Typical manifestations of the clinical picture of bronchial asthma have been described for a long time, even in the period of Antiquity. Then it was clearly formulated that heavy, wheezing breathing with exhalation, requiring special effort, which appears suddenly, is accompanied by a dry cough and also quickly disappears - there is nothing more than an attack of bronchial asthma.
Today, for various reasons, the symptoms of this disease very often do not fit into the framework of the classical description of the disease. The huge number of allergens around us, the growing popularity of antiallergic (antihistamines in particular) drugs, the uncontrolled use of antibiotics, smoking - all this leads to the fact that traditional symptoms, or at least some of them, may not be present in the course of bronchial asthma. For example, a cough - it is absent or is wet, wheezing is not always observed, blood pressure decreases, and so on. But let us dwell in more detail on the typical clinical picture of bronchial asthma, since the probability of its manifestation is the highest.
An asthma attack begins with a subjective feeling of heaviness, chest tightness, accompanied by a dry cough. At the same time, breathing becomes noisy, a little later wheezing and a barely caught whistle appear, which grows and after a while can be heard at a distance. Usually, a whistle is heard both during inhalation and exhalation, but exhalation is noticeably lengthened, and the patient spends a lot of energy to implement it. The patient, as a rule, takes a forced position, grasping fixed objects with his hands (head of the bed, table, or simply grabs his knees). In this case, an additional fixation point is created for the muscles of the chest, which makes breathing somewhat easier.
Despite the difficulty of inhaling and exhaling, the respiratory rate increases, but its depth decreases - shortness of breath occurs. The patient does not have enough air, oxygen starvation occurs, which leads to an increase in heart rate and blood pressure (systolic). The patient becomes restless.
Since exhalation is difficult, residual air accumulates in the lungs, overstretching them. The rib cage is slightly enlarged, becoming like a barrel.
If the obstruction (narrowing of the lumen) of the bronchi continues and asthma acquires a protracted course, the wheezing disappears, the whistling intensifies, there is tension in the muscles of the shoulder girdle and abdominal press (auxiliary respiratory muscles). Breathing becomes even more shallow, which indicates an unfavorable course of asthma and the risk of complications.
If a dry cough is replaced by a wet one, and at the same time thick viscous sputum leaves, then this indicates the resolution (completion) of the attack. Often, barely noticeable casts of small Bronchi (Kurshman's spirals) are found in the sputum. Microscopy also shows Charcot-Leiden crystals, which are of great diagnostic value.
The weakening of wheezing and the disappearance of "whistling" in the presence of a cough without phlegm is another unfavorable sign of asthma, indicating airway obstruction and requiring readiness for resuscitation measures (artificial lung ventilation - mechanical ventilation).
The clinic of bronchial asthma described above is general and does not take into account the severity of the disease, which is the most important criterion when choosing a treatment regimen. There are four degrees (stages) of severity. To determine a particular stage, certain criteria are used:
a) the number of daytime (per day and week) and night attacks per week;
b) the frequency of use of short-acting beta-2-adrenergic agonists (B2AM);
c) deterioration in sleep and disruption of physical activity;
d) change in objective indicators of bronchial patency (PSV, PSV difference in the morning and evening, FEV1 and others).
Stage 1. Episodic, mild intermittent bronchial asthma. Daytime symptoms - less than once a week. Night - no more than 2 times a month. There are no symptoms between attacks, and sleep and physical activity are not disturbed. Taking B2AM only in case of an attack. Objective indicators: FEV1 and PSV are reduced by no more than 20% of the norm.
Stage 2. Mild persistent asthma. Daytime symptoms - 1 time per week or more, but not every day. Nightly - more than twice a month. Sleep and physical activity are disturbed during periods of exacerbations of the disease. Taking B2AM only in case of an attack. FEV1 and PSV are reduced by no more than 20% of the proper value, but only outside the attack.
Stage 3. Asthma of moderate severity, persistent. Daytime symptoms every day, they significantly disrupt normal life and sleep, worsen the quality of life. Night symptoms - 2 times a week or more. Mandatory daily intake of B2AM. FEV1 and PSV are reduced by 20-40%.
Stage 4. Severe persistent asthma. Symptoms are constant throughout the day, bothering at night. The disease significantly limits physical activity. Taking B2AM is not enough, hormone therapy is prescribed. FEV1 and PSV are reduced by more than 40% of the norm.
