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Kim Viktor Yugenovich. Surgical treatment of bronchial asthma with radiofrequency electrical stimulation of the sympathetic trunks [Electronic resource]: Dissertation... Candidate of Medical Sciences: 14.00.27
Introduction
CLASS CHAPTER 1. Literature Review CLASS 9
1.1 Drug treatment of bronchial asthma 9
1.2 Surgical treatment of bronchial asthma - 12
CHAPTER 2. Material and research methods 17
2.1 Methodology of experimental studies on animals 17
2.2 Clinical characteristics of patients 21
2.3 Methods for studying patients 24
2.3.1 Function study external respiration 24
2.3.2 Study of the state of the autonomic and central nervous systems 25
2.3.3 Study of the state of the mine system 28
2.3.4 Study of acidic-acid state, blood gas. 29
2.3.5 Research of cardio-vascular system 29
2.1.3 Statistical processing of results... 31
CHAPTER 3 . Treatment of patients with bronchial asthma with electrical stimulation of sympathetic trunks 32
3.1 Indications and contraindications for implantation of stimulators and radiofrequency electrical stimulation of sympathetic trunks 32
3.2 Characteristics of the implanted electrical neurostimulator and surgical technique for its implantation on the cervical and thoracic parts of the sympathetic trunks - - 37
3.3 Method of radiofrequency electrical stimulation of sympathetic muscles - 44
CLASS CHAPTER 4. Research results 4 CLASS 5
4.1 Results of animal experiments 45
4.2 Immediate and long-term results of treatment of patients with bronchial asthma with radiofrequency electrical stimulation of the sympathetic trunks in their cervical part 56
4.3 Immediate and long-term results of treatment of patients with bronchial asthma with radiofrequency electrical stimulation of the sympathetic trunks in the thoracic part 68
4.4 Complications of treatment of bronchial asthma with radiofrequency electrical stimulation of sympathetic trunks, ways of their prevention and treatment 78
Conclusion 83
Bibliographic index 91
List of abbreviations, symbols5
Symbols, units and terms 102
Introduction to the work
Relevance of the problem
Over the past decades, most countries of the world have seen a significant increase in the incidence of bronchial asthma (BA). To date, at least 5% of the world's population suffers from this disease. The leading pathogenetic link of BA is chronic eosinophilic inflammation of the bronchi of allergic origin. Nervous mechanisms is also considered important in the development of bronchospasm. Current drug therapy for asthma includes mainly hormonal and adrenergic drugs. However, their long-term use can cause side effects - bleeding steroid gastric ulcers, diabetes mellitus, myocardial dystrophy, arterial hypertension, etc. Due to the long duration of treatment, addiction to the drugs gradually develops and their doses have to be increased. At the same time, the cost of treatment can reach 2 thousand US dollars per year. This cost of treatment is especially high for our population. Therefore, it seems relevant to search for more promising and less expensive treatment methods. Surgical methods of treating BA in the form of glomectomy, deirvation of the roots of the lungs, truncal vagotomy, autologous lung transplantation, animal tissue transplantation, cryodestruction of the nerves of the sinocarotid reflexogenic zone have not found such widespread use in clinical practice as drug therapy due to the fact that they did not always provide a pronounced therapeutic effect and were essentially organ-destructive operations that sometimes had life-threatening complications. Positive long-term results of using some of them, for example, glomectomy, denervacin of the roots of the lungs reached 45-75%.
Most of the surgical methods for treating asthma were based on the idea of dysfunction of the autonomic nervous system (ANS) in this disease: the predominance of the bronchial tubes and the constricting effects of its steam sympathetic division over the bronchodilatory effects of the sympathetic and non-adreergic pecholinergic (NANC) divisions. Removal or destruction of certain structures of the ANS can lead to an increase in the bronchodilatory effects of the ANS due to the activation of its sympathetic and NANC divisions.
A certain importance in the pathogenesis of asthma is also attached to the pathological dominant 7], disruption of the processes of excitation and inhibition in the central nervous system(CNS), in the structures of the ANS, neurodystrophic process.
According to modern concepts of physiology, stimulation of the sympathetic trunks in their cervical and thoracic parts leads to dilation of the bronchi. Mastery of the mechanisms for controlling the lumen of the airways through these structures can open up new prospects for the development of asthma surgery.
Purpose and objectives of the study
The purpose of this study was to study the effectiveness of treatment of AD using a new surgical method - radiofrequency electrical stimulation of the sympathetic trunks.
In accordance with. This goal defines the following research objectives:
1. To study the possibility of relieving and preventing the development of experimental bronchospasm by electrical stimulation of the cervical and thoracic sympathetic trunks in a model of BA in laboratory animals.
2. To study the effect of electrical stimulation of these sections of the sympathetic trunks on the body systems in laboratory animals in an experimental model of AD.
3. Determine the indications and contraindications for the use in clinical practice of a new surgical method for the treatment of asthma - radiofrequency electrical stimulation of the sympathetic trunks.
4. Test a new surgical method in clinical practice, study its effect on body systems and the course of asthma.
5. To give an objective assessment of the effectiveness of the method of surgical treatment of asthma - radiofrequency electrical stimulation of the sympathetic trunks.
Scientific novelty
It was revealed that electrical stimulation of the cervical or thoracic sympathetic trunk can lead to both expansion and contraction of the bronchi, depending on the parameters of the electrical stimulation current pulses.
It has been shown that periodic radiofrequency electrical stimulation of the sympathetic trunks with a pulsed current with individually selected parameters leads in the majority of patients with asthma to dilation of the bronchi in the background of a developing attack of suffocation and causes relief of some attacks without medication, reduces the use of anti-asthmatic drugs.
The possibility of implanting electrical stimulators on the thoracic part of the sympathetic trunks using video-thoracoscopic means has been demonstrated.
Practical significance of the work
The main indications and contraindications for the use of a new minimally invasive organ-preserving method of surgical treatment of asthma - radiofrequent electrical stimulation of the sympathetic trunks - have been determined.
It was revealed that periodic radiofrequency electrical stimulation of the sympathetic trunk in the cervical or thoracic parts leads to a significant reduction in the need of asthmatic patients for anti-asthmatic medications. This reduces the likelihood of them developing side effects of drug therapy and allows for effective treatment of severe, drug-resistant forms of asthma.
The main provisions made by the defense) 1. The cervical and thoracic parts of the sympathetic trunks in patients with BA are involved in the regulation of the lumen of the airways and cause their expansion or narrowing.
2. Periodic radiofrequency electrical stimulation of the cervical or thoracic parts of the sympathetic trunks with pulsed current with individually selected parameters that dilate the bronchi can be used to prevent and relieve some attacks of asthma without drugs, treat various forms of asthma, which reduces the need for anti-asthmatic drugs.
3. A new surgical method for the treatment of asthma - radiofrequency electrical stimulation of the sympathetic trunks - can be used as an additional method in complex anti-asthmatic drug therapy for asthma,
Approbation of work
18 works have been published based on the dissertation materials. The main provisions of the dissertation were presented and discussed at the third scientific and practical conference of surgeons of the North-West of Russia in 2001 and at three interdisciplinary scientific conferences with international participation in Petrozavodsk in 2002 (June 27-29), 2003 (June 23-25) and 2004 (June 21-23), as well as at the ninth Moscow International Congress on endoscopic surgery(Moscow, April 6-8, 2005). At the third international Moscow salon of innovations and investments in 2003 (February 4-7) at the All-Russian Exhibition Center, a new surgical technology treatment of asthma, which is the basis of this dissertation, was awarded a Gold Medal and a diploma from the Russian Agency for Patents and Trademarks. This work was also carried out in connection with the implementation of Petrozavodsk State University and the Russian Scientific Center of Surgery of the Russian Academy of Medical Sciences named after Acad. B.V. Petrovsky projects No. K0326, A0009 under the Federal Target Program of the Ministry of Education of the Russian Federation in 1998-2000. “Integration of fundamental science and higher education.”
Implementation of research results
Radiofrequency electrical stimulation of sympathetic trunks in patients with asthma was introduced in the clinic of the course general surgery Department of Anesthesiology, Reanimatology and General Surgery of Petrozavodsk State University on the basis of the Departmental Clinical Hospital at the station. Petrozavodsk Oktyabrskaya Railway (GTUZ Departmental Clinical Hospital at the Petrozavodsk station of JSC Russian Railways, located at the address: 185001 Petrozavodsk, Pervomaisky Ave., 17), in the Russian Scientific Center, Surgery of the Russian Academy of Medical Sciences. academician, B.V. Petrovsky, in the department of surgery of the lungs and mediastinum (119992, Moscow, Abrikosovsky lane, 2),
Scope and structure of the dissertation
The dissertation is presented on 104 pages of typewritten text and consists of an introduction, a literature review, and own research presented in three chapters. conclusions, conclusions, practical recommendations, bibliographic index, including 137 sources: 86 domestic and 51 foreign. The dissertation is illustrated with 20 tables and 35 figures.
Drug treatment of bronchial asthma
The main generally accepted method of treating AD is currently drug therapy. According to modern standards basic therapy B A includes bronchodilators and anti-inflammatory drugs, which are prescribed differentially depending on the severity of the disease. Hormonal and anti-inflammatory drugs, as a rule, are used only for moderate to severe BA, and bronchodilators - for any course of the disease. Currently in Russia, 60-75% of adult patients with bronchial asthma have a moderate to severe course.
The main anti-asthmatic medications include: 1, Bronchodilators: a) stimulants of alpha and beta adrenergic receptors (adrenaline hydrochloride, etc.); b) stimulators of bsta-1-, beta-2-adrenergic receptors, non-selective (isadrin, orciprenaline sulfate); c) stimulants of beta-2 adrenergic receptors, selective: short-acting (fenoterol, salbutamol, Berotek, terbutaigan) and long-acting (salmeter, Volmax), which are used in the form of metered-dose inhalers or tablets; d) short-acting methylxanthines (theophylline, aminophylline (aminophylline). If aerosols are ineffective, they are administered intravenously or long-acting theophylline preparations (teopec, Ventax, Retophil) are administered in tablets; e) anticholinergic drugs (atrovent (ipratropium bromide) troventol, berodual ( fenoterol + atrovent). These drugs are used for severe bronchorrhea or during an attack, in combination with beta-2-adrenergic stimulants. 2" Anti-inflammatory drugs: a) inhaled gLEOCOCORTICOIDS (beclomethasone dipropionate, pulmicorium flixrtide, flunisolide acetate (Ingacort) , and resorptive glucocorticoids (prediisolone, methylprednisolone, triamcinolone); b) mast cell membrane stabilizers (sodium cromoglycate; nsdocromil sodium, ketotifen, ditek). These drugs are used by inhalation to prevent attacks; c) lycotriene inhibitors; antagonists of leukotriene Ix receptors (zafirlukast (Acolate), montelukat (Singular), and inhibitors of leukotriene synthesis (Zileutop). The use of medications is not without side effects. Thus, long-term hormone therapy leads to the development of Cushing's syndrome, obesity, hypertension, type 2 diabetes mellitus, myocardial dystrophy, osteoporosis, respiratory tract candidomycosis, cataracts, dermatitis, steroid gastric ulcers, often complicated by gastroduodenal bleeding.
Frequent use of adrenomimetic drugs often leads to the development of adrenergic imbalance, in which adrenergic agonists not only cease to have a bronchodilator effect, but can themselves directly cause bronchospasm.
The use of antiasthmatic drugs does not cure VA, but only alleviates its course. There is a gradual increase in the need of patients for these medications. There is a greater severity of side effects, which can lead to disability,
Antiasthmatic drugs are expensive and are not readily available to patients with low level well-being (Table 1), there is a need to be hospitalized more often; such patients to hospitals. This increases healthcare costs for treating patients with asthma.
The minimum cost of one bed-day in a hospital reaches 500-900 rubles, excluding the cost of medications and examinations.
According to WHO experts, each patient with moderate to severe asthma annually spends more than 2 thousand US dollars (about 60 thousand rubles) on antiasthmatic drugs. The average level of well-being of the majority of Russian patients with this course of asthma does not exceed 15-30 thousand rubles per year.
The risk of complications as a result of the constant use of anti-asthmatic drugs and the high cost of treatment are prerequisites for the search for new, non-drug methods of treating asthma, including surgical ones.
Methodology of experimental studies on animals
The purpose of the experimental studies was to determine the optimal parameters of the electrical stimulation current of the sympathetic trunks in the cervical and thoracic parts, ensuring the prevention, relief or reduction of experimental bronchospasm.
The experiments were carried out in accordance with the rules of humane treatment of animals. Acute experiments were carried out on 34 Wistar rats, 3-4 months old, weighing 250-300 g. 17 animals were male, 17 were female.
To simulate experimental bronchospasm, animals were sensitized with horse serum at a dose of 0.25 ml/kg body weight subcutaneously for 3 days. A resolving dose of serum was administered intraperitoneally on days 10-12. In 20 rats, in order to identify the optimal model of bronchospasm, experimental bronchospasm was induced using hetamine and acetylcholine (before the administration of histamine and acetalcholine, these animals were not sensitized with horse serum).
Anesthesia during acute experiments was carried out by intraperitoneal administration of urethane at a dose of 1 g/kg body weight. Muscle relaxants were used according to a special technique,
Study respiratory system
To study the dynamics of respiratory tract resistance to air flow (Raw) during the development of experimental bronchospasm and its relief by electrical stimulation of the sympathetic trunks, the spirography method according to Kaminko M.E. was used. , which consisted of measuring the Raw value during each respiratory cycle using a special sensor during artificial ventilation (Fig. 1).
Measurement of minute volume of blood circulation (MCV) and cerebral pulse blood flow (CPF) was carried out using a PA-09 polyanalyzer and a computer.
Method of connecting electrostimulator electrodes to sympathetic trunks
Electrodes in the form of stainless steel wire or needle electrodes with a diameter of about 0.1 mm for electrical stimulation of the cervical and thoracic parts of the sympathetic trunks were connected to their upper third.
The current resistance of the electrodes ranged from 1.0 to 5.0 Ohms. Electrodes were connected to the right and left sympathetic trunks.
To control the adequacy of the selected current parameters in each animal during an acute experiment under anesthesia, before the introduction of a resolving dose of antigen or other brochospastic substance, threshold values of current pulse parameters (frequency, amplitude, pulse duration) were selected, achieving the appearance of a reflex in the form of an increase in heart rate (heart rate). The appearance of such a reflex confirmed the influence of electrical stimulation on body systems.
