease characterized by chronic or recurrent excessive secretion of mucus in the bronchi, leading to the appearance of a productive cough with annual exacerbations of up to 3 months or more in recent years. Emphysema is a disease caused by an increase in the air space of the end bronchioles as a result of destructive changes in their walls.

There are chronic catarrhal bronchitis, which is accompanied by the formation of sputum mucosa, and chronic mucopurulent bronchitis, in which there is periodic or constant presence of pus in the sputum. Chronic asthmatic bronchitis is characterized by repeated attacks of suffocation caused by various reasons; it is difficult to distinguish from bronchial asthma.

Emphysema results in a loss of organ elasticity and increased resistance to air flow. The same patient may have both chronic bronchitis and emphysema. Both diseases or any of them are characterized by chronic airway obstruction (COPD).

Complaints about difficulty breathing and coughing with the production of mucous or purulent sputum are characteristic. A physical examination determines the bronchial type of breathing, an increase in the duration of exhalation, wheezing (more during exhalation), in some cases, difficult exhalation by type of asthma. Sometimes breathing noises are heard from a distance. A barrel-shaped chest in patients with pulmonary emphysema is relatively rare [Paleev NR, 1998]. Dyspnea at rest, as a rule, is absent. PaCO2 is normal or moderately elevated (up to 50 mmHg) with moderately reduced PaO2. In the study of HPF, a moderate decrease in FEV1, an increase in airway resistance and a decrease in the maximum expiratory flow rate are detected. Emphysema is characterized by a decrease in their diffusion capacity. These data indicate chronic respiratory failure. With prolonged illness, there may be a rather high level of PaCO2, without a decrease in pH and an increase in symptoms of respiratory failure. The same can be said of chronic mild form of hypoxemia (PaO2 more than 70 mm Hg), which is often observed in patients with chronic bronchitis and pulmonary emphysema.

The clinical picture. The deterioration of the general condition of the patient in most cases is associated with the onset of infection, leading to the progression of respiratory failure in the obstructive type (FEV1 less than 25% of the norm). ONE is manifested by increased shortness of breath, which disturbs the patient even at rest; he is forced to take a half-sitting position, cannot talk. The increase in insufficiency is also evidenced by the participation in the breathing of the auxiliary muscles of the chest and anterior abdominal wall, the presence of “silent” zones in the lungs, and the patient’s complaint that he has not been sleeping and cannot clear his throat for the past few nights. PaCO2 in comparison with moderate initial hypercapnia increases, pH decreases, metabolic compensation is absent. PaO2 drops sharply to less than 60 mm Hg. Nevertheless, cyanosis may be absent, it is characteristic of the late stage of ONE. Blood pressure is often increased, but in the late stage it can decrease. Often there is arousal, sometimes there is a "respiratory panic", inadequate behavior, in a severe stage - depression, stupor and coma. Some patients have chronic pulmonary hypertension, which increases the risk of heart overload. In the late stage of ARF, an acute pulmonary heart can develop, the characteristic symptoms of which are dilated cervical veins, peripheral edema, and acute failure of the right heart.

Exacerbation of chronic bronchitis in connection with the onset of infection is manifested by increased cough, a change in sputum, which becomes yellow or green; an increase in body temperature without a significant shift in the blood formula - pronounced leukocytosis and any changes in the radiograph of the lungs.

In elderly patients suffering from atherosclerosis and hypertension, ONE can lead to left ventricular failure. Often there is a combination of ODN and cardiovascular failure, while one condition may mask another. Differential diagnosis is difficult, as some signs (shortness of breath, cyanosis, bloating of the veins of the neck, moist rales in the lungs) are observed in cases of acute respiratory failure and acute cardiovascular failure. Most often, a diagnosis of acute left ventricular failure is established, and ODN is not diagnosed, and targeted therapy is not carried out. Acute heart failure, not accompanied by ARF, usually occurs without exacerbation of chronic bronchitis - without severe cough, changes in sputum and other symptoms of bronchial obstructive disease.

Pulmonary embolism, which often complicates the course of the underlying disease, is characterized by the same clinical symptoms as ONE: shortness of breath, cough, changes in the gas composition of arterial blood, signs of pulmonary heart. Changes in the scan in this category of patients are not very specific.

Bacterial pneumonia usually occurs with a higher body temperature, leukocytosis, local changes in the lungs, detected by physical and radiological studies.

Broncho obstructive syndrome is a characteristic sign of ODN in chronic bronchitis and emphysema. It can be a manifestation of other diseases: bronchial asthma, bronchiectasis, obliterating bronchiolitis, cystic fibrosis and some pseudo-asthmatic conditions.