It is possible to establish the level of asthma only using the listed criteria only before starting treatment, since taking medications changes the clinical picture.
In addition to the steps, in the clinic of bronchial asthma, the following syndromes are distinguished (a set of certain, predominant symptoms):
- broncho-obstructive: suffocation and noisy breathing with a whistle prevail, wheezing, audible at a distance;
- bronchopulmonary: cough, shortness of breath, thick sputum, oxygen starvation;
- cardiopulmonary: increased heart rate, increased blood pressure;
- allergic: an attack is triggered by a certain allergen, positive allergic tests, the presence of itching, urticaria and other types of allergies;
- neuropsychic: headache, drowsiness, irritability, euphoria, tremors, inadequacy in behavior, aggressiveness - as a result of a lack of oxygen in the brain.
The clinical picture of bronchial asthma to a certain extent will also depend on its form.
- If this is an infectious asthma, then, in addition to everything, there will be fever, chills, weakness, pain in the chest, a change in the nature of the cough, the appearance of purulent, liquid sputum is possible.
- In case of aspirin asthma, the history of the disease must include the intake of aspirin (acetylsalicylic acid).
- Seasonal asthma occurs at certain times of the year, hay fever is characteristic.
- Dyshormonal bronchial asthma includes symptoms that indicate a pathology in the metabolism of a hormone or an endocrine gland (enlargement of the thyroid gland, sweating, overweight), and also occurs during pregnancy and menopause.
- The neuropsychic variant of asthma is accompanied by fluctuations in blood pressure, mood, fatigue, inability to cope with stress, etc.
Thus, it is obvious that the manifestations of the clinical picture of bronchial asthma are very diverse and sometimes not at all similar to the classical description of the disease. Perhaps that is why they say that bronchial asthma, like love, everyone knows it, but it is rather difficult to clearly define it.
Clinical manifestations of bronchial asthma are diverse and are not limited, as previously suggested, only to classical attacks of suffocation and asthmatic conditions. In all cases of the disease, its symptoms are based on transient bronchial obstruction caused by sensitization of the body with the development of allergic inflammation (damage) in the tissues of the tracheobronchial tree and altered sensitivity of the bronchi to a wide range of non-allergic stimuli.
Several main groups can be distinguished among the clinical manifestations of bronchial asthma.
In many patients, especially children and the elderly, clinical symptoms are often erased - outlined attacks of suffocation are absent or not expressed sharply, and other manifestations of transient bronchial obstruction come to the fore in the clinical picture.
In some patients, mainly elderly patients, symptoms of bronchial obstruction prolonged for a long time prevail, which may increase over time or decrease under the influence of treatment. These include dyspnea, increasing with exertion, and often at night, accompanied by an unproductive cough with mucous sputum. Above the lungs, whistling rales are heard, which intensify with an increase in the manifestation of bronchial obstruction. When studying lung function using spirometry or a peak meter, time-varying violations of bronchial patency are recorded. The course of the disease resembles the clinic of chronic obstructive bronchitis, however, unlike it, under the influence of pathogenetic treatment, the manifestations of bronchial obstruction are leveled.
The leading symptom of the disease can be a paroxysmal, mostly dry cough. He worries at times and at night. In these patients, wheezing is rarely determined, and manifestations of bronchial obstruction can be detected only by recording the flow-volume curve or by examining general plethysmography. Violations of bronchial patency are recorded at the level of large-caliber bronchi, which is explained by the predominant localization of allergic inflammation in the initial section of the tracheobronchial tree.
Quite rarely, bronchial asthma is manifested by symptoms of recurrent acute respiratory infections. In these cases, the patient's body temperature rises, a cough with mucous sputum and shortness of breath appear. A similar course of the disease is observed mainly in children with sensitization to plant pollen or household allergens.
The well-known and most well-defined clinical manifestation of the disease is an attack of expiratory suffocation. The leading role in its formation belongs to widespread bronchospasm. A choking attack occurs suddenly, more often at night or in the early morning hours. Often, its development is preceded by prodromal phenomena (harbingers) in the form of vasomotor disturbances of breathing through the nose, soreness along the trachea and dry coughing. At the time of the attack, the patient is agitated, feels a feeling of compression in the chest and lack of air. Inhalation occurs quickly and impulsively, followed by a difficult exhalation.