Method of electrostimulation of lm for relief of brynchosiasm
Severe bronchospasm usually developed within 5-7 minutes. after administration of a resolving dose of antigen, histamine or acetamine. Electrical stimulation was performed to relieve bronchospasm in the form of sessions lasting from 2 to 5 minutes, at intervals from 15 to 30 minutes, using an electrical stimulator "ISE-01", current pulses with parameters: 1.0-150.0 Hz, 1 ,0-100.0 V, 0.2-2.0 ms. The current value was in the range from 3 to 100 mA, more often 5-35 mA. Against the background of emerging brochospasm, electrical stimulation was performed alternately on each of the nerve trunks, and in the subsequent session, on both trunks at the same time. During electrical stimulation sessions, the parameters of the current pulses were increased or decreased, achieving a reduction or relief of bronchospasm.
Method of electrical stimulation to prevent the development of bronchospasm To prevent the development of experimental bronchospasm, electrical stimulation began immediately after the introduction of a resolving dose of antigen, acetylcholine or histamine, before the onset of bronchospasm, with current pulses with selected threshold parameters. The duration of such electrical stimulation sessions was from 2 to 5 minutes.
Indications and contraindications for implantation of stimulators and radiofrequency electrical stimulation of sympathetic trunks
Indications for the use of a surgical method of treating asthma - electrical stimulation of the sympathetic trunks
The method of radiofrequency electrical stimulation of the cervical and thoracic parts of the sympathetic trunks is advisable to use only for certain indications. The main ones are:
1) BA of mixed, infectious-allergic and atonic forms of moderate and severe course, complicated by the side effects of anti-asthmatic medications, with pronounced drug resistance, especially to hormonal and adrepomimetic drugs. The new method is symptomatic. Such a wide list of forms of asthma in which its use is possible is due to the fact that, regardless of the mechanisms of development of the disease, the mechanisms of bronchospasm always include elements of nervous control over the smooth muscle wall of the bronchi, and this method allows to control them to a certain extent, causing bronchodilation. In determining the indications, pronounced drug dependence is important, due to the fact that electrical stimulation of the sympathetic trunks can lead to a reduction in the need for anti-asthmatic medications, and therefore in the severity of such life-threatening side effects of hormonal and adrenergic therapy as steroid bleeding gastric ulcers, diabetes mellitus, obesity, hypertonic disease, myocardial dystrophy, osteoporosis and others.
2) Failure or ineffectiveness of previously used methods of treating BA (conservative and surgical) in achieving long-term remissions of the disease. In such patients, the disease is usually rapidly progressive. As asthma progresses, to achieve remissions it is necessary to steadily increase the doses of anti-asthmatic medications. Some of these patients have already undergone various operations (glomectomy, depervacygo of the roots of the lungs, etc.) and their effect turned out to be insufficient to achieve stable remission of asthma. .
3) A pronounced predominance of the tone of the parasympathetic section of the ANS over the tone of its sympathetic section according to variation pulsometry and other tests. New methods make it possible to significantly reduce the imbalance between the sympathetic and parasympathetic sections of the ANS towards the predominance of the tone of the sympathetic section, which significantly affects the clinical picture of the disease.
4) The presence of a functional reserve in the patient’s respiratory system, allowing the airways to sufficiently expand in response to adrenergic stimulation. Indirectly, the presence of such a reserve before surgery can be judged by the results of pneumotachometry during bronchodilator tests with adrepomimetic drugs (FEV] should increase by more than 15% 10-15 minutes after the use of adrepomimetic). Although, as practice has shown, a more significant criterion for indirectly assessing the amount of reserve is the analysis of the dose of adrenergic agonist used by the patient to relieve asthma attacks, as well as its type. The higher the dose and the stronger the adrenergic agonist used, the lower the reserve of the respiratory system for bronchodilation. Thus, in patients for whom one dose of “salbutamol” is enough to relieve an attack of suffocation, such a reserve of the respiratory system turns out to be significantly higher than in patients who are forced to use 2-3 doses of “salbutamol” or one dose of a stronger adrenergic agonist for the same purpose. A complete lack of functional reserve of the respiratory system for bronchodilation in patients with asthma is rare. The reasons for its absence may be pronounced sclerotic changes in the walls of the bronchi and degeneration of adrenergic receptors. For such patients, the use of a new surgical method is inappropriate.
5) Due to the low level of well-being of a number of asthma patients, it is possible to identify another indication for the use of new surgical methods - the difficult financial situation of the patient, which does not allow him to purchase expensive anti-asthmatic drugs. Due to the fact that electrical stimulation of the sympathetic trunks significantly alleviates the course of asthma and reduces the need for medications, the patient becomes more economically protected. The cost of an electrical stimulator does not exceed the costs of an asthma patient or anti-aotmatic drugs for six months. This indicates the obvious advantage of the new surgical method.
Contraindications to the use of the new surgical method:
1. The operation of implanting an electrical stimulator on the thoracic part of the sympathetic trunk is not advisable for patients with chronic pulmonary diseases, tuberculosis, or chronic bronchitis in the acute stage.
2. Respiratory failure of 2-3 degrees, cor pulmonale, previous pyeumonectomy. Implantation of an electrical stimulator on the thoracic part of the sympathetic trunk in such patients can lead to acute respiratory failure on the operating table, due to the fact that during the operation the lung must be temporarily collapsed. These patients can only undergo the operation of implanting an electrical stimulator on the cervical part of the sympathetic trunk.
3. Previous pleurisy, which led to the appearance of pronounced pleural adhesions, can also significantly complicate the implantation of an electrical stimulator on the thoracic part of the sympathetic trunk. Adhesions make it difficult to access the nerve
Results of animal experiments
The highest magnitude of experimental brochospasm was more often observed when it was modeled using horse serum (Table 3). This model more adequately reflects the pathophysiological mechanisms of the development of bronchospasm and asthma attacks (83), and therefore was accepted as the main one. The most pronounced bronchospasm usually developed 5-7 minutes after the administration of a permissive dose of horse serum, histamine or acetylcholine and did not decrease, and sometimes increased, throughout the experiment. During bronchospasm, most animals showed a significant decrease in MBF, PCM3, as well as an increase in heart rate and increased slow-wave activity of the brain, which indirectly indicated brain hypoxia due to deterioration of cerebral blood flow. Results of electrical stimulation of sympathetic trunks Electrical stimulation of sympathetic trunks in their cervical (Table 4) or thoracic (Table 5) parts in most experiments led to a decrease or relief of bronchospasm.
1. Complete relief of bronchospasm - in 55.8-61.8% of animals with ES of the CC CC and in 61.8-64.7% of animals with ES of the CC CC.
2. Reduction in the magnitude of bronchospasm by 50-99% - in 20.6-29.5% of animals with ES of the CC CC and in 23.5-29.5% of animals with ES of the CC CC.
3. A decrease in the magnitude of bronchospasm by 15-49% - in 8.8-11.8% of animals with ES of the CC CC and in 2.9-11.8% of animals with ES of the CC CC.
4. No change in the magnitude of bronchospasm - in 2.9-8.8% of animals with ESSHCHSSiESHCHSS
5. An increase in bronchospasm of 25% or more - in 1 animal with ES of the CC CC and in 1 animal (2.9%) with ES of the CC CC.
The effect of electrical stimulation did not depend on whether one or both sympathetic trunks were stimulated.
At a current of 71-150 Hz, 2.0 V, 0.2 ms, no bronchodilation was observed. Prevention and weakening of bronchospasm by electrical stimulation of sympathetic trunks
Preventive electrical stimulation with a current of 1-70 Hz, 2.0 V, 0.2 ms of the cervical (Table b) and Jordal (Table 7) parts of the sympathetic trunk was effective in most animals.
In 41.2-50% of animals with ES of the CC CC and v 41.5-55.9% of animals with ES of the CC CC, brochospasm did not develop. In the majority of other animals with ES HS SS and ES HS SS it was no more than 50% of the initial Raw level. This effect was independent of stimulation of one or both sympathetic trunks.
In 4 rats (11.8%) with ES of the CC SS and in 5 rats (14.7%) with ES of the HC SS there was no effect from proactive electrical stimulation of the sympathetic trunks. Current parameters: 71-150 Hz, 2.0 V, 0.2 ms - were ineffective in most animals.
Selection of current pulse parameters during electrical stimulation sessions revealed that the greatest bronchodilator effect was observed at a current frequency of 30.0 to 70.0 Hz, a voltage value of 2.0 V and above, and a current value of 5 mA or more.
The duration of the current pulses did not significantly influence the magnitude of the bronchodilator effect.
There were no significant differences in the results of electrical stimulation of the right, left, and both sympathetic trunks.
After the cessation of the electrical stimulation session, the majority of animals did not experience a resumption of bronchospasm during the experiment. Only in 3 rats, 15-20 minutes after the cessation of 2-minute electrical stimulation sessions, a resumption was observed. It, however, was significantly less pronounced than before the electrical stimulation session and was easily stopped by a repeated 2-5 minute electrical stimulation session.
No negative effects of electrical stimulation sessions on the state of the cardiovascular and nervous systems were noted. There was a tendency towards improvement of their condition: an increase in MOC5 GICM, normalization of the EEG (Table 4, Table 5, Table 6, Table 7).
Transection of the cervical sympathetic trunks in 8 animals and the thoracic sympathetic trunks in 12 animals did not lead to the cessation of the bronchodilator effect. This indicates the central mechanisms for its implementation.
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Operation technique
A skin incision up to 5 cm long is made along the inner edge of the sternocleidomastoid muscle or along its course. For cosmetic purposes, a skin incision is made along the fold of the neck. The middle of the incision should correspond to the place of greatest pulsation of the carotid artery, determined by palpation before surgery.After cutting the skin and subcutaneous muscle to the fourth fascia of the neck soft fabrics with the help of two dissectors (with long and short braces) they are moved apart without much difficulty along the inner edge of m. sternocleidomastoideus. The vaginal muscles are not opened. The fourth fascia, enveloping the vascular nerve bundle, dissected under the common carotid artery. When dissecting the fascia, one should avoid damaging the “outgoing branch of the hypoglossal nerve, which runs along the anterior edge of the common carotid artery to the rectus neck muscles.
After cutting the fourth fascia of the neck with a dissector, the sled arteries are isolated. Before isolating the carotid arteries, it is necessary to displace the internal jugular vein outward with a blunt hook so as not to injure it. Sometimes the vein is located above the carotid arteries and significantly complicates the operation. In such cases, it is advisable to cross the common facial vein between the ligatures, after which the internal jugular vein is freely shifted to the side.
It is also necessary to consider options for the origin of the superior thyroid artery. Sometimes it crosses the bifurcation of the carotid arteries and makes it difficult to isolate the carotid body. In such cases, it must be crossed between ligatures.
Considering anatomical features carotid arteries, the carotid body is isolated, starting with a Y-shaped dissection of the adventitia of the vessels. First, the adventitia is dissected along the anterior edge of the common carotid artery 1 cm below the fork, then the cut line is continued 2-2.5 cm along the anterior-outer edge of the external carotid artery and the anterior-inner edge of the internal carotid artery. In order not to damage the muscle layer of the vessel, the adventitia should be cut with long vascular scissors, lifting it with anatomical tweezers.
After dissecting the adventitia with a dissector with short jaws, sliding along the edge of the external and internal carotid arteries, a hole is made in the adventitia, respectively, on the postero-external and postero-internal surfaces of the carotid arteries. To prevent bleeding and make it easier to isolate the carotid artery, rubber holders are placed under the common carotid artery and its external branch. Lifting the carotid arteries with rubber grips, a dissector with long jaws mobilizes their posterior wall.
The cord formed between the internal and external carotid arteries is taken onto a catgut holder. Carefully isolate the carotid body from the carotid bulb as much as possible. Bleeding arising from the vasa pasorum is stopped by short pressure with a gauze ball. The artery of the carotid body is ligated with catgut and silk ligatures (in case one of them slips when the body is cut off).
The intercarotid cord is ligated with a catgut ligature below the hypoglossal nerve. Between the upper ligature and the carotid body, the cord is crossed under the dissector. The carotid body is lifted with anatomical forceps and cut off above the second ligature. The wound is sutured tightly. If increased bleeding was observed during the operation, to prevent the formation of a hematoma, a rubber strip from a glove is applied to the carotid arteries (E. S. Karashurov, 1971).
According to Nakayama (1961), Phyllips (1966) and E. S. Karashurova (1969), the main intervention in the sinocarotid zone should be considered the removal of the carotid body. Various methods denervation of the sinocarotid zone is hardly advisable, since innervation is subsequently restored. E. M. Rutkovsky (1967), on the contrary, sees the success of the operation in the denervation of the sinocarotid zone.
After exposing the bifurcation of the common carotid artery and the carotid sinus, the author first excises all the receptor fields of the chemo- and baroreceptors in the sinus caroticus (denervatio simplex sinus carotid), and then, separating the nerve bundle between the external and internal carotid arteries, containing sympathetic and parasympathetic fibers and Hering’s nerve , cuts off its peripheral part (denervatio radicalis sinuus oarotici).
During operations on the sinocarotid zone, complications such as damage to the dome of the pleura with subsequent pneumothorax in patients with a short neck, bleeding from the artery of the carotid body, cardiac arrest, aneurysm and rupture of the denervated sinus, separation of the superior thyroid artery from the external carotid artery, bleeding from the internal jugular vein and common vein face, mono- and hemiparesis, hemiplegia, paresis of the glossopharyngeal and recurrent nerves, laryngospasm, motor aphasia, increased blood pressure with symptoms of collapse.
In a number of patients, in the long term after surgery, hypertensive syndrome is observed (O. M. Tevit, 1968; M. I. Kuzin et al., 1968). Nakayama has the largest number of observations (more than 2000) on the surgical treatment of bronchial asthma in the sinocarotid zone. Immediately after surgery, good results were obtained in 25.6%, improvement in 63.8%, deterioration in 2.2%, and no changes were noted in 6.4% of cases. 2.1% of patients died. Later. 5 years after surgery, recovery was noted in 16%, improvement in 42%, deterioration in 7.1%, death in 4.5% of cases. Having operated on over 800 patients with bronchial asthma and studied their condition in the long term, E. M. Rutkovsky reports a cure for 70-80% of patients.
In our country, by the beginning of 1969, according to summary literature data (E. S. Karashurov), 1345 operations were performed on the sinocarotid zone in patients with bronchial asthma. According to domestic authors, immediate good and satisfactory results can be achieved in 60-80% of those operated on. In the long term, the results of surgical treatment of bronchial asthma are favorable. The positive effect of the operation persists only in 14-40% of observations (S. I. Babichev, G. N. Akzhigatav, 1968; V. M. Grubiik, V. V. Tinchuk, 1968; E. S. Karashurov, 1969; I. E. Velik, 1969; M. I. Kuzin, V. G. Ryabtsev, T. N. Dremina, 1968; N. B. Vasiliev, A. T. Lidsky, N. P. Makarov, V. A. Babaev, 3. S. Simonova, 1971).
