The invention relates to medicine, surgery, can be used in the treatment bronchial asthma with combined lesions gastrointestinal tract. A preliminary examination of a patient with bronchial asthma is carried out. Surgical correction of the incompetence of the ileocecal obturator apparatus and chronic disturbance of duodenal patency is performed when this pathology is detected. The method allows you to eliminate the cause of bronchial asthma.
The invention relates to medicine and can be used for the treatment of bronchial asthma (BA) in patients with combined lesions of the gastrointestinal tract. Treatment of all forms of asthma includes two main stages: relief of asthma attacks and anti-relapse treatment. During the exacerbation phase (stage of tactical therapy), individual selection of treatment measures depends on the severity of the exacerbation and the presence or absence of active, clinically pronounced inflammation and includes, inter alia, intravenous administration of glucocorticoid drugs, bronchodilators and membrane stabilizing agents. At the stage of strategic therapy, i.e. in the remission phase, individual therapy is carried out in accordance with the clinical and pathogenetic variants of the patient’s condition. Pharmacotherapy is of primary importance during the exacerbation phase of asthma. Maintenance minimal and sufficient pharmacotherapy should be carried out during the remission phase. The disadvantage of generally accepted standard approaches to the treatment of asthma is that they do not eliminate the cause of the disease and often further aggravate the patient’s condition, creating his dependence on one or another drug. In recent years, a number of publications have appeared on the relationship between the state of the gastrointestinal tract and the course of the disease in patients with asthma. In 1934, J. Bray pointed out this connection. Attacks of asthma occurred after a heavy meal. He believed that the stretching of the stomach plays a role in this, and therefore the vagal reflex occurs (Bray G. //Practitioner. - 1934. - Vo1.34, 4. - R. 368-370). In 1946, S. Mendelsohn observed aspiration of gastric contents into the bronchi, which caused a syndrome resembling asthma (Medelsohn S. // Amer. J. Obstet. Jynec. - 1946. - Vol. 52, 2. - P. 191-195) . In a number of works more late period a clear connection is shown between gastroesophageal reflux (GPR) and asthma (L.K. Parkhomenko, O.S. Radbil “Gastroesophageal reflux and bronchial asthma.” // Clinical Medicine. - 1994. - 6. - P.4 -7). In these works, special attention is paid to the presence of hydrochloric acid in the esophagus, which causes overstimulation of the vagus nerve with subsequent bronchospasm due to pathological centripetal impulses from the gastrointestinal tract (GIT) and pathological centrifugal impulses to the smooth muscles of the bronchi. Another part of the authors also points out the connection between ZhPR and various pulmonary pathology(including with BA), but considers the leading etiological factor to be imperceptible microaspiration of contents into the bronchi. In the presence of increased reactivity of the bronchial tree and allergic restructuring of the body due to these aspiration complications of gastrointestinal tract, asthma often develops. (V.V. Stonkus, K.I. Paltanavichyus “On gastroesophageal reflux in patients with infectious-allergic bronchial asthma.” // Clinical Medicine. - 1981. - 12. - P. 48-52). Others have revealed the positive effect of enterosorption in the treatment of asthma, which consists of reducing the severity of the disease, lengthening the period of remission, reducing the doses of medications used (A.V. Nikitin, E.P. Karpukhina, V.P. Silvestrov “Clinical effectiveness of enterosorbent polyphepan in complex therapy of patients with infectious-dependent bronchial asthma." //Therapeutic archive. - T. 65. -1993. - 3. - P. 25-26). The closest to the claimed method of treating BA is fundoplication, developed by Nissen. The authors note that antireflux surgery is only indicated in cases of severe esophagitis or recurrent pulmonary aspiration. The results of this treatment indicate that fundoplication does not always cause recovery or even improvement (L.K. Parkhomenko, O.S. Radbil “Gastroesophageal reflux and bronchial asthma.” // Clinical Medicine. - 1994. - 6. - P.4-7). This most common Nissen fundoplication method is performed as follows (Imre Litmann " Abdominal surgery", Publishing House of the Hungarian Academy of Sciences. Budapest. - 1970): upper-median laparotomy. A transverse incision is made to dissect the fold of tissue covering the abdominal segment of the esophagus or cardia, and the surgeon's finger bluntly mobilizes the lower segment of the esophagus. After isolating the esophagus, a rubber holder is placed around it by pulling in which the abdominal section of the esophagus and cardia are brought down into the abdominal cavity. The cardia and fundus of the stomach are mobilized by dissection using clamps upper section gastrohepatic ligament. Then the surgeon, with one or two fingers of his right hand, brings the fundus of the stomach to the posterior wall of the esophagus so that the wall of the stomach is to the right of it, where it is grasped with a soft gastric clamp or held with a holder. At the next stage, the abdominal part of the esophagus is immersed and fixed into the coupling formed by the bottom of the stomach, using separate silk sutures, capturing the muscular layer of the anterior wall of the esophagus. A total of 6-7 such sutures are applied. In this case, it is necessary to ensure that the sleeve created from the stomach lies freely, without squeezing the esophagus. Layer-by-layer suture of the median wound of the anterior abdominal wall. Disadvantages known method(Nissen fundoplication) are the following: 1 - often only the consequence is eliminated, namely gastrointestinal tract, which may be a consequence of another pathology; 2 - the possibility of relapse of gastrointestinal tract due to failure of the sutures that form the cuff around the esophagus. The reasons for this are varied; 3 - overstimulation of the vagus nerve can also occur due to damage to other parts of the digestive system, and not only due to pathology of the esophagus as a result of gastrointestinal tract. It can also lead to bronchospasm; 4 - endogenous intoxication is not eliminated, which is also one of the causes of asthma; 5 - food allergy as a factor in the etiopathogenesis of asthma is not eliminated; 6 - the condition of the entire digestive system does not improve, which largely, according to our data, depends on NICD and CNDP, which underlie the etiopathogenesis of BA. Therefore, the authors set the task of the proposed invention to eliminate the causes causing disease, improving the patient’s quality of life. The problem is solved thanks to a method of treating patients with asthma with pathological disorders of the gastrointestinal tract, carried out after drawing up, based on the results of a preliminary examination, a treatment regimen acceptable for him, including taking medications and other therapeutic agents and surgical intervention in the pathological zone of the gastrointestinal tract, in which, in accordance with With the proposed technical solution, when identifying NICD and the often associated chronic disorder of duodenal patency (CDDP), surgical correction of the defect is carried out. Features of the claimed invention, namely the detection of incompetence of the ileocecal valve, established according to clinical and radiological signs, implementation surgical correction it, the implementation of surgical correction also of chronic disorders of duodenal obstruction, are essential features of the invention. The failure of the ileocecal valve is established in the presence of such clinical signs as abdominal pain, heaviness in the abdomen, nausea, belching of air, regurgitation of food, heartburn and bitterness in the mouth, constipation, diarrhea and loose stools, intolerance to milk and other foods, bad smell from the mouth, bloating and rumbling in the stomach. However, the author is aware of cases where clinical signs of ileocecal valve incompetence did not appear. Then the diagnosis was established based only on irrigoscopy, namely the leakage of contrast into the ileum. And it is especially significant that the manifested defects of the gastrointestinal tract in patients with asthma are corrected surgically, which helps to cure this disease. Sources of patent and scientific and technical information have not identified a method of treating asthma with the proposed set of essential features. Therefore, the author believes that the proposed method meets the patentability criterion of “novelty”. In addition, the authors believe that the relationship between the state of the ileocecal obturator apparatus, CNDP and the course of asthma in patients was not obvious to specialists, as it was established as a result of many years of observation and analysis of the condition of this group of patients. Therefore, the authors believe that the second patentability criterion is present in the proposed technical solution. The method of treating BA in patients with concomitant pathology of the gastrointestinal tract in accordance with the proposed technical solution is carried out as follows: if before the operation, in case of failure of the ileocecal obturator apparatus, a chronic violation of duodenal patency of the CNDP is not detected, then a laparotomy is performed using an oblique incision according to Volkovich-Dyakonov in the right iliac region and Bauginoplasty using the technique we developed. The essence of the method is to create a semblance of a flap with its upper and lower lips, to form the ventral and dorsal frenulum and to prosthetize the sphincters of Varolius and Buzy (patent for the invention “Method of Bauginoplasty” under application 4952905/14/056000). If CNDP is detected before surgery during NICA, then a mid-median laparotomy is performed and the duodenum is inspected. If preoperative diagnosis revealed arteriomesenteric compression, one of the types of CNDP, with operational confirmation of this pathology in the form of expansion of the duodenum above its compression by the upper mesenteric vessels, then one of the types of anastomoses is applied between the initial section of the lower horizontal part of the duodenum to the upper mesenteric vessels and a section of the jejunum 20-30 cm below the ligament of Treitz. Methodology: interrupted nylon sutures are placed between the indicated sections over a distance of 6-7 cm with a distance of 5-6 mm between them. Stepping back from the resulting suture line by 5-6 mm, the wall of the duodenum and jejunum is dissected over a distance of 2-2.5 cm. Separate interrupted sutures are used to stitch the dissected walls of the duodenum and jejunum, which are located closer to the line of previously applied seromuscular sutures, thus forming back lip anastomosis. Also, the remaining dissected sections of the wall of the duodenum and jejunum are sewn together with interrupted sutures, forming the anterior lip of the anastomosis. This line of sutures is reinforced with a second row of seromuscular sutures. Thus, the exit from the duodenum is normalized. Plastic surgery of the ileocecal obturator apparatus is performed using the developed method. If, before the operation, compression of the duodenum by the upper mesenteric vessels is not detected, but only the high location of the duodenojejunal section is determined small intestine, then there is no need to perform a duodenojejunal anastomosis. The cause of CNDP in this case will most often be a scar-adhesive process in the distal part of the duodenum and the proximal part of the jejunum, as well as a scar-modified Treitz ligament, which compresses these parts of the intestine and pulls it up. These reasons interfere with the exit of contents from the duodenum. In this case, the scars and adhesions found are dissected. Above and to the left of the duodenojejunal junction, the parietal peritoneum is dissected and the duodenojejunal section is freed from adhesions in the retroperitoneal section. The ligament of Treitz stands out. Both of her legs are taken on two clamps each and crossed between them, and then bandaged. Thus, the duodenojejunal junction is straightened, its sharp bend is eliminated, which normalizes the exit from the duodenum. The exposed retroperitoneal space is peritonized with separate sutures. Plastic surgery of the ileocecal obturator apparatus according to the developed technique. Layer-by-layer suture of the wound of the anterior abdominal wall. Here is an example of a specific implementation. Patient S., 16 years old, was admitted to the proctology department of the Regional Clinical Hospital named after. ON THE. Semashko on 05/17/1995 with complaints of asthma attacks, more often at night, general weakness, headache, heaviness in the stomach after eating, regurgitation of food, a feeling of bitterness in the mouth, loose stools, rumbling in the stomach, bad breath, weight loss. He is a disabled person of the second group due to bronchial asthma. The diagnosis of bronchial asthma was made at the age of 4 years. Every year he was hospitalized up to 4 times. Hospitalized twice intensive care unit regarding status asthmaticus. IN Lately attacks of suffocation became more frequent, intensified, and became more difficult to respond to drug therapy. No introduction hormonal drugs the suffocation did not stop. Often we had to call an ambulance 2-3 times a night. Bronchospasm was caused by house dust, the hair of cats and dogs, the smell of various herbs and plants, cold air, milk, oranges, chocolate, chicken eggs. I constantly took theophedrine, ketotifen, aminophylline, and diphenhydramine. I slept sitting up that night. On admission the condition was of moderate severity. Skin pale. Breathing is difficult. Diffusely dry wheezing in the lungs. The belly is of the correct shape. The liver, kidneys, and spleen are not palpable. Pasternatsky's symptom is negative on both sides. Palpation of the abdomen is slightly painful in the right iliac region. Irrigoscopy revealed symptoms of colitis, reflux of a radiopaque substance into the ileum through the ileocecal valve. Ultrasound revealed deformation and kinking in the area of the body of the gallbladder, probing of the duodenum - signs of cholecysto-cholangitis, culture of portion “B” did not show any growth of microflora. An analysis of gastric juice revealed: hyperacidity in both phases of secretion, no growth of microflora was detected, but in the first portions, markers of anaerobic bacteria were determined by gas chromatography. During scatological examination found muscle fibers, neutral fat. An immunological examination showed: less than normal immunoglobulin G, decreased number of leukocytes (3000), lymphocytosis - 38%, increased number of B-lymphocytes (36%). The level of medium molecules in the blood serum is increased by 50% (0.36 units). The qualitative reaction of urine to indican is positive. Sigmoidoscopy: the mucosa is hyperemic, the vessels are injected. General analysis blood and urine tests are within normal limits. With a diagnosis of “Failure of the ileocecal valve; bronchial asthma of mixed origin, severe course,” the patient was routinely taken for surgery on May 29, 1995, as a result of which it was revealed that the ileocecal anastomosis was dilated to 4 cm, in the mesentery of the ileum there were 0.5 lymph nodes - 0.8 cm in diameter. 5 cm from the ileocecal anastomosis, the ileum is sharply deformed by adhesions. The adhesions are dissected. Bauginoplasty was performed with prosthetics of the sphincters of Varolius and Buzi with a strip of dura mater. Postoperative period went smoothly. On June 8, 1995, the patient was discharged home. A control examination in a hospital setting was carried out on April 22. to 05/17/1996. Since the operation, he has not noted any attacks of suffocation, does not take any medications, and signs of gastrointestinal discomfort have disappeared. However, control irrigoscopy revealed reflux of barium into the ileum. Given the absence of any clinical manifestations of bronchial asthma, the patient was monitored dynamically. 6 months after this follow-up examination and 1.5 years after surgery, the patient again developed signs of asthma. There was belching of air and bad breath. Functional and laboratory parameters were within normal limits, only the level of average molecules in the blood serum increased to 0.32 units. Due to relapse of ileocecal valve incompetence, the patient again undergoes bauginoplasty using a strip of vascular prosthesis. A year after repeated bauginoplasty, the patient underwent an inpatient examination at the Regional Clinical Hospital named after. N. A. Semashko from November 10, 1997 to November 24, 1997. The condition improved again: attacks of suffocation did not recur, medications does not accept. He is interested in winter fishing. Irrigoscopy revealed no organic pathology, radiopaque agent when the cecum is tightly filled, it does not enter the ileum. Immunological parameters are normal. The level of average molecules in the blood serum is 0.27 units. The ventilation function of the lungs is within normal limits. The patient was demonstrated at the Nizhny Novgorod Surgical Society in November 1997. Statistics
After receiving the first single positive results of treating BA using the proposed method, an analysis of gastroenterocolitic complaints in 134 patients with BA was carried out in order to identify the role of the gastrointestinal tract in the etiopathogenesis of BA. These patients noted abdominal pain in 63% of cases, heaviness in the abdomen - in 61%, nausea - in 49%, belching of air - in 61%, regurgitation of food - in 45%, heartburn and bitterness in the mouth - in 74%, constipation - in 47%, diarrhea and loose stools - in 43%, intolerance to milk and other foods - in 41%, bad breath - in 52%, bloating and rumbling in the abdomen - in 62% of cases. Various operations on the abdominal organs were performed in 48% of patients. All these complaints, in our experience, correspond to the failure of the ileocecal obturator apparatus and CNDP. 30 patients with BA were examined; irrigoscopy revealed incompetence of the ileocecal obturator apparatus, of which 26 had duodenography without hypotension and manometry confirmed the presence of CNDP. Duration of the disease is from 5 to 35 years, age from 13 to 57 years. All 30 patients were operated on, they underwent plastic surgery of the ileocecal obturator apparatus using the proposed method, in 26 - with simultaneous correction of CNDP (24 - dissection of the ligament of Treitz, 2 - jejunoduodenostomy). The operation brought success to 28 patients with bronchial asthma - asthma attacks either do not occur at all or occur very rarely and require a single dose of bronchodilators. In 2 patients, a year later, a recurrence of ileocecal obturator valve failure developed due to deviations from the surgical technique with the resumption of asthma attacks. Repeated operation According to the developed method, one of them was again relieved of the clinical symptoms of gastroenterocolitis and asthma. Chronic endogenous autointoxication due to failure of the ileocecal obturator apparatus is characteristic of the vast majority of patients. With this pathology, the qualitative reaction of urine to indican was positive in 95 cases, and after surgery for up to a year or more - negative in 95 cases. Vegetative dystonia syndrome SVD was identified in 92 patients with NICIA. After surgery, it disappeared in 66 patients, and in 17 cases there was a decrease in SVD. The definition of SVD was carried out according to the clinic ( increased fatigue, dizziness, palpitations, headaches, hyperhidrosis, vasomotor lability), tabular methods and intervalcardiography data with computer processing.
