Clinical guidelines for the treatment of bronchitis. Measurements are carried out with a special device

C In order to select the optimal tactics for managing patients with exacerbation of chronic bronchitis (CB), it is advisable to distinguish the so-called "infectious" And "non-infectious" exacerbations of chronic disease requiring an appropriate therapeutic approach. An infectious exacerbation of chronic disease can be defined as an episode of respiratory decompensation not associated with objectively documented other causes, and primarily with pneumonia.

Diagnosis of infectious exacerbation of chronic disease includes use of the following clinical, radiological, laboratory, instrumental and other methods of examining the patient:

Clinical study of the patient;

Study of bronchial patency (according to FEV 1);

X-ray examination of the chest (to rule out pneumonia);

Cytological examination of sputum (counting the number of neurophils, epithelial cells, macrophages);

Sputum Gram stain;

Laboratory tests (leukocytosis, neutrophil shift, increased ESR);

Bacteriological examination of sputum.

These methods make it possible, on the one hand, to exclude syndrome-like diseases (pneumonia, tumors, etc.), and, on the other hand, to determine the severity and type of exacerbation of chronic disease.

Clinical symptoms of exacerbations of chronic disease

Increased cough;

Increased amount of sputum discharge;

Change in the nature of sputum (increased purulence of sputum);

Increased shortness of breath;

Gain clinical signs bronchial obstruction;

Decompensation of concomitant pathologies (heart failure, arterial hypertension, diabetes and etc.);

Fever.

Each of these symptoms can be isolated or combined with each other, and also have varying degrees of severity, which characterizes the severity of the exacerbation and allows us to tentatively suggest the etiological spectrum of pathogens. According to some data, there is a connection between isolated microorganisms and indicators of bronchial obstruction in patients with exacerbation of chronic bronchitis. As the degree of bronchial obstruction increases, the proportion of gram-negative microorganisms increases with a decrease in gram-positive microorganisms in the sputum of patients with exacerbation of CB.

Depending on the number of symptoms present, different types of exacerbation of chronic bronchitis are distinguished, which acquires important prognostic significance and can determine the treatment tactics for patients with exacerbation of chronic bronchitis (Table 1).

For infectious exacerbation of CB, the main treatment method is empirical antibacterial therapy (AT). It has been proven that AT promotes faster relief of symptoms of exacerbation of CB, eradication of etiologically significant microorganisms, increasing the duration of remission, and reducing costs associated with subsequent exacerbations of CB.

Choice of antibacterial drug for exacerbation of chronic disease

When choosing an antibacterial drug, you must consider:

Clinical situation;

The activity of the drug against the main (most likely in this situation) pathogens of infectious exacerbation of the disease;

Taking into account the likelihood of antibiotic resistance in a given situation;

Pharmacokinetics of the drug (penetration into sputum and bronchial secretions, half-life, etc.);

No interaction with other medications;

Optimal dosing regimen;

Minimal side effects;

Cost indicators.

One of the guidelines for empirical antibiotic therapy (AT) for CB is the clinical situation, i.e. variant of exacerbation of CB, severity of exacerbation, presence and severity of bronchial obstruction, various factors poor response to AT, etc. Taking into account the above factors allows us to tentatively assume the etiological significance of a particular microorganism in the development of exacerbation of CB.

The clinical situation also allows us to assess the likelihood of antibiotic resistance of microorganisms in a particular patient (penicillin resistance of pneumococci, products H. influenzae(lactamases), which may be one of the guidelines when choosing the initial antibiotic.

Risk factors for penicillin resistance in pneumococci

Age up to 7 years and over 60 years;

Clinically significant concomitant pathology (heart failure, diabetes mellitus, chronic alcoholism, liver and kidney diseases);

Frequent and long-term previous antibiotic therapy;

Frequent hospitalizations and stays in places of charity (boarding schools).

Optimal pharmacokinetic properties of an antibiotic

Good penetration into sputum and bronchial secretions;

Good bioavailability of the drug;

Long half-life of the drug;

No interaction with other medications.

Among the aminopenicillins most frequently prescribed for exacerbations of chronic disease, amoxicillin, produced by Sintez OJSC under the brand name, has optimal bioavailability Amosin® , JSC "Sintez", Kurgan, which in this regard has advantages over ampicillin, which has rather low bioavailability. When taken orally, amoxicillin ( Amosin® ) has high activity against the main microorganisms etiologically associated with exacerbation of CB ( Str. Pneumoniae, H. influenzae, M. cattharalis). The drug is available in 0.25, 0.5 g No. 10 and in capsules 0.25 No. 20.

A randomized, double-blind, double-placebo-controlled study compared the effectiveness and safety of amoxicillin at a dose of 1 g 2 times a day (group 1) and 0.5 g 3 times a day (group 2) in 395 patients with exacerbation of CB. The duration of treatment was 10 days. Clinical effectiveness was assessed on days 3-5, days 12-15 and days 28-35 after the end of treatment. Among the ITT population (those who did not complete the study) clinical effectiveness in patients 1 and 2 groups were 86.6% and 85.6%, respectively. At the same time, in the RR population (completion of the study according to the protocol) - 89.1% and 92.6%, respectively. Clinical relapse in the ITT and RR populations was observed in 14.2% and 13.4% in group 1 and 12.6% and 13.7% in group 2. Statistical data processing confirmed the comparable effectiveness of both treatment regimens. Bacteriological effectiveness in groups 1 and 2 among the ITT population was noted in 76.2% and 73.7%.

Amoxicillin ( Amosin® ) is well tolerated, except in cases of hypersensitivity to beta-lactam antibiotics. In addition, it has virtually no clinically significant interaction with other medications prescribed to patients with chronic disease, both in connection with exacerbation and concomitant pathology.

Risk factors for poor response to AT during exacerbation of CB

Elderly and senile age;

Severe bronchial obstruction;

Development of acute respiratory failure;

Concomitant pathology;

Frequent previous exacerbations of chronic disease (more than 4 times a year);

The nature of the pathogen (antibiotic-resistant strains, Ps. aeruginosa).

The main options for exacerbation of chronic disease and AT tactics

Simple chronic bronchitis:

Patients' age is less than 65 years;

The frequency of exacerbations is less than 4 per year;

FEV 1 more than 50% of predicted;

Main etiologically significant microorganisms: St. pneumoniae H. influenzae M. cattarhalis(resistance to b-lactams is possible).

First line antibiotics:

Aminopenicillins (amoxicillin ( Amosin® )) 0.5 g x 3 times orally, ampicillin 1.0 g x 4 times a day orally). Comparative characteristics of ampicillin and amoxicillin ( Amosin® ) is presented in Table 2.

Macrolides (azithromycin (Azithromycin - AKOS, JSC Sintez, Kurgan) 0.5 g per day on the first day, then 0.25 g per day for 5 days, clarithromycin 0.5 g x 2 times a day orally .

Tetracyclines (doxycycline 0.1 g 2 times a day) can be used in regions with low pneumococcal resistance.

Alternative antibiotics:

Protected penicillins (amoxicillin/clavulanic acid 0.625 g every 8 hours orally, ampicillin/sulbactam (Sultasin®, Sintez OJSC, Kurgan) 3 g x 4 times a day),

Respiratory fluoroquinolones (sparfloxacin 0.4 g once daily, levofloxacin 0.5 g once daily, moxifloxacin 0.4 g once daily).

Complicated chronic bronchitis:

Age over 65 years;

Frequency of exacerbations more than 4 times a year;

Increased volume and purulence of sputum during exacerbations;

FEV 1 is less than 50% of predicted;

More severe symptoms exacerbations;

Main etiologically significant microorganisms: the same as in group 1 + St. aureus+ gram-negative flora ( K. pneumoniae), frequent resistance to b-lactams.

First line antibiotics:

Protected penicillins (amoxicillin/clavulanic acid 0.625 g every 8 hours orally, ampicillin/sulbactam 3 g x 4 times a day intravenously);
1-2 generation cephalosporins (cefazolin 2 g x 3 times a day IV, cefuroxime 0.75 g x 3 times a day IV;
“Respiratory” fluoroquinolones with antipneumococcal activity (sparfloxacin 0.4 g once a day, moxifloxacin 0.4 g per day orally, levofloxacin 0.5 g per day orally).

Alternative antibiotics:

3rd generation cephalosporins (cefotaxime 2 g x 3 times a day IV, ceftriaxone 2 g once a day IV).

Chronic purulent bronchitis:

Any age;

Constant release of purulent sputum;

Frequent concomitant pathology;

Frequent presence of bronchiectasis;

FEV 1 less than 50%;

Severe symptoms of exacerbation, often with the development of acute respiratory failure;

Main etiologically significant microorganisms: the same as in group 2 + Enterobactericae, P. aeruginosa.

First line antibiotics:

3rd generation cephalosporins (cefotaxime 2 g x 3 times a day IV, ceftazidime 2 g x 2-3 times a day IV, ceftriaxone 2 g once a day IV);
Respiratory fluoroquinolones (levofloxacin 0.5 g once daily, moxifloxacin 0.4 g once daily).