Some authors studied the immediate and immediate results of glomectomy in patients with bronchial asthma using the placebo method (Gain, Tulloch, 1964; Q. Rourke, 1964; Segal, 1965). In 138 cases, glomectomy was performed; In 68 patients, only a skin incision was made in the area of the sinocarotid zone. Despite minor surgical trauma (skin incision), 4 patients in the control group died after surgery. In patients who underwent glomectomy and in patients in the control group (skin incision), the results were the same.
Thus, according to a number of researchers, with dysfunction of the carotid body and ineffectiveness of drug treatment, indications for surgical intervention in the sipocarotid zone arise. To identify increased activity carotid body Takino (1968) suggests conducting tests with a 1% solution of sodium cyanide, which is administered intravenously in an amount of 0.3 ml, and examining the function of external respiration.
For the same purposes, Nakayama recommends an inhalation test of a weak solution of hydrochloric acid. To correctly substantiate the indications for surgery on the sinocarotid zone for bronchial asthma, E. M. Rutkovsky uses novocaine blockade of the sinocarotid zone at the height of the attack. The effectiveness of the blockade serves as a criterion for selecting patients. However, many issues related to surgical interventions in the sinocarotid zone remain unexplored.
Thus, the question regarding left-sided or right-sided glomectomy has not been resolved. E. S. Rutkovsky, I. E. Velik, I. A. Korshinov use left-sided access, Overholt and Planger - right-sided. E. S. Karashurov performs glomectomy on the side with large changes in the function of external respiration. There is no consensus on whether to perform unilateral or bilateral glomectomy. For example, Nakayama believes that if one-sided intervention is not successful, surgery on the other side is pointless.
However, according to I. E. Velik (1969) and E. S. Karashurov (1969), removal of the second carotid glomus when unilateral glomectomy is ineffective has an additional effect. At the same time, it is necessary to take into account that with bilateral intervention there is a greater possibility of severe hemodynamic disorders.
Contraindications to surgery on the sinocarotid zone are severe secondary changes in the lungs, tuberculosis, hypertension, decompensated heart disease, liver and kidney failure. Some authors believe that cardiac decompensation and pulmonary failure are direct indications for surgery (Phillips, 1966).
Childhood, according to some authors, is not a contraindication to glomectomy. When establishing indications for surgical treatment of bronchial asthma in children, E. S. Karashurov took into account the characteristics of this age and the possibility of self-healing upon reaching adulthood. However, in a number of observations, the author was convinced of the advisability of surgical intervention in children.
Having studied patients who developed bronchial asthma 20 years ago in childhood, Buffum and Jettipone (1966) found that the disease developed in individuals during whose treatment no positive dynamics were noted. This fact speaks in favor of surgical treatment of bronchial asthma in childhood, in the early stages of the disease. Trajan (1967) operated on 8 children using the Rutkowski method. Relapse of the disease occurred in only one child after influenza.
So, surgical treatment of patients with bronchial asthma is possible if complex conservative measures are ineffective. The most pathogenetically substantiated methods should be considered surgical interventions in the sinocarotid zone and denervation lung root. The indication for a particular intervention should follow from the genesis of the disease. In the atonic form of bronchial asthma, intervention in the sinocarotid zone is advisable, since it is less traumatic and dangerous.
In the infectious-allergic form of bronchial asthma, it is necessary to eliminate the infectious focus. Often, with this form of bronchial asthma, patients experience a destructive process in the lungs (E. N. Meshalkin, V. S. Sergievsky, L. Ya. Alperin, 1966; I. E. Belik, 1969; Abbot, Hopkins, Giulfail, Walner, 1950; Overholt e. a., 1952; D. Dimitrov-Sokodi, 1961). Resection of pathologically altered sections of lung tissue with denervation of the lung root is one of the pathogenetic methods of treating this group of patients.
If justified indications are established, surgical treatment of bronchial asthma is possible in childhood.
A.V. Glutkin, V.I. Kovalchuk
Mentions of B. a. found in the works of classic medicine since the time of Hippocrates. Classic description clinical picture B. a. belongs to G.I. Sokolsky (1838).
Before the emergence of the doctrine of allergies, R. Laennec (1825), M. Ya. Mudroe (1826), A. Rhodessky (1863) and others explained the pathogenesis asthmatic attack neurogenic spasm of the bronchial muscles.
G. I. Sokolsky, and later Kurschmann (N. Gurschmann, 1883) and E. Leiden (1886) paid attention to the inflammatory process (“catarrh”) in the bronchi with a special type of exudate, considering it the main cause of clinical manifestations of B. a. Wintrich (A. Wintrich, 1864) associated asthma attacks with spasms of the diaphragm muscles.
At the beginning of the 20th century. after describing the phenomenon of anaphylaxis in animals, almost simultaneously, E. O. Manoilov, N. F. Golubov and S. Meltzer proposed the allergic theory of B. a., which was later confirmed by a detailed clinical and immunological analysis of the disease. In the crust, the time of allergic genesis of B. a. is recognized by the overwhelming majority of researchers, however, there are certain differences in the interpretation of B. a. from the standpoint of nosology in our country and abroad.
Most foreign scientists consider B. a. as a syndromic concept that includes not only allergic damage to the bronchi, but also various bronchospastic reactions of non-allergic origin. Soviet researchers A.D. Ado, P.K. Bulatov, B.B. Kogan believe B. a. an independent allergic disease, and they propose to call clinically similar manifestations in other diseases asthmatic syndromes. Examples of the latter may be bronchospasm due to tumors and foreign bodies of the bronchi, carcinopdae, bronchovascular lesions of the lungs due to periarteritis nodosa and others.
The first attempts to classify B. a. depending on the etiological factors were made by N. Salter in 1860. There were 5 types of asthma - from “inhalation of particles”, inflammation of the airways, disorders of the blood, nervous reflexes and irritation of the c. n. With.
In subsequent years, with the evolution of the doctrine of B. a. A lot of classifications were proposed, most of which distinguished “idiopathic” asthma and asthma from inflammation of the airways. In connection with the allergic theory of genesis of B. a. and the introduction into practice of specific diagnostic methods, repeated attempts were made to classify the disease depending on the results of an allergological examination.
The most widespread abroad is the classification of Rackemann (F. Rackemann, 1918), who identified two forms of B.a. - exogenous and endogenous. The first includes cases caused by non-infectious exogenous allergens, the second is associated mainly with hron. inflammation of the bronchopulmonary apparatus or extrapulmonary foci hron. infections.
In the Soviet Union, the issue of classification of B. a. has been discussed since 1963. In the present time, the classification of the main etiological forms and stages of the disease, proposed by A.D. Ado and P.K. Bulatov, has been accepted and put into practice (Table 1). According to the classification, there are two main forms of B. a. - infectious-allergic and non-infectious-allergic (atopic). The first is associated with sensitization by bacterial allergens, which come from the lesions hron. infections localized primarily in the respiratory apparatus. The second form belongs to the group of hereditary allergic diseases (see Atopy) and is caused by non-infectious allergens.
B. a. is one of the most common diseases. According to WHO data published in 1966-1968, the incidence rate of B. a. the incidence of malignant tumors in the USA is 7 times higher, in England - 3 times, respiratory tuberculosis in the USA - almost 120 times, in England - more than 25 times. Incidence of B. a. per 1000 population is: in the USA - 23.4, Denmark - 6.9, Mexico - 17.2, Germany - 5.5, England - 8.5, France - 5.0, Sweden - 7.1.
In the Soviet Union, the incidence of B. a. different in different climatic zones and in areas with different levels of industrial development.
Sample studies of morbidity (per 1000 population) conducted by A. D. A before and A. V. Bogova (1968), M. M. Omerov (1967), Bureau of Sanitary Statistics of the Ministry of Health of the RSFSR (L. A. Brushlinskaya, 1961; reports treatment institutions in a number of cities, 1958), revealed the lowest incidence in desert areas Central Asia(0.5-1.1), in Siberia and the Urals (1.1 -1.3); in Moscow it was 2.2; the highest was in Vilnius (5.2), Riga (4.6) and Gomel (4.7). In recent years, there has been a clear trend towards an increase in the incidence of B. a.
Thus, in Moscow over the past 40 years it has increased 5 times, in Riga over 5 years - by l½ times.
The total incidence of men and women is approximately the same, but age groups There are some differences: in the first 10 years of life, boys are more likely to get sick, from 10 to 60 years old - slightly more often women, from 60 years old - men.
The most common infectious-allergic form of B. a.; the atopic form (according to the observations of a number of authors) is approx. 20% of all disease cases.
In some countries the mortality rate from B. a is very high. (complicated and uncomplicated). According to WHO statistics, Germany is in first place in this regard - 11.6 and Japan - 9.2 per 100,000 population.
The greatest importance in the etiology of the atopic form of B. a. adults have inhalation allergens, which are particles ranging in size from 10 to 100 microns, suspended in the atmospheric air and sensitizing the tissues of the upper respiratory tract and bronchi during breathing. Of this group of allergens, the most common cause of B. a. is household dust, in second place is plant pollen, in third place are spores of non-pathogenic fungi. Other allergens can be identified less frequently. Industrial dust (cotton, flour, tobacco, grenage, etc.) causes professional B. a. Medicines in the form of inhaled allergens can also cause B. a. from persons who come into contact with them at work. Relatively often, the allergen that causes B. a. is powder from daphnia, a freshwater crustacean used as food for aquarium fish. With the modern widespread introduction of chemistry into everyday life and production, the role of chemicals is very important. allergens. The research available in this area concerns mainly the sensitizing effect of plastics, pesticides, and metals, contact with which causes professional B. a.
Enteral allergens that cause B. a. are food products and medications, and food allergens more often cause B. a. in children.
The most pronounced asthmagenic effects are found in cereals (especially wheat), eggs, milk, fish, onions, and chocolate. Frequently, attacks of suffocation can be caused by the fruits and seeds of some plants, for example. sunflower seeds for allergies to its pollen, nuts for allergies to hazel pollen, etc. Cases of B. a. are described, the onset of which is associated with the parenteral administration of penicillin, vitamin B 1, various antitoxic serums, and vaccines.
At the beginning of the disease, an asthmatic's allergy may be monovalent; over time, the spectrum of allergens expands.
The problem of the etiology of the infectious-allergic form of B. a. is under study. A certain connection has been established between the formation of this form of the disease and acute and chronic diseases. infectious processes in the respiratory system (acute and chronic bronchitis, pneumonia, sinusitis, acute respiratory diseases, flu). Attempts to find out which microorganisms cause sensitization of the tissues of the bronchial tree are rare. A. D. Ado et al. (1968) showed that with the help of monostrain outs of action prepared from the flora of the contents of the bronchi and the secretions of the upper respiratory tract of patients with infectious B. a., it is possible to obtain positive skin and provocative inhalation tests in these patients. In this case, the majority of patients had a polyvalent bacterial allergy. The most common microbes that caused sensitization were Staphylococcus aureus, Klebsiella pneumoniae, Neisseria catarrhalis and fungi of the genus Candida. Most strains turned out to be opportunistic. Studies by other authors have obtained similar results, as well as indications of the etiological role of the influenza virus.
Cases of B. a. caused by roundworm antigens have been described among workers in helminthological laboratories. Sometimes symptoms of B. a. are observed along with skin allergic manifestations and eosinophilic pneumonia with certain helminthic infestations, in particular with strongyloidiasis in the phase of larval migration.
Long before the emergence of the doctrine of allergies, doctors noted a certain influence of heredity on the formation of B. a. Subsequently, it was found that this influence is especially clearly detected in the non-infectious-allergic (atopic) form of the disease, as well as in other clinical manifestations of atopy (see). In patients with this form, in approximately 50% of cases, atopic diseases are noted in the family, and not necessarily B. a., although according to a number of studies, the latter still predominates. In patients with infectious-allergic form of B. a. allergic heredity is established much less frequently (in 20-30% of cases).
A hereditary burden of allergic diseases is common in patients with B. a. with approximately the same frequency on the maternal and paternal lines. When there is a burden of heredity along two lines, the disease, as a rule, develops in the first years of life. A genetically determined predisposition to allergic diseases is usually called an allergic constitution, or allergic diathesis, which is characterized mainly by changes in immunocompetent tissues, as well as certain features of the mucous membranes, blood capillaries and the autonomic nervous system.
People with allergic diathesis tend to have several different manifestations of allergies throughout their lives, therefore, in the personal history of asthmatics, especially with the atopic form, it is often possible to establish previously suffered allergic diseases and reactions, in particular exudative diathesis.
In recent years, a hypothesis has been put forward that interprets B. a. as a result of a hereditary defect (partial blockade) of β-adrenergic receptors.
Attacks of B. a. initially they are always the result of an allergic reaction in the tissues of the bronchial tree. Subsequently, they can develop under the influence of non-allergic irritants.
Allergic mechanisms are much better studied in the atopic form of B. a.
Attack of atopic B. a. is the result of an immediate allergic reaction localized in the tissues of the bronchial tree. In the first, immunological, stage of the reaction, the antigen combines with antibodies (reagins) fixed on sensitized cells, including fat cells, a large number of which are contained in the connective tissue of the lungs.
In crust, reagins are mainly classified as immunoglobulins E. Then an allergic alteration of cells occurs with the release of chemically active mediators as a result of the action of proteases (the second, pathochemical, stage of the reaction). Participation in the formation of an attack of B. a has been proven. histamine and the slow-acting substance of anaphylaxis - SRS-A. The role of acetylcholine, serotonin, and bradykinin is probable, but not conclusively proven. The third, pathophysiological, stage of the reaction is expressed in spasm of the smooth muscles of small bronchi and 1 bronchioles, swelling of the mucous membrane due to a sharp increase in capillary permeability, hypersecretion of mucus-forming glands. At this stage, the main clinical symptoms of the disease are formed.
Pathogenesis of the infectious-allergic form of B. a. is under study. There are two main points of view on this issue. Hampton (S. Hampton, 1963) et al. identify the pathogenesis of both forms of asthma, thus considering an attack of infectious asthma to be an immediate allergic reaction of bronchial tissue to infectious allergens. Findeisen (D. Findeisen, 1968) assigns the main role to a delayed (cellular) allergic reaction. The possibility of the combined participation of two main types of allergies cannot be ruled out (see).