Accessory muscles are involved in breathing, the chest freezes, as it were, in the inhalation position. Physical signs of pulmonary emphysema are determined: against the background of weakened breathing, mainly in the expiratory phase, wheezing rales of different timbre are heard in the lungs. Usually, at the height of the attack, the sputum is not separated and begins to recede only after stopping it, viscous, scanty.
5. Complications of asthma
The most severe clinical manifestation of exacerbation of bronchial asthma is asthmatic condition, characterized by severe, persistent and prolonged bronchial obstruction lasting more than 12 hours. It is accompanied by increasing severe respiratory failure with a change in the gas composition of the blood, the formation of resistance to adrenomimetics and impaired drainage function of the bronchi. As a result, the sputum discharge stops and subsequently the “silent lung” syndrome is formed. The persistence and severity of the course of the broncho-obstructive syndrome in an asthmatic state are associated with the predominance of the edematous factor in the genesis of its development, as well as with the blockage of the lumen of the bronchi and bronchioles with thick mucus.
In accordance with the classification of A.G. Chuchalin (1986) distinguish between 3 stages of asthmatic condition.
In the pre-asthma stage, many patients have allergic or polypous rhinosinusitis. The manifestations of pre-asthma itself include paroxysmal cough (dry or with the release of a small amount of mucous viscous sputum), which is not relieved by conventional antitussive drugs and is eliminated by B.'s treatment. Coughing fits usually occur at night or in the early morning hours. Most often, the cough remains after a respiratory viral infection or exacerbation of chronic bronchitis, pneumonia. The patient does not yet experience breathing difficulties. With auscultation of the lungs, hard breathing is sometimes determined, very rarely - dry wheezing with forced expiration. Eosinophilia is found in the blood and sputum. When examining the functions of external respiration (FVD) before and after inhalation of a β-adrenergic agonist (izadrina, beroteka, etc.), a significant increase in the expiratory power can be established, indicating the so-called latent bronchospasm.
In the subsequent stages of B.'s development and. its main manifestations are asthma attacks, and in severe cases, also states of progressive suffocation, designated as status asthmaticus.
Bronchial asthma attack develops relatively suddenly, in some patients, following certain individual precursors (sore throat, itchy skin, nasal congestion, rhinorrhea, etc.). There is a feeling of congestion in the chest, shortness of breath, a desire to cough up, although the cough during this period is mostly dry and aggravates shortness of breath. Difficulty breathing, which the patient experiences at first only on exhalation, increases, forcing the patient to take a sitting position to engage the auxiliary respiratory muscles in the work (see Respiratory system). There are wheezing in the chest, which at first is felt only by the patient himself (or the doctor who listens to his lungs), then they become audible at a distance (distant wheezing) as a combination of different heights of the voices of the playing accordion (musical wheezing). At the height of the attack, the patient experiences severe suffocation, difficulty not only exhaling, but also inhaling (due to the setting in the respiratory pause of the chest and diaphragm in the position of deep inhalation).
The patient sits, resting his hands on the edge of the seat. The chest is enlarged; exhalation is significantly lengthened and is achieved by visible tension in the muscles of the chest and trunk (expiratory dyspnea); the intercostal spaces are drawn in on inhalation; the cervical veins swell on exhalation, collapse on inhalation, reflecting significant differences in intrathoracic pressure in the phases of inhalation and exhalation. With percussion of the chest, a boxy sound, a descent of the lower border of the lungs and a restriction of the respiratory mobility of the diaphragm are determined, which is also confirmed by an X-ray study, which also reveals a significant increase in the transparency of the pulmonary fields (acute distention of the lungs). Auscultation over the lungs reveals hard breathing and abundant dry rales of different tones with a predominance of buzzing (at the beginning and at the end of the attack) or sibilant (at the height of the attack). Palpitations are quickened. Heart sounds are often poorly defined due to distension of the lungs and the drowning volume of audible dry wheezing.
The attack can last from several minutes to 2-4 hours (depending on the treatment used). The resolution of the attack is usually preceded by a cough with a small amount of phlegm. The difficulty in breathing decreases and then disappears.
Asthmatic status is defined as a life-threatening increasing bronchial obstruction with progressive impairment of ventilation and gas exchange in the lungs, which is not relieved by bronchodilators that are usually effective in this patient.