Alternative antibiotics:

“Gram-negative” fluoroquinolones (ciprofloxacin 0.5 g x 2 times orally or 400 mg IV x 2 times a day);

4th generation cephalosporins (cefepime 2 g x 2 times a day IV);

Antipseudomonas penicillins (piperacillin 2.5 g x 3 times a day IV, ticarcillin/clavulanic acid 3.2 g x 3 times a day IV);

Meropenem 0.5 g x 3 times a day i.v.

In most cases of exacerbations of chronic disease, antibiotics should be prescribed orally. Indications for parenteral use of antibiotics are :

Gastrointestinal disorders;

Severe exacerbation of chronic disease;

The need for mechanical ventilation;

Low bioavailability of oral antibiotic;

Non-compliance of patients.

The duration of AT for exacerbations of chronic disease is 5-7 days. It has been proven that 5-day courses of treatment are no less effective than longer use of antibiotics.

In cases where there is no effect from the use of first-line antibiotics, a bacteriological examination of sputum or BALF is performed and prescribed alternative drugs taking into account the sensitivity of the identified pathogen.

When assessing the effectiveness of AT for exacerbations of CB, the main criteria are :

Direct clinical effect (rate of regression of clinical symptoms of exacerbation, dynamics of bronchial patency indicators;

Bacteriological effectiveness (achievement and timing of eradication of an etiologically significant microorganism);

Long-term effect (duration of remission, frequency and severity of subsequent exacerbations, hospitalization, need for antibiotics);

Pharmacoeconomic effect taking into account the drug cost/treatment effectiveness indicator.

Table 3 shows the main characteristics of oral antibiotics used to treat exacerbations of CB.

Literature:

1 Anthonisen NR, Manfreda J, Warren CP, Hershfield ES, Harding GK, Nelson NA. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann. Intern. Med. 1987; 106; 196-204

2 Allegra L, Grassi C, Grossi E, Pozzi E. Ruolo degli antidiotici nel trattamento delle riacutizza della bronchite cronica. Ital.J.Chest Dis. 1991; 45; 138-48

3 Saint S, Bent S, Vittinghof E, Grady D. Antibiotics in chronic obstructive pulmonary disease exacerbations. A meta-analysis. JAMA. 1995; 273; 957-960

4. R Adams S.G., Melo J., Luther M., Anzueto A. - Antibiotics are associated with lower relapse rates in outpatients with acute exacerbations of COPD. Chest, 2000, 117, 1345-1352

5. Georgopoulos A., Borek M., Ridi W. - Randomised, double-blind, double-dummy study comparing the efficacy and safety of amoxycillin 1g bd with amoxycillin 500 mg tds in the treatment of acute exacerbations of chronic bronchitis JAC 2001, 47, 67-76

6. Langan S., Clecner V., Cazzola C.M., et al. Short-course cefuroxime axetil therapy in the treatment of acute exacerbations of chronic bronchitis. Int J Clin Pract 1998; 52:289-97.),

7. Wasilewski M.M., Johns D., Sides G.D. Five-day dirithromycin therapy is as effective as 7-day erythromycin therapy for acute exacerbations of chronic bronchitis. J Antimicrob Chemother 1999; 43:541-8.

8. Hoepelman I.M., Mollers M.J., van Schie M.H., et al. A short (3-day) coarse of azithromycin tablets versus a 10-day course of amoxycillin-clavulanic acid (co-amoxiclav) in the treatment of adults with lower respiratory tract infections and the effect on long-term outcome. Int J Antimicrob Agents 1997; 9:141-6.)

9. R.G. Masterton, C.J. Burley, . Randomized, Double-Blind Study Comparing 5- and 7-Day Regimens of Oral Levofloxacin in Patients with Acute Exacerbation of Chronic Bronchitis International Journal of Antimicrobial Agents 2001;18:503-13.)

10. Wilson R., Kubin R., Ballin I., et al. Five day moxifloxacin therapy compared with 7 day clarithromycin therapy for the treatment of acute exacerbations of chronic bronchitis. J Antimicrob Chemother 1999; 44:501-13)

		Rowe B.H., Spooner C.H., Duchrame F.M. et al. Corticosteroids for
	preventing relapse following acute exacerbations of asthma // The Cochrane
	Library. – Oxford: Update Software, 2000. – Issue 3. Search date 1997;
	primary sources Cochrane Airways Review Group Register of Trials, Asth-
	ma, and Wheeze RCT Register.
		Higgenbottam T.W., Britton J., Lawrence D. On behalf of the Pulmi-
	cort Respules versus Oral Steroids: A prospective clinical trial in acute asthma-
	ma (prospects). Adult study team. Comparison of nebulised budesonide and
	prednisolone in severe asthma exacerbation in adults // Biodrugs. – 2000. –
	Vol. 14. – P. 247–254.
		Nahum A., Tuxen D.T. Management of asthma in the intensive care
	unit // Evidence Based Asthma Management / Eds J.M. FitzGerald et al. –
	Hamilton: Decker, 2000. – P. 245–261.
		Behbehani N.A., Al-Mane F.D., Yachkova Y. et al. Myopathy follow-
	ing mechanical ventilation for acute severe asthma: the role of muscle relax-
	ants and corticosteroids // Chest. – 1999. – Vol. 115. – P. 1627–1631.
		Georgopoulos D., Burchardi H. Ventilatory strategies in adult patients
	with status asthmaticus // Eur. Respira. Mon. – 1998. – Vol. 3, N 8. –

		Keenan S.P., Brake D. An evidence based approach to non-invasive
	ventilation in acute respiratory failure // Crit. Care Clin. – 1998. – Vol. 14. -

		Rowe B.H., Bretzlaff J.A., Bourdon C. et al. Magnesium sulfate for
	treating acute asthmatic exacerbations of acute asthma in the emergency
	department // The Cochrane Library. – Oxford: Update Software, 2000. –

	Register of Trials, review articles, textbooks, experts, primary authors of
	included studies, and hand searched references.
		Nannini L.J., Pendino J.C., Corna R.A. et al. Magnesium sulfate as a
	vehicle for nebulized salbutamol in acute asthma // Am. J. Med. – 2000. –
	Vol. 108. – P. 193–197.
	Vol. 108. – P. 193–197.
		Boonyavoroakui C., Thakkinstian A., Charoenpan P. Intravenous mag-
bronchial	nesium sulfate in acute severe asthma // Respirology. – 2000. – Vol. 5. -
bronchial	36. USP Therapy Asthma. The United States Pharmacopoeia Conven-

		Picado C. Classification of severe asthma exacerbation; a proposal //
	Eur. Respira. J. – 1996. – Vol. 9. – P. 1775–1778.
		Grant I. Severe acute or acute severe asthma // BMJ. – 1983. –
	Vol. 287. – P. 87.
Exacerbation	tion, Inc., 1997.
Exacerbation		Neville E., Gribbin H., Harisson B.D.W. Acute severe asthma // Respir.

	Med. – 1991. – Vol. 85. – P. 163–474.

	Atopic dermatitis / Ed. A.G. Chuchalina. – M.: Atmosphere, 2002.

ACUTE BRONCHITIS

Acute bronchitis (AB) is a predominantly infectious inflammatory disease of the bronchi, manifested by a cough (dry or with sputum) and lasting no more than 3 weeks.

ICD-10: J20 Acute bronchitis. Abbreviation: OB - acute bronchitis.

Epidemiology

The epidemiology of acute bronchitis (AB) is directly related to the epidemiology of influenza and other respiratory viral diseases. Typically, the typical peaks in the incidence of diseases are the end of December and the beginning of March. Special Research on the epidemiology of OB in Russia has not been carried out.

Prevention

1 . You should pay attention to maintaining personal hygiene rules A: frequent hand washing, minimizing eye-hand and nose-hand contact. Rationale: Most viruses are transmitted through this contact route. Evidence: specific studies of these preventive measures in day care for children

And adults showed their high effectiveness.

2. Annual influenza prophylaxis reduces the incidence

occurrence of OBA.

Indications for annual influenza vaccination: all persons over 50 years of age, persons with chronic diseases regardless of age in closed groups children and adolescents receiving long-term aspirin therapy women in the second and third

trimesters of pregnancy during the flu epidemic period.
trimesters of pregnancy during the flu epidemic period.
Evidence of effectiveness
Many multicenter randomized studies
research has shown the effectiveness of vaccination campaigns. Even
ity by 50%, and hospitalization by 40%.
in elderly weakened patients, when immunogenicity and effectiveness
vaccine effectiveness decreases, vaccination reduces mortality

Vaccination of middle-aged people reduces the number of episodes of influenza and the resulting loss of ability to work.

Vaccination medical personnel leads to a reduction in mortality among elderly patients.

3 . Drug prophylaxis antiviral drugs during the epidemic period reduce the frequency and severity of influenza C.

Indications for drug prophylaxis

During a proven epidemic period, non-immunized individuals with high risk occurrence of influenza - taking rimantadine (100 mg 2 times a day per os) or amantadine (100 mg 2 times a day per os).