CLAIM
A method for the treatment of bronchial asthma, including a preliminary examination of the patient and surgical correction of the incompetence of the ileocecal obturator apparatus and chronic disturbance of duodenal patency when this pathology is detected.Among patients undergoing operations with inhalation anesthesia, an average of 3.5% suffer from bronchial asthma. These patients are more likely to have complications during and after surgery, so assessing the severity and ability to control the course of bronchial asthma, assessing the risk of anesthesia and this type of surgery, as well as preoperative preparation are extremely important. The following factors should be considered:
- Acute airway obstruction causes ventilation-perfusion disturbances, increasing hypoxemia and hypercapnia.
- Endotracheal intubation can provoke bronchospasm.
- Drugs used during surgery (for example, morphine, meperidine, D-tubocurarine) can provoke bronchospasm.
- Heavy bronchial obstruction in combination with postoperative pain syndrome may disrupt the coughing process and lead to the development of atelectasis and nosocomial pneumonia.
To prevent exacerbation of bronchial asthma in patients with a stable condition on regular inhalations of glucocorticoids, it is recommended to prescribe prednisolone 40 mg/day orally 2 days before surgery, and give this dose in the morning on the day of surgery. In case of severe asthma, the patient should be hospitalized several days before surgery to stabilize the respiratory function (administration of glucocorticoids intravenously). In addition, it should be borne in mind that patients receiving systemic glucocorticoids for 6 months or more are at high risk of adrenal-pituitary insufficiency in response to surgical stress, so they are shown prophylactic administration of 100 mg hydrocortisone intravenously before and during surgery and after it.
Complications of bronchial asthma
Pneumothorax, pneumomediastinum, pulmonary emphysema, respiratory failure, cor pulmonale.
Forecast of the course of bronchial asthma
The prognosis of the course of bronchial asthma depends on the timeliness of its detection, the patient’s level of education and his ability to self-control. Elimination of provoking factors and timely seeking qualified medical help are of decisive importance.
Clinical examination
Patients need constant monitoring by a therapist at their place of residence (with complete control of symptoms at least once every 3 months). For frequent exacerbations, constant monitoring by a pulmonologist is indicated. According to indications, an allergological examination is carried out.
Mentions of B. a. found in the works of classic medicine since the time of Hippocrates. Classic description clinical picture of B. a. belongs to G.I. Sokolsky (1838).
Before the emergence of the doctrine of allergy, R. Laennec (1825), M. Ya. Wise (1826), A. Rhodessky (1863) and others explained the pathogenesis of an asthmatic attack by neurogenic spasm of the bronchial muscles.
G. I. Sokolsky, and later Kurschmann (N. Gurschmann, 1883) and E. Leiden (1886) paid attention to the inflammatory process (“catarrh”) in the bronchi with a special type of exudate, considering it the main cause of clinical manifestations of B. a. Wintrich (A. Wintrich, 1864) associated asthma attacks with spasms of the diaphragm muscles.
At the beginning of the 20th century. after describing the phenomenon of anaphylaxis in animals, almost simultaneously, E. O. Manoilov, N. F. Golubov and S. Meltzer proposed the allergic theory of B. a., which was later confirmed by a detailed clinical and immunological analysis of the disease. In the crust, the time of allergic genesis of B. a. is recognized by the overwhelming majority of researchers, however, there are certain differences in the interpretation of B. a. from the standpoint of nosology in our country and abroad.
Most foreign scientists consider B. a. as a syndromic concept that includes not only allergic damage to the bronchi, but also various bronchospastic reactions of non-allergic origin. Soviet researchers A.D. Ado, P.K. Bulatov, B.B. Kogan believe B. a. an independent allergic disease, and they propose to call clinically similar manifestations in other diseases asthmatic syndromes. Examples of the latter may be bronchospasm due to tumors and foreign bodies of the bronchi, carcinopdae, bronchovascular lesions of the lungs due to periarteritis nodosa and others.
The first attempts to classify B. a. depending on the etiological factors were made by N. Salter in 1860. There were 5 types of asthma - from “inhalation of particles”, inflammation airways, blood disorders, nerve reflexes and irritation c. n. With.
In subsequent years, with the evolution of the doctrine of B. a. A lot of classifications were proposed, most of which distinguished “idiopathic” asthma and asthma from inflammation of the airways. In connection with the allergic theory of genesis of B. a. and introduction into practice of methods specific diagnostics Repeated attempts have been made to classify the disease depending on the results of an allergological examination.
The most widespread abroad is the classification of Rackemann (F. Rackemann, 1918), who identified two forms of B.a. - exogenous and endogenous. The first includes cases caused by non-infectious exogenous allergens, the second is associated mainly with hron. inflammation of the bronchopulmonary apparatus or extrapulmonary foci hron. infections.
In the Soviet Union, the issue of classification of B. a. has been discussed since 1963. In the present time, the classification of the main etiological forms and stages of the disease, proposed by A.D. Ado and P.K. Bulatov, has been accepted and put into practice (Table 1). According to the classification, there are two main forms of B. a. - infectious-allergic and non-infectious-allergic (atopic). The first is associated with sensitization by bacterial allergens, which come from the lesions hron. infections localized primarily in the respiratory apparatus. The second form belongs to the group of hereditary allergic diseases (see Atopy) and is caused by non-infectious allergens.
B. a. is one of the most common diseases. According to WHO data published in 1966-1968, the incidence rate of B. a. the incidence of malignant tumors in the USA is 7 times higher, in England - 3 times, respiratory tuberculosis in the USA - almost 120 times, in England - more than 25 times. Incidence of B. a. per 1000 population is: in the USA - 23.4, Denmark - 6.9, Mexico - 17.2, Germany - 5.5, England - 8.5, France - 5.0, Sweden - 7.1.
In the Soviet Union, the incidence of B. a. different in different climatic zones and in areas with different levels of industrial development.
Sample studies of morbidity (per 1000 population) conducted by A. D. A before and A. V. Bogova (1968), M. M. Omerov (1967), Bureau of Sanitary Statistics of the Ministry of Health of the RSFSR (L. A. Brushlinskaya, 1961; reports treatment institutions in a number of cities, 1958), revealed the lowest incidence in the desert regions of Central Asia (0.5-1.1), in Siberia and the Urals (1.1-1.3); in Moscow it was 2.2; the highest was in Vilnius (5.2), Riga (4.6) and Gomel (4.7). In recent years, there has been a clear trend towards an increase in the incidence of B. a.
Thus, in Moscow over the past 40 years it has increased 5 times, in Riga over 5 years - by l½ times.
The total incidence of men and women is approximately the same, but there are certain differences by age groups: in the first 10 years of life, boys are more likely to get sick, from 10 to 60 years - slightly more often women, from 60 years - men.
The most common infectious-allergic form of B. a.; the atopic form (according to the observations of a number of authors) is approx. 20% of all disease cases.
In some countries the mortality rate from B. a is very high. (complicated and uncomplicated). According to WHO statistics, Germany is in first place in this regard - 11.6 and Japan - 9.2 per 100,000 population.
The greatest importance in the etiology of the atopic form of B. a. adults have inhalation allergens, which are particles ranging in size from 10 to 100 microns, suspended in the atmospheric air and sensitizing the tissues of the upper respiratory tract and bronchi during breathing. Of this group of allergens, the most common cause B. a. is household dust, in second place is plant pollen, in third place are spores of non-pathogenic fungi. Other allergens can be identified less frequently. Industrial dust (cotton, flour, tobacco, grenage, etc.) causes professional B. a. Medicines in the form of inhaled allergens can also cause B. a. from persons who come into contact with them at work. Relatively often, the allergen that causes B. a. is powder from daphnia, a freshwater crustacean used as food for aquarium fish. With the modern widespread introduction of chemistry into everyday life and production, the role of chemicals is very important. allergens. The research available in this direction concerns mainly the sensitizing effect of plastics, pesticides, and metals, contact with which causes professional B. a.
Enteral allergens that cause B. a., - food products and medications, and food allergens more often cause B. a. in children.
The most pronounced asthmagenic effects are found in cereals (especially wheat), eggs, milk, fish, onions, and chocolate. Frequently, attacks of suffocation can be caused by the fruits and seeds of some plants, for example. sunflower seeds for allergies to its pollen, nuts for allergies to hazel pollen, etc. Cases of B. a. are described, the onset of which is associated with parenteral administration penicillin, vitamin B 1, various antitoxic serums, vaccines.
At the beginning of the disease, an asthmatic's allergy may be monovalent; over time, the spectrum of allergens expands.
The problem of the etiology of the infectious-allergic form of B. a. is under study. A certain connection has been established between the formation of this form of the disease and acute and chronic diseases. infectious processes in the respiratory system (acute and chronic bronchitis, pneumonia, sinusitis, acute respiratory diseases, flu). Attempts to find out which microorganisms cause sensitization of the tissues of the bronchial tree are rare. A. D. Ado et al. (1968) showed that with the help of monostrain outs of action prepared from the flora of the contents of the bronchi and the secretions of the upper respiratory tract of patients with infectious B. a., it is possible to obtain positive skin and provocative inhalation tests in these patients. In this case, the majority of patients had a polyvalent bacterial allergy. The most common microbes that caused sensitization were Staphylococcus aureus, Klebsiella pneumoniae, Neisseria catarrhalis and fungi of the genus Candida. Most strains turned out to be opportunistic. Studies by other authors have obtained similar results, as well as indications of the etiological role of the influenza virus.
Cases of B. a. caused by roundworm antigens have been described among workers in helminthological laboratories. Sometimes symptoms of B. a. observed along with skin allergic manifestations and eosinophilic pneumonia with certain helminthic infestations, in particular with strongyloidiasis in the phase of larval migration.
Long before the emergence of the doctrine of allergies, doctors noted a certain influence of heredity on the formation of B. a. Subsequently, it was found that this influence is especially clearly detected in the non-infectious-allergic (atopic) form of the disease, as well as in other clinical manifestations of atopy (see). In patients with this form, in approximately 50% of cases, atopic diseases are noted in the family, and not necessarily B. a., although according to a number of studies, the latter still predominates. In patients with infectious-allergic form of B. a. allergic heredity is established much less frequently (in 20-30% of cases).
A hereditary burden of allergic diseases is common in patients with B. a. with approximately the same frequency on the maternal and paternal lines. When there is a burden of heredity along two lines, the disease, as a rule, develops in the first years of life. A genetically determined predisposition to allergic diseases is usually called an allergic constitution, or allergic diathesis, which is characterized mainly by changes in immunocompetent tissues, as well as certain features of the mucous membranes, blood capillaries and the autonomic nervous system.