There are three options for the onset of status asthmaticus: the rapid development of coma (sometimes observed in patients after the withdrawal of glucocorticoids), the transition to the asthmatic status of an asthma attack (often against the background of an overdose of adrenergic agonists) and the slow development of progressive suffocation, most often in patients with infectious B. a ... According to the severity of the patient's condition and the degree of gas exchange disturbances, there are three stages of status asthmaticus.
Stage I is characterized by the appearance of persistent expiratory dyspnea, against the background of which frequent attacks of suffocation occur, forcing patients to resort to repeated inhalations of adrenomimetics, but the latter only temporarily relieve suffocation (without completely eliminating expiratory dyspnea), and after a few hours this effect is also lost. The patients are somewhat agitated. Percussion and auscultation of the lungs reveal changes similar to those in B.'s attack and., But dry wheezing is usually less abundant and high-pitched wheezing prevails. As a rule, tachycardia is determined, especially pronounced with intoxication with adrenergic agonists, when tremors of the fingers of the hands, pallor, increased systolic blood pressure, sometimes extrasystole, and dilated pupils are also found. The tension of oxygen (pO 2) and carbon dioxide (pCO 2) in arterial blood is close to normal, there may be a tendency to hypocapnia.
Stage II of status asthmaticus is characterized by a severe degree of expiratory suffocation, fatigue of the respiratory muscles with a gradual decrease in the minute volume of respiration, and increasing hypoxemia. The patient either sits, leaning on the edge of the bed, or reclining. Excitement is replaced by more and more lengthening periods of apathy. The tongue, skin of the face and trunk are cyanotic. Breathing remains quickened, but it is less deep than in stage I. Percussion is determined by the picture of acute swelling of the lungs, auscultatory - weakened hard breathing, which over individual parts of the lungs may not be heard at all (zones of the "silent" lung). The amount of audible dry wheezing is significantly reduced (there are not abundant and quiet wheezing wheezes). Tachycardia is noted, sometimes extrasystole; on the ECG - signs of pulmonary hypertension (see. Hypertension of the pulmonary circulation), a decrease in the T wave in most leads. The pO 2 of arterial blood drops to 60-50 mm Hg. Art., moderate hypercapnia is possible.
Stage III of status asthmaticus is characterized by pronounced arterial hypoxemia (pO 2 within 40-50 mm Hg) and increasing hypercapnia (pCO 2 above 80 mm Hg) with the development of respiratory acidotic coma. There is a pronounced diffuse cyanosis. Dryness of the mucous membranes, a decrease in tissue turgor (signs of dehydration) are often determined. Breathing gradually decreases and becomes less and less deep, which during auscultation is reflected by the disappearance of wheezing and a significant weakening of respiratory sounds with the expansion of the zones of the "silent" lung. Tachycardia is often combined with various cardiac arrhythmias. Death can occur from respiratory arrest or acute cardiac arrhythmias due to myocardial hypoxia.
Separate forms of brochial asthma have features of anamnesis, clinical manifestations and course.
Atopic B. and. more often begins in childhood or adolescence. A family history of more than 50% of cases reveals asthma or other atonic diseases, in the patient's history - allergic rhinitis, atopic dermatitis. To attacks of suffocation at atopic B. and. often preceded by prodromal symptoms: itching in the nose and nasopharynx, nasal congestion, sometimes itching in the chin, neck, interscapular region. The attack often begins with a dry cough, then the typical pattern of expiratory suffocation with remote dry wheezing quickly develops. Usually, an attack can be quickly stopped by using? -Adrenomimetics or aminophylline; the attack ends with the release of a small amount of light viscous sputum. After an attack, auscultatory symptoms of asthma are completely eliminated or remain minimal.
For atopic B. and. characterized by a relatively mild course, late development of complications. Severe course, development of status asthmaticus are rare. In the early years of the disease, remissions are typical when contact with allergens is terminated. Spontaneous remissions are not uncommon. Complete recovery with atopic B. and. rarely in adults.
Infection-dependent B. and. observed in people of different ages, but adults are more likely to get sick. A family history of asthma is relatively common, and atopic diseases are rare. B.'s combination is characteristic and. with polypous rhinosinusitis. The onset of the disease is usually associated with acute, often viral infections or exacerbations of chronic diseases of the respiratory system (sinusitis, bronchitis, pneumonia). Asthma attacks differ less than with atopic B. and., The severity of development, longer duration, less clear and quick resolution in response to the use of adrenergic agonists. After the relief of the attack, during auscultation of the lungs, hard breathing with prolonged exhalation, dry buzzing rales persist, in the presence of inflammatory exudate in the bronchi - moist rales. With this form B. and. a severe course with repeated asthmatic status is more common, complications develop faster.