In elderly people and patients with renal failure the dose of amantadine is reduced to 100 mg per day due to possible neurotoxicity.

Efficiency . Prevention is effective in 80% of individuals. Screening: no data available.

Classification

There is no generally accepted classification. By analogy with others acute diseases respiratory organs, etiological and functional classification characteristics can be distinguished.

Etiology (Table 1). Usually there are 2 main types of OB: viral and bacterial, but other (rare) etiological options are also possible (toxic, burn); they are rarely observed in isolation, are usually a component of systemic damage and are considered within the boundaries of their respective diseases.

	Table 1 . Etiology of acute bronchitis

	Pathogens	Character traits



	Influenza A virus	Major epidemics once every 3 years, exciting
		entire countries; most common cause clinically
		severe flu; severe course of the disease and
		high mortality during epidemics
		high mortality during epidemics

	Influenza B virus	Epidemics once every 5 years, pandemics less often or less
		more severe than influenza A virus infection

	Parainfluenza (types 1–3)
		interconnected
		interconnected
	Adenoviruses	Isolated cases, not epidemiologically

	End of table. 1



Pneumococci	In middle-aged or elderly people
	An unexpected start
	Signs of damage to the upper respiratory tract

Mycoplasmas	In people over 30 years of age
	Signs of upper respiratory tract damage
	early stages
	Dry cough
Bordetella pertussis	Prolonged cough
	Smokers and patients with chronic bronchitis

Moraxella catarrhalis	Chronic bronchitis and immunocompromised persons

Functional classification OB that takes into account the severity of the disease has not been developed, since uncomplicated OB usually proceeds stereotypically and does not require differentiation in the form of classification by severity.

Diagnostics

The diagnosis of “acute bronchitis” is made in the presence of an acute cough that lasts no more than 3 weeks (regardless of the presence of sputum), in the absence of signs of pneumonia and chronic lung diseases, which may be the cause of the cough.

The diagnosis is based on the clinical picture, the diagnosis is made by exclusion.

The cause of the clinical syndrome of OB is various infectious agents (primarily viruses). These same agents can cause other clinical syndromes that occur simultaneously with OB. Below are summary data (Table 2) characterizing the main symptoms in patients with OB.

Given in table. 2 The diverse clinical symptoms of OB suggest the need for a careful differential diagnosis of coughing patients.

Possible causes of prolonged cough associated with disease -

respiratory organs: bronchial asthma chronic bronchitis

chronic infectious diseases lungs, especially tuberculosis sinusitis postnasal drip syndrome gastroesophageal reflux sarcoidosis cough caused by connective tissue diseases and their treatment asbestosis, silicosis

"farmer's lung" by-effect Drugs (ACE inhibitors,

Acute bronchitis

Table 2 . Frequency of clinical signs of acute bronchitis in adult patients

		Frequency (%)

	Complaints and anamnesis



Sputum production


A sore throat
Weakness

Headache

Flow of mucus from the nose into the upper respiratory tract





	Wheezing

	Purulent nasal discharge
	Muscle pain
	Fever

	Sweating

	Pain in the paranasal sinuses

	Painful breathing

	Chest pain

	Difficulty swallowing
	Swelling of the pharynx

	Physical examination

	Redness of the throat

	Cervical lymphadenopathy

	Remote wheezing


	Sensitivity of the sinuses upon palpation
	Purulent discharge from the nose

	Ear congestion

	Swelling of the tonsils

	Body temperature >37.8 ° C
	Body temperature >37.8 ° C

	Extended exhalation

	Reduced breathing sounds

	Wet wheezing
	Wet wheezing
	Swelling of the tonsils

β-blockers, nitrofurans) lung cancer pleurisy

heart failure.

Modern standard methods (clinical, radiological)

logical, functional, laboratory) make it quite easy to carry out differential diagnosis.

Prolonged cough in patients with arterial hypertension and heart diseases

■ ACE inhibitors. If a patient is taking an ACE inhibitor, it is very likely that this drug is causing the cough. An alternative is to select another ACE inhibitor or switching to angiotensin II receptor antagonists, which usually do not cause cough.

■ β-blockers(including selective) can also cause cough, especially in patients predisposed to atopic reactions or with hyperreactivity of the bronchial tree.

■ Heart failure. It is necessary to examine the patient for the presence of heart failure. The first sign of mild heart failure is a cough at night. In this case, it is first necessary to perform a chest x-ray.

Prolonged cough in patients with connective tissue diseases

■ Fibrosing alveolitis- one of the possible causes of cough (sometimes in combination with rheumatoid arthritis or scleroderma). First of all, it is necessary to conduct a chest x-ray. A typical find is pulmonary fibrosis, but in the early stages it may be radiologically invisible, although the diffusion capacity of the lungs, reflecting the exchange of oxygen in the alveoli, may already be reduced, and when performing dynamic spirometry, restrictive changes may be detected.

■ Influence of drugs. Cough may be caused by exposure to drugs (a side effect of gold, sulfasalazine, penicillamine, methotrexate).

Prolonged cough in smokers. The most likely causes are prolonged acute bronchitis or chronic bronchitis. It is necessary to remember the possibility of cancer in middle-aged patients, especially in people over 50 years of age. It is necessary to find out whether the patient has hemoptysis.

Acute bronchitis

Prolonged cough in people of certain professions

Asbestosis. It is always necessary to remember about the possibility of asbestosis if the patient worked with asbestos. First, a chest x-ray and spirometry are performed (restrictive changes are detected). If asbestosis is suspected, it is necessary to consult with specialists.

"Farmer's Lung". Farmer's lung (hypersensitivity pneumonitis caused by exposure to moldy hay) or bronchial asthma may be suspected in agricultural workers. First, a chest x-ray, measurement of PEF at home, spirometry (including a test with bronchodilators) are performed. If "farmer's lung" is suspected, it is necessary consult with specialists.

Occupational bronchial asthma , which begins with a cough, can develop in people of various professions associated with exposure to chemical agents, solvents (isocyanates, formaldehyde, acrylic compounds, etc.) in car repair shops, dry cleaners, plastic production, dental laboratories, dental offices etc.

Prolonged cough in patients with atopy, allergies or hypersensitivity to acetylsalicylic acid

The most likely diagnosis is bronchial asthma.

Most frequent symptoms- transient shortness of breath and separation of mucous sputum.

Primary studies: measurement of PEF at home, spirometry and a test with bronchodilators, if possible - determination of hyperreactivity of the bronchial tree (provocation with inhaled histamine or methacholine hydrochloride) assessment of the effect of inhaled corticosteroids.

Prolonged cough and fever accompanied by purulent sputum

It is necessary to suspect tuberculosis, and in patients with lung diseases, the possibility of developing an atypical pulmonary infection caused by atypical mycobacteria. Vasculitis may begin with such manifestations (for example, periarteritis nodosa, Wegener's granulomatosis). It is also necessary to remember about eosinophilic pneumonia.

Primary studies: chest x-ray, smear and sputum culture, general blood test, determination of C-reactive protein in the blood serum (may increase with vasculitis).

Other causes of prolonged cough

■ Sarcoidosis. Chronic cough may be the only manifestation of pulmonary sarcoidosis. Primary investigations include: chest x-ray (portal hyperplasia lymph nodes, infiltrates in the parenchyma) level of ACE in the blood serum.

■ Nitrofurans (subacute reaction of the lungs to nitrofurans): it is necessary to ask the patient if he has taken nitrofurans to prevent infections urinary tract in subacute cases, eosinophilia may not be present.

■ Pleurisy. Cough may be the only manifestation of pleurisy. To identify the etiology, the following should be performed: a thorough objective examination, puncture and biopsy of the pleura.

■ Gastroesophageal reflux- a common cause of chronic cough, occurring in 40% of coughing individuals. Many of these patients complain of reflux symptoms (heartburn or sour taste in the mouth). However, in 40% of people whose cough is caused by gastroesophageal reflux, no symptoms of reflux are indicated.

■ Postnasal drip syndrome(postnasal drip syndrome - flow of nasal mucus into the respiratory tract). A diagnosis of postnasal drip may be suspected in patients who describe a sensation of mucus flowing into the throat from the nasal passages or a frequent need to “clear” the throat by coughing. Most patients have mucous or mucopurulent nasal discharge. With the allergic nature of postnasal drip, eosinophils are usually found in nasal secretions. Postnasal drip can be caused by general cooling, allergic and vasomotor rhinitis, sinusitis, irritating environmental factors and drugs (for example, ACE inhibitors).

Differential diagnosis

The most important in the differential diagnosis of OB are pneumonia, bronchial asthma, acute and chronic sinusitis.