People with allergic diathesis tend to have several various manifestations allergies, therefore, in the personal history of asthmatics, especially with the atopic form, it is often possible to establish previously suffered allergic diseases and reactions, in particular exudative diathesis.
In recent years, a hypothesis has been put forward that interprets B. a. as a result of a hereditary defect (partial blockade) of β-adrenergic receptors.
Attacks of B. a. initially they are always the result of an allergic reaction in the tissues of the bronchial tree. Subsequently, they can develop under the influence of non-allergic irritants.
Allergic mechanisms are much better studied in the atopic form of B. a.
Attack of atopic B. a. is the result of an immediate allergic reaction localized in the tissues of the bronchial tree. In the first, immunological, stage of the reaction, the antigen combines with antibodies (reagins) fixed on sensitized cells, including fat cells, a large number of which are contained in the connective tissue of the lungs.
In crust, reagins are mainly classified as immunoglobulins E. Then an allergic alteration of cells occurs with the release of chemically active mediators as a result of the action of proteases (the second, pathochemical, stage of the reaction). Participation in the formation of an attack of B. a has been proven. histamine and the slow-acting substance of anaphylaxis - SRS-A. The role of acetylcholine, serotonin, and bradykinin is probable, but not conclusively proven. The third, pathophysiological, stage of the reaction is expressed in spasm of the smooth muscles of small bronchi and 1 bronchioles, swelling of the mucous membrane due to a sharp increase in capillary permeability, hypersecretion of mucus-forming glands. At this stage, the main clinical symptoms of the disease are formed.
Pathogenesis of the infectious-allergic form of B. a. is under study. There are two main points of view on this issue. Hampton (S. Hampton, 1963) et al. identify the pathogenesis of both forms of asthma, thus considering an attack of infectious asthma to be an immediate allergic reaction of bronchial tissue to infectious allergens. Findeisen (D. Findeisen, 1968) assigns the main role to a delayed (cellular) allergic reaction. The possibility of the combined participation of two main types of allergies cannot be ruled out (see).
During the course of developed B. a. neurogenic and emotional, endocrine, climatic factors influence. A. D. A before (1952, I 1959) it was established that during an allergic reaction the threshold of excitability of nerve receptors in relation to ordinary, non-allergic stimuli is significantly reduced. This explains the appearance of attacks of suffocation: in long-term patients with B. a. to irritants such as cold air, non-antigenic dust, strong odors, sudden changes humidity and atmospheric pressure, forced breathing during physical activity, coughing, laughter. Participation of higher departments c, n. With. reflected in the concept; P.K. Bulatova (1964) about the pathological dominant of B. a., formed under the influence of interoceptive unconditioned reflexes, on the basis of which can be formed conditioned reflexes. Emotional factors, which ultimately act through the autonomic nervous system, can also cause an attack of suffocation in a patient with B. a.
Ratios endocrine system and B. a. complex and diverse. The influence on the course of B. a has been studied. pituitary gland system - adrenal cortex and female sex hormones. V.I. Pytsky (1968) established that B. a. is accompanied by the development of glucocorticoid insufficiency, which in its origin can be either adrenal or extra-adrenal. The latter develops due to an increase in the ability of blood plasma proteins to bind cortisol and a decrease in the sensitivity of certain cells to cortisol. The influence of female sex hormones is most often expressed by premenstrual exacerbations of the disease and a more severe course during menopause. Most researchers explain these facts by the indirect effect of the dishormonal background on the neuromuscular apparatus of the bronchi through the autonomic nervous system. Climatic influences on the occurrence and course of B. a. varied. In addition to the direct effect of climatic factors, as mentioned above, climate can contribute to the incidence of respiratory infections, the spread of plants with antigenic pollen or spore-forming fungi and thus secondarily increase the incidence of B.a.
In the pathoanatomical picture of B. a., both atopic and infectious-allergic, one can distinguish changes that develop during an attack and hron. changes.
In those who died during an attack of B. a. from asphyxia, a bluish tint of the skin and mucous membranes is noted; plethora of brain matter and meninges; liquid blood in the cavities of the heart and blood vessels; congestion of visceral organs, pinpoint hemorrhages in the pleura, hemorrhages in the substance of the brain.
The appearance of the lungs is especially characteristic. They are increased in volume and cover the area of the anterior mediastinum and the anterior surface of the heart. The lungs are fluffy to the touch, gray-pink in color when cut. The wall of the bronchi is thickened. The mucous membrane of the trachea and large bronchi is covered with viscous mucus. There is thick mucus in the lumen of the bronchi.
At microscopic examination(color. Fig. 5 and 6) it is clear how mucus forms concentric layers in the lumen of the bronchi and bronchioles.
It contains many eosinophils, cells and entire layers of desquamated epithelium. The bronchial mucosa is edematous, loosely infiltrated with lymphoid, plasma cells and eosinophils. In the subsegmental and smaller bronchi, the mucous membrane is corrugated, as it were, with polyp-like protrusions, in which muscle bundles are located. The walls of the small bronchi and bronchioles are densely infiltrated with eosinophils, spreading to the adjacent alveolar septa. The basement membrane is thickened and homogenized. In the epithelium there are phenomena of hypersecretion and desquamation. The goblet cells of the epithelium, the lumens of the mucous glands and the dilated excretory ducts are filled with a secretion that has a CHIC-positive reaction. The muscle bundles are swollen. IN lung tissue- phenomena of emphysema, alveoli and their entrances are enlarged, there are foci of atelectasis and eosinophilic pneumonia. There is dilation and congestion of the blood vessels of the walls of the bronchi and lung tissue, expansion of the lumens of arteriovenous anastomoses, and sometimes narrowing of blood vessels, which indicates functional changes not only in the bronchi, but also in blood vessels and circulatory disorders that increase oxygen deficiency.
In patients with a long course of B. a. hron develops. obstructive pulmonary emphysema, cor pulmonale. Microscopically, muscle hypertrophy, sharp thickening and homogenization of the basement membrane are noted in the bronchi; metaplasia of the epithelium into multilayered squamous epithelium and sclerosis of the alveolar septa are often observed.
Electron microscopic studies have shown that thickening of the basement membrane occurs as a result of sclerosis and an increase in collagen mass.
At immunological research Conducted in recent years by American scientists, the localization of immunoglobulin E on the basement membranes, in epithelial cells and mucous glands (mainly small bronchi) has been established both during an attack and for some time after it.
It is assumed that the interaction of immunoglobulin E with the antigen occurs on the basement membrane.
As a rule, B. a. preceded by other diseases of the respiratory system (pre-asthma). Infectious-allergic form of B. a. usually preceded by acute protracted or chronic. bronchitis, acute protracted or chronic. pneumonia, infectious-allergic rhinosinusopathy with or without polyposis, purulent lesions paranasal sinuses nose Listed chronicles. Infectious processes subsequently accompany B. a., influencing its course. The atopic form is preceded by allergic non-infectious rhinosinusopathy without polyposis, allergic non-infectious bronchitis.
The clinical picture of preasthma, in addition to the symptoms characteristic of the listed diseases, is characterized by a paroxysmal cough, dry or with a small amount of sputum, without a subjective feeling of difficulty breathing. When auscultating the lungs, especially during a coughing attack, dry rales are heard. Eosinophils and Charcot-Leyden crystals are usually found in sputum. When studying function indicators external respiration a moderately severe violation of bronchial obstruction is determined. However, preasthma does not occur in all patients. Often, especially in the atopic form, the disease begins suddenly, without clinical warning signs. The duration of preasthma varies - from several days to several years. At proper treatment transition to B. a. not required.
B. a. is a chronic disease, occurs with exacerbations, which in most cases are replaced by periods of remission. In the first stage of the disease, its main expression in both forms is attacks of expiratory suffocation. Depending on the severity of the attacks, the disease is classified into mild, moderate and severe. The first stage of the infectious-allergic form (when attacks of suffocation are mild, poorly defined, but the clinical picture of diffuse bronchitis is pronounced, elements characteristic of the allergic process are found in the sputum and blood) is often called asthmatic bronchitis.
The second stage is characterized by almost constant expiratory shortness of breath, against which severe attacks of suffocation and an asthmatic state occur. More often B. a. begins with mild attacks, passing successively through the stages of moderate and severe manifestations of the first stage, and then passes into the second stage of the disease. However, this is not natural. The disease may remain mild for many years or begin with more or less severe symptoms and progress quickly.
The severity of the attack is determined by the subjective characteristics of the patient, the severity of suffocation, auscultatory data, and the method of administering the medications necessary to relieve it (mild attacks are stopped by inhaling bronchodilators or taking them orally, more severe ones require subcutaneous or intravenous injections).
During a mild attack, the patient experiences slight expiratory difficulty breathing; he moves freely, there is no pallor or cyanosis. With percussion - a pulmonary sound, with auscultation - the exhalation is moderately prolonged, the number of dry wheezing rales is small.
Moderate attacks may be accompanied by a more pronounced feeling of suffocation, pallor of the skin, and moderate cyanosis. Breathing is noisy, wheezing can be heard from a distance. During percussion, the sound has a boxy tint. On auscultation, exhalation is prolonged and there is a significant amount of dry wheezing. In severe attacks, all of the listed symptoms are even more pronounced. The patient takes a forced position - sitting, leaning on his elbows or palms, which helps to include auxiliary muscles in the act of breathing. The skin is pale and moist. The chest is fixed in position take a deep breath. Breathing is initially rapid, then slows down, and buzzing and whistling wheezing can be heard from a distance. Upon percussion, a box sound is detected, the lower boundaries of the lungs are lowered. It is almost impossible to determine the nature of the main respiratory sounds by auscultation; exhalation is sharply prolonged. On inhalation and especially on exhalation, a lot of high-pitched dry rales are heard.
The asthmatic condition is characterized by more or less severe expiratory suffocation, which cannot be relieved with conventional bronchodilator drugs during the day. The general condition of the patient is grave, the position is forced, as in a severe asthma attack. The skin is cyanotic. With percussion and auscultation of the lungs, a picture is similar to that of a severe asthmatic attack. In the most severe cases, due to increasing obstruction of the bronchial tree with viscous mucus, respiratory sounds may not be audible (symptom of a “silent” chest). Long-term disturbance of alveolar ventilation causes increasing hypoxia (see), then hypercapnia (see) and respiratory acidosis (see). The latter can lead to the development of a clinical picture of acidotic coma (see).
Patients in a severe asthmatic condition cannot move, refuse to take food and liquids, and therefore symptoms of dehydration are possible (see Dehydration).
In severe attacks of suffocation and especially in an asthmatic state, symptoms are usually observed that reflect the state of the cardiovascular system: tachycardia without severe heart rhythm disturbances, often transient arterial hypertension. The boundaries of relative cardiac dullness are difficult to determine due to pulmonary emphysema. Heart sounds are dull, more clearly heard at the site of the tricuspid valve projection, with a slight accent of the second tone on the pulmonary trunk.
Symptoms of right ventricular heart failure may be observed: swelling of the neck veins, congestive enlargement of the liver with positive symptom hepatic-jugular reflex (swelling of the jugular veins when pressing on the liver), edema starting from the lower extremities and reaching the degree of anasarca in severe cases. The ECG shows signs of overload of the right heart. In severe cases of B. a. an asthmatic condition can also occur in the first stage of the disease. The severity and nature of the course are largely determined by the form of the disease.
In the non-infectious allergic form of B. a. An attack of suffocation is most characterized by a sudden onset, rapid development and rapid completion under the influence of bronchodilators, but prodromal phenomena are often observed in the form of an allergic runny nose, itching in the nasopharynx, skin itching, a feeling of constriction in the chest, drowsiness, yawning. This form is characterized by a mild to moderate course. After an attack, a cough appears with the release of a small amount of mucous sputum. Outside of an attack in the early stages of the disease, no pathology can be detected in the lungs. Laboratory examination reveals moderate blood eosinophilia (5-8%), in the sputum there are eosinophils, spiral-shaped threads of dense mucus (Curschmann spirals) and Charcot-Leyden crystals formed during the breakdown of eosinophils.
Characteristic signs of dysfunction of external respiration in the form of a pronounced decrease in the vital capacity of the lungs, the volume of one-second forced expiration, the Tiffno index (see Votchala - Tiffno test), a decrease in the volumetric expiratory flow rate, and an increase in the work of external respiration are found in uncomplicated atopic asthma only during an attack.
In the infectious-allergic form of B. a. the attacks are prolonged and do not have a “classical” acute onset and a clear ending. Cough occurs not only at the end of an attack, but also at the beginning, as well as in the inter-attack period. The sputum is mucopurulent. Prodromal phenomena are less common. Auscultatory symptoms in the form of prolonged exhalation, dry low-pitched wheezing or moist medium-bubbling wheezing (a picture of diffuse bronchitis) remain even outside of an attack. In the blood test - often high eosinophilia (10-20%), often neutrophilic leukocytosis with a shift to the left, accelerated ROE. In sputum analysis, in addition to the elements listed above, there is a significant number of neutrophils.
Signs of dysfunction of external respiration are detected not only during an attack, but also in the inter-attack period, although less pronounced.
For the infectious-allergic form of B. a. Moderate to severe course is typical. As a severe, prognostically unfavorable variant of infectious allergic B. a. allocate the so-called asthmatic triad - a combination of asthma, recurrent nasal polyposis and intolerance to acetylsalicylic acid and pyrazolone analgesics (eg, amidopyrine).
The difference between atopic asthma and infectious-allergic asthma, in addition to the nature of the attack and the severity of the course, is the following: an earlier age of onset of the disease, a more frequent presence of allergic diseases in the family and personal history, frequent spontaneous remissions (due to cessation of contact with a specific allergen - the so-called elimination effect ).