During the course of developed B. a. neurogenic and emotional, endocrine, climatic factors influence. A. D. A before (1952, I 1959) it was established that during an allergic reaction the threshold of excitability of nerve receptors in relation to ordinary, non-allergic stimuli is significantly reduced. This explains the appearance of attacks of suffocation: in long-term patients with B. a. to irritants such as cold air, non-antigenic dust, strong odors, sudden changes humidity and atmospheric pressure, forced breathing during physical activity, coughing, laughter. Participation of higher departments c, n. With. reflected in the concept; P.K. Bulatova (1964) about the pathological dominant of B. a., formed under the influence of interoceptive unconditioned reflexes, on the basis of which conditioned reflexes can be formed. Emotional factors, which ultimately act through the autonomic nervous system, can also cause an attack of suffocation in a patient with B. a.
Relationship between the endocrine system and B. a. complex and diverse. The influence on the course of B. a has been studied. pituitary gland system - adrenal cortex and female sex hormones. V.I. Pytsky (1968) established that B. a. is accompanied by the development of glucocorticoid insufficiency, which in its origin can be either adrenal or extra-adrenal. The latter develops due to an increase in the ability of blood plasma proteins to bind cortisol and a decrease in the sensitivity of certain cells to cortisol. The influence of female sex hormones is most often expressed by premenstrual exacerbations of the disease and a more severe course during menopause. Most researchers explain these facts by the indirect effect of the dishormonal background on the neuromuscular apparatus of the bronchi through the autonomic nervous system. Climatic influences on the occurrence and course of B. a. varied. In addition to the direct effect of climatic factors, as mentioned above, climate can contribute to morbidity respiratory infections, the spread of plants with antigenic pollen or spore-forming fungi and thus secondarily increase the incidence of B.a.
In the pathoanatomical picture of B. a., both atopic and infectious-allergic, one can distinguish changes that develop during an attack and hron. changes.
In those who died during an attack of B. a. from asphyxia, a bluish tint of the skin and mucous membranes is noted; congestion of the brain and meninges; liquid blood in the cavities of the heart and blood vessels; congestion of visceral organs, pinpoint hemorrhages in the pleura, hemorrhages in the substance of the brain.
The appearance of the lungs is especially characteristic. They are increased in volume and cover the area of the anterior mediastinum and the anterior surface of the heart. The lungs are fluffy to the touch, gray-pink in color when cut. The wall of the bronchi is thickened. The mucous membrane of the trachea and large bronchi is covered with viscous mucus. There is thick mucus in the lumen of the bronchi.
Microscopic examination (color Fig. 5 and 6) shows how mucus forms concentric layers in the lumen of the bronchi and bronchioles.
It contains many eosinophils, cells and entire layers of desquamated epithelium. The bronchial mucosa is edematous, loosely infiltrated with lymphoid, plasma cells and eosinophils. In the subsegmental and smaller bronchi, the mucous membrane is corrugated, as it were, with polyp-like protrusions, in which muscle bundles are located. The walls of the small bronchi and bronchioles are densely infiltrated with eosinophils, spreading to the adjacent alveolar septa. The basement membrane is thickened and homogenized. In the epithelium there are phenomena of hypersecretion and desquamation. The goblet cells of the epithelium, the lumens of the mucous glands and the dilated excretory ducts are filled with a secretion that has a CHIC-positive reaction. The muscle bundles are swollen. In the lung tissue there are phenomena of emphysema, the alveoli and their entrances are expanded, there are foci of atelectasis and eosinophilic pneumonia. There is dilation and congestion of the blood vessels of the walls of the bronchi and lung tissue, expansion of the lumens of arteriovenous anastomoses, and sometimes narrowing of blood vessels, which indicates functional changes not only in the bronchi, but also in blood vessels and circulatory disorders that increase oxygen deficiency.
In patients with a long course of B. a. hron develops. obstructive pulmonary emphysema, cor pulmonale. Microscopically, muscle hypertrophy, sharp thickening and homogenization of the basement membrane are noted in the bronchi; metaplasia of the epithelium into multilayered squamous epithelium and sclerosis of the alveolar septa are often observed.
Electron microscopic studies have shown that thickening of the basement membrane occurs as a result of sclerosis and an increase in collagen mass.
At immunological research Conducted in recent years by American scientists, the localization of immunoglobulin E on the basement membranes, in epithelial cells and mucous glands (mainly small bronchi) has been established both during an attack and for some time after it.
It is assumed that the interaction of immunoglobulin E with the antigen occurs on the basement membrane.
As a rule, B. a. preceded by other diseases of the respiratory system (pre-asthma). Infectious-allergic form of B. a. usually preceded by acute protracted or chronic. bronchitis, acute protracted or chronic. pneumonia, infectious-allergic rhinosinusopathy with or without polyposis, purulent lesions paranasal sinuses nose Listed chronicles. Infectious processes subsequently accompany B. a., influencing its course. The atopic form is preceded by allergic non-infectious rhinosinusopathy without polyposis, allergic non-infectious bronchitis.
The clinical picture of preasthma, in addition to the symptoms characteristic of the listed diseases, is characterized by a paroxysmal cough, dry or with a small amount of sputum, without a subjective feeling of difficulty breathing. When auscultating the lungs, especially during a coughing attack, dry rales are heard. Eosinophils and Charcot-Leyden crystals are usually found in sputum. When examining indicators of external respiration function, a moderately severe impairment of bronchial obstruction is determined. However, preasthma does not occur in all patients. Often, especially in the atopic form, the disease begins suddenly, without clinical warning signs. The duration of preasthma varies - from several days to several years. With proper treatment, transition to B. a. not required.
B. a. is a chronic disease, occurs with exacerbations, which in most cases are replaced by periods of remission. In the first stage of the disease, its main expression in both forms is attacks of expiratory suffocation. Depending on the severity of the attacks, they distinguish between mild, moderate severity and severe course of the disease. The first stage of the infectious-allergic form (when attacks of suffocation are mild, poorly defined, but the clinical picture of diffuse bronchitis is pronounced, elements characteristic of the allergic process are found in the sputum and blood) is often called asthmatic bronchitis.
The second stage is characterized by almost constant expiratory shortness of breath, against which severe attacks of suffocation and an asthmatic state occur. More often B. a. begins with mild attacks, passing successively through the stages of moderate and severe manifestations the first stage, and then passes into the second stage of the disease. However, this is not natural. The disease may remain mild for many years or begin with more or less severe symptoms and progress quickly.
The severity of the attack is determined by the subjective characteristics of the patient, the severity of suffocation, auscultatory data, and the method of administering the medications necessary to relieve it (mild attacks are stopped by inhaling bronchodilators or taking them orally, more severe ones require subcutaneous or intravenous injections).
During a mild attack, the patient experiences slight expiratory difficulty breathing; he moves freely, there is no pallor or cyanosis. With percussion - a pulmonary sound, with auscultation - the exhalation is moderately prolonged, the number of dry wheezing rales is small.
Moderate attacks may be accompanied by a more pronounced feeling of suffocation, pallor of the skin, and moderate cyanosis. Breathing is noisy, wheezing can be heard from a distance. During percussion, the sound has a boxy tint. On auscultation, exhalation is prolonged and there is a significant amount of dry wheezing. In severe attacks, all of the listed symptoms are even more pronounced. The patient takes a forced position - sitting, leaning on his elbows or palms, which helps to include auxiliary muscles in the act of breathing. The skin is pale and moist. The chest is fixed in the position of deep inspiration. Breathing is initially rapid, then slows down, and buzzing and whistling wheezing can be heard from a distance. Upon percussion, a box sound is detected, the lower boundaries of the lungs are lowered. It is almost impossible to determine the nature of the main respiratory sounds by auscultation; exhalation is sharply prolonged. On inhalation and especially on exhalation, a lot of high-pitched dry rales are heard.
The asthmatic condition is characterized by more or less severe expiratory suffocation, which cannot be relieved with conventional bronchodilator drugs during the day. The general condition of the patient is grave, the position is forced, as in a severe asthma attack. The skin is cyanotic. With percussion and auscultation of the lungs, a picture is similar to that of a severe asthmatic attack. In the most severe cases, due to increasing obstruction of the bronchial tree with viscous mucus, respiratory sounds may not be audible (symptom of a “silent” chest). Long-term disturbance of alveolar ventilation causes increasing hypoxia (see), then hypercapnia (see) and respiratory acidosis (see). The latter can lead to the development of a clinical picture of acidotic coma (see).
Patients in a severe asthmatic condition cannot move, refuse to take food and liquids, and therefore symptoms of dehydration are possible (see Dehydration).
In severe attacks of suffocation and especially in an asthmatic state, symptoms are usually observed that reflect the state of the cardiovascular system: tachycardia without severe heart rhythm disturbances, often transient arterial hypertension. The boundaries of relative cardiac dullness are difficult to determine due to pulmonary emphysema. Heart sounds are dull, more clearly heard at the site of the tricuspid valve projection, with a slight accent of the second tone on the pulmonary trunk.
Symptoms of right ventricular heart failure may be observed: swelling of the jugular veins, congestive enlargement of the liver with a positive symptom of the hepatojugular reflex (swelling of the jugular veins when pressing on the liver), edema starting with lower limbs and reaching the degree of anasarca in severe cases. The ECG shows signs of overload of the right heart. At severe course B. a. an asthmatic condition can also occur in the first stage of the disease. The severity and nature of the course are largely determined by the form of the disease.
In the non-infectious allergic form of B. a. An attack of suffocation is most characterized by a sudden onset, rapid development and rapid completion under the influence of bronchodilators, but prodromal phenomena are often observed in the form of an allergic runny nose, itching in the nasopharynx, skin itching, a feeling of constriction in the chest, drowsiness, yawning. This form is characterized by a mild to moderate course. After an attack, a cough appears with the release of a small amount of mucous sputum. Outside of an attack in the early stages of the disease, no pathology can be detected in the lungs. Laboratory examination reveals moderate blood eosinophilia (5-8%), in the sputum there are eosinophils, spiral-shaped threads of dense mucus (Curschmann spirals) and Charcot-Leyden crystals formed during the breakdown of eosinophils.
Characteristic signs of dysfunction of external respiration in the form of a pronounced decrease in the vital capacity of the lungs, the volume of one-second forced expiration, the Tiffno index (see Votchala - Tiffno test), a decrease in the volumetric expiratory flow rate, and an increase in the work of external respiration are found in uncomplicated atopic asthma only during an attack.
In the infectious-allergic form of B. a. the attacks are prolonged in nature and do not have a “classical” acute onset and clear ending. Cough occurs not only at the end of an attack, but also at the beginning, as well as in the inter-attack period. Sputum - mucopurulent. Prodromal phenomena are less common. Auscultatory symptoms in the form of prolonged exhalation, dry low-pitched wheezing or moist medium-bubbling wheezing (a picture of diffuse bronchitis) remain even outside of an attack. In the blood test - often high eosinophilia (10-20%), often neutrophilic leukocytosis with a shift to the left, accelerated ROE. In sputum analysis, in addition to the elements listed above, there is a significant number of neutrophils.
Signs of dysfunction of external respiration are detected not only during an attack, but also in the inter-attack period, although less pronounced.
For the infectious-allergic form of B. a. Moderate to severe course is typical. As a severe, prognostically unfavorable variant of infectious allergic B. a. allocate the so-called asthmatic triad - a combination of asthma, recurrent nasal polyposis and intolerance to acetylsalicylic acid and pyrazolone analgesics (eg, amidopyrine).
The difference between atopic asthma and infectious-allergic asthma, in addition to the nature of the attack and the severity of the course, is the following: an earlier age of onset of the disease, a more frequent presence of allergic diseases in the family and personal history, frequent spontaneous remissions (due to cessation of contact with a specific allergen - the so-called elimination effect ).
In cases of severe course with any form of B. a. Neuropsychic disorders often develop, and depression may occur.
A typical complication of B. a. is obstructive pulmonary emphysema (see). In the atopic form of the disease, it develops only as a result of a long-term course; in the infectious form, it develops much earlier, often already in the first or second year of the disease. For infectious-allergic B. a. the development of peribronchial diffuse pneumosclerosis is characteristic (see). Chron. infectious bronchitis often develops during a long course of atopic bronchitis, being its complication. Acute hypoxia during attacks and morphological changes in the lung tissue lead to the development of hypertension in the pulmonary artery system with the subsequent formation of cor pulmonale and right ventricular heart failure (see Cor pulmonale). Development hron. Pulmonary heart failure more often and earlier complicates the course of the infectious-allergic form of B. a.
In rare cases, there may be more or less extensive atelectasis (see), spontaneous pneumothorax (see) due to rupture of an emphysematous lung at the height of an attack. Rib fractures have been described at the height of an attack during long-term treatment with corticosteroids.
Diagnosis of B. a. includes: diagnosis of the disease and specific diagnostics - determination of the spectrum of allergens that are the causative factors of the disease in a given patient.
The diagnosis of the disease and an approximate determination of its form are made on the basis of the typical clinical signs listed above.
Great importance given to laboratory research.
In cases where clinical manifestations do not provide sufficient grounds for diagnosis, acetylcholine and novodrinum tests may be recommended as an additional research method. The acetylcholine test determines the threshold of sensitivity of the tissues of the bronchial tree to acetylcholine. The latter is given to the patient by inhalation in increasing quantities, starting from 10 mcg. In healthy people, signs of bronchial obstruction, recorded by special devices, appear after inhaling 10,000 mcg of acetylcholine. With B. a. the threshold of excitability is lowered - signs of impaired bronchial obstruction are observed after inhalation of 10 - 1000 mcg of acetylcholine.
The novodrinovy test is used to identify the so-called. hidden bronchospasm. In a person who does not have B. a., inhaling a solution of novodrin does not cause an increase in the Tiffno index. Patient B. a. with subclinical impairment of bronchial obstruction it increases by 10-20%.
Specific diagnosis of B. a. carried out in qualified medical institutions. An allergic history often gives reason to assume the etiological role of household allergens based on the elimination effect (remission when leaving home), as well as epidermal, food, and occupational allergens; for pollen B. a. there is a clear seasonality of exacerbations; infectious - characterized by the connection of exacerbations with respiratory infections.
Skin tests (see) begin with the scarification method and only with negative or questionable results proceed to the intradermal method, since with it a reaction in the form of an attack of suffocation is possible. In older and older people, due to age-related changes in the skin, its blood vessels and due to altered general immunological reactivity, skin tests for allergens are less indicative.