■ Pneumonia. It is fundamentally important to differentiate OB from pneumatic

	mony, since it is this step that determines the purpose of the information

	intensive antibacterial therapy. Below (Table 3)
	symptoms observed in coughing patients are indicated, indicating
	their diagnostic value for pneumonia.
	■ Bronchial asthma. In cases where bronchial asthma is
	■ Bronchial asthma. In cases where bronchial asthma is
	cause of cough, patients usually experience episodes of wheezing
	shortness of breath. Regardless of the presence or absence of whistling
Body temperature more than 37.8 ° C
Heart rate > 100 per minute

Respiratory rate > 25 per minute

Dry wheezing

Wet wheezing



Egophony

Pleural friction rub

Dullness to percussion

general breathing, in patients with bronchial asthma, when studying the function of external respiration, reversible bronchial obstruction is detected in tests with β2-agonists or in a test with methacholine. However, 33% of tests with β2-agonists and 22% of tests with methacholine may be false positive. If you suspect false positives functional testing is the best way to make a diagnosis bronchial asthma- conducting trial therapy for a week with β2-agonists, which, in the presence of bronchial asthma, should stop or significantly reduce the severity of cough.

Whooping cough is not a very common cause of acute cough, but very important for epidemiological reasons. Whooping cough is characterized by: cough lasting at least 2 weeks, cough paroxysms with a characteristic inspiratory “cry” and subsequent vomiting without other visible causes. In the diagnosis of whooping cough

laboratory proven whooping cough.

Adults immunized against pertussis as children often do not exhibit classic pertussis infection.

Availability of anamnestic and clinical data on contacts with children who were not immunized (for organizational or religious reasons) against whooping cough.

Identify risk groups among those in contact with infectious agents to conduct adequate diagnostics.

Despite immunization during adolescence and childhood, whooping cough remains an epidemic threat due to suboptimal immunization in some children and

adolescents and due to a gradual (over 8–10 years after immunization) decrease in pertussis immunity.

Below (Table 4) are the main differential diagnostic signs of acute bronchitis.

Table 4. Differential diagnosis of acute bronchitis

Disease	Main features

Severe form of inflammation of the respiratory system, chronic obstructive bronchitis develops as a result of untimely or improper treatment acute stage of the disease.

The disease is accompanied by structural changes and disruption of the respiratory function of the bronchi.

At an early stage of the chronic process, changes can be completely cured.

In advanced cases, the pathological process becomes irreversible.

– diffuse inflammation of the bronchial tree, characterized by persistent swelling of the mucous membrane and increased sputum production.

Accumulating inside the bronchial tract, phlegm blocks the path to air.

The acute form of the disease develops as a result of inadequate treatment of ARVI or with prolonged exposure to polluted air on the bronchi.

Ineffective treatment of acute obstructive bronchitis provokes its transition to a chronic form.

According to ICD 10, chronic bronchitis is classified as obstructive pulmonary disease, and therefore has the same code as COPD J44.

WHO experts consider a form of bronchitis to be chronic if the disease lasts more than 2 months with exacerbation more than 2 times a year.

Stages of development of the chronic form

The disease goes through several stages in its development:

The result of constant filling of the airways with mucus is structural changes in the walls of the airways.

The serous glands that produce bronchial secretions hypertrophy. At the last stage, “bald bronchus” syndrome develops, caused by the complete death of bronchial cilia.

Impaired gas exchange in the lungs due to blockage of the bronchial channels gradually leads to the development of pneumosclerosis.

Classification

The development of the disease is classified according to severity. The classification is based on the volume of formed inspiration - FEV:

light: FEV 70% of the norm for a healthy respiratory system;
average: from 50 to 69%;
heavy: 50% or less.

Based on the nature of the sputum formed in the bronchi, the disease is divided into the following types:

Catarrhal– most light form with diffuse inflammation.
Catarrhal-purulent– inflammation is accompanied by the formation of pus.
Purulent obstructive– the patient produces purulent sputum.

On late stages the inflammatory process affects the deep tissues of the bronchi and lungs, structural changes in the tissues become irreversible, and the disease develops into COPD.

Causes of inflammation

Medical history includes primary and secondary causes. Primary ones serve as an impetus for inflammation, secondary ones contribute to the progression of the disease:

Primary reasons:

Secondary causes contributing to the development of inflammation under the influence of irritants, are associated with the state of human health and living conditions.

Predisposing factors that accelerate the development of the disease are:

penchant for allergic reactions;
weakened immune system;
genetic predisposition;
frequent colds;
living in unfavorable climatic conditions.

Video consultation: Causes of obstructive bronchitis.

Dr. Komarovsky will list the causes of obstructive bronchitis. Recommendations, conclusions, advice.

Symptoms

The main sign of the development of the disease is slowly progressive obstruction with gradually increasing respiratory failure.

The pathological process reaches its peak at approximately 40-50 years of age.

At this time, the narrowing of the bronchi is no longer amenable to the usual effects of bronchodilators.

COB occurs with periodic exacerbations and remissions. Symptoms during exacerbation:

headache;
cough with purulent mucous sputum;
chills, fever;
nausea, dizziness.

During remission, the following clinical manifestations are observed:

In the later stages of COB, visual signs appear that are noticeable even to a non-specialist:

movements of the respiratory muscles;
swelling of the veins in the neck;
bloated chest;
blue skin;
horizontal arrangement of ribs.

Oxygen starvation causes damage to other organs and the development of associated symptoms:

Pressure surges, heart rhythm disturbances, bluish lips with damage to the cardiovascular system;
Lower back pain, swelling of the legs due to damage to the urinary system;
Impaired consciousness, absent-mindedness, memory loss, hallucinations, blurred vision are evidence of central nervous system damage;
Loss of appetite, pain in the epigastric region due to disruption of the gastrointestinal tract.

IMPORTANT! Chronic hypoxia leads to further deterioration of the body's condition, gradually developing chronic diseases liver, kidneys, circulatory system.

Diagnostics

Diagnosis and treatment of COB is carried out by local therapists or pulmonologists.

The diagnosis is based on examination of the patient and analysis of complaints about the condition of the body.

The main method of making an initial diagnosis is listening to the lungs with special instruments.

Signs confirming the diagnosis:

the sound when tapping the lungs is boxy;
hard breathing at the beginning of the disease, whistling in the lungs as inflammation develops;
symmetrical voice tremors in the initial stages, weakening of the voice in the later stages.

To confirm the diagnosis, the doctor prescribes the following tests:

inhalation tests - inhalation of a bronchodilator to determine the reversibility of obstruction;
blood test for acid-base balance and gas composition;
chest x-ray;
spirometry - measuring lung volume by charting inhalation and exhalation;
bronchography;

To assess the degree, a study of external respiration function - FVD - is performed.

Before the examination, smoking patients are asked to give up their bad habit for a day; the patient is also prohibited from drinking coffee, strong tea and alcohol and avoiding physical activity.

30 minutes before the procedure, the patient should be in a state of complete physical and psychological rest.

Measurements are carried out with a special device - a spirometer.

The patient is seated in a chair with armrests and asked to exhale into the device after a deep breath.

A decrease in indicators with each exhalation means the presence of chronic obstructive bronchitis.

Treatment

Treatment of COB is complex and consists of taking medications, physiotherapeutic procedures and breathing exercises.

Lung disease and medium degree treated on an outpatient basis.

The patient is issued sick leave for a period of 15 to 30 days. A severe stage of exacerbation requires hospitalization of the patient.

Medication

The main group of medications for the treatment of COB are bronchodilators:

Ipratropium bromide, Salmeterol, Formoterol - drugs for inhalation that restore the mucous membrane;
Fenoterol (Salbutamol, Terbutaline) is used during periods of exacerbation to relieve inflammation.

An important part of therapy is the use of expectorants. The components of the drugs thin the mucus and promote the regeneration of mucosal cells.

The most popular drugs in this group are:

"Carbocysteine";
"Fluimucil";
"Lazolvan";
"Bromhexine";
"Herbion".

In the acute stage, inflammation is relieved with antibiotics from the macrolide group, cephalosporins or penicillins.

In some cases, patients are prescribed antiviral drugs: “Acyclovir”, “Cernilton”, “Arbidol”.

To maintain immunity in medical complex include immunomodulators: “Immunal”, “Imudon”, “Bronchomunal”, “IRS-19”, “Ekhinacin”.

IMPORTANT! During the period of remission, salty air has a beneficial effect on the state of the respiratory system of patients. Therefore, annual trips to the seashore, as well as procedures in salt chambers (halotherapy), are recommended for patients with bronchitis.

Physiotherapy

Physiotherapeutic procedures in the treatment of bronchitis are aimed at stimulating mucus production and correcting respiratory function.

The following methods are used:

The range of procedures and duration of the course depends on the stage of the disease and general condition patient.

Traditional methods

Traditional methods of treating chronic bronchitis complement the intake of medications and help speed up recovery.

According to patient reviews, the following folk remedies are most effective:

Prevention

The main conditions for preventing the development of chronic obstructive bronchitis are timely treatment of acute respiratory infections and acute forms of the disease, as well as minimizing risk factors for negative effects on the respiratory system.

To give up smoking, hardening, maintaining a healthy lifestyle, balanced diet- This is the basis for preventing the disease.

People with weak respiratory system It is worth paying attention to living and working conditions.

It is recommended to do daily wet cleaning and ventilation of the room.