The cause of ARF in patients with chronic bronchitis and pulmonary emphysema, especially in the elderly, may be the appointment of sedatives. Surgical intervention and anesthesia in this category of patients, prolonged immobilization, the use of narcotic analgesics in the postoperative period, leading to the suppression of the cough reflex, can lead to the development of this complication.

Treatment. The main goal is to maintain the blood gas composition at a level that excludes the progression of hypoxia and hypercapnia. This cannot be done without restoring normal airway patency, eliminating bronchial obstruction, pulmonary infection. Naturally, patients with ONE require constant monitoring of not only lung function, but also of the cardiovascular system. It should be borne in mind the possibility of various complications in which quick diagnosis and appropriate therapy are necessary.

Oxygen therapy. Bronchial obstructive syndrome is accompanied by significant hypoxemia, and the patient can adapt to this condition to a certain limit. PaO2 is significantly lower than 50 mm Hg. Art. when breathing air. Oxygen inhalations are carried out in concentrations sufficient to maintain RaO2 at the level of 55-60 mm Hg. Patients with chronic or acute hypercapnia are shown to have low oxygen concentrations, i.e. 2-3 l / min when using nasal catheters. It is better to use a Venturi mask with FiO2 0.24 or 0.28. In this case, monitoring of PaCO2, PaO2, pH and the clinical condition of the patient is necessary. Oxygen therapy leads to a decrease in hypoxic vasoconstriction of the pulmonary artery and bronchospasm, increases the oxygen content in the blood, improves its transport to tissues, and promotes the excretion of water by the renal tubules.

Oxygen therapy can also have negative consequences. In patients with hypercapnia, high oxygen concentrations can lead to a further increase in PaCO2. High oxygen concentrations are also dangerous with some manifestations, united by the concept of “oxygen toxicity”. Nevertheless, with the progression of hypoxia, higher oxygen concentrations and masks should be prescribed, which create FiO2 capabilities of 0.35-0.45. A slight increase in PaCO2 is quite expected and does not pose a direct threat to the patient's life. However, with severe hypercapnia, as well as with the progression of hypoxia, despite the ongoing oxygen therapy, tracheal intubation and supporting mechanical ventilation are indicated.

The restoration of the drainage function of the bronchi is achieved by the appointment of bronchodilators, antibacterial drugs and physiotherapy of the chest.
Beta-Agonists along with bronchodilation cause an improvement in mucociliary clearance. These drugs (orciprenaline, isotarin, terbutaline, etc.) are prescribed as inhalations or subcutaneously. At the same time, postural drainage, percussion massage of the chest, stimulation of the cough reflex by placing an endotracheal catheter and introducing a 1.3% solution of sodium bicarbonate or mucolytic agents into the trachea are used, which is accompanied by the discharge of a large amount of sputum and a decrease in airway obstruction.

An important role in the treatment of bronchial obstructive syndrome is played by the appointment of aminophylline. It has a bronchodilator effect, enhances the activity of both departments of the heart, which is especially important in this category of patients; increases mucociliary clearance and airway contractility. The bronchodilating effect of aminophylline increases with the simultaneous use of sympathomimetic agents. A stable therapeutic effect is achieved when theophylline concentration in blood serum is 10-20 mg / l. “Loading” doses of aminophylline up to 6 mg / kg body weight for 20 minutes are used only if theophylline preparations have not been used in the last 24 hours. Maintenance doses are 0.4 mg / kg / h. In heart failure, liver and kidney diseases, both loading and supporting doses should be reduced by 2 times!

Corticosteroid therapy is indicated for the most severe forms of bronchial obstructive syndrome, especially when refractory to bronchodilators and history of hormone therapy. The minimum effective dose cannot be determined in advance. The most acceptable dose of dexamethasone or celestone is 4 mg every 6 hours until the bronchial obstructive status is completely eliminated. Sometimes this dose is increased to 8 mg (simultaneously) and even more, or equivalent doses of prednisolone and other corticosteroids are used. At the same time, euphyllin therapy does not stop.

Antibacterial therapy, Etiotropic antibiotic therapy is difficult due to the diversity of flora, insensitive to certain antibiotics. If it is not possible to identify the microbial agent, broad-spectrum antibiotics are prescribed.