Aspirin asthma in typical cases is characterized by B.'s combination and. with recurrent polyposis of the nose and its paranasal sinuses and intolerance to acetylsalicylic acid (the so-called aspirin triad, sometimes referred to as the asthmatic triad). However, nasal polyposis is sometimes absent. More often adult women are ill, but the disease also occurs in children. It usually begins with polyposis rhinosinusitis; polyps after their removal quickly recur. At some stage of the disease, after the next polypectomy or taking aspirin, analgin is joined by B. and., The manifestations of which persist in the future and without taking non-steroidal anti-inflammatory drugs. Taking these drugs invariably causes exacerbations of the disease of varying severity - from manifestations of rhinitis to severe asthmatic status with a fatal outcome. Polypectomy is also often accompanied by severe exacerbations of B. and. The majority of clinicians believe that for aspirin B. and. a severe course is characteristic. Atopy is rare among these patients.
Asthma of physical effort, or post-exercise bronchospasm, is not, apparently, an independent form of B. a. It has been established that in 50-90% of patients with any form of B. and. physical effort can cause an attack of suffocation 2-10 minutes after the end of the load. Attacks are rarely severe, lasting 5-10 minutes, sometimes up to 1 hour; pass without the use of drugs or after inhalation of? -adrenomimetic. Exercise asthma is more common in children than in adults. It has been noticed that some types of physical efforts (running, playing football, basketball) especially often cause post-exercise bronchospasm. Lifting weights is less dangerous; swimming and rowing are relatively well tolerated. The duration of physical activity is also important. In a provocative test, loads are usually given for 6-8 minutes; with a longer load (12-16 minutes), the severity of post-exercise bronchospasm may be less - the patient seems to jump over bronchospasm.
Intermittent (episodic): asthma attacks less than 2 times a week, nocturnal attacks less than 2 times a month, FEV1> 80%, upon completion of an attack - normal, fluctuations in peak flowmetry indicators are less than 20%;
Persistent: attacks or other manifestations of transient bronchial obstruction occur no more than 2 times a week, night symptoms more often than 2 times a month, fluctuations in peak flowmetry and FEV1 are 20-30% of the due value.
Moderate degree (moderate persistent asthma).
It manifests itself daily with symptoms of respiratory discomfort, requiring daily use of bronchodilators. Nocturnal symptoms occur more frequently than once a week, peak flow fluctuations> 30%; FEV1 from 60 to 80% of the due value. Exacerbations significantly reduce the patient's quality of life.
3. Severe (severe persistent asthma).
Bronchial obstruction of varying severity persists almost constantly, sharply limiting the patient's activity. Frequent night attacks, the development of complications (status asthmaticus); FEV1<60%, колебания показателей пикфлоуметрии >30%.
A more detailed classification of bronchial asthma by severity (taking into account the requirements of Art. 52 of the Schedule of Diseases and TDT, approved by the RF Government Decree No. 390, 1995) is presented in Table No. 1.
The clinical picture of bronchial asthma
The most clearly outlined clinical manifestation of the disease is an attack of expiratory suffocation, the leading role in the formation of which belongs to widespread bronchospasm. The attack occurs suddenly, more often at night or in the early morning hours, often its appearance is preceded by a prodrome in the form of vasomotor disturbances of nasal breathing, a tickling sensation along the trachea, and coughing. At the time of the attack, the patient is agitated, feels a feeling of compression in the chest, lack of air. Inhale - fast, impulsive; exhalation is difficult, lengthened. The auxiliary muscles are involved in breathing, there are signs of acute emphysema of the lungs, physically, against the background of weakened respiratory noises, whistling dry rales of various timbre and sonority are heard. Characterized by the absence of sputum separation during an attack and profuse bronchorrhea, indicating its end.
Clinical manifestations of asthma are diverse and are not limited, as previously assumed, only by classical attacks of asthma and status asthmaticus. an unproductive cough with scanty mucous sputum is a symptom that resembles the clinical picture of chronic obstructive bronchitis in the exacerbation phase. The differential diagnostic criterion that allows to clarify the diagnosis in these patients is the rapid dynamics of bronchial patency indicators while taking short-acting bronchodilators.