Maintain optimal humidity levels.

If inflammation of the bronchi is provoked by the environment or working conditions, it is worth changing your place of residence and work.

Professor L.I. Butler
MMA named after I.M. Sechenov

In order to select the optimal tactics for managing patients with exacerbation of chronic bronchitis (CB), it is advisable to distinguish the so-called "infectious" And "non-infectious" exacerbations of chronic disease requiring an appropriate therapeutic approach. An infectious exacerbation of chronic disease can be defined as an episode of respiratory decompensation not associated with objectively documented other causes, and primarily with pneumonia.

Diagnosis of infectious exacerbation of chronic disease includes the use of the following clinical, radiological, laboratory, instrumental and other methods of examining the patient:

– clinical examination of the patient;

– study of bronchial patency (according to FEV 1);

– X-ray examination chest (exclude pneumonia);

– cytological examination of sputum (counting the number of neurophils, epithelial cells, macrophages);

– sputum Gram stain;

– laboratory tests (leukocytosis, neutrophil shift, increased ESR);

– bacteriological examination of sputum.

These methods allow, on the one hand, to exclude syndrome-like diseases (pneumonia, tumors, etc.), and, on the other hand, to determine the severity and type of exacerbation of chronic disease.

Clinical symptoms of exacerbations of chronic disease

– increase in the amount of sputum discharge;

– change in the nature of sputum (increased purulence of sputum);

– increased clinical signs of bronchial obstruction;

– decompensation of concomitant pathologies (heart failure, arterial hypertension, diabetes mellitus, etc.);

Choice of antibacterial drug for exacerbation of chronic disease

When choosing an antibacterial drug, you must consider:

– the activity of the drug against the main (most likely in this situation) pathogens of infectious exacerbation of the disease;

– taking into account the likelihood of antibiotic resistance in a given situation;

– pharmacokinetics of the drug (penetration into sputum and bronchial secretions, half-life, etc.);

– no interaction with other medications;

– optimal mode dosing;

– minimal side effects;

One of the guidelines for empirical antibiotic therapy (AT) for CB is the clinical situation, i.e. variant of CB exacerbation, severity of exacerbation, presence and severity of bronchial obstruction, various factors of poor response to AT, etc. Taking into account the above factors allows us to tentatively assume the etiological significance of a particular microorganism in the development of exacerbation of CB.

Risk factors for penicillin resistance in pneumococci

– Age up to 7 years and over 60 years;

– clinically significant concomitant pathology (heart failure, diabetes mellitus, chronic alcoholism, liver and kidney diseases);

– frequent and long-term previous antibiotic therapy;

– frequent hospitalizations and stays in places of charity (boarding schools).

Optimal pharmacokinetic properties of an antibiotic

– Good penetration into sputum and bronchial secretions;

– good bioavailability of the drug;

– long half-life of the drug;

– no interaction with other medications.

Among the aminopenicillins most frequently prescribed for exacerbations of chronic disease, amoxicillin, produced by Sintez OJSC under the brand name, has optimal bioavailability Amosin® , JSC "Sintez", Kurgan, which in this regard has advantages over ampicillin, which has rather low bioavailability. When taken orally, amoxicillin ( Amosin® ) has high activity against the main microorganisms etiologically associated with exacerbation of CB ( Str. Pneumoniae, H. influenzae, M. cattharalis). The drug is available in 0.25, 0.5 g No. 10 and in capsules 0.25 No. 20.

A randomized, double-blind and double placebo-controlled study compared the effectiveness and safety of amoxicillin at a dose of 1 g 2 times a day (group 1) and 0.5 g 3 times a day (group 2) in 395 patients with exacerbation of CB. The duration of treatment was 10 days. Clinical efficacy was assessed on days 3–5, days 12–15, and days 28–35 after completion of treatment. Among the ITT population (who did not completely complete the study), clinical efficacy in patients of groups 1 and 2 was 86.6% and 85.6%, respectively. At the same time, in the RR population (completion of the study according to the protocol) – 89.1% and 92.6%, respectively. Clinical relapse in the ITT and RR populations was observed in 14.2% and 13.4% in group 1 and 12.6% and 13.7% in group 2. Statistical data processing confirmed the comparable effectiveness of both treatment regimens. Bacteriological effectiveness in groups 1 and 2 among the ITT population was noted in 76.2% and 73.7%.

Amoxicillin ( Amosin® ) is well tolerated, except in cases of hypersensitivity to beta-lactam antibiotics. In addition, it has virtually no clinically significant interaction with other medications prescribed to patients with chronic disease, both in connection with exacerbation and concomitant pathology.

Risk factors for poor response to AT during exacerbation of CB

– Elderly and senile age;

– pronounced violations bronchial obstruction;

– development of acute respiratory failure;

– frequent previous exacerbations of chronic disease (more than 4 times a year);

– nature of the pathogen (antibiotic-resistant strains, Ps. aeruginosa).

The main options for exacerbation of chronic disease and AT tactics

Simple chronic bronchitis:

– patients’ age is less than 65 years;

– frequency of exacerbations less than 4 per year;

– FEV 1 more than 50% of predicted;

– main etiologically significant microorganisms: St. pneumoniae H. influenzae M. cattarhalis(resistance to b-lactams is possible).

First line antibiotics:

Aminopenicillins (amoxicillin ( Amosin® )) 0.5 g x 3 times orally, ampicillin 1.0 g x 4 times a day orally). Comparative characteristics of ampicillin and amoxicillin ( Amosin® ) is presented in Table 2.

Macrolides (azithromycin (Azithromycin - AKOS, JSC Sintez, Kurgan) 0.5 g per day on the first day, then 0.25 g per day for 5 days, clarithromycin 0.5 g x 2 times a day orally .

Tetracyclines (doxycycline 0.1 g 2 times a day) can be used in regions with low pneumococcal resistance.

Protected penicillins (amoxicillin/clavulanic acid 0.625 g every 8 hours orally, ampicillin/sulbactam (Sultasin®, Sintez OJSC, Kurgan) 3 g x 4 times a day),

Respiratory fluoroquinolones (sparfloxacin 0.4 g once daily, levofloxacin 0.5 g once daily, moxifloxacin 0.4 g once daily).

Complicated chronic bronchitis:

– age over 65 years;

– frequency of exacerbations more than 4 times a year;

– increased volume and purulence of sputum during exacerbations;

– FEV 1 is less than 50% of predicted;

– more pronounced symptoms of exacerbation;

– main etiologically significant microorganisms: the same as in group 1 + St. aureus+ gram-negative flora ( K. pneumoniae), frequent resistance to b-lactams.

First line antibiotics:

· Protected penicillins (amoxicillin/clavulanic acid 0.625 g every 8 hours orally, ampicillin/sulbactam 3 g x 4 times a day intravenously);

· Cephalosporins 1–2 generations (cefazolin 2 g x 3 times a day IV, cefuroxime 0.75 g x 3 times a day IV;

· “Respiratory” fluoroquinolones with antipneumococcal activity (sparfloxacin 0.4 g once a day, moxifloxacin 0.4 g per day orally, levofloxacin 0.5 g per day orally).

3rd generation cephalosporins (cefotaxime 2 g x 3 times a day IV, ceftriaxone 2 g once a day IV).

Chronic purulent bronchitis:

– constant release of purulent sputum;

– frequent concomitant pathology;

– frequent presence of bronchiectasis;

– severe symptoms of exacerbation, often with the development of acute respiratory failure;

– main etiologically significant microoriginisms: the same as in group 2 + Enterobactericae, P. aeruginosa.

First line antibiotics:

· 3rd generation cephalosporins (cefotaxime 2 g x 3 times a day IV, ceftazidime 2 g x 2-3 times a day IV, ceftriaxone 2 g once a day IV);

· Respiratory fluoroquinolones (levofloxacin 0.5 g once daily, moxifloxacin 0.4 g once daily).

“Gram-negative” fluoroquinolones (ciprofloxacin 0.5 g x 2 times orally or 400 mg IV x 2 times a day);

4th generation cephalosporins (cefepime 2 g x 2 times a day IV);

Antipseudomonas penicillins (piperacillin 2.5 g x 3 times a day IV, ticarcillin/clavulanic acid 3.2 g x 3 times a day IV);

Meropenem 0.5 g x 3 times a day i.v.

In most cases of exacerbations of chronic disease, antibiotics should be prescribed orally. Indications for parenteral use of antibiotics are :

– disorders of the gastrointestinal tract;

– severe exacerbation of chronic disease;

– need for mechanical ventilation;

– low bioavailability of oral antibiotic;

The duration of AT for exacerbations of chronic disease is 5–7 days. It has been proven that 5-day courses of treatment are no less effective than longer use of antibiotics.

In cases where there is no effect from the use of first-line antibiotics, a bacteriological examination of sputum or BALF is performed and alternative drugs are prescribed taking into account the sensitivity of the identified pathogen.