In cases of severe course with any form of B. a. Neuropsychic disorders often develop, and depression may occur.
A typical complication of B. a. is obstructive pulmonary emphysema (see). In the atopic form of the disease, it develops only as a result of a long-term course; in the infectious form, it develops much earlier, often already in the first or second year of the disease. For infectious-allergic B. a. the development of peribronchial diffuse pneumosclerosis is characteristic (see). Chron. infectious bronchitis often develops during a long course of atopic bronchitis, being its complication. Acute hypoxia during attacks and morphological changes in the lung tissue lead to the development of hypertension in the pulmonary artery system with the subsequent formation of cor pulmonale and right ventricular heart failure (see Cor pulmonale). Development hron. Pulmonary heart failure more often and earlier complicates the course of the infectious-allergic form of B. a.
In rare cases, there may be more or less extensive atelectasis (see), spontaneous pneumothorax(see) due to rupture of an emphysematous lung at the height of an attack. Rib fractures have been described at the height of an attack during long-term treatment with corticosteroids.
Diagnosis of B. a. includes: diagnosis of the disease and specific diagnostics - determination of the spectrum of allergens that are the causative factors of the disease in a given patient.
The diagnosis of the disease and an approximate determination of its form are made on the basis of the typical clinical signs listed above.
Great importance is attached to laboratory research.
In cases where clinical manifestations do not provide sufficient grounds for diagnosis, acetylcholine and novodrinum tests may be recommended as an additional research method. The acetylcholine test determines the threshold of sensitivity of the tissues of the bronchial tree to acetylcholine. The latter is given to the patient by inhalation in increasing quantities, starting from 10 mcg. In healthy people, signs of bronchial obstruction, recorded by special devices, appear after inhaling 10,000 mcg of acetylcholine. With B. a. the threshold of excitability is lowered - signs of impaired bronchial obstruction are observed after inhalation of 10 - 1000 mcg of acetylcholine.
The novodrinovy test is used to identify the so-called. hidden bronchospasm. In a person who does not have B. a., inhaling a solution of novodrin does not cause an increase in the Tiffno index. Patient B. a. with subclinical impairment of bronchial obstruction it increases by 10-20%.
Specific diagnosis of B. a. carried out in qualified conditions medical institutions. An allergic history often gives reason to assume the etiological role of household allergens based on the elimination effect (remission when leaving home), as well as epidermal, food, and occupational allergens; for pollen B. a. there is a clear seasonality of exacerbations; infectious - characterized by the connection of exacerbations with respiratory infections.
Skin tests (see) begin with the scarification method and only with negative or questionable results proceed to the intradermal method, since with it a reaction in the form of an attack of suffocation is possible. In older and older people, due to age-related changes in the skin, its blood vessels and due to altered general immunological reactivity, skin tests for allergens are less indicative.
Of the provocative tests (see), inhalation tests are used for etiological diagnosis. Sometimes the Prausnitz-Küstner reaction is used (see). If there is a suspicion of drug and food allergies carry out cell tests - leukocyte tests (see), thrombocytopenic test (see), basophil test (see), mast cell degranulation reaction (see). A specific diagnosis can be considered correct only if the results of all or most of the methods used coincide. Great importance is attached to specific diagnostic methods when deciding on the profession and character of B.a.
Differentiate B. a. accounts primarily for hron. bronchitis and asthmatic syndromes. Banal chronicle. bronchitis (see) may be accompanied by attacks of expiratory shortness of breath, but it usually does not reach the degree of suffocation characteristic of B. a.; dry wheezing of a lower tone, absent typical signs allergies (blood eosinophilia, corresponding elements in sputum). Skin allergy tests are negative. Attacks of suffocation during chronic bronchitis is usually not relieved by adrenaline and other bronchodilators, but only alleviated.
Asthmoid syndromes with tumors and foreign bodies of the bronchi, in addition to the absence of signs of allergy, often give more pronounced auscultatory symptoms on the affected side, as well as characteristic radiological and bronchoscopic data. Asthmoid syndrome with periarteritis nodosa (see Periarteritis nodosa) is characterized by blood hypereosinophilia. Often this syndrome exists for years as the only sign of the underlying disease and only later are the symptoms of a systemic vascular disease characteristic of the latter added.
Often B. a. must be differentiated from cardiac asthma (see table. Main indicators of differential diagnosis of bronchial and cardiac asthma). An important point in the differential diagnosis is anamnesis. Indications of arterial hypertension, coronary insufficiency, previous myocardial infarction, valvular lesions of the heart, as well as increased size of the heart and liver, edema and other symptoms noted during an objective examination, speak in favor of cardiac asthma (see). Particularly difficult differential diagnosis, when with B. a. decompensation occurs according to the right ventricular type.
If clinical differences cannot be identified, then a number of medications can be used to relieve an attack, which are effective in both forms of asthma - intravenous administration of xanthine drugs (aminophylline, etc.) in combination with strophanthin.
In recent years, cases of cystic fibrosis have been described in children and adults, when a viscous mucous secretion in the bronchi creates an auscultatory picture similar to B. a., and the need for a differential diagnosis arises. These patients are characterized by simultaneous lesions of the gastrointestinal tract. tract, pancreas, high concentration of chlorides and sodium in the secretion of the sweat glands (see Cystic fibrosis).
The main methods of x-ray examination for B. a. are fluoroscopy and radiography of the chest cavity. For a more detailed study of the functional state of the lungs and examination of work ability, more complex special x-ray techniques are used: x-ray kymography (see) 7 electrokymography (see) and x-ray cinematography (see). X-ray examination for B. a. helps determine the severity of asthma, as well as the presence of complications and concomitant diseases. X-ray picture lungs with B. a. depends on the stage of development of the disease and the severity of the course. During the interictal period at the onset of the disease, there are no radiological changes. In the first stage, in severe cases, and in the second stage, pulmonary emphysema, cor pulmonale, and other complications of B. a. are detected radiologically.
During an attack of suffocation in patients, the following is determined: increased transparency of the pulmonary fields with a decrease or complete absence of differences in transparency during inhalation and exhalation; sharp limitation or complete absence of mobility of the diaphragm, flattening and low standing of its domes; limited mobility of the ribs with their horizontal direction and expansion of the intercostal spaces; excited pulsation of the heart, bulging of the outflow tract of the right ventricle and the arch of the pulmonary trunk; an increase in the shadow of the roots of the lungs and blurring of their contours, an increase in the pulmonary pattern. Most of the listed symptoms are explained by acute swelling of the lungs and circulatory disorders in them. These changes can be observed against the background of complications and concomitant diseases (pulmonary emphysema, acute or chronic pneumonia, pleural changes, petrification, tuberculosis infiltrates).
In the second stage of the disease, bronchiectasis and other morphological changes may appear.
In the atopic form of B. a. in the first and even second stages of the disease, after cessation of contact with a specific allergen or as a result of specific hyposensitization, recovery or long-term remission may occur. Working capacity is impaired during periods of severe exacerbations, and is lost completely only during a long course with the addition of hron. bronchitis and typical complications. Fatalities with this form are rare.
Infectious-allergic asthma is prognostically much more severe. The ability to work is often impaired, especially during the cold seasons of the year. Remissions are rare. In severe cases and early development of complications, patients often become disabled in the 2-3rd year of the disease. The prognosis for the asthmatic triad is considered especially unfavorable. In recent years, cases of death in an asthmatic state due to infectious-allergic asthma have become more frequent.
Treatment |
Acute attack of B. a. usually relieved by adrenaline and its derivatives, ephedrine, aminophylline. Depending on the severity of the attack, it may be recommended different ways administration of drugs. In recent years, sympathomimetic drugs have been synthesized that selectively stimulate (32-adrenergic receptors (isadrin, novodrin, euspiran, alupent, asthmapent, etc.) and therefore are almost devoid of side effects characteristic of adrenaline. They are used, as a rule, in inhalations, certain per os and usually quickly stop mild asthma attacks.However, an overdose of these drugs in inhalation (use more than 4-6 times a day) can provoke an inflammatory process in the respiratory tract due to increased desquamation of the epithelium or cause bronchospasm due to the formation of adrenaline derivatives with (β- blocking effect and lead to an asthmatic condition (the so-called drug-induced breathing syndrome).For oral administration, a mixture of aminophylline (0.15 g) with ephedrine hydrochloride (0.025 g) or aminophylline in an alcohol mixture according to the prescription is also recommended:
Rp. Euphyllini 3.0 Sir. Althaeae 40.0 Spirit. vini 12% ad 400.0 MDS. 1 table each. l. appointment.
The use of atropine preparations is not recommended due to the fact that they complicate the separation of sputum. Widespread for stopping and preventing attacks of B. a. received combination drugs - theofedrine, antasman, solutan, but the first two contain amidopyrine, the third - iodine, to which patients are often allergic. Patients with manifestations of allergic rhinitis are prescribed antihistamines(diphenhydramine, etc.), which in themselves are usually an attack of B. a. not docked.
Moderate asthma attacks can be treated with the drugs listed above, but more often in the form of subcutaneous injections: Sol. Adrenalini hydrochloridi 0.1%-0.2 ml + Sol Ephedrini hydrochloridi 5%-0.5 ml; At the same time, it is rational to inhale any of the sympathomimetic drugs. The administration of adrenaline in large doses is dangerous due to possible adverse reactions from the cardiovascular system.
For severe attacks, all of the listed remedies are indicated, and if the effect does not occur, intravenous administration of Sol. Euphyllini 2.4% -10 ml +Sol. Glucosae 40% -20 ml (administer slowly over 4-6 minutes). At the same time, oxygen is inhaled. Drugs of the morphine group, due to their inhibitory effect on the respiratory center, as well as histamine-liberating and antitussive effects, are strictly contraindicated in patients with B. a.
When providing emergency care, the severity of complications must be taken into account. So, with severe emphysema of the lungs and hron. respiratory failure, oxygen is indicated even for mild attacks. Signs of chronic pulmonary heart with right ventricular failure serve as an indication for the administration of appropriate drugs. Cardiac glycosides are prescribed in usual doses: digoxin 0.25 mg 3 times a day for 3-4 days, then switch to maintenance doses - 0.25 mg per day. In severe cases, intravenous administration of 0.5-1 ml of 0.06% solution of corglycon or 0.5-1 ml of 0.05% solution of strophanthin is indicated, usually in a dropper along with 10 ml of 2.4% solution of aminophylline in 200-250 ml of 5% glucose solution or isotonic sodium chloride solution. Among diuretics, hypothiazide (25-100 mg per day), furasemide in combination with aldosterone antagonists (aldactone 0.1-0.2 g per day) are recommended. Restriction of fluid and salt intake is indicated.
In the USSR and abroad, acupuncture is used for uncomplicated forms of B. a., as well as to relieve attacks (see).
An asthmatic condition is an indication for emergency hospitalization in a therapeutic or intensive care unit. If the patient's condition is not very severe, they begin with an intravenous drip of Sol. Euphyllini 2.4% -10 ml+Sol. Ephedrini hydrochloridi 5% -1 ml+Sol. Corglyconi 0.06% -1 ml in 500 ml of 5% glucose solution or isotonic sodium chloride solution (the amount of liquid can be increased to 1.5-2 l if signs of dehydration are noted). If there is no effect after 30-40 minutes. after the start of drip infusion, it is necessary to administer intravenous drips of corticosteroids. The dose of the latter is prescribed purely individually, based on the severity of the condition, as well as whether the patient has previously been treated with these drugs, for how long and in what doses. The minimum initial dose for a patient who has not received steroids is 30 mg3% prednisolone hydrochloride solution. In severe cases, up to 150-180 mg of prednisolone per day can be administered parenterally.
The use of ACTH intramuscularly up to 40 units per day is less effective and does not exclude the possibility of an allergic reaction. Synthetic drugs of similar action (humactide - 28-0.4 mg, corresponding to 40 units of ACTH, synacthen - 0.25 mg) are safe in terms of the possibility of sensitization and are very effective in moderate asthmatic conditions.
Regardless of the severity of the condition, it is necessary to immediately prescribe drugs that thin sputum and promote coughing, antibacterial therapy, if indicated, and tranquilizers. For acidosis, intravenous drip administration of a 5% sodium bicarbonate solution is indicated - 100 ml or more (under the control of determining blood pH). Inhalations of pure humidified oxygen are indicated, but for patients with pulmonary emphysema and previous chronic. respiratory failure should be prescribed with caution, because they develop hypoxemic stimulation respiratory center, and an overdose of oxygen can lead to respiratory arrest.
Of additional importance in the treatment of an asthmatic condition, as well as the usual exacerbation of the disease, is the administration of native plasma and albumin, which bind chemical mediators circulating in the blood.
If the above measures have no effect, mechanical drainage of the bronchial tree should be started using a catheter inserted through the nose, an endotracheal tube or a bronchoscope. Before starting to suck out mucus using suction, it is useful to inject endotracheally to liquefy it 50 mg of crystalline trypsin dissolved in 10 ml of isotonic sodium chloride solution. Lavage of the bronchial tree is effective - washing the bronchi with large quantities of warm isotonic sodium chloride solution or antiseptic solution with simultaneous suction of the rinsing water. During this manipulation, all lobar bronchi are sequentially washed. The total amount of liquid for rinsing is 500-750 ml. If the patient's condition continues to deteriorate, resuscitation measures are indicated.
Features of resuscitation in asthmatic conditions. The need for resuscitation arises during a prolonged and pronounced attack of B. a., when ventilation disturbances lead to the threat of the development of terminal conditions due to deep hypoxia, respiratory and metabolic acidosis. These pathological changes determine the features of resuscitation for B. a.