Of the provocative tests (see), inhalation tests are used for etiological diagnosis. Sometimes the Prausnitz-Küstner reaction is used (see). If there is a suspicion of drug and food allergies carry out cell tests - leukocyte tests (see), thrombocytopenic test (see), basophil test (see), mast cell degranulation reaction (see). A specific diagnosis can be considered correct only if the results of all or most of the methods used coincide. Great importance is attached to specific diagnostic methods when deciding on the profession and character of B.a.
Differentiate B. a. accounts primarily for hron. bronchitis and asthmatic syndromes. Banal chronicle. bronchitis (see) may be accompanied by attacks of expiratory shortness of breath, but it usually does not reach the degree of suffocation characteristic of B. a.; dry wheezing of a lower tone, absent typical signs allergies (blood eosinophilia, corresponding elements in sputum). Skin allergy tests negative. Attacks of suffocation during chronic bronchitis is usually not relieved by adrenaline and other bronchodilators, but only alleviated.
Asthmoid syndromes with tumors and foreign bodies of the bronchi, in addition to the absence of signs of allergy, often give more pronounced auscultatory symptoms on the affected side, as well as characteristic radiological and bronchoscopic data. Asthmoid syndrome with periarteritis nodosa (see Periarteritis nodosa) is characterized by blood hypereosinophilia. Often this syndrome exists for years as the only sign of the underlying disease and only later are the symptoms of a systemic vascular disease characteristic of the latter added.
Often B. a. must be differentiated from cardiac asthma (see table. Main indicators of differential diagnosis of bronchial and cardiac asthma). An important point in differential diagnosis is anamnesis. Indications of arterial hypertension, coronary insufficiency, previous myocardial infarction, valvular lesions of the heart, as well as increased size of the heart and liver, edema and other symptoms noted during an objective examination, speak in favor of cardiac asthma (see). The differential diagnosis is especially difficult when with B. a. decompensation of the right ventricular type occurs.
If clinical differences cannot be identified, then a number of medications can be used to relieve an attack, which are effective in both forms of asthma - intravenous administration of xanthine drugs (aminophylline, etc.) in combination with strophanthin.
In recent years, cases of cystic fibrosis have been described in children and adults, when a viscous mucous secretion in the bronchi creates an auscultatory picture similar to B. a., and the need for a differential diagnosis arises. These patients are characterized by simultaneous lesions of the gastrointestinal tract. tract, pancreas, high concentration of chlorides and sodium in the secretion of the sweat glands (see Cystic fibrosis).
The main methods of x-ray examination for B. a. are fluoroscopy and radiography of organs chest cavity. For more detailed research functional state of the lungs and examination of work ability, more complex special x-ray techniques are used: x-ray kymography (see) 7 electrokymography (see) and x-ray cinematography (see). X-ray examination for B. a. helps determine the severity of asthma, as well as the presence of complications and concomitant diseases. X-ray picture of the lungs with B. a. depends on the stage of development of the disease and the severity of the course. During the interictal period at the onset of the disease, there are no radiological changes. In the first stage, in severe cases, and in the second stage, pulmonary emphysema, cor pulmonale, and other complications of B. a. are detected radiologically.
During an attack of suffocation in patients, the following is determined: increased transparency of the pulmonary fields with a decrease or complete absence of differences in transparency during inhalation and exhalation; sharp limitation or complete absence of mobility of the diaphragm, flattening and low standing of its domes; limited mobility of the ribs with their horizontal direction and expansion of the intercostal spaces; excited pulsation of the heart, bulging of the outflow tract of the right ventricle and the arch of the pulmonary trunk; an increase in the shadow of the roots of the lungs and blurring of their contours, an increase in the pulmonary pattern. Most of the listed symptoms are explained by acute swelling of the lungs and circulatory disorders in them. These changes can be observed against the background of complications and concomitant diseases (pulmonary emphysema, acute or chronic pneumonia, pleural changes, petrification, tuberculosis infiltrates).
In the second stage of the disease, bronchiectasis and other morphological changes may appear.
In the atopic form of B. a. in the first and even second stages of the disease, after cessation of contact with a specific allergen or as a result of specific hyposensitization, recovery or long-term remission may occur. Working capacity is impaired during periods of severe exacerbations, and is lost completely only during a long course with the addition of hron. bronchitis and typical complications. Fatalities with this form are rare.
Infectious-allergic asthma is prognostically much more severe. The ability to work is often impaired, especially during the cold seasons of the year. Remissions are rare. In severe cases and early development complications, patients often become disabled in the 2-3rd year of the disease. The prognosis for the asthmatic triad is considered especially unfavorable. In recent years, cases of death in an asthmatic state due to infectious-allergic asthma have become more frequent.
Treatment |
Acute attack of B. a. usually relieved by adrenaline and its derivatives, ephedrine, aminophylline. Depending on the severity of the attack, different routes of drug administration may be recommended. In recent years, sympathomimetic drugs have been synthesized that selectively stimulate (32-adrenergic receptors (isadrin, novodrin, euspiran, alupent, asthmapent, etc.) and therefore are almost devoid of side effects characteristic of adrenaline. They are used, as a rule, in inhalations, certain per os and usually quickly stop mild asthma attacks.However, an overdose of these drugs in inhalation (use more than 4-6 times a day) can provoke an inflammatory process in the respiratory tract due to increased desquamation of the epithelium or cause bronchospasm due to the formation of adrenaline derivatives with (β- blocking effect and lead to an asthmatic condition (the so-called drug-induced breathing syndrome).For oral administration, a mixture of aminophylline (0.15 g) with ephedrine hydrochloride (0.025 g) or aminophylline in an alcohol mixture according to the prescription is also recommended:
Rp. Euphyllini 3.0 Sir. Althaeae 40.0 Spirit. vini 12% ad 400.0 MDS. 1 table each. l. appointment.
The use of atropine preparations is not recommended due to the fact that they complicate the separation of sputum. Widespread for stopping and preventing attacks of B. a. received combination drugs - theofedrine, antasman, solutan, but the first two contain amidopyrine, the third - iodine, to which patients are often allergic. Patients with manifestations of allergic rhinitis are prescribed antihistamines (diphenhydramine, etc.), which in themselves usually cause an attack of B. a. not docked.
Moderate asthma attacks can be treated with the drugs listed above, but more often in the form of subcutaneous injections: Sol. Adrenalini hydrochloridi 0.1%-0.2 ml + Sol Ephedrini hydrochloridi 5%-0.5 ml; At the same time, it is rational to inhale any of the sympathomimetic drugs. The administration of adrenaline in large doses is dangerous due to possible adverse reactions from the cardiovascular system.
For severe attacks, all of the listed remedies are indicated, and if the effect does not occur, intravenous administration of Sol. Euphyllini 2.4% -10 ml +Sol. Glucosae 40% -20 ml (administer slowly over 4-6 minutes). At the same time, oxygen is inhaled. Drugs of the morphine group, due to their inhibitory effect on the respiratory center, as well as histamine-liberating and antitussive effects, are strictly contraindicated in patients with B. a.
When providing emergency care, the severity of complications must be taken into account. So, with severe emphysema of the lungs and hron. respiratory failure, oxygen is indicated even for mild attacks. Signs of chronic pulmonary heart with right ventricular failure serve as an indication for the administration of appropriate drugs. Cardiac glycosides are prescribed in usual doses: digoxin 0.25 mg 3 times a day for 3-4 days, then switch to maintenance doses - 0.25 mg per day. In severe cases, intravenous administration of 0.5-1 ml of 0.06% solution of corglycon or 0.5-1 ml of 0.05% solution of strophanthin is indicated, usually in a dropper along with 10 ml of 2.4% solution of aminophylline in 200-250 ml of 5% glucose solution or isotonic sodium chloride solution. Among diuretics, hypothiazide (25-100 mg per day), furasemide in combination with aldosterone antagonists (aldactone 0.1-0.2 g per day) are recommended. Restriction of fluid and salt intake is indicated.
In the USSR and abroad, acupuncture is used for uncomplicated forms of B. a., as well as to relieve attacks (see).
An asthmatic condition is an indication for emergency hospitalization in a therapeutic or intensive care unit. If the patient's condition is not very severe, they begin with an intravenous drip of Sol. Euphyllini 2.4% -10 ml+Sol. Ephedrini hydrochloridi 5% -1 ml+Sol. Corglyconi 0.06% -1 ml in 500 ml of 5% glucose solution or isotonic sodium chloride solution (the amount of liquid can be increased to 1.5-2 l if signs of dehydration are noted). If there is no effect after 30-40 minutes. after the start of drip infusion, it is necessary to administer intravenous drips of corticosteroids. The dose of the latter is prescribed purely individually, based on the severity of the condition, as well as whether the patient has previously been treated with these drugs, for how long and in what doses. The minimum initial dose for a patient who has not received steroids is 30 mg3% prednisolone hydrochloride solution. In severe cases, up to 150-180 mg of prednisolone per day can be administered parenterally.
The use of ACTH intramuscularly up to 40 units per day is less effective and does not exclude the possibility of an allergic reaction. Synthetic drugs of similar action (humactide - 28-0.4 mg, corresponding to 40 units of ACTH, synacthen - 0.25 mg) are safe in terms of the possibility of sensitization and are very effective in moderate asthmatic conditions.
Regardless of the severity of the condition, it is necessary to immediately prescribe drugs that thin sputum and promote coughing, antibacterial therapy, if indicated, and tranquilizers. For acidosis, intravenous drip administration of a 5% sodium bicarbonate solution is indicated - 100 ml or more (under the control of determining blood pH). Inhalations of pure humidified oxygen are indicated, but for patients with pulmonary emphysema and previous chronic. respiratory failure should be prescribed with caution, because they establish hypoxemic stimulation of the respiratory center, and an overdose of oxygen can lead to respiratory arrest.
Of additional importance in the treatment of an asthmatic condition, as well as the usual exacerbation of the disease, is the administration of native plasma and albumin, which bind chemical mediators circulating in the blood.
If the above measures have no effect, mechanical drainage of the bronchial tree should be started using a catheter inserted through the nose, an endotracheal tube or a bronchoscope. Before starting to suck out mucus using suction, it is useful to administer 50 mg endotracheally to liquefy it. crystalline trypsin, dissolved in 10 ml of isotonic sodium chloride solution. Lavage of the bronchial tree is effective - washing the bronchi with large quantities of warm isotonic sodium chloride solution or antiseptic solution with simultaneous suction of the rinsing water. During this manipulation, all lobar bronchi are sequentially washed. The total amount of liquid for rinsing is 500-750 ml. If the patient's condition continues to deteriorate, resuscitation measures are indicated.
Features of resuscitation in asthmatic conditions. The need for resuscitation arises during a prolonged and pronounced attack of B. a., when ventilation disturbances lead to the threat of the development of terminal conditions due to deep hypoxia, respiratory and metabolic acidosis. These pathological changes determine the features of resuscitation for B. a.
Since hypoxia is the most dangerous, the prelude requires oxygen therapy (see) using inhalers or an anesthesia machine (see Oxygen-breathing equipment). Another attempt to reduce bronchospasm is anesthesia with fluorotane or nitrous oxide with oxygen. The use of ether is undesirable. In some cases, epidural anesthesia gives favorable results (see Local anesthesia). As the bronchodilator effect of fluorotane manifests itself (facilitation of inhalation, reduction of cyanosis, deepening of breathing), it is necessary to reduce the concentration of its vapors or stop its inhalation altogether, because with the restoration of alveolar ventilation and a rapid drop in p CO 2 in the arterial blood, a decrease in blood pressure occurs, to -swarm as a result of the ganglion-blocking effect of ftorotan can worsen up to asystole.
Nitrous oxide and ether are inferior to fluorothane in terms of bronchodilator effect; The disadvantage of ether is also the stimulation of the secretion of glands of the bronchial mucosa and the ability to cause excitement.
In case of a coma or the threat of its development, you should immediately begin artificial respiration (see) in the mode of intermittent positive pressure. Positive inspiratory pressure is increased to 45-50 cm of water. Art.; the negative phase during exhalation is contraindicated. To synchronize the patient's breathing with a respirator in the first hours of treatment, a large minute volume of breathing (exceeding the patient's own minute breathing volume) with a high oxygen content in the respiratory mixture (80-100%) is required. Systematic intravenous administration of sodium hydroxybutyrate in combination with antihistamines and analgesics is also indicated. In case of pronounced bronchospasm and the ineffectiveness of these measures, muscle relaxants are used (see). To reduce the viscosity of sputum and facilitate its removal, it is necessary to constantly drip into the trachea an isotonic solution of sodium chloride with proteolytic enzymes or include an aerosol inhaler, preferably an ultrasonic one, in the apparatus circuit. After reducing hypoxia and hypercapnia, it is necessary to correct the operation of the respirator by gradually reducing the minute volume of breathing by slowing breathing to 18-16 per minute while maintaining a large tidal volume (600 - 800 ml) and reducing the oxygen concentration to 40-60%. Subsequent cessation of artificial ventilation should be done gradually.
In case of a pronounced attack of bronchospasm, reaching the degree of total bronchospasm, lung massage is sometimes used (see Bronchospasm).
In the complex of resuscitation measures, medications should be used that have a bronchodilator effect, adrenomimetic, antihistamine, antispasmodic, anticholinergic substances, glucocorticoids, etc. The effectiveness of these drugs during resuscitation should not be overestimated, since they are usually used in the treatment of B. a ., and the attack occurs against the background of their therapy. Drugs that promote bronchial contraction are contraindicated. For example, β-blockers should not be used to combat tachycardia.
Correction of water-electrolyte and acid-base balance, parenteral nutrition are necessary.
Nonspecific treatment methods. In severe cases of the disease, when all other interventions are insufficiently effective, the use of corticosteroid hormones and their analogues is indicated (see Corticosteroid drugs). However, they must be prescribed very carefully due to the possibility of serious complications with long-term treatment. When prescribing for the first time, a daily dose of prednisolone of 20-30 mg is recommended (triamcinolone, respectively, 16-20 mg, dexamethasone 2-3 mg). The course of treatment should be short: once the effect is achieved, the dose of prednisolone is reduced by 5 mg every day. IN Lately offer the so-called alternating treatment with corticosteroids: the drug is prescribed every other day or three days a week in a row (the other four days the patient does not receive it). With this treatment, adrenal function is less inhibited. Attempts to cancel hormones or reduce doses during long-term treatment with them can be carried out while taking drugs that potentiate their effect - ascorbic acid, resokhin (Delagil, Plaquenil) and stimulating adrenal function (etimizole).
To prevent and eliminate complications of steroid therapy, it is necessary to prescribe anabolic hormones, potassium preparations, diuretics, and alkalis according to indications.