Often the leading symptom of the disease can be a paroxysmal dry cough, which occurs more often at night and is a manifestation of impaired bronchial patency at the level of large bronchi. Physically, these patients show minimal changes - single wheezing rales that disappear after coughing up, exhalation is slightly lengthened.
The most severe complication of asthma, which is often the first clinical manifestation of the disease, is status asthmaticus - an "unusual" asthma attack that is resistant to the bronchodilator therapy usually effective for a given patient (A.G. Chuchalin; 1997). In the pathogenesis of this condition, the leading role belongs to the progressive functional blockade of beta-adrenergic receptors, pronounced disorders of mucociliary transport and edema of the bronchial mucosa.
DIAGNOSTICS OF BRONCHIAL ASTHMA
Diagnosis of asthma is based on the detection of spontaneously or under the influence of treatment of obstructive breathing disorders, clinically manifesting themselves in the form of episodic attacks of expiratory dyspnea (suffocation), paroxysmal cough, feeling of difficulty breathing, feeling of heaviness and chest, distant wheezing in the chest. Very often there is a clear relationship between the appearance (aggravation) of these symptoms and the inhalation of cold air, exercise, dust exposure, allergenic exposure, etc.
Objectification of existing obstructive respiratory dysfunctions and their reversibility while taking bronchodilators using instrumental diagnostics methods (spirography, pneumotachometry, peak flowmetry, recording of the flow-volume curve) is a prerequisite for verifying the diagnosis of asthma. The most frequently analyzed indicators characterizing bronchial patency are: FEV 1, Tiffno's index, PSV, MOS.
The characteristic signs of bronchial obstruction in BA patients include:
a) the presence of actual bronchial obstruction with a decrease in FEV 1 (in comparison with the proper values) by 840 ml or more in men and by 620 ml or more in women;
b) the reversible nature of bronchial obstruction - an increase in FEV 1 by 9% or more or PSV by 60 l / min or more after inhalation of 200 μg fenoterol (beroteka) or 100 μg salbutamol (ventolin);
c) variability of PSV values (15%) during daily monitoring (using individual peak flowmeters).
The presence in the patient of the corresponding signs of bronchial obstruction (decrease in FEV 1, Tiffno index, PSV), a positive reaction when tested with bronchodilators (beta 2 - short-acting agonists - berotek, ventolin, etc.) with restoration to normal (proper) values of FEV 1 and or PSV or their increase, respectively, by 9% or more and 60 l / min or more allows you to easily diagnose BA.
The lack of reversibility of bronchial obstruction during testing with beta 2 - agonists may require trial therapy with anti-inflammatory and bronchodilator drugs for 2-6 weeks with daily monitoring of PSV. Revealing in this case the reversibility of bronchial obstruction will also testify in favor of the diagnosis of asthma.
In cases of partially reversible bronchial obstruction or its absence, differential diagnosis of asthma with a number of syndromic diseases should be carried out - chronic obstructive bronchitis, cystic fibrosis, tracheal compression, foreign body in the tracheo-bronchial tree, etc.
The absence of signs of bronchial obstruction in a patient with complaints characteristic of BA dictates the need to monitor PSV for 2-4 weeks. As you know, in a healthy person, fluctuations in the morning and evening values of PSV do not exceed 8%; at the same time, the highest values of PSV are determined at 16-17 o'clock, and the lowest - at 4-5 o'clock in the morning. In the process of daily monitoring of PSV, the patient should be advised to conduct peak flowmetry at the same time, for example, at 7-8 am and at 19-20 hours with threefold determination of PSV (the best of the recorded values is selected). If the daily spread of PSV values is 15% or more, then this fact can be considered as a weighty argument in favor of the diagnosis of AD.
With prolonged remission of the disease (5 years), in order to verify the diagnosis, a number of authors (Alekseev V.G., 2000) recommend provocative bronchoconstrictor tests (with acetylcholine, histamine, obzidan, etc.) in order to identify bronchial hyperreactivity. These tests make it possible to establish the minimum threshold concentration of acetylcholine or another drug of a similar action, which, during inhalation, causes a deterioration in bronchial patency indicators by 10% or more from the initial level.