Since hypoxia is the most dangerous, the prelude requires oxygen therapy (see) using inhalers or an anesthesia machine (see Oxygen-breathing equipment). Another attempt to reduce bronchospasm is anesthesia with fluorotane or nitrous oxide with oxygen. The use of ether is undesirable. In some cases, epidural anesthesia gives favorable results (see Local anesthesia). As the bronchodilator effect of fluorotane manifests itself (facilitation of inhalation, reduction of cyanosis, deepening of breathing), it is necessary to reduce the concentration of its vapors or stop its inhalation altogether, because with the restoration of alveolar ventilation and a rapid drop in p CO 2 in the arterial blood, a decrease in blood pressure occurs, to -swarm as a result of the ganglion-blocking effect of ftorotan can worsen up to asystole.
Nitrous oxide and ether are inferior to fluorothane in terms of bronchodilator effect; The disadvantage of ether is also the stimulation of the secretion of glands of the bronchial mucosa and the ability to cause excitement.
In case of a coma or the threat of its development, you should immediately begin artificial respiration (see) in the mode of intermittent positive pressure. Positive inspiratory pressure is increased to 45-50 cm of water. Art.; the negative phase during exhalation is contraindicated. To synchronize the patient's breathing with a respirator in the first hours of treatment, a large minute volume of breathing (exceeding the patient's own minute breathing volume) with a high oxygen content in the respiratory mixture (80-100%) is required. Systematic intravenous administration of sodium hydroxybutyrate in combination with antihistamines and analgesics is also indicated. In case of pronounced bronchospasm and the ineffectiveness of these measures, muscle relaxants are used (see). To reduce the viscosity of sputum and facilitate its removal, it is necessary to constantly drip into the trachea an isotonic solution of sodium chloride with proteolytic enzymes or include an aerosol inhaler, preferably an ultrasonic one, in the apparatus circuit. After reducing hypoxia and hypercapnia, it is necessary to correct the operation of the respirator by gradually reducing the minute volume of breathing by slowing breathing to 18-16 per minute while maintaining a large tidal volume (600 - 800 ml) and reducing the oxygen concentration to 40-60%. Subsequent cessation of artificial ventilation should be done gradually.
In case of a pronounced attack of bronchospasm, reaching the degree of total bronchospasm, lung massage is sometimes used (see Bronchospasm).
In the complex of resuscitation measures, medications should be used that have a bronchodilator effect, adrenomimetic, antihistamine, antispasmodic, anticholinergic substances, glucocorticoids, etc. The effectiveness of these drugs during resuscitation should not be overestimated, since they are usually used in the treatment of B. a ., and the attack occurs against the background of their therapy. Drugs that promote bronchial contraction are contraindicated. For example, β-blockers should not be used to combat tachycardia.
Correction of water-electrolyte and acid-base balance, parenteral nutrition are necessary.
Nonspecific treatment methods. In severe cases of the disease, when all other interventions are insufficiently effective, the use of corticosteroid hormones and their analogues is indicated (see Corticosteroid drugs). However, they must be prescribed very carefully due to the possibility of serious complications with long-term treatment. When prescribing for the first time, a daily dose of prednisolone of 20-30 mg is recommended (triamcinolone, respectively, 16-20 mg, dexamethasone 2-3 mg). The course of treatment should be short: once the effect is achieved, the dose of prednisolone is reduced by 5 mg every day. Recently they have been offering the so-called. alternating treatment with corticosteroids: the drug is prescribed every other day or three days a week in a row (the other four days the patient does not receive it). With this treatment, adrenal function is less inhibited. Attempts to cancel hormones or reduce doses during long-term treatment with them can be carried out while taking drugs that potentiate their effect - ascorbic acid, resokhin (Delagil, Plaquenil) and stimulating adrenal function (etimizole).
To prevent and eliminate complications of steroid therapy, it is necessary to prescribe anabolic hormones, potassium preparations, diuretics, and alkalis according to indications.
There are reports of attempts to treat B. a. immunosuppressants such as 6-mercaptopurine. The widespread use of these drugs is still limited due to their toxicity.
With infectious B. a. in the acute stage in cases of pneumonia and other infectious processes, antibacterial therapy is necessary. Before prescribing it, you need to carefully ask the patient about episodes of drug allergies. Indications of even mild reactions exclude the use of the drug that caused them. Due to its pronounced antigenic properties, it is better not to prescribe penicillin to asthmatics at all. Antibiotics wide range action and long-acting sulfonamides (sulfadimethoxine, etc.) are prescribed in usual doses for at least two weeks. Careful monitoring is necessary during treatment. If local allergic reactions, skin itching, urticaria, or increased blood eosinophilia occur, the drug is immediately discontinued. It can only be replaced with a drug from another group that does not have a similar chemical structure. In the remission stage, surgical sanitation of such foci is necessary. infections, such as purulent sinusitis, hron. tonsillitis.
In cases of difficulty in coughing up mucus, especially with concomitant bronchitis, expectorants are necessary. It is best to use a 3% solution of potassium iodide, 1 tablespoon at a time. l. 3-4 times a day, in cases of iodine intolerance - ammonium chloride 0.5-1.0 g 3-4 times a day. With caution, given the possibility of allergic reactions, inhalation of enzyme solutions (trypsin, chymopsin, deoxyribonuclease) can be used. It is safe and in some cases effective to prescribe inhalations of isotonic sodium chloride solution heated to 37°C (5-10 ml). Special exercises in a complex of therapeutic gymnastics (see below) are good for coughing.
In almost all cases B. a. Sedative and tranquilizing therapy is indicated.
For mild neurotic reactions, psychotherapy is sufficient. In other cases, depending on the manifestations (insomnia, fear, tearfulness, irritability), small doses of barbiturates and minor tranquilizers (seduxen, elenium, nopatone, etc.) in usual dosages are indicated. The administration of major tranquilizers (aminazine, etc.) is not recommended due to their inhibitory effect on the respiratory center.
In 1967 in England it was proposed in principle new drug for long-term treatment of B. a. - intal. It is believed that its mechanism of action is reduced to inhibition of the release of all chemical mediators caused by the antigen-antibody reaction. The drug is most effective for the atopic form of the disease.
Treatment of B. a. histaglobulin is more effective in childhood.
All patients with B. a. Diet therapy is indicated: the so-called. hypoallergenic diet with the exclusion of foods with pronounced antigenic properties (eggs, citrus fruits, fish, nuts, strawberries), spicy, sour, irritating dishes and seasonings. It is recommended to eat small meals 4-5 times a day in small quantities. Patients for whom food products are allergens are prescribed individual elimination diets.
Specific treatment is effective in the early stages of the disease in the absence of significant complications. Specific therapy for the atopic form of B. a is well developed and used in specialized medical institutions. It includes cessation of contact with specific allergens, where possible, and specific hyposensitization (see).
Subject to a complete specific diagnosis and taking into account contraindications, specific therapy gives good long-term results in 70-80% of cases of atopic B. a. The most effective treatment for pollen (hay) and dust (household) asthma.
As a specific therapy for the infectious-allergic form of the disease, treatment with auto- and heterovaccines and bacterial allergens is used after preliminary specific diagnosis. Efficiency approx. 50%.
Physiotherapeutic treatment of patients with B. a. can be carried out both during an exacerbation and during a period of remission, depending on the severity of the course and treatment conditions (hospital, clinic, sanatorium).
During attacks, physiotherapy for infectious-allergic and atopic forms of B. a. is aimed at reducing or eliminating bronchospasm, restoring the ventilation and drainage functions of the bronchopulmonary system. To treat patients with infectious-allergic forms, physiotherapy is widely used in combination with other treatment methods; For patients with atopic form, physiotherapy is prescribed only if hyposensitizing therapy is insufficiently effective.
During this period, a number of treatment methods are used, but the most effective are considered to be exposure to currents and fields of high, ultra-high and ultra-high frequencies, as well as ultrasound. A UHF electric field with a power of 80-100 W is applied to the chest area with anteroposterior or lateral placement of the electrodes, the dose is low-thermal; per course 6-8 procedures lasting 10-15 minutes. daily (see UHF therapy).
Inductothermy (see) is carried out on the interscapular area with an inductor - a cable or disk at a current strength of 180-220 mA daily or every other day; per course 10-12 procedures lasting 10-15 minutes. daily.
Microwave therapy (see) with a power of 30-40 W is carried out on the interscapular area with a cylindrical emitter with a diameter of 14 or 18 cm. The distance between the emitter and the skin surface is 5-7 cm; per course 10-12 procedures for 10-15 minutes. daily.
Ultrasound treatment is carried out according to the scheme. On the first day of treatment, paravertebral fields D I - D XII are affected; ultrasound intensity 0.2 W/cm 2, exposure duration 3 minutes. to the right and left margins. On the second day, the paravertebral fields are affected according to the above method, as well as the VI-VII intercostal spaces (below the shoulder blades); the intensity of the last exposure is 0.4 W/cm 2, duration is 2 minutes. left and right. On the third day, an effect on the subclavian zones is added to the indicated zones, the intensity is 0.2 W/cm2, duration is 1 minute. from each side. Then all subsequent procedures are carried out without changes daily for 8 days, and then every other day, for a total of 12-15 per course. Vaseline oil is applied to the affected areas during ultrasound treatment.
Ultrasound can be used to administer medications; this method is called phonophoresis. In patients with B. a. hydrocortisone phonophoresis is used. To do this, an ointment of the following composition is applied to the areas affected by ultrasound: hydrocortisone suspension - 5 ml, petroleum jelly and lanolin - 25 g each. Hydrocortisone introduced by ultrasound, enhancing the effect of the latter, has a desensitizing and anti-inflammatory effect. Hydrocortisone phonophoresis is successfully used to prevent complications that arise in patients with B. a. when withdrawing corticosteroid hormones (see Ultrasound therapy), to increase the glucocorticoid function of the adrenal glands, electromagnetic oscillations of the decimeter-wave range are used at the site of their projection - UHF-therapy (see Microwave therapy) or inductothermy. DMV therapy is carried out at level D X - L II in front and behind at a distance of 5-10 cv from the skin; intensity of exposure 30-40 watts, duration 7-10 minutes. on the field every day; per course 16-18 procedures. Inductothermy is carried out with an inductor cable around the body at level D x - L IV at a current strength of 160-180 mA for 15 minutes; for a course of 10-12 procedures, 4 per week with breaks of 1-2 days.
But to stop an attack or if there are contraindications to the above effects, patients are shown electrophoresis of calcium chloride, papaverine, aminophylline, ascorbic acid, novocaine, etc. (see Electrophoresis, medicinal substances). A pad with the recommended medicinal substance is placed on the interscapular area. The current strength is up to 6-8-10 mA. for a course of 10 - 12 procedures every other day, lasting 15-20 minutes. You can also use ultraviolet radiation in erythemal doses. Field irradiation of the chest is used more often; field area 300-400 cm 2. The irradiation intensity in the first procedure is 2-3 biodoses per field, with each subsequent procedure the irradiation intensity increases by 1-2 biodoses. One field is irradiated in one procedure, a total of three irradiations of each field are performed after 1-2 days (see Erythemotherapy).
The procedures listed above can be carried out in combination with inhalations of bronchodilators, expectorants, sulfonamides, antibiotics, enzymes, taking into account the individual characteristics of the patient.
In the interictal period of infectious-allergic and non-infectious-allergic forms of B. a. Inhalation of aerosols and electroaerosols of bronchodilators, expectorants and other drugs is used. For the treatment of vasomotor rhinitis and allergic rhinosinusopathy, intranasal electrophoresis of calcium chloride and diphenhydramine is indicated. To influence the higher regulatory centers of the nervous system, electrosleep (see) is used at a pulse frequency of 10-20 Hz daily or every other day; per course 10-15 procedures lasting 20-40 minutes. In order to have a desensitizing effect and improve lung ventilation, aeroionotherapy with negative charges is used; per course 10-15 procedures for 5-15 minutes. daily (see Aeroionization). During the same period, restorative treatment is indicated.
Spa treatment of patients with B. a. is one of the stages of complex therapy and is carried out at resorts with a mountain climate (An-Tash, Kislovodsk, Kuryi, Nalchik, Surami, Tsemi, Cholpon-Ata, Shovi, Shusha), sea (Alushta, Gelendzhik, Yalta) and in local sanatoriums for treatment of patients with non-tuberculosis lung diseases (sanatorium "Barnaulsky" in the Altai Territory, "Zholinsky" - Gorky Region, "Chernaya Rechka" - Leningrad Region, "Ivanteevka" - Moscow Region, "Solnechny" - Chelyabinsk Region, "Cheremshany" - Saratov Region region, “Shivanda” - Chita region, etc.).
Resort treatment in a mountain climate is indicated for patients with the atopic form of B. a. regardless of the stage of the disease, for patients with an infectious-allergic form - in the absence of severe emphysema and exacerbation inflammatory process. Persons with severe pulmonary insufficiency and signs of prolonged inflammatory process in the lungs, but without frequent severe attacks of suffocation, without signs of fungal allergies and high sensitivity to physical factors(humidity, insolation) treatment at seaside resorts is indicated. When choosing a period of year for spa treatment the degree of meteotropicity of patients is taken into account.
Contraindication for the treatment of patients with B. a. at climatic resorts are: general contraindications that exclude sending patients to a resort, frequent attacks of suffocation in the infectious-allergic form of asthma, long-term use of large doses of corticosteroids, activation of the inflammatory process in the respiratory system against the background of significant organic changes in the lungs and decompensation of the pulmonary heart .
Treatment at local resorts should be recommended for patients with severe disease in order to consolidate the effect of drug treatment, as well as for persons with unstable remission and a tendency to frequent exacerbations of the inflammatory process in the lungs.
