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BRONCHIAL ASTHMA — a chronic recurrent disease with a primary lesion of the respiratory tract. It is characterized by altered reactivity of the bronchi. A mandatory sign of the disease is an asthma attack and / or asthmatic status.
Two forms of bronchial asthma are distinguished - immunological and non-immunological - and a number of clinical and pathogenetic options: atonic, infectious-allergic, autoimmune, dishormonal, neuropsychiatric, adrenergic imbalance, primarily altered bronchial reactivity (including the “aspirin” physical effort of asthma and ), cholinergic.
Etiology and pathogenesis. A common pathogenetic mechanism inherent in different variants of bronchial asthma is a change in the sensitivity and reactivity of the bronchi, determined by the reaction of patency of the bronchi in response to the effects of physical and pharmacological factors. It is believed that in 1/3 of patients (mainly streets suffering from an atonic variant of the disease), asthma has a hereditary origin. In the occurrence of allergic forms of asthma, non-bacterial (house dust, plant pollen, etc.) and bacterial (bacteria, viruses, fungi) allergens play a role. The most studied allergic mechanisms of asthma, which are based on IgE or IgG-induced reactions. The central place in the pathogenesis of "aspirin" asthma is given to leukotrienes. With asthma of physical effort, the process of heat transfer from the surface of the respiratory tract is disrupted.
Symptoms, course. The disease often begins with a paroxysmal cough, accompanied by expiratory dyspnea with the discharge of a small amount of vitreous sputum (asthmatic bronchitis). A detailed picture of bronchial asthma is characterized by the appearance of lungs, moderate or severe asthma attacks. An attack can begin with a harbinger (copious secretion of a watery secretion from the nose, sneezing, paroxysmal cough, etc.). An asthma attack is characterized by a short inhalation and elongated exhalation, accompanied by rattles heard from a distance. The chest is in the maximum inspiratory position. The muscles of the shoulder girdle, back, and abdominal stack take part in breathing. With percussion over the lungs, a box sound is determined, a lot of dry rales are heard. The attack, as a rule, ends with the separation of viscous sputum. Severe protracted seizures can go asthmatic - one of the most formidable variants of the course of the disease.
An asthmatic condition is characterized by increasing resistance to bronchodilator therapy and unproductive cough. There are two forms of an asthmatic condition - anaphylactic and metabolic. In the anaphylactic form, due to immunological or pseudo-allergic reactions with the release of a large number of mediators of an allergic reaction (most often in people with hypersensitivity to drugs), an acute severe asthma attack occurs. The metabolic form associated with functional blockade of adrenergic receptors and resulting from an overdose of sympathomimetics with respiratory infections, adverse meteorological factors, due to the rapid withdrawal of corticosteroids, is formed within a few days. In the I (initial) stage, sputum ceases to go away, pain appears in the muscles of the shoulder girdle, chest and in the abdominal area. Hyperventilation, loss of moisture with exhaled air leads to an increase in the viscosity of sputum and obstruction of the lumen of the bronchi with a viscous secret. The formation of “dumb lung” in the posterior parts of the lungs indicates the transition of status to stage II with a clear discrepancy between the severity of distance rales and their absence during auscultation. The condition of patients is extremely serious. The chest is emphysematically swollen. The pulse exceeds 120 in 1 min. Blood pressure tends to increase. On the ECG - signs of overload of the right heart. Respiratory or mixed acidosis is formed. In stage III (hypoxic-hypercapnic coma), shortness of breath and cyanosis increase, sharp excitement gives way to loss of consciousness, convulsions are possible. The pulse is paradoxical, blood pressure decreases.
The course of the disease is often cyclical: the phase of exacerbation with characteristic symptoms and data from laboratory and instrumental studies is replaced by a phase of remission. Complications of bronchial asthma: emphysema, often the accession of infectious bronchitis, with a long and severe course of the disease - the appearance of a pulmonary heart.