When assessing the effectiveness of AT for exacerbations of CB, the main criteria are:

– immediate clinical effect (rate of regression of clinical symptoms of exacerbation, dynamics of bronchial patency indicators;

– bacteriological effectiveness (achievement and timing of eradication of an etiologically significant microorganism);

– long-term effect (duration of remission, frequency and severity of subsequent exacerbations, hospitalization, need for antibiotics);

– pharmacoeconomic effect taking into account the indicator cost of the drug / treatment effectiveness.

Table 3 shows the main characteristics of oral antibiotics used to treat exacerbations of CB.

1 Anthonisen NR, Manfreda J, Warren CP, Hershfield ES, Harding GK, Nelson NA. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann. Intern. Med. 1987; 106; 196–204

2 Allegra L, Grassi C, Grossi E, Pozzi E. Ruolo degli antidiotici nel trattamento delle riacutizza della bronchite cronica. Ital.J.Chest Dis. 1991; 45; 138–48

3 Saint S, Bent S, Vittinghof E, Grady D. Antibiotics in chronic obstructive pulmonary disease exacerbations. A meta-analysis. JAMA. 1995; 273; 957–960

4. R Adams S.G., Melo J., Luther M., Anzueto A. – Antibiotics are associated with lower relapse rates in outpatients with acute exacerbations of COPD. Chest, 2000, 117, 1345–1352

5. Georgopoulos A., Borek M., Ridi W. – Randomised, double–blind, double–dummy study comparing the efficacy and safety of amoxycillin 1g bd with amoxycillin 500 mg tds in the treatment of acute exacerbations of chronic bronchitis JAC 2001, 47, 67–76

6. Langan S., Clecner V., Cazzola C.M., et al. Short-course cefuroxime axetil therapy in the treatment of acute exacerbations of chronic bronchitis. Int J Clin Pract 1998; 52:289–97.),

7. Wasilewski M.M., Johns D., Sides G.D. Five–day dirithromycin therapy is as effective as 7–day erythromycin therapy for acute exacerbations of chronic bronchitis. J Antimicrob Chemother 1999; 43:541–8.

8. Hoepelman I.M., Mollers M.J., van Schie M.H., et al. A short (3–day) coarse of azithromycin tablets versus a 10–day course of amoxycillin–clavulanic acid (co–amoxiclav) in the treatment of adults with lower respiratory tract infections and the effect on long–term outcome. Int J Antimicrob Agents 1997; 9:141–6.)

9. R.G. Masterton, C.J. Burley, . Randomized, Double–Blind Study Comparing 5– and 7–Day Regimens of Oral Levofloxacin in Patients with Acute Exacerbation of Chronic Bronchitis International Journal of Antimicrobial Agents 2001;18:503–13.)

Bronchitis is a specific disease that occurs as a result of inflammation of the lining of the bronchi, caused by viruses (respiratory, adenoviruses), bacteria, infections, allergens and other physical and chemical factors. The disease can occur in chronic and acute forms. In the first case, there is damage to the bronchial tree, which is diffuse change airways under the influence of irritants (changes in the mucous membrane, harmful agents, sclerotic changes in the walls of the bronchi, dysfunction of this organ, etc.). Acute bronchitis is characterized by acute inflammation of the lining of the bronchi, as a result of an infectious or viral lesion, hypothermia or decreased immunity. This disease is often caused by fungi and chemical factors (paints, solutions, etc.).

This disease occurs in patients of any age, but most often the peak incidence falls on the age of the working population from 30-50 years. According to WHO recommendations, the diagnosis of chronic bronchitis is made after the patient complains of coughing lasting for 18 months or more. This form of the disease often leads to changes in the composition of pulmonary secretions, which are retained in the bronchi for long time.

Treatment of the chronic form of the disease begins with the prescription of mucolytics, taking into account the peculiarity of their action:

Drugs that affect adhesion. This group includes “Lazolvan”, “Ambraxol”, “Bromhexine”. These drugs contain the substance mucoltin, which promotes the rapid removal of mucus from the bronchi. Depending on the intensity and duration of the cough, mucolytics are prescribed in a daily dosage of 70-85 mg. Taking these medications is indicated in the absence of sputum or when a small amount is discharged, without shortness of breath and bacterial complications.
Medicines with antioxidant properties are Bromhexine bromide and ascorbic acid. 4-5 inhalations per day are prescribed, after completion of the course of treatment, consolidation therapy with mucolytics in tablets “Bromhexine” or “Mukaltin” is carried out. They help thin mucus and also affect its elasticity and viscosity. The dosage is selected individually by the attending physician.
Medicines that affect mucus synthesis (containing carbocysteine).

Standards of treatment

Treatment of chronic bronchitis occurs according to symptoms:

Treatment: mucolytics in tablets “Bromhexine”, “Mukoltin”; inhalation "Bromhexie bromide" 1 ampoule + ascorbic acid 2 g (3-4 times a day).

Severe cough, causing the veins in the neck to dilate and the face to swell.

Treatment: oxygen therapy, diuretics, mucolytics.

Treatment: during the period of infectious exacerbation - macrolide antibiotics (Clarithromycin, Azithromycin, Erythromycin); after the exacerbation subsides - antiseptic drugs in inhalation in combination with immunotherapy with the Bronchovax, Ribumunil, and Bronchomunal vaccines.

Treatment: mucolytics “Bromhexine”, “Lazolvan”; during exacerbation - inhalation through a nebulizer with mucolytics in combination with corticosteroids enterally; in case of ineffectiveness conservative treatment– bronchoscopy.

Treatment: prescription of anticoagulants, in advanced cases - bloodletting of 250-300 ml of blood until the test results normalize.

The disease in its acute form occurs as a result of inflammation of the bronchial mucosa due to an infectious or viral lesion. Treatment of the acute form in adults is carried out in a day hospital or at home, and for young children on an outpatient basis. For viral ethology, antiviral drugs are prescribed: “Interferon” (in inhalation: 1 ampoule diluted with purified water), “Interferon-alpha-2a”, “Rimantadine” (on the first day 0.3 g, subsequent days until recovery 0.1 d.) is taken orally. After recovery, therapy is carried out to strengthen the immune system with vitamin C.

In case of acute illness with the addition of an infection, antibacterial therapy is prescribed (antibiotics intramuscularly or in tablets): Cefuroxime 250 mg per day, Ampicillin 0.5 mg twice a day, Erythromycin 250 mg three times a day. Inhalation is recommended if toxic fumes or acids are inhaled. ascorbic acid 5%, diluted with purified water. Bed rest and plenty of warm (not hot!) drinks, mustard plasters, cups and warming ointments are also indicated. If fever occurs, use is indicated acetylsalicylic acid 250 mg or paracetomol 500 mg. three times a day. Mustard plasters can be used only after the temperature has dropped.

Bronchitis is one of the most common diseases. Both acute and chronic cases occupy the top places among respiratory pathologies. Therefore, they require high-quality diagnosis and treatment. Having summarized the experience of leading experts, appropriate clinical guidelines for bronchitis are being created at the regional and international levels. Compliance with standards of care is an important aspect of evidence-based medicine, which allows for optimization of diagnostic and therapeutic measures.

Causes and mechanisms

No recommendations can be made without considering the causes of the pathology. It is known that bronchitis is of an infectious and inflammatory nature. The most common causative agents of the acute process are viral particles (influenza, parainfluenza, respiratory syncytial, adeno-, corona- and rhinoviruses), and not bacteria, as previously thought. Outside of seasonal outbreaks, it is possible to establish a certain role for other microbes: whooping cough bacillus, mycoplasma and chlamydia. But pneumococcus, Moraxella and Haemophilus influenzae can cause acute bronchitis only in patients who have undergone surgery on the respiratory tract, including tracheostomy.

Infection also plays a crucial role in the development of chronic inflammation. But bronchitis is of secondary origin, occurring against the background of a violation of local protective processes. Exacerbations are provoked mainly by bacterial flora, and long-term bronchitis is due to the following factors:

Smoking.
Occupational hazards.
Air pollution.
Frequent colds.

If during acute inflammation there is swelling of the mucous membrane and increased mucus production, then the central link of the chronic process becomes disturbances in mucociliary clearance, secretory and protective mechanisms. The long course of the pathology often leads to obstructive changes when, due to thickening (infiltration) of the mucosa, stagnation of sputum, bronchospasm and tracheobronchial dyskinesia, obstacles are created to the normal passage of air through the respiratory tract. This leads to functional impairments with further development pulmonary emphysema.

Bronchitis is provoked by infectious agents (viruses and bacteria), and becomes chronic under the influence of factors that disrupt the protective properties of the respiratory epithelium.

Symptoms

Analysis of clinical information will allow us to assume pathology at the primary stage. The doctor assesses the medical history (complaints, onset and course of the disease) and conducts a physical examination (examination, auscultation, percussion). This way he gets an idea of the symptoms, on the basis of which he makes a preliminary conclusion.

Acute bronchitis occurs independently or against the background of ARVI (most often). In the latter case, it is important to pay attention to catarrhal syndrome with runny nose, sore throat, sore throat, as well as fever with intoxication. But pretty soon signs of bronchial damage appear:

Intense cough.
Discharge of scanty mucous sputum.
Expiratory shortness of breath (difficulty primarily exhaling).