Features of spa treatment of patients with B. a. lie in the cumulative effect of climate, health path and mineral waters, which are different at different resorts. The climatic factor is of primary importance. Climatic mountain resorts and coastal resorts are year-round medical centers and have a high ability to rehabilitate patients. The effectiveness of treatment at local resorts with a typical climate for patients is ensured by the cleanliness of the air, the absence of substances that irritate the respiratory system, and allergens found in ordinary homes and working conditions. The positive effect of the coastal climate is due to the purity of the air, the presence of aerosols, various salts in it and the stimulation of the thermal adaptation mechanisms of patients. It should, however, be taken into account that in conditions of high coastal humidity, the “pathogenicity” of certain allergens (house dust, fungi) may increase, and excessive ultraviolet radiation can contribute to increased sensitization. The mountain climate, due to low atmospheric pressure, daily fluctuations in air temperature and the absence of allergens, promotes the activation of adaptive mechanisms of the external respiration and circulatory apparatus, strengthening the glucocorticoid function of the adrenal cortex and reducing the specific sensitization of patients.
The therapeutic effect of climate therapy increases from the use of health paths and therapeutic exercises aimed at reducing hyperventilation of the lungs, normalizing the ratio of the inhalation and exhalation phases and developing the diaphragmatic type of breathing. The nature of physical activity must be adequate to the degree of fitness of patients and the state of external respiration function. Long walks along routes with high elevations are indicated only for patients with stable remission in the absence of pulmonary emphysema.
At climatic and balneological resorts, balneotherapy is successfully used. The effect of this type of treatment is associated with complex neurohumoral mechanisms. Balneotherapy is indicated for patients with B. a. in the absence of severe pulmonary insufficiency caused by pulmonary emphysema and hron. inflammatory process in the bronchopulmonary apparatus, as well as in the absence of exacerbation of chronic diseases. inflammatory process. Carbon dioxide bicarbonate-sodium waters increase the histaminopectic properties of blood serum in patients with allergic diseases. Mineral waters containing sulfur have an anti-inflammatory effect, so they are indicated for patients with B. a. from chronicle inflammatory process in the bronchopulmonary apparatus during remission. Carbon dioxide bicarbonate-sulfate-calcium-magnesium-sodium water (Kislovodsk resort) helps to increase bronchial patency and increase the reserve capacity of the external respiration apparatus. One of the types of treatment at balneological resorts is inhalation of mineral water aerosols, which are indicated in the interictal period, regardless of the form of the disease.
The effect of spa treatment is increased by the use of specific hyposensitization with non-infectious and infectious allergens. If this type of treatment was carried out before arriving at the resort, it should be continued, but taking into account the fact that the threshold of sensitivity of patients to allergens in a resort usually decreases.
In a number of countries (USSR, Poland) for treatment early stages B. a., especially in children, treatment in salt mines (exhausted), with the organization of sanatoriums near the mines and the use of climatic therapy, is successfully used. Spa treatment of patients with B. a. carried out in combination with other treatment methods.
Therapeutic exercise is an obligatory part of the complex treatment of B. a. in patients of any age. It helps restore impaired respiratory functions, promotes the separation of sputum, prevents the development or progression of emphysema, deformities of the chest and spine, increases the body's resistance, and strengthens the nervous system.
Therapeutic exercise is indicated in the inter-attack period of the disease. Contraindications may include exacerbation of the disease process, increased temperature, and the occurrence of severe complications.
The following forms of physical therapy are used: therapeutic exercises, dosed walking, hygienic exercises, and when working with children, also games and simulation exercises. Therapeutic gymnastics classes are carried out in the treatment prof. institutions (hospital, clinic, sanatorium) and at home.
A special feature of the method of therapeutic exercises is the use of special breathing exercises: exercises with an emphasis on prolonged exhalation, exercises to strengthen the main and auxiliary respiratory muscles, to develop diaphragmatic breathing, as well as exercises with loud pronunciation of the vowel sounds u, o, a and the consonants f, s, w. General strengthening exercises with gradually increasing load (use of dosed walking, running, certain exercises of a sports nature) are of great importance.
Classes are conducted individually with each patient or with a small group of 3-5 patients. For children, organized therapeutic gymnastics classes using a special technique can begin from the age of 4. The duration of treatment in a clinic setting should be at least 6 months. When visiting a physical therapy room 3 times a week.
In addition to gymnastics, chest massage, swimming, walking, especially before bed, and hardening are useful. Sunbathing is not recommended. During periods of long-term remissions, swimming, skating, skiing, rowing, and short-distance hiking are indicated. Participation in sports competitions prohibited until complete recovery. Daily gymnastics at home is recommended. Therapeutic gymnastics should gradually move into general physical education and be an obligatory element of the patient’s entire future life.
Surgical treatment is sometimes used in cases of ineffectiveness of conservative therapy for B. a. Clear indications and contraindications for surgical treatment have not yet been developed. Surgical interventions for B. a. can be divided into 4 types: tissue therapy, operations on the autonomic nervous system in the cervical and thoracic region, lung reimplantation and operations on the sinocarotid zone.
The method of tissue therapy proposed by V.P. Filatov (1939) and modified by G.E. Rumyantsev (1951) and others is not used today due to its low effectiveness.
The first operation on the autonomic nervous system for B. a. performed by Kiimmel in 1923. He removed the superior cervical sympathetic ganglion in four patients. In subsequent years, I. I. Grekov (1925) and V. S. Levit (1926) performed a two-stage operation - sympathectomy and then vagotomy. Later Miscall and Rovenstine (L. Miscall, E. A. Rovenstine, 1943-1950) in order to more completely interrupt reflex arc between vegetative nervous system and the lungs began to use the removal of 3-4 thoracic ganglia. However, the results of these operations were unsatisfactory.
In 1964 E. N. Meshalkin used new method surgical treatment of B. a. - lung reimplantation. A study of the immediate and long-term results of 20 lung reimplantations showed that this dangerous and complex operation does not solve the problem of surgical treatment of B. a.
The most widespread are operations on the sinocarotid zone in various modifications: glomectomy, glomectomy with denervation and subsequent alcoholization of the sinocarotid zone, alcoholization of the sinocarotid zone, resection of the sinus nerve.
For the first time, removal of the carotid glomus (see) in patients with B. a. performed by Nakayama (K. Nakayama) in 1942. Of 3914 patients who underwent glomectomy, positive results(noticeable or slight improvement) were detected in 2535 patients, which is 64.7% (1958, 1961, 1962).
According to E. S. Karashurov (1969), the results of glomectomy for up to 7 years are as follows: remission and significant improvement in 32.6-44.5% of patients, improvement in 33-41.8%, no effect was obtained in 22-44.5% of patients. 26.7% of patients.
Glomectomy surgery can be performed under local anesthesia, but better under anesthesia. Skin incision approx. 5 cm is made along the inner edge of the sternocleidomastoid muscle. The middle of the incision should be at the level of the upper edge of the cricoid cartilage, in the projection of the division of the common carotid artery. After dissecting the subcutaneous tissue and subcutaneous muscle, the tissues are moved apart to the fascia enveloping neurovascular bundle. After longitudinal opening of the fascia with a dissector, the common carotid artery and its branches are isolated.
Then the glomus is removed (see), after ligating the small artery that feeds it. The wound is sutured in layers, leaving a rubber strip in place for a day.
After surgery, in cases of difficulty breathing, bronchodilators are prescribed. Doses of steroid hormones, if they were used before surgery, are gradually reduced.
The main social and hygienic measures for the prevention of asthma are improving working and living conditions, combating air pollution and smoking, proper organization of work and rest, and reasonable methods of hardening the body. Of great importance is: limiting vaccinations for people with an allergic constitution; dispensary observation and rational treatment of patients with pre-asthmatic diseases - hron. bronchitis, chronic pneumonia, allergic, polypous and purulent diseases of the upper respiratory tract; specific therapy for hay fever and perennial allergic rhinitis.
For constitutional allergy sufferers, the choice of profession plays an important role - the professions of pharmacists and chemists are contraindicated for them; work in pharmaceutical factories, bakeries, in the production of natural silk, plastics, cotton processing, wool spinning and some other enterprises is not recommended.
In old and senile age as a result of hron. inflammatory processes in the respiratory tract (chronic bronchitis, chronic nonspecific pneumonia), as a rule, an infectious-allergic form of the disease develops. Age-related changes in the nervous and endocrine systems and features of the body’s reactivity, on the one hand, create a certain predisposition to the occurrence of the disease in the presence of sensitization, on the other hand, they determine a less acute, smoothed clinical course.
In most cases B. a. in such patients it manifests itself as a state of constant difficulty breathing with periodic attacks of suffocation. In this case, as a rule, hron is found in the lungs. inflammatory process. A characteristic attack of B. a. Against the background of complete health, it is extremely rare in elderly and old people. Exacerbation of the disease is mainly due to activation of hron. inflammatory process in the lungs or upper respiratory tract. Physical stress is also a provoking factor.
Current of B. a. in such patients it is progressive. Chron. inflammatory processes in the lungs cause the rapid progression of obstructive emphysema with the subsequent development of pulmonary heart failure. Consequently pulmonary insufficiency During an attack, increased breathing is observed. In some cases, acute heart failure develops, associated with reflex spasm of the coronary vessels, increased pressure in the pulmonary artery system, against the background of an already existing age-related weakening of myocardial contractility. This is largely facilitated by the hypoxia that occurs during an attack. Treatment tactics for B. a. in old and senile age it has certain features. During an attack of B. a. It is always necessary to include cardiovascular drugs in the complex of therapeutic measures, since due to age-related changes in the cardiovascular system, circulatory failure easily occurs in older people. Oxygen therapy is indicated. To relieve bronchospasm, both during an attack and in the interictal period, preference should be given to xanthine-type drugs (aminophylline, aminophylline, etc.).
The administration of adrenaline usually provides rapid relief of bronchospasm and thereby stopping the attack, however, caution is required when prescribing it, since it often causes pronounced changes in the cardiovascular system - a prolonged rise in blood pressure, overload of the left ventricle of the heart, various types of dysfunction of excitability, cerebrovascular accident. The dose of adrenaline should not exceed 0.3-0.5 ml in a dilution of 1: 1000. Before using adrenaline, ephedrine should be administered and isopropyl-norepinephrine preparations should be prescribed, which have a much lesser effect on hemodynamics.
The administration of various bronchodilator mixtures in the form of aerosols deserves special attention. The use of atropine should be avoided, since it promotes the formation of viscous sputum, which in elderly patients is difficult to separate, and this can lead to bronchial obstruction with the subsequent development of atelectasis. The use of drugs (morphine, promedol, pantopon, etc.) is contraindicated because they can easily lead to depression of the respiratory center.
Hormonal therapy (cortisone, hydrocortisone and their derivatives) gives a good effect both in terms of relief acute attack, and in his warning. However, due to the frequent development of side effects (increased blood pressure, exacerbation of latent diabetes, the emergence of a tendency to thrombus formation, the development of hypokalemia, progression of age-related osteoporosis), corticosteroids should be prescribed with great caution: their doses should be 2-3 times lower than for young, and the duration of treatment is no more than three weeks. It is less dangerous to administer hormonal drugs in the form of aerosols.
The use of potassium iodide is worthy of attention. If anxiety is expressed, taking minor tranquilizers is indicated. It should be remembered that taking barbiturates in elderly and elderly people can cause increased excitability and depression of the respiratory center.
Specific hyposensitization in elderly and senile people is rarely carried out.
Great importance should be attached to physical therapy, breathing exercises. The choice of spa treatment, as well as the amount of physical activity, should always be decided individually.
In recent decades, children, as well as adults, have seen an increase in the incidence of B. a. At the present time in the USSR, according to S. G. Zvyagintseva, S. Yu. Kaganov, N. A. Tyurin and other authors, it is approximately 3 per 1000 children's population. Usually children get sick with B. a. at the age of 2-4 years, with the atopic (non-infectious-allergic) form somewhat more often under the age of 3 years, and the infectious-allergic form at an older age. The distinction between infectious-allergic and atopic forms in children is often conditional. So, in patients with atopic form of B. a. attacks of suffocation may subsequently occur under the influence of infectious (usually respiratory) diseases, i.e., a polyvalent allergy develops. In such cases, they speak of a mixed form of B. a. Pathological anatomy of B. a. in children with a long course of the disease does not differ from that in adults.
Clinical picture. The appearance of the first attacks of B. a. in children, preasthma is often preceded: repeated respiratory diseases occurring against the background of allergies (exudative-catarrhal diathesis, urticaria, eosinophilia, etc.) or accompanied by asthmatic syndrome. Preasthma is most clearly expressed in children with an infectious-allergic form of the disease. Appropriate treatment during this period can help prevent B. a.
The immediate cause of the first attack of asthma, as a rule, is diseases of the upper respiratory tract, bronchitis, pneumonia, and less often - food allergens, injections of serums or vaccines, mental and physical injuries, etc.
Attacks of B. a. in children, regardless of the form, they usually develop gradually, over several hours or days, thanks to which a period of precursors of an attack can be distinguished: changes in behavior (excitement, excessive mobility or, conversely, lethargy, drowsiness), allergic runny nose, itchy nose, sneezing or obsessive cough, shortness of breath easily occurs. In the future, if it is not possible to prevent the deterioration of the condition, an attack of suffocation develops.
During an attack, the patient’s position is usually forced, semi-sitting; the expression on the face and eyes is frightened, the pupils are dilated. The skin is pale gray, cyanosis around the mouth and acrocyanosis are noted.
The chest is sharply swollen, the shoulders are raised; there is retraction of the chest below the nipples; expanded costal arches.