Hydration. Its purpose is the elimination of water deficiency and hypovolemia, the creation of conditions for adequate hydration of the mucous membrane of the respiratory tract. Dehydration often accompanies ODN, being, as it were, its background, contributes to an increase in blood viscosity and thickening of the tracheobronchial secretion. However, the importance of hydration should not be exaggerated and large amounts of fluid administered intravenously or orally. Excessive infusion therapy in this category of patients is dangerous, since it can worsen the patient's condition.

Additional methods. Some physiotherapeutic methods can significantly improve the patient’s condition, facilitate sputum discharge and reduce respiratory function. The most effective auxiliary cough, careful postural drainage, vibration massage, percussion and vacuum massage of the chest. In some cases, sputum evacuation is facilitated by microtracheostomy, which is effective with adequate hydration of the respiratory tract (especially in patients of senile age), with an insufficient cough reflex.

Bronchoscopic lavage of the tracheobronchial tree with ONE, hypoxia and hypercapnia is a danger to the patient's life. An indication for its use is a large amount of sputum in the trachea and large bronchi with the impossibility of coughing. For its implementation, tracheal intubation is first performed.

Features of mechanical ventilation. Indications for mechanical ventilation should be strictly defined. It is necessary to use all the possibilities of "conservative" treatment and only with the progression of signs of hypoxia and (or) hypercapnia, confirmed by a series of tests, mechanical ventilation is performed without stopping drug therapy. Initially, orotracheal intubation with a tube with an internal diameter of 8–9 mm is preferable, since constant rehabilitation of the respiratory tract is necessary. Subsequently, orotracheal intubation is replaced by nasotracheal. During mechanical ventilation, constant physiotherapy in the chest area is necessary. Every 2 hours, the lungs are inflated with an Ambu bag, every 4 hours - stimulation of cough, inhalation of bronchodilators with the patient turning to the side, every 8-12 hours - therapeutic percussion and vacuum massage of the chest.

DO and BH should be calculated so that PaCO2 is not lower than the initial level familiar to the patient. Blood buffer systems are adapted to these changes due to delayed sodium bicarbonate by the kidneys. Hyperventilation leads to a restructuring of this mechanism, accompanied by a decrease in cerebral blood flow, often a decrease in blood pressure.

Indications for stopping mechanical ventilation are elimination of infection and improvement of lung function so that gas exchange is normal in chronic pulmonary diseases. MOD should be no more than 10 l, PaCO2 within mild hypercapnia or normal, PaO2 at least 60 mm Hg, up to at least 5 ml / kg. However, if the proper value of one or two indicators is not achieved, this does not mean that ventilation cannot be stopped. Observation of the patient for several hours when determining the gas composition of the blood will allow you to find the right solution. Extubation is usually carried out in the first half of the day. Before this, pharmacological agents that suppress the respiratory center should not be prescribed.

During the treatment of ODN, complications are possible:

• cardiac arrhythmias (polytopic supraventricular tachycardia, etc.), which are associated with hypoxia and an increase in blood pH. They can occur as a result of the action of various drugs with a cardiotoxic property;

• left ventricular failure. It should be remembered that hypoxia leads to an increase in pressure in the pulmonary artery. With the initial pathology of the cardiovascular system amid hypoxia, left ventricular decompensation may dominate the clinical picture. Cardiac glycosides are prescribed only with the restored gas composition of the blood. In case of stagnation in the pulmonary circulation or general hyperhydration, saluretics must be used, while controlling the concentration of potassium and other electrolytes in the blood;

• pulmonary embolism (pulmonary embolism) - a common difficult to diagnose complication. Its prevention consists in the appointment of low doses of heparin (5000 units in 8-12 hours);

• gastrointestinal bleeding. They are possible with the formation of stress ulcers on the mucous membrane of the stomach and intestines. For their prevention, nasogastric aspiration, antacids and cimetidine are used.

Forecast. ODN in patients with chronic bronchitis and pulmonary emphysema is an extremely serious complication and very often leads to death. This is evidenced by numerous data published in the United States and Western Europe. Until 1960, the hospital mortality rate of patients with chronic bronchitis and pulmonary emphysema complicated by ONE was about 50%. As the intensive care and resuscitation departments were organized, this indicator gradually decreased. Currently, with the first episode of respiratory failure, it reaches 25%, and 5-year survival, according to R. G. Ingram (1993), is only 15-20%. Risk factors for developing chronic bronchitis and emphysema include smoking, air pollution, harmful professions, family and genetic factors. The performance of patients who have undergone ODN is often significantly reduced. They have depression, anxiety, decreased activity. After discharge from the hospital, vigorous implementation of the rehabilitation program is necessary.
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CHRONIC Bronchitis and Pulmonary Emphysema

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