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1.2. CHRONIC OBSTRUCTIVE LUNG DISEASE

Treatment goals:

1. Prevention of COPD progression

2. Reducing the severity of symptoms

3. Increased exercise tolerance

4. Improving health and quality of life

5. Prevention and treatment of complications

6. Mortality reduction



The patient management tactic is characterized by a stepwise increase in the volume of therapy, depending on the severity of the disease. At all stages:

> Reducing the adverse effects of atmospheric and home pollutants;

> Anti-nicotine program (doctor's interview, development of a patient behavior strategy, nicotine replacement therapy, detection and treatment of COPD, prevention of exacerbations);

> Annual influenza vaccine prophylaxis, pneumococcal vaccine prophylaxis once every 3-5 years.



I: mild COPD

Add short-acting bronchodilators to treatment as needed:

> Inhaled M-anticholinergic drugs:

IPRATROPIA BROMIDE (ATROVENT) (aerosol. D / ing. Dosing., 20 mcg / 1 dose, 200 and 300 doses), 40-80 mcg (2-4 ing.) 3-4 r / day .;

TROVENTOL (aerosol. D / ing. Dosing., 20 mcg / 1 dose, 21 g), 20-80 mg (1-4 ing.) 2-3 r / day.

? Inhaled G32-agonists:





SALBUTAMOL and its analogues (aerosol. D / ing. Dosing., 100 mcg / 1 dose, 90 doses), 100-200 mcg (1-2 ing.) 3-4 r / day;

TERBUTALINE and its analogues (aerosol. D / ing. Dosing., 250 mcg / 1 dose) 250-500 (1-2 ing.) Every 6 hours;

FENOTEROL (BEROTEK) (aerosol d / ing. Dosing., 100 and 200 mcg / 1 dose, 200 and 300 doses) 100-200 mcg (1-2 ing.) 1-3 r / day not> 1.6 mg / day



II: moderate COPD

Add to treatment the continuous use of one or more bronchodilators:

> Long-acting inhaled M-anticholinergics:

THIOTROPY BROMIDE (SPIRIVA) (cape, from p. D / ing .; 18 mcg) 18 mcg 1 r / day using a Handihaler inhaler

> Inhalation (? 2 - long-acting agonists:

FORMOTEROL (OXIS TURBUCHALER) (cape, from p. D / ing; 4.5 and 9.0 mcg), 2 ing. 2 r / day; SALMETEROL (SEREVENT) (aerosol. D / ing. Dosing., 25 mcg / 1 dose, 60 and 120 doses) 50-100 mcg 2 r / day

> Combined drugs:

M-anticholinergic drug with rapid action:

BERODUAL (aerosol. D / ing. Dosage; ipratropium bromide + phenoterol hydrobromide - 21 mcg + 50 mcg / 1 dose; 200 doses) 1-2 ing. 3 times a day (up to 8 ing. / Day.) Inhaled GCS with a long-acting rg agonist:

SERETID MULTIDISK (por. D / ing; salmeterol + fluticasone - 50 + 100; 50 + 250; 50 + 500 mcg / 1 dose) 1 ing. 2 r / day

SERETID (aerosol. D / ing. Dosage; salmeterol + fluticasone - 25 + 50; 25 + 125; 25 + 250 mcg / 1 dose; 120 doses) 1 ing. 2 r / day

SYMBICORT TURBUCHALER (por. D / ing; budesonide + formoterol-80 + 4.5; 160 + 4.5 mcg / 1 dose; 60 and 120 doses) 1-2 ing. 2 r / day

> Inhaled corticosteroids with severe symptoms of COPD and a proven spirometric response (increase in BMD ^> 15% after 2-week therapy with prednisolone at a dose of 40 mg per os)

BECLOMETASONE and its analogues (aerosol. D / ing. Dosing., 50, 100, 250 mcg / 1 dose, 200 doses) 200 mcg 2 r / day;

FLUNISOLIDE (INGACORT) (aerosol. D / ing. Dosing., 250 mcg / 1 dose, 120 doses) up to 2 mg / day. (8 inhalations); BUDESONIDE (PULMICORT TURBUCHALER) (aerosol d / ing. Dosing., 200 mcg / 1 dose, 100 and 200 doses) 200 mcg 2 r / day;

PULMICORT (suspension for nebulizers 0.5 mg), 2 ing. 2 r / day

FLUTICASONE (FLICOTID) (aerosol. D / ing. Dosing., 125 and 250 mcg / 1 dose, 60 and 120 doses) 100-1000 mcg 2 r / day

Add rehabilitation measures to treatment (regimen, exercise therapy, breathing exercises, physiotherapeutic procedures, spa treatment).