Breathing is rapid (in children early age up to 70-80 breaths per minute), with somewhat difficult inhalation and significantly difficult exhalation. The exhalation is prolonged and noisy, accompanied by dry wheezing. The cough may be rare, but usually worsens at the end of the attack; thick, viscous, viscous sputum is separated with great difficulty. In children, Kurschmann spirals and Charcot-Leyden crystals are rarely detected, and eosinophils are contained in significant quantities.
 The pulse is frequent; at the height of an attack of suffocation during inhalation, the filling of the pulse decreases, which can give the impression of arrhythmia. Blood pressure is determined within the upper limit of normal; the heart is located in the middle, its boundaries are difficult to determine due to pulmonary emphysema; Heart sounds are sharply muffled. The liver protrudes from the hypochondrium by 2 - 4 cm. The ECG shows tachycardia, deviation of the electrical axis of the heart to the right, high P wave in II - III leads, decreased T waves, signs of increased pressure in the pulmonary artery system and impaired myocardial recovery processes. A serious condition caused by an attack of suffocation gradually improves under the influence of treatment: breathing becomes freer, sputum is separated more easily. In the post-attack period, over the course of several days or weeks, the changes in the respiratory and circulatory organs that arose as a result of the attack reverse development. Often, against the background of organic changes in the lungs (chronic pneumonia), children experience the development of an asthmatic condition. Of the complications of an attack of B. a. It should be noted pulmonary atelectasis, pneumonia, much less often interstitial and subcutaneous emphysema, spontaneous pneumothorax. With a long and severe course of B. a. in combination with hron. bronchopulmonary process may develop hron. pulmonary heart. Death can occur from asphyxia during an attack of suffocation, less often - due to anaphylactic shock, adrenal hypofunction. The diagnosis is made on the basis of anamnesis, clinical, laboratory and radiological data, as well as the results of skin allergy tests. B. a. in children it is necessary to differentiate with bronchiolitis, pneumonia occurring with asthmatic syndrome, congenital enzymopathies (cystic fibrosis, α 1-antitrypsin deficiency, etc.), foreign bodies, developmental abnormalities and tumors of the respiratory tract; Difficulty breathing in children can also occur due to compression of the trachea and bronchi by enlarged lymph nodes and the thymus gland. ForecastTimely initiation of complex, systematically carried out staged treatment (hospital-sanatorium - clinic - forest school) in most children leads to an improvement in the condition and cessation of asthma attacks. In some patients, however, no improvement is observed. TreatmentTo relieve an attack of B. a. In children, the same drugs are used as in adults (in appropriate doses). Particular attention should be paid to mild and moderate attacks to prevent them from developing into severe, life-threatening ones. To do this, when the first symptoms of an attack appear, bronchodilators are used in the form of powders, tablets, suppositories or inhalations; It is recommended to place cups, make a foot and hand hot bath, drip a 3% solution of ephedrine hydrochloride into the nose. It is necessary to calm the child, distract his attention with toys, books, and provide good access to fresh air. In more severe cases, switch to subcutaneous injections solutions of adrenaline (0.1%, 0.15 - 0.2 ml per injection), ephedrine hydrochloride or intravenous (preferably drip) injections of a solution of aminophylline (theophylline) in an isotonic solution of glucose or sodium chloride. Among the drugs that improve the function of the circulatory organs, we can recommend injections of cordiamine, ATP, intravenous infusions of corglycone, cocarboxylase; The use of vitamin C is indicated. Inhalation of oxygen is recommended only in severe and prolonged asthmatic conditions; in other cases, fresh, cool air is preferable. If it is impossible to eliminate an asthma attack using these means, glucocorticoids (hydrocortisone, prednisolone, etc.) are prescribed intravenously or intramuscularly. In case of threatening asphyxia and the development of atelectasis, therapeutic bronchoscopy is indicated; it can only be performed in special conditions (intensive care unit) under general anesthesia with the use of muscle relaxants by a doctor who is fluent in the technique of bronchoscopy in children. During bronchoscopy, mucus from the bronchi is sucked out and bronchodilators are administered intratracheally. Because attacks of B. a. in children they are often accompanied by a bronchopulmonary infectious process, exacerbation of chronic purulent foci (tonsillitis, sinusitis, cholecystitis, etc.); in such cases, the prescription of antibacterial drugs is indicated. In the interictal period, children, as well as adults, are shown complex treatment of B. a., including specific and nonspecific (histaglobulin) hyposensitization, physiotherapy, physical therapy, compliance with the regime and diet, reorganization of chronic. foci of infection, spa treatment. Spa treatment for children and adolescents suffering from asthma is carried out at the resorts of the southern coast of Crimea, in Anapa, Kabardinka, and Kislovodsk. It is advisable to carry out treatment in local sanatoriums immediately after an exacerbation of the disease. Indications for spa treatment of children are determined by the nature of the clinical course of the disease and the climatic and geographical conditions of the resort. Usually it is indicated for patients with atopic and infectious-allergic B. a., in the absence of frequent attacks of suffocation and hron. pneumonia stages II and III, after sanitation of foci of infection. Climatotherapy has a hyposensitizing effect and helps to harden the body of children. For this purpose, in good weather, strictly dosed air and sun baths are used. If arrival at the resort does not cause activation of the inflammatory process in the lungs, balneotherapy is prescribed, and at sea coast resorts - sea bathing. Therapeutic exercises, walks, and games help normalize lung ventilation, strengthen the respiratory muscles and strengthen the nervous system. Prevention of B. a. in children is to reduce the possibility of sensitization of the body and prevent respiratory diseases: hardening and physical education from early childhood, early detection of exudative diathesis, exclusion of strong food allergens, strict adherence to contraindications when carrying out preventive vaccinations. Timely and rational treatment of children with preasthma is necessary. Are you categorically unhappy with the prospect of disappearing from this world forever? 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Surgical treatment is sometimes used in cases of ineffective conservative therapy for bronchial asthma. Clear indications and contraindications for surgical treatment have not yet been developed. Surgical interventions for bronchial asthma can be divided into 4 types: tissue therapy, operations on the autonomic nervous system in the cervical and thoracic region, lung reimplantation and operations on the sinocarotid zone.
The method of tissue therapy proposed by V.P. Filatov (1939) and modified by G.E. Rumyantsev (1951) and others is currently not used due to its low efficiency.
The first operation on the autonomic nervous system for bronchial asthma was performed by Kiimmel in 1923. He removed the superior cervical sympathetic ganglion in four patients. In subsequent years, I. I. Grekov (1925) and V. S. Levit (1926) performed a two-stage operation - sympathectomy and then vagotomy. Later, Miscall and Rovenstine (L. Miscall, E. A. Rovenstine, 1943-1950), in order to more completely interrupt the reflex arc between the autonomic nervous system and the lungs, began to use the removal of 3-4 thoracic ganglia. However, the results of these operations were unsatisfactory.
In 1964, E. N. Meshalkin used a new method of surgical treatment of bronchial asthma - lung reimplantation. A study of the immediate and long-term results of 20 lung reimplantations showed that this dangerous and complex operation does not solve the problem of surgical treatment of bronchial asthma.
The most widespread are operations on the sinocarotid zone in various modifications: glomectomy, glomectomy with denervation and subsequent alcoholization of the sinocarotid zone, alcoholization of the sinocarotid zone, resection of the sinus nerve.
For the first time, removal of the carotid glomus in patients with bronchial asthma was performed by Nakayama (K. Nakayama) in 1942. Of 3914 patients who underwent glomectomy, positive results (noticeable or slight improvement) were found in 2535 patients, which is 64.7% (1958, 1961 , 1962).
According to E. S. Karashurov (1969), the results of glomectomy for up to 7 years are as follows: remission and significant improvement in 32.6-44.5% of patients, improvement in 33-41.8%, no effect was obtained in 22-4. 26.7% of patients.
The glomectomy operation can be performed under local anesthesia, but it is better under general anesthesia. A skin incision about 5 cm long is made along the inner edge of the sternocleidomastoid muscle. The middle of the incision should be at the level of the upper edge of the cricoid cartilage, in the projection of the division of the common carotid artery. After dissection of the subcutaneous tissue and subcutaneous muscle, the tissues are moved apart to the fascia enveloping the neurovascular bundle. After longitudinal opening of the fascia with a dissector, the common carotid artery and its branches are isolated.
Then the glomus is removed, after ligating the small artery that feeds it. The wound is sutured in layers, leaving a rubber strip in place for a day.
After surgery, in cases of difficulty breathing, bronchodilators are prescribed. Doses of steroid hormones, if they were used before surgery, are gradually reduced.
- Treatment:
(Journal "Bulletin of Surgery" named after I.I. Grekov. Vol. 135. No. 10. 1985. P. 3-10)
Academician of the USSR Academy of Medical Sciences F.G. Uglov, Ph.D. tech. Sciences V.A.Kopylov, A.I.Vazhenin, V.V.Davydenko, E.I.Dzyamidzenko
EXTERNAL PAIN IN THE TREATMENT OF BRONCHIAL ASTHMA
Department of Surgical Diseases for subordinates (headed by Academician of the USSR Academy of Medical Sciences F.G. Uglov) of the 1st Leningrad Medical Institute named after. acad. I.P. Pavlova
The problem of bronchial asthma is one of the most pressing in medicine. This is due to the prevalence of this disease, the severity of its course in recent years, and the difficulty of choosing effective therapy.
A disease that significantly reduces work ability, leading to most patients to disability, forces them to look for more and more new means to combat it. Despite the variety of available modern methods of treating bronchial asthma, all of them are ultimately aimed at some link in the pathogenesis of this disease - eliminating bronchospasm, reducing edema, reducing the secretion of bronchial glands. However, acting only on visible manifestations diseases, these methods still do not eliminate the cause that leads to the occurrence of bronchial asthma in a person.
Conventionally, all available treatment methods can be divided into medicinal (medicinal) and non-medicinal. Drug therapy almost always ultimately leads the patient to drug dependence, even hormonal dependence. It should be noted that the early use of hormonal therapy in a number of pulmonology institutions does not lead to recovery, but to the development of dysfunction of the hormonal system with its subsequent inhibition. Drug therapy for this disease is long-term, often continuous and, without restoring the impaired function, only weakens the body.
Of the non-medicinal treatment methods, the most widely used are acupuncture, barotherapy, sanatorium-resort treatment, hypnosis, aeroionotherapy, bee sting treatment, etc. The effectiveness of these methods, according to various authors, varies widely, but most researchers consider it necessary to use them in combination with drug therapy .
Acupuncture, of course, deserves the closest attention, since it allows you to improve the condition of patients both in complex therapy and when used in its “pure form,” although the percentage of good results, according to various authors, varies widely. However, these are mainly patients with mild to moderate severity of the disease. Therefore, today the indications for the use of acupuncture are only stage 1 bronchial asthma and pre-asthma. In the presence of pulmonary heart failure, persistent morphological changes in the lungs (emphysema, pneumosclerosis), and long-term use of corticosteroid drugs, the method is considered contraindicated.
As for other treatment methods (barotherapy, spa treatment, hypnosis, etc.), they can only be used in the complex therapy of bronchial asthma and, due to their low efficiency, are not used independently.
We use method of treating bronchial asthma using external pain (EPP). It is based on the idea of the development of favorable, natural neuroendocrine changes in the body that occur under the influence of short-term dosed pain stimulation. A method that allows effective treatment for patients with any stage of bronchial asthma, which makes it possible for most of them to refuse drug therapy, opens up new prospects for the successful treatment of this serious disease.
For the first time, scientific testing of this treatment method took place from October 1984 to February 1985 in the clinic of surgical diseases for subordinates of the 1st LMI named after. acad. I. P. Pavlova. This was a preliminary period when, in addition to assessing the effectiveness of the method, knowledge of the mechanisms and causes of bronchial asthma was deepened. Accordingly, material was accumulated for the preparation and conduct of subsequent stages of treatment of patients. In addition, specific techniques were developed in relation to various forms of bronchial asthma. This was a randomly recruited group of patients with various forms, severity, age and duration of the disease, of which 36 were women and 19 men. All of them had previously been treated with traditional methods, and many were treated with acupuncture (17 people), barotherapy, therapeutic fasting, and were on spa treatment However, no lasting positive effect was obtained.
We, like some other authors, considered it tactically necessary to identify groups of patients with different forms of the disease depending on the trigger mechanism (cold, physical activity). In this work, almost all variants of bronchial asthma were studied, with the exception of those when the main mechanism of the attack was a sharp change in ambient temperature (cold snap). This group was not subjected to treatment, since the methodology for it had not been finally developed.
Distribution of patients by disease duration: up to 1 year - 4 people, from 1 year to 5 years - 23, from 5 to 10 years - 16, more than 10 years - 12. Distribution of patients by age: up to 15 years - 18 people, from 15 up to 30 years - 6, from 30 to 45 years - 14, from 45 to 60 years - 15, over 60 years - 2. Distribution of patients by duration of taking corticosteroid drugs: up to 1 year - 5 people, from 1 year to 5 years - 5, from 5 years to 10 years - 1.
When distributing according to the severity of the disease, we took into account the following criteria.
By mild severity of the disease we understood the presence of rare (up to 2-3 times a year) attacks of suffocation, long-term remissions, the absence of clinical symptoms of the disease and morphological changes in the lungs, and the absence of drug therapy during periods of remission.
We classified patients with frequent attacks of suffocation, short remissions, and the need for frequent use as moderate severity. medicines, the presence of clinical and laboratory signs of bronchospasm even during the period of remission.
We classified as severe forms of bronchial asthma patients taking hormonal medications, as well as those with frequent (several times a day) attacks of asthma, severe morphological changes in the lungs, severe impairments in the ventilation ability of the lungs, patients forced to take medications daily due to frequent attacks or difficulty breathing and a history of asthmatic status.
In accordance with this classification, our patients were distributed according to the severity of the disease as follows: mild degree- 9 people, average degree- 21, severe degree - 25.