There are reports of attempts to treat B. a. immunosuppressants such as 6-mercaptopurine. The widespread use of these drugs is still limited due to their toxicity.
With infectious B. a. in the acute stage in cases of pneumonia and other infectious processes, antibacterial therapy is necessary. Before prescribing it, you need to carefully ask the patient about episodes of drug allergies. Indications of even mild reactions exclude the use of the drug that caused them. Due to its pronounced antigenic properties, it is better not to prescribe penicillin to asthmatics at all. Broad-spectrum antibiotics and long-acting sulfonamides (sulfadimethoxine, etc.) are prescribed in normal doses for at least two weeks. Careful monitoring is necessary during treatment. When locals appear allergic reactions, skin itching, urticaria, increased blood eosinophilia, the drug is immediately discontinued. It can only be replaced with a drug from another group that does not have a similar chemical structure. In the remission stage, surgical sanitation of such foci is necessary. infections, such as purulent sinusitis, hron. tonsillitis.
In cases of difficulty in coughing up mucus, especially with concomitant bronchitis, expectorants are necessary. It is best to use a 3% solution of potassium iodide, 1 tablespoon at a time. l. 3-4 times a day, in cases of iodine intolerance - ammonium chloride 0.5-1.0 g 3-4 times a day. With caution, given the possibility of allergic reactions, inhalation of enzyme solutions (trypsin, chymopsin, deoxyribonuclease) can be used. It is safe and in some cases effective to prescribe inhalations of isotonic sodium chloride solution heated to 37°C (5-10 ml). Special exercises in a complex of therapeutic gymnastics (see below) are good for coughing.
In almost all cases B. a. Sedative and tranquilizing therapy is indicated.
For mild neurotic reactions, psychotherapy is sufficient. In other cases, depending on the manifestations (insomnia, fear, tearfulness, irritability), small doses of barbiturates and minor tranquilizers (seduxen, elenium, nopatone, etc.) in usual dosages are indicated. The administration of major tranquilizers (aminazine, etc.) is not recommended due to their inhibitory effect on the respiratory center.
In 1967, a fundamentally new drug for long-term treatment of B. a. was proposed in England - intal. It is believed that its mechanism of action is reduced to inhibition of the release of all chemical mediators caused by the antigen-antibody reaction. The drug is most effective for the atopic form of the disease.
Treatment of B. a. histaglobulin is more effective in childhood.
All patients with B. a. Diet therapy is indicated: the so-called. hypoallergenic diet with the exclusion of foods with pronounced antigenic properties (eggs, citrus fruits, fish, nuts, strawberries), spicy, sour, irritating dishes and seasonings. It is recommended to eat small meals 4-5 times a day in small quantities. Patients for whom food products are allergens are prescribed individual elimination diets.
Specific treatment is effective in the early stages of the disease in the absence of significant complications. Specific therapy for the atopic form of B. a is well developed and used in specialized medical institutions. It includes cessation of contact with specific allergens, where possible, and specific hyposensitization (see).
Subject to a complete specific diagnosis and taking into account contraindications, specific therapy gives good long-term results in 70-80% of cases of atopic B. a. The most effective treatment for pollen (hay) and dust (household) asthma.
As a specific therapy for the infectious-allergic form of the disease, treatment with auto- and heterovaccines and bacterial allergens is used after preliminary specific diagnosis. Efficiency approx. 50%.
Physiotherapeutic treatment of patients with B. a. can be carried out both during an exacerbation and during a period of remission, depending on the severity of the course and treatment conditions (hospital, clinic, sanatorium).
During attacks, physiotherapy for infectious-allergic and atopic forms of B. a. is aimed at reducing or eliminating bronchospasm, restoring the ventilation and drainage functions of the bronchopulmonary system. To treat patients with infectious-allergic forms, physiotherapy is widely used in combination with other treatment methods; For patients with atopic form, physiotherapy is prescribed only if hyposensitizing therapy is insufficiently effective.
During this period, a number of treatment methods are used, but the most effective are considered to be exposure to currents and fields of high, ultra-high and ultra-high frequencies, as well as ultrasound. Electric field UHF with a power of 80-100 W is used on the chest area with anteroposterior or lateral placement of electrodes, the dose is low-thermal; per course 6-8 procedures lasting 10-15 minutes. daily (see UHF therapy).
Inductothermy (see) is carried out on the interscapular area with an inductor - a cable or disk at a current strength of 180-220 mA daily or every other day; per course 10-12 procedures lasting 10-15 minutes. daily.
Microwave therapy (see) with a power of 30-40 W is carried out on the interscapular area with a cylindrical emitter with a diameter of 14 or 18 cm. The distance between the emitter and the skin surface is 5-7 cm; per course 10-12 procedures for 10-15 minutes. daily.
Ultrasound treatment is carried out according to the scheme. On the first day of treatment, paravertebral fields D I - D XII are affected; ultrasound intensity 0.2 W/cm 2, exposure duration 3 minutes. to the right and left margins. On the second day, the paravertebral fields are affected according to the above method, as well as the VI-VII intercostal spaces (below the shoulder blades); the intensity of the last exposure is 0.4 W/cm 2, duration is 2 minutes. left and right. On the third day, an effect on the subclavian zones is added to the indicated zones, the intensity is 0.2 W/cm2, duration is 1 minute. from each side. Then all subsequent procedures are carried out without changes daily for 8 days, and then every other day, total number 12 -15 per course. Vaseline oil is applied to the affected areas during ultrasound treatment.
Ultrasound can be used to administer medications; this method is called phonophoresis. In patients with B. a. hydrocortisone phonophoresis is used. To do this, an ointment of the following composition is applied to the areas affected by ultrasound: hydrocortisone suspension - 5 ml, petroleum jelly and lanolin - 25 g each. Hydrocortisone introduced by ultrasound, enhancing the effect of the latter, has a desensitizing and anti-inflammatory effect. Hydrocortisone phonophoresis is successfully used to prevent complications that arise in patients with B. a. when withdrawing corticosteroid hormones (see Ultrasound therapy), to increase the glucocorticoid function of the adrenal glands, they act on the site of their projection electromagnetic vibrations decimeter wave range - UHF therapy (see Microwave therapy) or inductothermy. DMV therapy is carried out at level D X - L II in front and behind at a distance of 5-10 cv from the skin; intensity of exposure 30-40 watts, duration 7-10 minutes. on the field every day; per course 16-18 procedures. Inductothermy is carried out with an inductor cable around the body at level D x - L IV at a current strength of 160-180 mA for 15 minutes; for a course of 10-12 procedures, 4 per week with breaks of 1-2 days.
But to stop an attack or if there are contraindications to the above effects, patients are shown electrophoresis of calcium chloride, papaverine, aminophylline, ascorbic acid, novocaine, etc. (see Electrophoresis, medicinal substances). A pad with the recommended medicinal substance is placed on the interscapular area. The current strength is up to 6-8-10 mA. for a course of 10 - 12 procedures every other day, lasting 15-20 minutes. You can also use ultraviolet radiation in erythemal doses. Field irradiation of the chest is used more often; field area 300-400 cm 2. The irradiation intensity in the first procedure is 2-3 biodoses per field, with each subsequent procedure the irradiation intensity increases by 1-2 biodoses. One field is irradiated in one procedure, a total of three irradiations of each field are performed after 1-2 days (see Erythemotherapy).
The procedures listed above can be carried out in combination with inhalations of bronchodilators, expectorants, sulfonamides, antibiotics, enzymes, taking into account the individual characteristics of the patient.
In the interictal period of infectious-allergic and non-infectious-allergic forms of B. a. Inhalation of aerosols and electroaerosols of bronchodilators, expectorants and other drugs is used. For the treatment of vasomotor rhinitis and allergic rhinosinusopathy, intranasal electrophoresis of calcium chloride and diphenhydramine is indicated. To influence the higher regulatory centers of the nervous system, electrosleep (see) is used at a pulse frequency of 10-20 Hz daily or every other day; per course 10-15 procedures lasting 20-40 minutes. In order to have a desensitizing effect and improve lung ventilation, aeroionotherapy with negative charges is used; per course 10-15 procedures for 5-15 minutes. daily (see Aeroionization). During the same period, restorative treatment is indicated.
Spa treatment of patients with B. a. is one of the stages complex therapy and is carried out at resorts with a mountain climate (An-Tash, Kislovodsk, Kuryi, Nalchik, Surami, Tsemi, Cholpon-Ata, Shovi, Shusha), sea (Alushta, Gelendzhik, Yalta) and in local sanatoriums for the treatment of patients with non-tuberculosis lung diseases nature (sanatorium "Barnaulsky" in the Altai Territory, "Zholinsky" - Gorky Region, "Chernaya Rechka" - Leningrad Region, "Ivanteevka" - Moscow Region, "Solnechny" - Chelyabinsk Region, "Cheremshany" - Saratov Region, "Shivanda" - Chita region, etc.).
Resort treatment in a mountain climate is indicated for patients with the atopic form of B. a. Regardless of the stage of the disease, patients with an infectious-allergic form - in the absence of severe emphysema and exacerbation of the inflammatory process. Persons with severe pulmonary insufficiency and signs of a protracted inflammatory process in the lungs, but without frequent severe attacks of suffocation, without signs of fungal allergies and high sensitivity to physical factors (humidity, insolation) are indicated for treatment at seaside resorts. When choosing a period of year for spa treatment the degree of meteotropicity of patients is taken into account.
Contraindication for the treatment of patients with B. a. at climatic resorts are: general contraindications that exclude sending patients to a resort, frequent attacks of suffocation in the infectious-allergic form of asthma, long-term use of large doses of corticosteroids, activation of the inflammatory process in the respiratory system against the background of significant organic changes in the lungs and decompensation of the pulmonary heart .
Treatment at local resorts should be recommended for patients with severe disease in order to consolidate the effect of drug treatment, as well as for persons with unstable remission and a tendency to frequent exacerbations of the inflammatory process in the lungs.
Features of spa treatment of patients with B. a. lie in the cumulative effect of climate, health path and mineral waters, which are different at different resorts. The climatic factor is of primary importance. Climatic mountain resorts and coastal resorts are year-round medical centers and have a high ability to rehabilitate patients. The effectiveness of treatment at local resorts with a typical climate for patients is ensured by the cleanliness of the air, the absence of substances that irritate the respiratory system, and allergens found in ordinary homes and working conditions. The positive effect of the coastal climate is due to the purity of the air, the presence of aerosols, various salts in it and the stimulation of the thermal adaptation mechanisms of patients. It should, however, be taken into account that in conditions of high coastal humidity, the “pathogenicity” of certain allergens (house dust, fungi) may increase, and excessive ultraviolet radiation can contribute to increased sensitization. The mountain climate, due to low atmospheric pressure, daily fluctuations in air temperature and the absence of allergens, promotes the activation of adaptive mechanisms of the external respiration and circulatory apparatus, strengthening the glucocorticoid function of the adrenal cortex and reducing the specific sensitization of patients.
The therapeutic effect of climate therapy increases from the use of health paths and therapeutic exercises aimed at reducing hyperventilation of the lungs, normalizing the ratio of the inhalation and exhalation phases and developing the diaphragmatic type of breathing. The nature of physical activity must be adequate to the degree of fitness of patients and the state of external respiration function. Long walks along routes with high elevations are indicated only for patients with stable remission in the absence of pulmonary emphysema.
At climatic and balneological resorts, balneotherapy is successfully used. The effect of this type of treatment is associated with complex neurohumoral mechanisms. Balneotherapy is indicated for patients with B. a. in the absence of severe pulmonary insufficiency caused by pulmonary emphysema and hron. inflammatory process in the bronchopulmonary apparatus, as well as in the absence of exacerbation of chronic diseases. inflammatory process. Carbon dioxide bicarbonate-sodium waters increase the histaminopectic properties of blood serum in patients with allergic diseases. Mineral waters containing sulfur have an anti-inflammatory effect, so they are indicated for patients with B. a. from chronicle inflammatory process in the bronchopulmonary apparatus during remission. Carbon dioxide bicarbonate-sulfate-calcium-magnesium-sodium water (Kislovodsk resort) helps to increase bronchial patency and increase the reserve capacity of the external respiration apparatus. One of the types of treatment at balneological resorts is inhalation of mineral water aerosols, which are indicated in the interictal period, regardless of the form of the disease.
The effect of spa treatment is increased by the use of specific hyposensitization with non-infectious and infectious allergens. If this type of treatment was carried out before arriving at the resort, it should be continued, but taking into account the fact that the threshold of sensitivity of patients to allergens in a resort usually decreases.
In a number of countries (USSR, Poland), treatment in salt mines (exhausted), with the organization of sanatoriums near the mines and the use of climatotherapy, is successfully used to treat the early stages of asthma, especially in children. Spa treatment of patients with B. a. carried out in combination with other treatment methods.
Therapeutic exercise is an obligatory part of the complex treatment of B. a. in patients of any age. It helps restore impaired respiratory functions, promotes the separation of sputum, prevents the development or progression of emphysema, deformities of the chest and spine, increases the body's resistance, and strengthens the nervous system.
Therapeutic exercise is indicated in the inter-attack period of the disease. Contraindications may include exacerbation of the disease process, increased temperature, and the occurrence of severe complications.
The following forms of physical therapy are used: therapeutic exercises, dosed walking, hygienic exercises, and when working with children, also games and simulation exercises. Therapeutic gymnastics classes are carried out in the treatment prof. institutions (hospital, clinic, sanatorium) and at home.
A feature of the method of therapeutic exercises is the use of special breathing exercises: exercises with an emphasis on prolonged exhalation, exercises to strengthen the main and auxiliary respiratory muscles, for the development diaphragmatic breathing, as well as exercises with loud pronunciation of the vowel sounds u, o, a and the consonants f, s, sh. Are of great importance general strengthening exercises with a gradually increasing load (use of dosed walking, running, certain exercises of a sports nature).
Classes are conducted individually with each patient or with a small group of 3-5 patients. For children, organized therapeutic gymnastics classes using a special technique can begin from the age of 4. The duration of treatment in a clinic setting should be at least 6 months. When visiting a physical therapy room 3 times a week.
In addition to gymnastics, chest massage, swimming, walking, especially before bed, and hardening are useful. Sunbathing is not recommended. During periods of long-term remissions, swimming, skating, skiing, rowing, and short-distance hiking are indicated. Participation in sports competitions is prohibited until full recovery. Daily gymnastics at home is recommended. Therapeutic gymnastics should gradually move into general physical education and be a mandatory element of all later life sick.