You may even experience pain in the chest, the nature of which is associated with muscle strain during an annoying cough. Shortness of breath appears only when the small bronchi are damaged. Percussion sound, like vocal tremor, are not changed. Auscultation reveals hard breathing and dry rales (buzzing, whistling), which become moist during the period of resolution of acute inflammation.

If the cough continues for more than 3 months, then there is every reason to suspect chronic bronchitis. It is accompanied by the discharge of sputum (mucous or purulent), and is less often unproductive. At first, this is observed only in the morning, but then any increase in respiratory rate leads to expectoration of accumulated secretions. Shortness of breath with prolonged exhalation occurs when obstructive disorders appear.

During the acute stage, there is an increase in body temperature, sweating, weakness, the volume of sputum increases and its purulence increases, and the intensity of the cough increases. The frequency of chronic bronchitis is quite pronounced, inflammation is especially activated in the autumn-winter period and during sudden changes weather conditions. The function of external respiration in each patient is individual: in some it remains at an acceptable level for a long time (non-obstructive bronchitis), while in others shortness of breath with ventilation disturbances appears early, which persists during periods of remission.

Upon examination, you can notice signs indicating chronic respiratory failure: expansion of the chest, pale skin with acrocyanosis, thickening of the terminal phalanges of the fingers (“ Drumsticks"), changes in nails ("watch glasses"). About development pulmonary heart may indicate swelling of the legs and feet, swelling of the neck veins. Percussion in simple chronic bronchitis does not give anything, and obstructive changes can be assumed by the boxy tint of the resulting sound. The auscultatory picture is characterized by harsh breathing and scattered dry rales.

Bronchitis can be suspected based on clinical signs that are identified during questioning, examination, and other physical methods (percussion, auscultation).

Additional diagnostics

Clinical recommendations contain a list of diagnostic measures that can be used to confirm the doctor’s assumption, determine the nature of the pathology and its causative agent, and identify associated disorders in the patient’s body. The following studies may be prescribed on an individual basis:

General blood analysis.
Blood biochemistry (acute phase indicators, gas composition, acid-base balance).
Serological tests (antibodies to pathogens).
Analysis of nasopharyngeal swabs and sputum (cytology, culture, PCR).
Chest X-ray.
Spirography and pneumotachometry.
Bronchoscopy and bronchography.
Electrocardiography.

The study of external respiration function plays a key role in determining bronchial conduction disturbances in a chronic process. In this case, two main indicators are assessed: the Tiffno index (the ratio of the forced expiratory volume in 1 second to the vital capacity of the lungs) and the peak expiratory flow rate. Radiologically, with simple bronchitis, one can only notice an increase in the pulmonary pattern, but long-term obstruction is accompanied by the development of emphysema with increased transparency of the fields and a low position of the diaphragm.

Treatment

Having diagnosed bronchitis, the doctor immediately begins treatment measures. They are also reflected in clinical recommendations and standards that guide specialists when prescribing certain methods. Drug therapy plays a central role in acute and chronic inflammation. In the first case, the following drugs are used:

Antiviral (zanamivir, oseltamivir, rimantadine).
Expectorants (acetylcysteine, ambroxol).
Antipyretics (paracetamol, ibuprofen).
Antitussives (oxeladin, glaucine).

The last group of drugs can only be used for intense hacking cough that cannot be relieved by other means. And it should be remembered that they should not inhibit mucociliary clearance and be combined with medications that increase mucus secretion. Antibiotics are used only in cases where the bacterial origin of the disease is clearly proven or there is a risk of developing pneumonia. The recommendations after bronchitis include vitamin therapy, immunotropic agents, giving up bad habits and hardening.

Acute bronchitis is treated with medications that affect the infectious agent, the mechanisms of the disease and individual symptoms.

Treatment chronic pathology involves different approaches during periods of exacerbation and remission. The first direction is due to the need to sanitize the respiratory tract from infection and involves the prescription of the following medications:

Antibiotics (penicillins, cephalosporins, fluoroquinolones, macrolides).
Mucolytics (bromhexine, acetylcysteine).
Antihistamines (loratadine, cetirizine).
Bronchodilators (salbutamol, fenoterol, ipratropium bromide, aminophylline).

Medicines that eliminate bronchospasm occupy an important place not only during exacerbation, but also as a basic therapy for chronic inflammation. But in the latter case, preference is given to prolonged forms (salmeterol, formoterol, tiotropium bromide) and combination drugs (Berodual, Spiolto Respimat, Anoro Ellipta). For severe obstructive bronchitis, theophyllines are added. Inhaled corticosteroids, such as fluticasone, beclomethasone or budesonide, are also indicated for this category of patients. Like bronchodilators, they are used for long-term (basic) therapy.

The presence of respiratory failure requires oxygen therapy. The set of recommended measures also includes influenza vaccination to prevent exacerbations. Important place in rehabilitation program occupied by individually selected breathing exercises, a high-calorie and fortified diet. And the appearance of single emphysematous bullae may require their surgical removal, which has a beneficial effect on ventilation parameters and the condition of patients.

Bronchitis is a very common respiratory tract disease. It occurs in acute or chronic form, but each of them has its own characteristics. Methods for diagnosing bronchial inflammation and methods for its treatment are reflected in international and regional recommendations that guide the doctor. The latter were created to improve the quality of service medical care, and some have even been put into practice at the legislative level in the form of relevant standards.

Chronic obstructive bronchitis guidelines for general practitioners

Definition: Chronic obstructive bronchitis (COB) is a disease characterized by chronic diffuse allergic inflammation of the bronchi, leading to a progressive impairment of pulmonary veil and gas exchange of the obstructive type and manifested by cough, shortness of breath and sputum production, not associated with damage to other organs and systems.

Chronic obstructive bronchitis and emphysema are collectively referred to as chronic obstructive pulmonary disease (COPD)

Chronic obstructive bronchitis is characterized by progressive airway obstruction and increased bronchoconstriction in response to nonspecific irritants. Obstruction in COB developed from irreversible and reversible components . Irreversible the component is determined by the destruction of the elastic collagen base of the lungs and fibrosis, changes in shape and obliteration of bronchioles. Reversible the component is formed due to inflammation, contraction of bronchial smooth muscles and hypersecretion of mucus.

There are three known absolute risk factors for the development of hob:

Severe congenital alpha-1 antitrypsin deficiency,

Increased levels of dust and gases in the air associated with occupational hazards and poor environmental conditions.

Available many probable factors: passive smoking, respiratory viral infections, socioeconomic factors, living conditions, alcohol consumption, age, gender, family and genetic factors, airway hyperresponsiveness.

Diagnostics of hob.

Establishing a diagnosis of COB is based on identifying the main clinical signs of the disease, taking into account predisposing risk factors and

excluding lung diseases with similar symptoms.

Most patients are heavy smokers. There is often a history of respiratory diseases, mainly in winter.

The main symptoms of the disease that force the patient to see a doctor are increasing shortness of breath, accompanied by a cough, sometimes producing sputum and wheezing.

Dyspnea - can vary within very wide limits: from a feeling of lack of air with standard physical activity to severe respiratory distress. Shortness of breath usually develops gradually. For patients with COB, shortness of breath is main reason deterioration in quality of life.

Cough - in the overwhelming majority - productive. The quantity and quality of sputum produced may vary depending on the severity of the inflammatory process. However, a large amount of sputum is not typical for COB.

Diagnostic significance objective examination with COB it is insignificant. Physical changes depend on the degree of airway obstruction and the severity of emphysema. Classic signs include wheezing during a single inhalation or during a forced exhalation, indicating a narrowing of the airways. However, these signs do not reflect the severity of the disease, and their absence does not exclude the presence of COB in the patient. Other signs, such as weakened breathing, limited chest excursion, participation of additional muscles in the act of breathing, and central cyanosis also do not indicate the degree of airway obstruction.

Steady progression of the disease - the most important sign of COB. The severity of clinical signs in patients with COB is constantly increasing. Repeated FEV1 determinations are used to determine disease progression. Decrease in FEV1 by more than 50 ml. per year, a witness about the progression of the disease.

The quality of life - an integral indicator that determines the patient’s adaptation to the presence of the disease and the ability to perform the patient’s usual functions related to his socio-economic status (at work and at home). To determine the quality of life, special questionnaires are used.

Bronchitis is a disease that means inflammation of the bronchial mucosa, the cause of which is various internal and external factors affecting a person. The disease has several forms and degrees of progression, depending on which the doctor decides what recommendations to give the patient for complete recovery for bronchitis.

Acute bronchitis

Acute pathology in medicine is defined as a limited inflammatory process occurring in the respiratory tract. Main symptom illness - cough. Acute bronchitis lasts up to 3 weeks. But when exposed to specific factors, a prolonged cough can last up to 6 weeks. In the international document ICD-10, the pathology is noted under the code J20 - J22. The main causative agents of acute bronchitis are described here, and basic recommendations for doctors are presented.