Negative results of bronchoprovocation tests, as well as the absence of additional research methods characteristic of BA (increased IgE levels, data from allergological tests, eosinophilia of peripheral blood and sputum) indicate the need for a diagnostic search in a number of known diseases / pathological conditions in the clinical picture of which broncho-obstructive syndrome.
The main symptom of bronchial asthma is an attack of suffocation, which is most often provoked by contact with an allergen, physical exertion, exacerbation of bronchopulmonary infection. The attack may be preceded by smoking, cooling, etc.
During the course of the disease, the following periods are distinguished: precursors; paroxysmal; post-attack; interictal.
The period of precursors occurs a few minutes or days before the attack and is characterized by anxiety, sneezing, itchy eyes, lacrimation, rhinorrhea, headache, sleep disturbance, dry cough.
An attack of suffocation is characterized by shortness of breath against the background of a sharp restriction of chest mobility, wheezing, scattered wheezing and buzzing wheezing. During an attack, a person takes a sitting position and rests his hands on the edge of a bed or chair.
The skin is pale, dry, the accessory muscles are tense, there may be a slight cyanosis, tachycardia, deaf heart sounds. Boxed sound is noted percussion.
The duration of an attack at the onset of the disease is 10-20 minutes, with a prolonged course - up to several hours. There are cases of the continuation of the attack for more than a day, which leads to a significant deterioration in the general condition of the person.
An attack of suffocation ends with the discharge of viscous mucous sputum (post-attack period). A prolonged attack of bronchial asthma is called an asthmatic condition.
The asthmatic condition, or status asthmaticus, is characterized by persistent and long-term bronchial obstruction, impaired drainage function of the bronchi and an increase in respiratory failure. This is explained by diffuse edema of the mucous membrane of the small bronchi and their blockage with thick mucus.
The development of the status is often facilitated by: overdose of sympathomimetics, abrupt withdrawal of glucocorticoids, or strong exposure to an allergen. With untimely assistance for status asthmaticus, death from asphyxia may occur.
In sputum with bronchial asthma, eosinophils are found, Kurshman's spirals are a kind of casts of small bronchi (elongated sputum clots) and Charcot-Leiden crystals, consisting of acidophilic granules of ocytes (eosinophils).
In the blood, leukopenia and eosinophilia are often noted, a tendency to increase the number of erythrocytes.
With fluoroscopy of the chest organs, an increased transparency of the pulmonary fields and a restriction of the mobility of the diaphragm are determined.
The study of the function of external respiration is of great diagnostic value.
Peak flowmetry is a measurement of peak expiratory flow rate (PSV) using a portable device - peak flow meter. Measurements are carried out 2 times a day. The results are recorded in a special schedule. The daily spread of the peak speed is determined. The spread of PSV indices by more than 20% is a diagnostic sign of an asthma attack.
Allergen skin tests are performed to diagnose allergies in patients. Specific immunoglobulins E. are also determined in blood serum.
It is difficult to diagnose asthma in the elderly, with cough and exercise asthma.
BA in the elderly, especially in the climacteric period, acquires an aggressive course. High eosinophilia and poor tolerance to antihistamines are characteristic. It must be distinguished from coronary artery disease with left ventricular failure.
Cough option. Coughing may be the only symptom of AD. The cough often occurs at night and is not accompanied by wheezing. Allergological examination and daily monitoring of PSV confirm the diagnosis of BA.
Physical exertion asthma. Asthma attacks occur under the influence of submaximal physical activity within 10 minutes after the end of the load. Attacks often occur after running, playing football, basketball, or lifting weights. Diagnosed with a provocative exercise test.
"Aspirin" asthma. BA inducers are aspirin, analgin, ibuprofen and other non-steroidal anti-inflammatory drugs. The first symptoms of the disease appear at the age of 20-30. First, rhinitis occurs, then - polypous growths of the nasal mucosa, and subsequently - intolerance to aspirin (an attack of suffocation).
Patients with "aspirin asthma" can also react to salicylates contained in food (cucumbers, tomatoes, strawberries, raspberries), a number of vitamins, β-blockers, yellow foods (soda water, ice cream, sweets, etc.).
The diagnosis of aspirin asthma is based on a triad of symptoms: the presence of asthma, polypous rhinosinusopathy, and a history of aspirin intolerance.
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