The diagnosis is made on the basis of typical attacks of expiratory suffocation, eosinophilia in the blood and, especially, in sputum, a carefully collected medical history, allergological examination with skin and, in some cases, provocative inhalation tests, immunoglobulin E and G studies. A thorough analysis of medical history, clinical, radiological and laboratory data (if necessary, and the results of bronchological studies) allows to exclude the syndrome of bronchial obstruction with non-specific and specific inflammatory respiratory diseases, connective tissue diseases, parasitic infestations, bronchial obstruction (foreign body, tumor), endocrine pathology humoral (hypoparathyroidism, carcinoid syndrome, etc.), hemodynamic disorders in lesser circulation, affective disorders, and so on. d.
Treatment for bronchial asthma should be strictly individualized, taking into account the course, phase of the disease, the presence of complications, concomitant diseases, patient tolerability of drugs and their most rational use during the day.
With atopic bronchial asthma, first of all, elimination therapy is prescribed - the most complete and permanent cessation of contact with the allergen. If the allergen is identified, but the patient cannot be isolated from it, specific hyposensitization in specialized allergological institutions in the remission phase is indicated. Patients with atopic asthma (especially with uncomplicated forms of the disease) are prescribed cromolyn sodium (intal) 20 mg 4 times a day, spraying it with a special inhaler. If asthma is combined with other allergic manifestations, it is preferable to ingest zaditen (ketotifen) 1 mg 2 times a day. The effect of both drugs occurs gradually (assessment of therapeutic efficacy is possible in at least 3-4 weeks). In the absence of effect, glucocorticoids are prescribed, in mild cases, preferably in the form of inhalations (becotide 50 μg every 6 hours). In severe exacerbations, oral administration of glucocorticoids is indicated, starting with prednisolone at 15-20 mg / day or triamcinolone at 12-16 mg / day; after the clinical effect is achieved, the dose is gradually reduced. With food allergies, the use of unloading and dietary therapy in a hospital is indicated.
Patients with an infectious-allergic form of asthma are recommended treatment with an auto vaccine, sputum autolysate, hetero vaccines, which are currently being prepared using a new technology. Vaccine treatment is carried out in a specialized hospital. In case of violations in the immune system, appropriate immunocorrective therapy is prescribed (levamisole, pyrogenal, etc.). During remission, foci of chronic infection are sanitized. The issue of indications for antibiotic therapy is decided by the nature of the inflammation at the moment. The reference is the cell composition of sputum: with eosinophilia, antibacterial drugs are not recommended.
In this category of patients, glucocorticoids are more often used; Intal and zadit less effective.
With an infectious-dependent form of asthma, wellness measures are shown: physical activity, regular classes in therapeutic gymnastics, hardening procedures. In connection with the violation of mucociliary clearance, sputum-thinning therapy is necessary: plentiful warm drink, alkaline warm inhalations, 3% potassium iodide solution (1 tablespoon 5-6 times a day, subject to tolerability), decoction of herbs - rosemary, coltsfoot and others, mucolytic agents.
Patients with asthma of physical effort are prescribed corinfar with a positive pharmacological test with it: a decrease in bronchospasm at 6-10 minutes of rest after taking 20 mg of corinfar sublingually 1.5 hours before exercise. With prolonged use, the drug is taken 10 mg 3 times a day. In the case of a negative result of a pharmacological test, a long-term treatment with intalom or zaditen is carried out. Physical training is advisable: swimming or running quietly in a warm room; with good tolerance, increase the load by 1 minute every week (up to 60 minutes).
With "aspirin" asthma, foods containing acetylsalicylic acid (berries, tomatoes, potatoes, citrus fruits) are excluded from the diet. It is strictly forbidden to take non-steroidal anti-inflammatory drugs. If necessary, prescribed intal, zaditen or corticosteroids.
With severe emotional disorders, a qualified examination and treatment of a psychotherapist with an individual selection of psychotropic drugs is necessary. Rational psychotherapy, reflexology therapy are shown.