Surgical treatment is sometimes used in cases of ineffectiveness of conservative therapy for B. a. Clear indications and contraindications for surgical treatment have not yet been developed. Surgical interventions for B. a. can be divided into 4 types: tissue therapy, operations on the autonomic nervous system in the cervical and thoracic region, lung reimplantation and operations on the sinocarotid zone.
The method of tissue therapy proposed by V.P. Filatov (1939) and modified by G.E. Rumyantsev (1951) and others is not used today due to its low effectiveness.
The first operation on the autonomic nervous system for B. a. performed by Kiimmel in 1923. He removed the superior cervical sympathetic ganglion in four patients. In subsequent years, I. I. Grekov (1925) and V. S. Levit (1926) performed a two-stage operation - sympathectomy and then vagotomy. Later, Miscall and Rovenstine (L. Miscall, E. A. Rovenstine, 1943-1950), in order to more completely interrupt the reflex arc between the autonomic nervous system and the lungs, began to use the removal of 3-4 thoracic ganglia. However, the results of these operations were unsatisfactory.
In 1964 E. N. Meshalkin used new method surgical treatment of B. a. - lung reimplantation. A study of the immediate and long-term results of 20 lung reimplantations showed that this dangerous and complex operation does not solve the problem of surgical treatment of B. a.
The most widespread are operations on the sinocarotid zone in various modifications: glomectomy, glomectomy with denervation and subsequent alcoholization of the sinocarotid zone, alcoholization of the sinocarotid zone, resection of the sinus nerve.
For the first time, removal of the carotid glomus (see) in patients with B. a. performed by Nakayama (K. Nakayama) in 1942. Of 3914 patients who underwent glomectomy, positive results (noticeable or slight improvement) were found in 2535 patients, which is 64.7% (1958, 1961, 1962).
According to E. S. Karashurov (1969), the results of glomectomy for up to 7 years are as follows: remission and significant improvement in 32.6-44.5% of patients, improvement in 33-41.8%, no effect was obtained in 22-44.5% of patients. 26.7% of patients.
The glomectomy operation can be performed under local anesthesia, but it is better under general anesthesia. Skin incision approx. 5 cm is made along the inner edge of the sternocleidomastoid muscle. The middle of the incision should be at the level of the upper edge of the cricoid cartilage, in the projection of the division of the common carotid artery. After dissection of the subcutaneous tissue and subcutaneous muscle, the tissues are moved apart to the fascia enveloping the neurovascular bundle. After longitudinal opening of the fascia with a dissector, the common carotid artery and its branches are isolated.
Then the glomus is removed (see), after ligating the small artery that feeds it. The wound is sutured in layers, leaving a rubber strip in place for a day.
After surgery, in cases of difficulty breathing, bronchodilators are prescribed. Doses of steroid hormones, if they were used before surgery, are gradually reduced.
The main social and hygienic measures for the prevention of asthma are improving working and living conditions, combating air pollution and smoking, proper organization of work and rest, and reasonable methods of hardening the body. Of great importance is: limiting vaccinations for people with an allergic constitution; dispensary observation and rational treatment of patients with pre-asthmatic diseases - hron. bronchitis, chronic pneumonia, allergic, polypous and purulent diseases of the upper respiratory tract; specific therapy for hay fever and perennial allergic rhinitis.
For constitutional allergy sufferers, the choice of profession plays an important role - the professions of pharmacists and chemists are contraindicated for them; work in pharmaceutical factories, bakeries, the production of natural silk, plastics, cotton processing, wool spinning and some other enterprises is not recommended.
In old and senile age as a result of hron. inflammatory processes in the respiratory tract (chronic bronchitis, chronic nonspecific pneumonia), as a rule, an infectious-allergic form of the disease develops. Age-related changes in the nervous and endocrine systems and features of the body’s reactivity, on the one hand, create a certain predisposition to the occurrence of the disease in the presence of sensitization, on the other hand, they determine a less acute, smoothed clinical course.
In most cases B. a. in such patients it manifests itself as a state of constant difficulty breathing with periodic attacks of suffocation. In this case, as a rule, hron is found in the lungs. inflammatory process. A characteristic attack of B. a. Against the background of complete health, it is extremely rare in elderly and old people. Exacerbation of the disease is mainly due to activation of hron. inflammatory process in the lungs or upper respiratory tract. Physical stress is also a provoking factor.
Current of B. a. in such patients it is progressive. Chron. inflammatory processes in the lungs cause the rapid progression of obstructive emphysema with the subsequent development of pulmonary heart failure. As a consequence of pulmonary insufficiency, increased breathing is observed during an attack. In some cases, acute heart failure develops, associated with reflex spasm of the coronary vessels, increased pressure in the pulmonary artery system, against the background of an already existing age-related weakening of myocardial contractility. This is largely facilitated by the hypoxia that occurs during an attack. Treatment tactics for B. a. in old and senile age it has certain features. During an attack of B. a. It is always necessary to include cardiovascular drugs in the complex of therapeutic measures, because due to age-related changes cardiovascular system in older people, circulatory failure easily occurs. Oxygen therapy is indicated. To relieve bronchospasm, both during an attack and in the interictal period, preference should be given to xanthine-type drugs (aminophylline, aminophylline, etc.).
The administration of adrenaline usually provides rapid relief of bronchospasm and thereby stopping the attack, however, caution is required when prescribing it, since it often causes pronounced changes in the cardiovascular system - a prolonged rise in blood pressure, overload of the left ventricle of the heart, various types of dysfunction of excitability, cerebrovascular accident. The dose of adrenaline should not exceed 0.3-0.5 ml in a dilution of 1: 1000. Before using adrenaline, ephedrine should be administered and isopropyl-norepinephrine preparations should be prescribed, which have a much lesser effect on hemodynamics.
The administration of various bronchodilator mixtures in the form of aerosols deserves special attention. The use of atropine should be avoided, since it promotes the formation of viscous sputum, which in elderly patients is difficult to separate, and this can lead to bronchial obstruction with the subsequent development of atelectasis. The use of drugs (morphine, promedol, pantopon, etc.) is contraindicated because they can easily lead to depression of the respiratory center.
Hormonal therapy (cortisone, hydrocortisone and their derivatives) gives a good effect both in relieving an acute attack and in preventing it. However, due to the frequent development of side effects (increased blood pressure, exacerbation of latent diabetes, the emergence of a tendency to thrombus formation, the development of hypokalemia, progression of age-related osteoporosis), corticosteroids should be prescribed with great caution: their doses should be 2-3 times lower than for young, and the duration of treatment is no more than three weeks. It is less dangerous to administer hormonal drugs in the form of aerosols.
The use of potassium iodide is worthy of attention. If anxiety is expressed, taking minor tranquilizers is indicated. It should be remembered that taking barbiturates in elderly and elderly people can cause increased excitability and depression of the respiratory center.
Specific hyposensitization in elderly and old age is rarely carried out.
Great importance should be attached to physical therapy and breathing exercises. The choice of spa treatment, as well as the amount of physical activity, should always be decided individually.
In recent decades, children, as well as adults, have seen an increase in the incidence of B. a. At the present time in the USSR, according to S. G. Zvyagintseva, S. Yu. Kaganov, N. A. Tyurin and other authors, it is approximately 3 per 1000 children's population. Usually children get sick with B. a. at the age of 2-4 years, with the atopic (non-infectious-allergic) form somewhat more often under the age of 3 years, and the infectious-allergic form at an older age. The distinction between infectious-allergic and atopic forms in children is often conditional. So, in patients with atopic form of B. a. attacks of suffocation may subsequently occur under the influence of infectious (usually respiratory) diseases, i.e., a polyvalent allergy develops. In such cases, they speak of a mixed form of B. a. Pathological anatomy of B. a. in children with a long course of the disease does not differ from that in adults.
Clinical picture. The appearance of the first attacks of B. a. in children, preasthma is often preceded: repeated respiratory diseases occurring against the background of allergies (exudative-catarrhal diathesis, urticaria, eosinophilia, etc.) or accompanied by asthmatic syndrome. Preasthma is most clearly expressed in children with an infectious-allergic form of the disease. Appropriate treatment during this period can help prevent B. a.
The immediate cause of the first attack of asthma, as a rule, is diseases of the upper respiratory tract, bronchitis, pneumonia, and less often - food allergens, injections of serums or vaccines, mental and physical injuries, etc.
Attacks of B. a. in children, regardless of the form, they usually develop gradually, over several hours or days, thanks to which a period of precursors of an attack can be distinguished: changes in behavior (excitement, excessive mobility or, conversely, lethargy, drowsiness), allergic runny nose, itchy nose, sneezing or obsessive cough, shortness of breath easily occurs. In the future, if it is not possible to prevent the deterioration of the condition, an attack of suffocation develops.
During an attack, the patient’s position is usually forced, semi-sitting; the expression on the face and eyes is frightened, the pupils are dilated. The skin is pale gray, cyanosis around the mouth and acrocyanosis are noted.
The chest is sharply swollen, the shoulders are raised; there is retraction of the chest below the nipples; expanded costal arches.
Breathing is rapid (in young children up to 70-80 breaths per minute), with somewhat difficult inhalation and significantly difficult exhalation. The exhalation is prolonged and noisy, accompanied by dry wheezing. The cough may be rare, but usually worsens at the end of the attack; thick, viscous, viscous sputum is separated with great difficulty. In children, Kurschmann spirals and Charcot-Leyden crystals are rarely detected, and eosinophils are contained in significant quantities.
 The pulse is frequent; at the height of an attack of suffocation during inhalation, the filling of the pulse decreases, which can give the impression of arrhythmia. Blood pressure is determined within the upper limit of normal; the heart is located in the middle, its boundaries are difficult to determine due to pulmonary emphysema; Heart sounds are sharply muffled. The liver protrudes from the hypochondrium by 2 - 4 cm. The ECG shows tachycardia, deviation of the electrical axis of the heart to the right, high P wave in II - III leads, decreased T waves, signs of increased pressure in the pulmonary artery system and impaired myocardial recovery processes. A serious condition caused by an attack of suffocation gradually improves under the influence of treatment: breathing becomes freer, sputum is separated more easily. In the post-attack period, over the course of several days or weeks, the changes in the respiratory and circulatory organs that arose as a result of the attack reverse development. Often, against the background of organic changes in the lungs (chronic pneumonia), children experience the development of an asthmatic condition. Of the complications of an attack of B. a. It should be noted pulmonary atelectasis, pneumonia, much less often interstitial and subcutaneous emphysema, spontaneous pneumothorax. With a long and severe course of B. a. in combination with hron. bronchopulmonary process may develop hron. pulmonary heart. Death can occur from asphyxia during an attack of suffocation, less often - due to anaphylactic shock, adrenal hypofunction. The diagnosis is made on the basis of anamnesis, clinical, laboratory and radiological data, as well as the results of skin allergy tests. B. a. in children it is necessary to differentiate with bronchiolitis, pneumonia occurring with asthmatic syndrome, congenital enzymopathies (cystic fibrosis, α 1-antitrypsin deficiency, etc.), foreign bodies, developmental abnormalities and tumors of the respiratory tract; Difficulty breathing in children can also occur due to compression of the trachea and bronchi by enlarged lymph nodes and the thymus gland. ForecastTimely initiation of complex, systematically carried out staged treatment (hospital-sanatorium - clinic - forest school) in most children leads to an improvement in the condition and cessation of asthma attacks. In some patients, however, no improvement is observed. TreatmentTo relieve an attack of B. a. In children, the same drugs are used as in adults (in appropriate doses). Particular attention should be paid to mild and moderate attacks to prevent them from developing into severe, life-threatening ones. To do this, when the first symptoms of an attack appear, bronchodilators are used in the form of powders, tablets, suppositories or inhalations; It is recommended to place cups, make a foot and hand hot bath, drip a 3% solution of ephedrine hydrochloride into the nose. It is necessary to calm the child, distract his attention with toys, books, and provide good access to fresh air. In more severe cases, they switch to subcutaneous injections of solutions of adrenaline (0.1%, 0.15 - 0.2 ml per injection), ephedrine hydrochloride or intravenous (preferably drip) injections of a solution of aminophylline (theophylline) in an isotonic solution of glucose or sodium chloride. Among the drugs that improve the function of the circulatory organs, we can recommend injections of cordiamine, ATP, intravenous infusions of corglycone, cocarboxylase; The use of vitamin C is indicated. Inhalation of oxygen is recommended only in severe and prolonged asthmatic conditions; in other cases, fresh, cool air is preferable. If it is impossible to eliminate an asthma attack using these means, glucocorticoids (hydrocortisone, prednisolone, etc.) are prescribed intravenously or intramuscularly. In case of threatening asphyxia and the development of atelectasis, therapeutic bronchoscopy is indicated; edges can only be performed in special conditions(intensive care unit) under general anesthesia with the use of muscle relaxants by a doctor who is fluent in the technique of bronchoscopy in children. During bronchoscopy, mucus from the bronchi is sucked out and bronchodilators are administered intratracheally. Because attacks of B. a. in children they are often accompanied by a bronchopulmonary infectious process, exacerbation of chronic purulent foci (tonsillitis, sinusitis, cholecystitis, etc.); in such cases, the prescription of antibacterial drugs is indicated. In the interictal period, children, as well as adults, are shown complex treatment B. a., including specific and nonspecific (histaglobulin) hyposensitization, physiotherapy, exercise therapy, adherence to the regimen and diet, chronic rehabilitation. foci of infection, spa treatment. Spa treatment for children and adolescents suffering from asthma is carried out at the resorts of the southern coast of Crimea, in Anapa, Kabardinka, and Kislovodsk. It is advisable to carry out treatment in local sanatoriums immediately after an exacerbation of the disease. Indications for spa treatment of children are determined by the nature of the clinical course of the disease and the climatic and geographical conditions of the resort. Usually it is indicated for patients with atopic and infectious-allergic B. a., in the absence of frequent attacks of suffocation and hron. pneumonia stages II and III, after sanitation of foci of infection. Climatotherapy has a hyposensitizing effect and helps to harden the body of children. For this purpose, in good weather, strictly dosed air and sun baths are used. If arrival at the resort does not cause activation of the inflammatory process in the lungs, balneotherapy is prescribed, and at sea coast resorts - sea bathing. Therapeutic exercises, walks, and games help normalize lung ventilation, strengthen the respiratory muscles and strengthen the nervous system. Prevention of B. a. in children is to reduce the possibility of sensitization of the body and prevent respiratory diseases: hardening and physical education from early childhood, early detection of exudative diathesis, exclusion of strong food allergens from the diet, strict adherence to contraindications when carrying out preventive vaccinations. Timely and rational treatment of children with preasthma is necessary. Are you categorically unhappy with the prospect of disappearing from this world forever? 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Despite the great successes of allergology, conservative therapy remains unsuccessful in a significant proportion of patients with bronchial asthma. This is due to the difficulty of identifying allergens in the atopic form of the disease, which in turn complicates pathogenetic therapy.