Thus, the majority of patients were patients with moderate and severe severity of bronchial asthma, of which 11 people were patients taking corticosteroid drugs for a long time.
The technique assumes the possibility of immediate withdrawal from drug therapy, which was possible in almost all patients, with the exception of a small part of patients taking hormonal drugs, in whom the dose of corticosteroids was reduced gradually. Sessions were performed every other day in an amount of 15 or more for 1 month or longer, depending on the severity of the disease. All patients underwent the necessary laboratory tests X-ray studies, ECG before and after treatment. A study of pulmonary ventilation was conducted in 44 people to more strictly and objectively assess the effectiveness of this treatment method. We borrowed the criteria for assessing the degree of bronchial obstruction from the relevant guidelines. The study of the function of pulmonary ventilation was carried out in the laboratory of the Department of Hospital Therapy of the 1st LMI using the spirographic method and the general plethysmography method on the "Respiratory System - 2300" apparatus from Ohio (USA), as well as in the clinic No. 85 of Leningrad using the spirographic method and pneumotachometry. It should be noted here that the majority of patients before the course of treatment could undergo a functional examination of pulmonary ventilation only while on drug therapy, and some patients could not undergo the examination at all due to the severity of the condition. In addition, this examination was not carried out in young children due to their inability to correctly perform functional tests.
As a rule, subjective improvement in well-being was noted by patients immediately after the first sessions. In some patients during treatment, more often by the 5th-7th session, there was some exacerbation of the disease (increased cough, increase in the amount of sputum, the appearance of asthma attacks, rise in temperature), which soon passed on its own, did not require the administration of drugs and no longer resumed.
The improvement in condition was confirmed by objective clinical data: attacks of suffocation and shortness of breath completely disappeared, breathing became free, dry wheezing and cough decreased and then disappeared, ECG indicators improved (tachycardia decreased, the load on the right side of the heart was relieved), and pulmonary ventilation indicators improved. Here's an example.
Patient M., 15 years old, was admitted to the clinic with a diagnosis of infectious-allergic bronchial asthma, severe. From the anamnesis it is known that she has been ill since the age of 9, when, after suffering acute bronchitis attacks of suffocation began to occur, often turning into asthmatic conditions. She was treated several times in hospitals. Due to the severity of the condition, she received courses of prednisolone intravenously and orally.
On admission the condition is akin to seriousness. Complains of constant attacks of suffocation several times a day, shortness of breath at rest, weakness, cough with a scanty amount of sputum. Objectively: forced body position, exhalation is difficult, prolonged, breathing is noisy, whistling, audible at a distance. Shortness of breath at rest up to 36 per 1 min. Cyanosis of lips. Pulse up to 100 beats/min, blood pressure 120/70 mm Hg. Art. Percussion sound with a boxy tint, auscultation-hard breathing with an abundance of dry buzzing wheezing. Nonproductive cough with glassy sputum. Maintenance therapy: aminophylline - 2 tablets per day (0.3 g), asthmapent. There are no “light” intervals during the day.
Due to a sharp change in climate when moving to Leningrad, and inadequate supportive therapy, her condition quickly deteriorated; therefore, she could not even undergo a functional examination of the lungs. Soon the patient was transferred to the intensive care unit in a state of status asthmaticus. Immediately after recovery from the asthmatic state, she was accepted for treatment using the VBB method. My health began to improve quickly. Soon all drug therapy was stopped. After a month's course of treatment, there were no complaints about attacks of suffocation or difficulty breathing. Clinical examination shows no cyanosis and shortness of breath. In the lungs there is vesicular breathing, no wheezing. A study of the pulmonary ventilation function revealed normalization of indicators: vital capacity 2772 ml (110%), FEV1 2.44 l (112%), Tiffno test 91%, FRC 2777 ml, TLC 1226 ml (109%), TLC 3998 ml (96% ), bronchial resistance 3.07, specific conductivity 0.117.
Currently, 4 months have passed since the end of treatment: he feels good, has no asthma attacks, does not use medications.
In patients with light current The disease only needed a few sessions to get a lasting positive effect.
Since we were not able to conduct a functional study of pulmonary ventilation in all patients, the final results were assessed based on the subjective state and data from an objective clinical examination. When assessing the results of treatment of bronchial asthma using the method of external pain, we used a three-point system: “good”, “satisfactory” and “unsatisfactory”.
By good results we understood the complete disappearance of attacks of suffocation, as well as episodes of difficulty breathing, the disappearance of clinical signs of the disease (wheezing, shortness of breath, dry wheezing, cough with glassy sputum).
We classified as satisfactory results those observations when the attacks of suffocation disappeared, but episodes of difficulty breathing still persisted and went away on their own, the amount of dry wheezing in the lungs significantly decreased, the cough decreased or disappeared, and sputum began to pass away easily.
We classified all patients with no effect from the treatment as unsatisfactory results.
We considered it necessary and appropriate to separate patients who were taking corticosteroids on the day of starting treatment with this method into a separate group, and evaluate the results using a different classification from the previous one.
By good results here we mean “separation” of patients from corticosteroids, the disappearance of asthma attacks, improvement in clinical indicators, and the absence of the need for drug therapy.
We classified as satisfactory results the observations with “separation” from corticosteroid drugs, the disappearance of asthma attacks, but there were still episodes of difficulty breathing that went away on their own, a cough with sputum discharge without difficulty, and the absence of drug therapy.
We classified as unsatisfactory results all patients in whom it was impossible to do without hormone replacement therapy.
Taking into account the above criteria, the treatment results are presented in table. 1.
Results of treatment of patients with bronchial asthma
Analyzing immediate results of treatment, we can say that a clear improvement in condition was achieved in almost all patients (54 out of 55), with good results obtained in 46 of them, including 8 out of 11 patients taking corticosteroids. In all 54 people, it was possible to achieve complete abolition of all drug therapy already in the early stages of treatment.
Data from a functional study of pulmonary ventilation in 44 patients are presented in Table. 2.
Table 2. Results of a functional study of pulmonary ventilation
In general, an improvement in pulmonary ventilation was detected in 38 out of 44 patients, including 27 patients whose pulmonary ventilation function was completely restored. We have not found similar results in the literature about the possibility of restoring ventilation in patients with severe bronchial asthma, especially when taking hormonal drugs.
As for unsatisfactory results or observations where pulmonary ventilation function has not been restored, this occurs in patients who initially had signs of severe outcomes of chronic pneumonia (emphysema, pneumosclerosis), or with severe changes in the endocrine system against the background of many years of massive use of hormonal drugs. This is confirmed by data from numerous studies by various authors. They have proven that with long-term hormonal therapy (more than 1 year), atrophy of the adrenal cortex develops.
Observations of patients with bronchial asthma who, before admission to us, received various doses of hormonal drugs, showed that their course of the disease and prognosis sharply worsened. Taking hormones inevitably leads to a decrease in function, and then atrophy of the endocrine glands: pituitary gland, adrenal glands, gonads, which removes the patient’s general resistance to adverse factors, makes him practically helpless, and all other types of treatment turn out to be little or completely ineffective. Until recently, we were forced to refuse treatment to patients with hormone-dependent bronchial asthma in our clinic, since any type of treatment without the use of hormones was ineffective for them, and we did not want to continue to aggravate their hopeless situation by further giving hormones. That is why we believe that in case of bronchial asthma, as in a number of other similar diseases, the transition to the use of hormonal drugs should be sharply limited (only for vital indications - asthmatic status), since, by destroying the entire hormonal system, they lead the patient to severe disability. It is especially unacceptable and even criminal to treat children and adolescents with hormonal drugs when the endocrine system, as well as other systems and organs, are still being formed. An example is the following case history.
Patient K., 13 years old, was admitted to the clinic with a severe form of infectious-allergic bronchial asthma. From the anamnesis it is known that at the age of 3 months he suffered from acute pneumonia, after which the disease often worsened. At the age of 1 year, asthma attacks began and bronchial asthma was diagnosed. Due to the ineffectiveness of therapy and the worsening of the disease, at the age of 8 years, corticosteroid drugs (dexamethasone, prednisolone) were first prescribed. According to his mother, there were periods when, due to the severity of his condition, the boy was forced to take up to 17 dexamethasone tablets per day (!) as prescribed by doctors. Upon admission, he complains of difficulty breathing, cough with a scant amount of glassy sputum. The patient is small in stature, with signs of Cushing's disease (moon-shaped face, red stretch marks, distribution of fatty tissue according to the female type, extreme emotional lability), with underdeveloped genitals corresponding to 3-4 years of age, and the absence of secondary sexual characteristics. With systematic use of hormonal drugs, the condition is relatively satisfactory. Exhalation is difficult and prolonged. Respiration rate 20 per minute. Pulse 100 beats/min. Percussion: above the lungs there is a sound with a boxy tint. Auscultation: hard breathing with an abundance of buzzing dry wheezing. Maintenance therapy: 6 mg of polcortolone per day, asthmapent. The patient was examined by an endocrinologist: it was suggested that there was secondary (due to hormonal therapy) pituitary dwarfism. The level of 11-OKS blood is 10 mcg%.
Repeated attempts were made to withdraw from hormone replacement therapy, but the treatment was not successful.
Only the IBB method, with enormous difficulties in the majority of patients, where complete atrophy of the endocrine glands had not yet occurred, was achieved not only complete abolition of hormones, but also a significant improvement in condition (cessation of attacks, absence of difficulty breathing) and even complete normalization of pulmonary ventilation function . Here's an example.
Patient Sh., 16 years old, was admitted to the clinic with a diagnosis of severe infectious-allergic bronchial asthma. From the anamnesis it is known that in infancy suffered acute pneumonia, followed by annual exacerbations of the disease. From the age of 3, attacks of suffocation appeared against the background of exacerbations of pneumonia, which tended to become more severe in each subsequent case. From the age of 6, due to the severity of the condition, he was transferred to oral corticosteroid drugs (prednisolone), which was subsequently replaced by polcortolone. Upon admission, he complains of shortness of breath, weakness, attacks of suffocation several times a day, cough with a scanty amount of difficult to separate sputum. Moderate condition. The chest is barrel-shaped, there are areas of its deformation, kyphoscoliosis. Forced body position. Exhalation is significantly prolonged, wheezing can be heard from a distance. Shortness of breath at rest up to 26 breaths per minute. Cyanosis of lips. Pulse 120 beats/min. Blood pressure 110/60 mm Hg. Art. Percussion: a boxy sound above the lungs; auscultation: harsh breathing with a lot of dry wheezing. Maintenance therapy: 1 mg of polcortolone per day, novodrin (inhalation) several times a day. An examination of the external respiratory function reveals sharp disturbances: vital capacity 3168 ml (77%), total volume capacity 2387 ml (158%), volumetric capacity 5555 ml (98%), bronchial resistance 5, specific conductivity 0.051.
Treatment was carried out in 2 stages with a total duration of 3 1/2 months. At the first sessions, it became necessary to add prednisolone intravenously against the background of reduction and withdrawal of oral medications, which was then also discontinued. Upon discharge, the patient's condition was satisfactory. There is no shortness of breath even during physical activity. There is no clinical evidence for bronchospasm. In the lungs: vesicular breathing, no wheezing. The function of pulmonary ventilation has also undergone significant dynamics: bronchospastic disorders have completely disappeared, only restrictive ones remain, caused by pneumosclerosis, limited mobility of the ribs, ossification of the costal cartilages due to rickets suffered in childhood and therefore are irreversible: vital capacity 3168 ml (77%), FEV1 2.21 l (70%). TLC 1414 ml (93%), TLC 4582 ml (80%), bronchial resistance 3.27, specific conductivity 0.109.
Currently he feels well, there are no attacks of suffocation or episodes of difficulty breathing. Doesn't use medications.
Among our patients, the majority were patients with bronchial asthma of infectious-allergic origin (80% experienced the first attacks of suffocation after an exacerbation of chronic pneumonia), but the method has also proven itself well in people with purely atopic bronchial asthma. An example is the following case history.
Patient A., 6 years old, has been suffering from attacks of bronchial asthma since he was 3 years old, when he visited Georgia in the summer. There is no history of inflammatory lung diseases. Exacerbation of the disease in autumn-spring, as well as when going out into cold air, during physical activity. I constantly received aminophylline, especially before going outside. Before treatment, there was a moderate decrease in pulmonary ventilation. 30 sessions were conducted. I stopped using medications from the very beginning of treatment. Neither cold nor physical activity provoke attacks. There is no difficulty breathing. There is vesicular breathing in the lungs, no wheezing. Pulmonary ventilation indicators are normal.
It is also interesting to note that along with the improvement of pulmonary ventilation and the cessation of clinical manifestations of bronchial asthma, in parallel there was an improvement in the functions of other systems and organs: improvement in myocardial nutrition according to ECG data, cessation of extrasystoles, improvement in general well-being, normalization of sleep, increased vitality, increased performance.
Analyzing the overall results of treating patients with bronchial asthma using the VBB method, we can come to the following conclusion.
The VBB method is effective for bronchial asthma of any origin (both infectious-allergic and atopic) and for any severity of the disease, which is proven by 80% of good results in groups of patients with moderate and severe disease. It is most advisable to use the method in the early stages of the disease, where drug, and especially hormonal, therapy has not yet been used and when you can count on a quick and complete restoration of impaired functions. It gives a clear improvement even in patients with long-term use hormonal drugs, allowing you to completely stop taking corticosteroids, and is promising in terms of the possibility of eliminating any drug dependence.
The VBB method is easy to use, accessible, physiological and gives positive results without the use of drug therapy. No negative side effects were identified. In the process of treatment using the method of external pain, there is an improvement in the general condition of the patient and the functions of various systems and organs.
LITERATURE
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