To relieve asthma attacks, individually selected bronchodilator therapy is prescribed. The optimal dose of bronchodilators is selected empirically (from a small dose to the most effective). The positive effect in most patients is exerted by selective stimulants of? 2-adrenergic receptors (salbutamol, berotek, etc.), produced in the form of metered-in manual (pocket) inhalers. During an attack, 2 breaths of aerosol help. In mild cases, such preparations can be used in the form of tablets. For more severe seizures, injections of brikanil (1 ml of a 0.005% solution) or ephedrine (0.5-1 ml of a 5% solution), less often adrenaline (0.3-0.5 ml of a 0.1% solution) are used, s / c. Patients should be warned about the danger of abuse of sympathomimetics, in particular in the form of metered-dose inhalers, which can be used no more than 3-4 times a day. An overdose of these drugs (especially with hypoxia) can have a cardiotoxic effect; In addition, the frequent use of sympathomimetics causes blockade of? receptors. Eufillin remains the effective bronchodilator, prescribed in severe cases, iv (5-10 ml of 2.4% solution). The drug is also used in the form of tablets (0.15 g each) and suppositories (0.3 g each).
Cholinoblockers (atropine, belladonna, platifillin) are preferred for the infectious-allergic form of the disease, especially for obstruction of large bronchi. Often these drugs are attached to other bronchodilators. Solutan (10-30 drops after a meal) and anti-asthma fees in the form of powder for smoking or cigarettes (asthmatol, asthmatine) help some patients. The effect of anticholinergics on mucociliary clearance should be taken into account, which leads to thickening of sputum and difficulty in its separation. An effective drug of this group is atrovent, released in metered-dose inhalers; it can be used to prevent attacks of 2 breaths 3-4 times a day. The drug slightly affects mucociliary clearance. The different mechanisms of bronchial obstruction in each patient determines the advisability of a combination of drugs. An effective drug is berodup - a combination of berotek and atrovent in the form of a metered-dose inhaler.
Treatment of asthmatic status is carried out differentially depending on its stage, form, cause. With the anaphylactic form, a subcutaneous solution of adrenaline is administered and glucocorticoids are immediately used, prescribing with 100 mg of intravenous hydrocortisone. If there is no obvious improvement in the next 15-30 minutes, the effect of hydrocortisone is repeated and iv infusion of aminophylline (10-15 ml of 2.4% solution) is started. At the same time carry out oxygen therapy through a nasal catheter or mask (2-6 l / min). Treatment should be carried out in an intensive care unit.
Treatment of the metabolic form of asthmatic status is carried out depending on its stage. Initially, it is necessary to eliminate the unproductive cough, improve sputum discharge through warm alkaline inhalations, and plenty of warm drinking. If the asthmatic condition is due to the cancellation or overdose of sympathomimetics, a drip of 30 mg prednisolone every 3 hours iv is indicated until the status is stopped. The development of acidosis dictates the need for / in the infusion of 2% sodium bicarbonate solution. Mandatory rehydration by introducing a large amount of liquid. In stage II of the asthmatic state, the dose of glucocorticoids is increased (prednisone up to 60–90–120 mg every 60–90 min). If the picture of a “silent lung” does not disappear in the next 1.5 hours, controlled ventilation with active dilution and aspiration of sputum is indicated. In stage III, intensive care is carried out together with a resuscitator.
After removing from an asthmatic condition, the dose of glucocorticoids is immediately halved, and then gradually reduced to a maintenance one. More than 50% of patients receiving glucocorticoids need their long-term use, often for years. In such cases, we are talking about a steroid-dependent variant of bronchial asthma. Clinical observation of such patients, the maximum reduction in the maintenance dose of glucocorticoids, if possible switch to their inhalation use, combination with other drugs (zadit, intal, bronchospasmolytics, etc.), intermittent use of glucocorticoids, use of psychotropic drugs and physical rehabilitation can minimize complications glucocorticoid therapy.
In severe patients with no effect or insufficient effect of conventional therapy, as well as with a high need for glucocorticoids and in asthmatic status, the use of plasmapheresis is indicated.
During remission, hypersensitizing therapy, sanitation of foci of infection, physiotherapy exercises, physical training (walking, swimming), physiotherapy, and spa treatment are carried out. Of greatest importance is the treatment at local resorts, since it has become apparent that the processes of adaptation to new climatic conditions and after a short time of rehabilitation do not have a training effect. Qualitative psychotherapy significantly improves the effect of complex therapy.
Forecast. With follow-up (at least 2 times a year), rationally selected treatment, the prognosis is favorable. A lethal outcome can be associated with severe infectious complications, untimely and irrational therapy, progressive pulmonary heart failure in patients with pulmonary heart disease.
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