Classification

The causes of bronchial pathology in acute form are associated with the causes of influenza and viral diseases. Respiratory diseases and bronchitis are often recorded in the autumn-winter period. 80% of all factors causing disease are viruses. Viral infection is detected and confirmed clinical studies. It has been determined that acute bronchitis is most often caused by the following viruses:

rhinosyncytial;
coronavirus;
rhinovirus;
adenovirus;
parainfluenza;
influenza strains A and B.

Another common factor causing illness, is a bacterial infection. The causative agents of the disease are: chlamydia, pneumococcus, mycoplasma, hemophilus influenzae.

Medical research provides evidence that inflammation of the bronchi in acute period is the fifth most common disease that begins with a cough. The clinic has been sufficiently studied, which makes it possible to correctly diagnose the disease and give recommendations for the treatment of acute bronchitis.

Causes and clinical picture

When an infection affects the human body, the disease can develop as a primary and secondary pathology. Its occurrence is influenced by the following causal factors:

living or working in environmentally unfavorable conditions;
damage to the mucous membrane due to penetration of a viral or bacterial infection;
allergic reactions when allergens enter the respiratory tract;
exposure to chemicals or vapors on the bronchial mucosa.

The clinical international protocols on pulmonology define the main clinical picture acute bronchitis in patients. Of course, bronchitis manifests itself differently in each sick person, but there are main symptoms by which a doctor determines bronchitis.

The temperature rise may be sharp. Depending on what pathogen affects the human body, hyperthermia will manifest itself suddenly, gradually, for a long time, in a short period of time, and so on.

Cough. In the first days of illness it is a dry, hacking cough. After 3-5 days it is moisturized, the condition of the sick person improves. This is the main symptom of the disease. Along with the cough, phlegm begins to come out, removing pathological microorganisms from the bronchi, freeing up the narrowed airways.
General intoxication. The patient feels unwell, sweats profusely, and sometimes develops a fever. Often with acute bronchitis there is a headache.
Wheezing. When the first visible symptoms of the disease occur, the presence of wheezing allows one to classify the pathology. On auscultation, a person’s breathing will be harsh, with wheezing in the area of large-caliber bronchi.

Important: Only a doctor can listen to wheezing and make an appropriate diagnosis based on the data.

Diagnostics

There is a list of basic diagnostic tests to laboratory determine the presence of acute bronchitis. It is not necessary to undergo all recommended studies, some of them are additional to differentiate the diagnosis.

General blood test. Mandatory for patients over 75 years of age, as at this age there is a risk of developing respiratory failure. It is recommended to do it when the cough does not stop for 3 weeks, there is a suspicion of the development of pneumonia, and the temperature is constantly rising. The analysis helps to make an accurate differential diagnosis.
Fluorography. Prescribed to confirm the diagnosis. The indications are the same as for a blood test.
Sputum analysis. Allows you to determine which bacteria are in the bacterial secretion. Culture gives clarity on the issue of prescribing a specific group of antibiotics.

Microscopic examination of sputum according to Gram.
Spirography. Prescribed for suspected bronchial asthma.
Radiography. Shows the pattern of the bronchi, allowing you to accurately determine the form of the disease.
ECG. Allows you to diagnose changes in the functioning of the heart muscle as a result of a prolonged inflammatory process in the bronchi.

Clinical recommendations for the treatment of bronchitis in children and adults depend on physical examination data: body temperature measurements, the presence of scattered dry rales. A complete blood count may show increased value erythrocyte sedimentation rate, slight leukocytosis.

To make a correct diagnosis, it is necessary to exclude the presence of pathologies of the gastrointestinal tract and ENT organs.

If there are symptoms such as cough (but no increased breathing, shortness of breath, or asthma attacks), runny nose or nasal congestion, hyperthermia, a diagnosis of acute bronchitis is made. In adults and children, recommendations for the treatment of bronchitis are as follows:

Non-drug treatment. Recommendations on how to treat bronchitis non-drug means, can be obtained from a competent specialist. For better sputum discharge and reduction of intoxication, it is necessary to maintain hydration daily - drink up to 3 liters of fruit drinks, water, tea. Provide the patient with bed rest, clean and humid air. Avoid the presence of factors that irritate the bronchi - smoke, dust, very humid and cold air, strong odors.

signs of bronchitis

Antibiotics. Immediately after the onset of symptoms of the pathology, antibacterial therapy is not prescribed. If the sputum produced is even green in color, this is not the reason for such treatment. There must be good reasons for prescribing antibiotics: if there is no effect of treatment, with hyperthermia and intoxication for more than 7 days, in patients over 65 years of age with these symptoms. For treatment, antibacterial drugs are prescribed that are active in destroying pneumococci, mycoplasma, chlamydia, and Haemophilus influenzae. Drugs from the aminopenicillin group are often chosen. But if the patient is allergic to this group, a combination of protected aminopenicillins, macrolides or 2nd and 3rd generation cephalosporins is prescribed. On average, drugs are given for 5-7 days at the same time.
Mucoactive drugs. These are thinning, expectorant drugs with mucolytic or reflex action. Often these are Ambroxol, Acetylcysteine, Carbocysteine, Bisolvon. Reflex action provide herbal preparations, for example, Pectolvan, Gerbion, Pertussin and so on.

Bronchodilators. Prescribed especially to young patients when obstructive bronchitis in children is diagnosed. Bronchodilator drugs are effective for bronchial hyperreactivity. Medicines of several groups: beta-2 antagonists, anticholinergics, hormonal drugs. Among them, Salbutamol, Berodual, and Ipratropium bromide are actively used.
Antiviral agents. Practical ones are not applied. It is possible to use Ingavirin and neuraminidase inhibitors.
Antitussive drugs. They are used in the first few days of illness, when there is no sputum production and the person is accompanied by a dry, hacking cough. When the cough has become wet, the simultaneous use of an antitussive and mucolytics is prohibited.

Chronical bronchitis

Chronic bronchitis in children and adults develops gradually and progresses. Accompanied by changes in the structure of the bronchial tree, while the mucous membrane of the respiratory tract and bronchial walls undergo changes. Bronchitis is considered chronic if it lasts more than 3 months over 2 years. To make a diagnosis, you need to exclude a number of other diseases that may cause a prolonged cough.

At-risk groups

The development of chronic bronchitis is caused by constant negative impact from outside. Common reasons manifestations of the disease are:

passive and active smoking;
ozone;
air pollution;
the effect of chemicals on the bronchial mucosa;
frequent infectious diseases of the respiratory tract in childhood.

Symptoms appear at first as in acute bronchitis, but then the course of the disease becomes more complicated with shortness of breath, changes in complexion and nails. The face and nails also undergo changes in later stages of the disease.

Diagnosis of pathology

Since this type of illness is often diagnosed as the presence of chronic bronchitis in children, treatment will be effective if the recommendations are followed. To determine a differentiated diagnosis, the following is carried out:

auscultation - in case of chronic pathology, the doctor listens to dry wheezing;
general blood test - no obvious changes in leukemia;
sputum examination - pus is found in the sputum;
spirography – vital capacity functions and FEV decrease;
X-ray – the image shows clearly enhanced patterns of the lungs, emphysema of the organ is in question;
urine analysis - with prolonged bronchial pathology, the inflammatory process can affect the functioning of the kidneys, their functions are assessed after the analysis.

Additionally, examinations of the gastrointestinal tract and ENT organs may be prescribed. The doctor often speaks about the need before examining other organs. medical sciences A. Myasnikov (interview 2017), when it comes to the treatment of bronchitis. Increased acidity, sinusitis and other causes can cause a patient to cough for months, but ill-informed treatment does not lead to improvement.

Chronic bronchitis can be confused with obstructive syndrome, asthma, bronchiolitis, presence foreign body, pneumonia. That’s why it’s so important to get tested on time.

Principles of treatment

If children often have bronchitis and are prone to allergic reactions, there is a risk of the acute form of the disease becoming chronic. Chronic inflammation of the bronchi is extremely difficult to treat, especially in young children and smokers. To begin therapeutic measures, it is necessary to eliminate any irritating factors.

The main principles of treatment are:

reduction in the intensity of symptoms of the disease;
preventing exacerbations;
maximum support for lung function;
increasing human activity and quality of life.

Expectorants. Treatment of the protective apparatus of the bronchial mucous layer is the restoration of cilia activity to move pathological mucus out through the airways. Prevention of bacterial complications. They use herbal preparations that stimulate the removal of phlegm, as well as artificial mucolytics that thin and remove phlegm.
Antibiotics. Prescribed for exacerbation chronic course diseases. Macrolides of the latest generations, the generation of amoxicillin and clavulanic acid, and combinations with mucolytics are often prescribed. Therapy with cephalosporins and fluoroquinolones is possible, depending on test results.
Bronchodilators. Drugs that widen the narrow lumen of the bronchi. Used mainly in inhalations. Hormonal drugs are often prescribed to quickly stop the pathological process.

If the patient’s well-being does not improve, he is hospitalized. With effective treatment, all symptoms should disappear.