III: severe COPD

> Continuous use of one or more bronchodilators (see above)

> Inhaled GCS with severe symptoms of COPD and a proven spirometric response or repeated exacerbations requiring treatment with antibiotics and / or systemic GCS

> Rehabilitation activities (see above)



IV: extremely severe COPD

> Continuous use of one or more bronchodilators (see
higher)

> Inhaled GCS with severe symptoms of COPD and a proven spirometric response or repeated exacerbations requiring treatment with antibiotics and / or systemic GCS

> Rehabilitation activities

> Treatment of complications







> Oxygen therapy: long-term (18 hours per day) low-flow (2-5 l per min.)

> Surgical treatment

The basic principles of managing patients with exacerbation of COPD:

1. Inhalation of bronchodilators (especially 62-agonists and / or M-anticholinergics), theophylline and GCS (with systemic, mainly oral administration) are effective for treating exacerbation of COPD (level of evidence A).

2. In severe exacerbation of COPD, nebulizer therapy with bronchodilators is preferred (level of evidence: B).

3. Combinations of bronchodilators may be more effective and cause fewer undesirable drug reactions (level of evidence A).

4. For exacerbations of COPD with clinical signs of bronchial infection (an increase in the number and color of sputum and / or fever), antibiotic therapy is indicated for patients. The choice of antibiotic depends on the sensitivity to antibiotics typical of exacerbation of COPD microorganisms: S. pneumoniae, H. influenzae, M. catatrhalis. In severe exacerbations, the antibiotic must be active not only against these typical pathogens, but also against K. pneumoniae and P. aeruginosa.

5. With exacerbation of COPD with a decrease in FEV! less than 50% of the due systemic corticosteroids (prednisone in an average daily dose of 30-40 mg or its equivalent) are prescribed in parallel with bronchodilator therapy for 10-14 days (level of evidence D).

6. A short course of systemic GCS is not an accurate prognostic sign of a long-term response to GCS.

7. In some patients with COPD responding to a trial course of systemic corticosteroids, the use of a combination of corticosteroids with long-acting P2 agonists is indicated.

8. Long-term treatment with systemic corticosteroids does not increase efficiency, but increases the risk of undesirable drug reactions,

9. Non-invasive pulmonary ventilation (IVL) with intermittent positive pressure improves blood gas composition and pH, reduces hospital mortality, the need for tracheal intubation and mechanical ventilation (mechanical ventilation), and the duration of hospital treatment (level of evidence A). The goal of oxygen therapy is to achieve Ra02 in the range of 60-65 mm Hg. Art. and Sa02 90-92%.

10. With a slight exacerbation of the disease, there is a need to change the usual bronchodilator therapy (increase in dose and / or frequency of taking drugs). If an exacerbation of COPD is of a bacterial nature, the administration of amoxicillin or macrolides (azithromycin, clarithromycin) is indicated.

11. With moderate exacerbation, along with increased therapy, a medical assessment of the clinical situation is required. In the case of a bacterial nature of exacerbation, amoxicillin / clavulanate or cephalosporins of the II and III generation or respiratory fluoroquinolones are prescribed. The duration of AB therapy should be at least 10 days.

12. With severe exacerbation of COPD, hospitalization of the patient is necessary.

13. In the treatment of patients with multiple organ pathologies, tachycardia, hypoxemia, the role of anticholinergics increases. Ipratropium bromide is prescribed both as monotherapy and in combination with B2 agonists. A more pronounced and rapid subjective improvement is achieved with the use of a nebulized solution of berodual.

14. All patients with severe and extremely severe stages of COPD during exacerbation of the disease with the development of ONE should be prescribed antibacterial treatment. Respiratory fluoroquinolones are recommended as first-line therapy in this category of patients.

15. Additional anti-inflammatory therapy: Fenspiride (Erespal) (tab. 80 mg) orally at 80-160 mg 2-3 r / day. together with basic therapy, in Art. remissions of 80 mg 1 r / day for up to 6 months.

16. Mucolytic therapy: Ambroxol hydrochloride (Ambrohexal) (tab. 30 mg; solution 50 and 100 ml) inside 30 mg 3 r / day or 4 ml solution 3 r / day, treatment 4-14 days
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