Not effective enough conservative methods and in the infectious-allergic form of bronchial asthma, especially in cases of localization of the infectious focus in the lung tissue. Repeated exacerbations of chronic bronchopulmonary inflammatory process contribute to the frequency and severity of asthma attacks.
The failure of conservative therapy in these groups of patients prompts us to look for pathogenetic methods of treating bronchial asthma, which include some surgical methods.
Surgical treatment of bronchial asthma has a half-century history. The first operation was performed by Ktimmel in 1923. Many methods of surgical interventions have been proposed, some of which have only historical meaning, others have become firmly established in the arsenal of treatment for bronchial asthma.
Surgical methods for treating bronchial asthma can be divided into: 1) tissue therapy; 2) various interventions (blockades and operations) on the autonomic nervous system in the thoracic and cervical regions and sinocarotid zone; 3) treatment of bronchial asthma by resection of pathologically changed areas of the lungs.
The history of surgery for bronchial asthma includes tissue therapy proposed by V.P. Filatov in 1939. In the hope of the positive effect of biogenic stimulants formed during tissue preservation, the author implanted a piece of cadaveric skin into the subcutaneous tissue of the chest wall of a patient with bronchial asthma. In some patients, a favorable result was observed immediately after the operation, but after 1-2 months the attacks of suffocation resumed.
The followers of V.P. Filatov, having comprehensively studied the long-term condition of patients treated with tissue therapy, also failed to note its positive therapeutic effect on the course of bronchial asthma (A.A. Korolenko, 1951; V.V. Skorodinskaya, Sh. I Shpak, 1953; S. R. Munchik, 1963; V. P. Khripenko, M. I. Obukhova, 1965).
Attempts to change the type of implanted tissue (adrenal glands of young dogs, cattle, pieces of skin along with thyroid tissue, blood “according to Klyukvina”) also did not improve the results of treatment (K. A. Arikhbaev, 1936; L. F. Kolmakova, 1954; G. A. Alekseev, 1957; A. Ya. Tsikunsha, 1960; Gerber, 1956, etc.). The attempts to treat brunchial asthma using heterotissue implantation methods due to its theoretical groundlessness and practical failure have ceased.
As is known, pathological reflex processes play a decisive role in the mechanism of an asthmatic attack. Forming between the vegetative centers and the lungs through the external vegetative pathways, they lead to a vicious circle. In a state of sensitization, there is a significant increase in the excitability of sensory nerve endings vagus nerve, lying in the bronchial wall. Prolonged and intense irritation under such conditions contributes to the development of neurosis and the formation of foci of stagnant excitation in the central nervous system (A. D. Ado, 1952; P. K. Bulatov, 1963; D. Dimitrov-
Sokodi, 1961).
The pathogenetic basis of surgical treatment of bronchial asthma is the impact on the pathological reflex process by chemical (blockade) or surgical means. These methods reduce the tone of the vagus nerve, eliminate bronchospasm, and change the reaction of the shock zone.
All kinds of blockade of various parts of the autonomic nervous system have become widespread thanks to the famous works of A.V. Vishnevsky, A.A. Vishnevsky.
With the help of a blockade—“chemical neurotomy”—a temporary break can be reproduced reflex arcs, which leads primarily to the switching off of pathological reflexes. Various types of blockade can be used. chemical substances. Levin (1935) alcoholized the borderline trunk of the sympathetic nerve by introducing 2.5 ml of ethyl alcohol pleurally into the fourth and fifth intercostal spaces. 17 out of 23 patients treated with this method had a positive result.
The most widespread are novocaine blockades. E. M. Rutkovsky (1971) recommends novocaine blockade of the carotid sinus. The injection is given at leading edge m. sternocleidomastoideus at the level of the upper edge of the thyroid cartilage. Inject 3-5 ml of 0.5% novocaine solution. The course of treatment consists of 10-14 blockades, performed 2-3 times a week alternately on the left and right sides.
According to V.A. Bondar (1966), cessation of bronchial asthma attacks under the influence of novocaine blockade and alcoholization of the carotid sinocarotid zone occurred in 35 of 47 patients treated with this method. After 1-3 years, stable recovery was noted in 18 observations.
The ago-sympathetic novocaine blockade according to Vishnevsky has also become widespread in the treatment of an attack of bronchial asthma. D. Dimitrov-Sokodi (1961) supplemented the bilateral vagosympathetic blockade with a blockade of the upper thoracic nodes of the sympathetic border trunks. After five blockades carried out every other day, the author observed the cessation of attacks within a period of 3 to 18 months. However, with vagosympathetic blockade, the cardiac fibers of the vagus nerve are almost completely switched off, which can lead to cardiac arrhythmias and vascular collapse.
The above complications are excluded when performing transbronchial blockade of the pulmonary plexuses. The blockade is carried out through a bronchoscope with a special needle 50 cm long. The membranous part of the main bronchus is pierced on the right in the middle of the distance between the bifurcation of the trachea and the mouth of the upper lobe bronchus, on the left - at the border of the middle and distal third from the bifurcation to the mouth of the upper lobe bronchus. Up to 20 ml of 0.5-1% novocaine solution is injected peribronchially.
With concomitant endobronchitis, some researchers administer a medicinal mixture consisting of 40-50 ml of a 0.5% solution of novocaine with the addition of a single dose of ephedrine, diphenhydramine, hydrocortisone and 300,000 - 500,000 units of penicillin (A. T. Lidsky, N. P. Makarova , V. A. Babaev, 3. S. Simonova, 1971). The therapeutic effect of transbronchial blockade is similar to the effect of vagosympathetic blockade and blockade of the upper thoracic sympathetic nodes.
According to D. Dimitrov-Sokodi (1961) and L. Ya. Alperin (1969|, transbronchial blockade can be recommended as part of a general set of measures to relieve an attack of suffocation that is not controlled by medications. Contraindications to its use are tuberculosis, exacerbation of chronic inflammatory pulmonary process, as well as rigidity of the bronchial wall, since in these cases mediastinal emphysema may develop during the administration of drugs.
Some authors (F.U. Uglov, E.E. Grigorieva, 1969) observed effective relief of an attack of bronchial asthma under the influence of bilateral blockade of the first cervical sympathetic node. The needle is inserted at the intersection of two lines: a vertical one, drawn 2 cm posterior from the edge of the vertical branch of the lower jaw, and a horizontal one, drawn at the level of the lower edge of the mastoid process. The needle is inserted to a depth of 2.5-3 cm, resting on the transverse process cervical vertebra. Then, pulling the needle 0.5 cm and changing direction, it is advanced 0.5 cm forward. Up to 20 ml of a 0.5% novocaine solution is injected into this area.
Thus, blockade of various parts of the autonomic nervous system and the sinocarotid zone has a positive effect on attacks of bronchial asthma, which is obviously explained by the occurrence of a pathological dominant in the absence of allergen action. The beneficial effect of “chemical neurotomy” is difficult to overestimate, especially in cases of prolonged asthma attacks that cannot be controlled with medications. Under these conditions, blockade of shock reflexogenic zones is an effective method of providing emergency assistance in the general complex of treatment of patients with bronchial asthma.
Unfortunately, the effect of the blockade is short-lived. While stopping an attack of bronchial asthma in most cases, “chemical neurotomy” does not prevent the occurrence of new ones, since it affects extremely complex mechanism the antigen-antibody reaction occurs only at the end point of its implementation, temporarily interrupting the flow of pathological reflexes. These reflexes can be interrupted for a longer period only by surgery.
As stated above, surgical interventions for bronchial asthma can be divided into: 1) operations on the autonomic nervous system in the cervical and thoracic regions; 2) operations on the sinocarotid zone.
The first operation on the autonomic nervous system for bronchial asthma was the removal of the superior cervical sympathetic ganglion performed by Kiimmel (1923). The positive results obtained by the author attracted the attention of many surgeons to simiatectomy for bronchial asthma. By 1928, according to world statistics, 212 such operations were performed (E.R. Hesse). However, sympathectomy is far from a harmless operation. It can contribute to the development of complications such as Horner's symptom complex, the appearance of pain in the parotid gland, atrophy of the muscles of the face, tongue, upper limb, and anhidrosis.
Further development of surgical interventions on the sympathetic nervous system - upper cervical sympathectomy with stelectomy (E. V. Bush, 1927; Levine, Grow, 1950), removal of the stellate ganglion (Steiner, (1951) - did not lead to improved results.
In parallel with operations on the sympathetic nervous system, there was a search for interventions for bronchial asthma on the parasympathetic nervous system. In 1924, Kappis proposed right-sided vagotomy. The vagus nerve was divided from the cervical approach below the origin of the recurrent nerve. Some authors tried to perform two-stage sympathectomy and vagotomy (I. I. Grenov, 1925; V. S. Levit, 1926).
However, the percentage of positive results from surgical treatment of bronchial asthma remained the same as with removal of the superior cervical sympathetic node, while the number of complications increased due to disruption of the innervation of internal organs.
The desire of researchers to reduce the number of complications led to the development of surgical interventions on the pulmonary nerve plexuses.
In 1926, Kiimmel proposed to cross the branches of the vagus nerve in the region of the root of the right lung. Braeuner (1938) supplemented plexotomy with complete skeletonization of the main bronchus and vessels of the root of the lung (in 21 patients). In the long term after surgery (4-8 years), the condition of 7 patients improved and 9 died.
Due to the insufficiently pronounced effect of right-sided plexotomy, Salman (1950) supplemented the operation by intersecting the fibers of the vagus nerve located in the pulmonary ligament of the left lung. The results of bilateral plexotomy, according to Adams (1950), Blades et al (1950), Abbot et al (1950), are somewhat better.
Trying to achieve a more complete break of reflex pathways, some researchers supplemented bilateral plexotomy by removing the adventitia of the pulmonary artery and veins on the left for 2-3 cm (E. N. Meshalkin, L. Ya. Alperin, N. I. Kremlev, G. A. Savinsky , A. M. Shurgaya, 1967; Blades, Blattia, Elias, 1950). Other authors have observed positive effect resection of 3-4 nodes of the sympathetic trunk below the stellate (Miscal, Rowenstine, 1943; Carre, Chondler, 1948).
In 1952, D. Dimitrov-Sokodi proposed removing the nodes (from 2 to 5) of the sympathetic border trunk and the pulmonary branches of the vagus nerve, providing a permanent break in the pathological reflexes and stopping the reflex processes leading to a vicious circle and supporting asthmatic attacks.
The author's studies have shown the resistance of the bronchi to histamine-like substances and increased sensitivity to adrenaline. 192 patients were operated on using this technique. In 120 cases, bilateral denervation was performed, in 72 - unilateral. According to the author, immediately after the operation, allergic and inflammatory processes in asthmatic lungs stopped, spastic state bronchi, a reverse development of a number of secondary asthmatic changes occurred (emphysema, congestion in the pulmonary circulation).
A.V. Glutkin, V.I. Kovalchuk
Shortness of breath, a feeling of lack of air, chest congestion, attacks of suffocation indicate bronchial asthma. Below in the article you will find the causes of the disease; the doctors who treat him; necessary medical procedures for treatment; as well as general information about the disease, its localization, features of diagnosis of diseases and their treatment. However, we advise you to consult a doctor, because self-medication is 90% fraught with the disease developing into chronic stage with extremely unpleasant complications
Bronchial asthma. general information
Bronchial asthma- chronic inflammatory disease of the respiratory tract, accompanied by symptoms such as bronchial hyperreactivity, cough, shortness of breath and asthma attacks caused by impaired bronchial obstruction varying degrees and duration.
Our clinic employs the best doctors in Moscow, who have extensive experience in the treatment of BRONCHIAL ASTHMA.
WHEN YOU SHOULD SOUND THE ALARM, SYMPTOMS OF BRONCHIAL ASTHMA
Paroxysmal dry cough, often early in the morning or at night, which may be accompanied by wheezing in the chest. At the end of the attack, a small amount of viscous yellow sputum may be released.
- Shortness of breath with predominantly difficulty exhaling.
- Feeling short of air.
- Feeling of congestion in the chest.
- Whistling in the chest.
- Attacks of suffocation.
DIAGNOSIS OF BRONCHIAL ASTHMA
Bronchial asthma is characterized by extremely unstable clinical signs, so a careful history taking and examination of external respiration parameters are especially necessary. In 3 out of 5 patients, bronchial asthma is diagnosed only in the late stages of the disease, since during the interictal period there may be no clinical manifestations of the disease.
Examination for bronchial asthma:
Laboratory research:
- OAC-clinical blood test (once every 10 days);
- Biochemical blood test (bilirubin, ALT, AST, urea, glucose);
- RW, HIV;
- sputum analysis (culture for flora + bacterioscopy); In the absence of sputum, the induced fraction is collected.
If necessary, additional laboratory tests, additional allergological examinations, and instrumental studies are carried out
COMPLICATIONS OF BRONCHIAL ASTHMA
OR WHAT WILL HAPPEN IF IT IS NOT TREATED OR TREATED INCORRECTLY
With proper treatment of bronchial asthma, complications are almost impossible. In this connection, the occurrence of any complication of asthma is almost always the result of inadequate treatment. Despite the fact that the bronchi (airways) in asthma can not only narrow, but also expand under the influence of adequate treatment, in the absence of proper anti-inflammatory treatment, their ability to expand may be limited and chronic obstructive pulmonary disease may develop.
The so-called status asthmaticus- extremely pronounced narrowing of the bronchi with the formation of mucus plugs in small airways. This complication cannot disappear on its own; urgent hospitalization is required.
Another complication of asthma (usually a severe attack) is spontaneous pneumothorax- penetration of air through a gap in the lung into the pleural cavity, which also requires emergency hospitalization.
TREATMENT OF BRONCHIAL ASTHMA
- Stopping contact with allergens (in the atopic form) by using: air purifiers, air conditioners, humidifiers, fighting dust mites, cockroaches, special covers for bedding, avoiding carpets and keeping pets, a hypoallergenic diet and other measures.
- Drug therapy is prescribed taking into account the severity of the disease, complications of the underlying disease and the presence of concomitant pathologies.
- Allergen specific immunotherapy- ASIT is one and effective methods treatment of atopic and mixed forms of bronchial asthma.
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