Bronchial asthma severe treatment. Drug prevention of bronchial asthma attacks

Bronchial asthma is one of the most frequent chronic diseases of modern society. It register more than 5% of the adult population and almost 10% of children.

TA Perseva, Corresponding Member of the AMN of Ukraine, D.M., Professor, E.Yu. Gashinova, Ph.D., Department of Faculty Therapy and Endocrinology of the Dnipropetrovsk State Medical Academy

Dum Spiro Spero.
(While I breathe I hope)
Ovidi

Epidemiology
General practitioners and pulmonologists, daily assisting patients with bronchial asthma, do not know the seriousness of this disease, its increasing prevalence and related steadily growing economic costs.
Data on the prevalence of severe asthma is contradictory, partly due to the lack of universal definition of this form of the disease. However, along with the widespread growth of the total number of patients with asthma, a steady tendency arose to increase the number of patients in need of emergency care, often hospitalized due to the severe course of the disease, the aggravation of which is often a threatening nature.

Definition
In the global strategy for the treatment and prevention of asthma (GINA, 2005), the disease is considered to be a disease for which daily symptoms that limit physical activity, frequent exacerbations and night manifestations, as well as the decrease in FEV1 less than 60% of the proper values \u200b\u200band daily fluctuations of the peak exhalation rate (PSV ) Over 30%.
British Thoracic Society classifies heavy asthma, taking into account sufficient drug therapy as a disease in which control is achieved only using high doses of inhalation corticosteroids and / or systemic effects.
In 2000, the American thoracic community determined the "refractory asthma" as a condition with the presence of one and more basic and two and smaller criteria that take into account the need for medicines, asthma symptoms, the frequency of exacerbations and the degree of respiratory tract.
In the study of the European Community of ENFUMOSA, the diagnosis of "heavy asthma" was established to patients with persistent symptoms of the disease and repeating, despite the high doses of inhalation corticosteroids and bronchodiators of long-term action, exacerbations; Sick asthma in need of constant reception of corticosteroids that provide a systematic action to achieve control of the disease; Patients with threatening life attacks of asthma in history.
The definition should be considered in which heavy asthma is considered as severely controlled, resistant to therapy, refractory asthma, poor control over which is confirmed by persistent symptoms, frequent exacerbations and constant variable bronchial obstruction, despite the use of high doses of corticosteroids in inhalation form or system act.

Clinical options (terminology)
In world medical literature, a number of terms are used to designate difficult to treat bronchial asthma: acute and chronic heavy, resistant to therapy, difficult to control, refractory, steroid-dependent, steroidant, mortal (fatal), "difficult", "fragile" (unstable). Such an abundance of titles reflects the heterogeneity of clinical manifestations of severe asthma. They characterize the sequence of symptoms and exacerbations, chronization and speed of the development of attacks, response to the therapy. Sourcing all the variety of existing terms, three main clinical options of severe asthma can be distinguished.

1. Bronchial asthma with frequent heavy exacerbations
Today, a large number of factors causing the development of heavy exacerbations are known. These are respiratory viral infections, atypical bacterial pathogens (Mycoplasma Pneumoniae, Chlamydia Pneumoniae), the effects of allergens, industrial and household pollutants, stopping the reception of basic preparations, hormonal imbalance (for example, premenstrual voltage syndrome). An important role is played by the psychosocial status of a patient, from which the desire and ability to fulfill the appointment of a doctor directly depends, and therefore achieving control over ASTMA.
Asthma with frequent exacerbations is the "fragile" (unstable) asthma - a disease for which high chaotic PSV variability is characterized, despite the reception of inhalation corticosteroids in high doses. The pathogenetic base of unstable asthma is the hyperreactivity of respiratory tract. There are two clinical phenotype of fragile asthma. The first is characterized by constant high PSV variability, despite the treatment selected according to existing standards. Patients with the first type of unstable asthma often celebrate psychological disorders. One of the probable reasons for exacerbation can be gastroesophageal reflux as a consequence of the use of anti-asthma drugs in high doses. Perhaps the instability of asthma is associated with the content of freon in the inhalers, and, appointing the same drugs in the form of a dry powder, can significantly improve the patient's condition. Patients with an unstable asthma of the first type are well reacting to β 2 -agonists used through the nebulizer, or their prolonged forms.
The second phenotype is characterized by a sudden sporadic decrease in PSV in patients with a well-controlled disease at the initial stage. An example of this clinical option is the intolerance to aspirin and other NSAIDs, in which patients with a good initial state after receiving the provoking drug may develop the most severe exacerbation. Patients with the second type of unstable asthma often marked food allergies. Since the occurrence of exacerbation is almost always unpredictable, it is extremely difficult to prevent it. The forecast for such patients is always serious.
The terms "asthmatic status" should be characterized, "suddenly occurring severe asthmatic attack", "slowly developing asthmatic attack", which reflect the processes of exacerbation of the disease.
Asthmatic status is characterized by a clinical picture of an increasing exacerbation and a sharp decrease in the effectiveness of bronchussessing drugs. In the clinical picture of the exacerbation of bronchial asthma, such syndrome appears as "a silent light", hypoxic coma develops in particularly severe cases. The main cause of the development of asthmatic status is the uncontrolled reception of β 2 -agonists.
Suddenly, or slowly developing asthmatic attack reflects the rate of developing the disease. So, an example is the slow down aggravation of the disease in respiratory viral infection.
The term "fatal asthma" is used to describe a severe exacerbation or sudden death in a patient with bronchial asthma. The group of increased risk of the emergence of fatal asthma includes patients with episodes of acute respiratory failure, requiring intubation, respiratory acidosis, two and more hospitalizations about bronchial asthma, despite treatment with corticosteroids that have a systematic effect, two and more cases of pneumothorax or pneumomediastinum, which developed in connection with asthma. In patients receiving preparations of three or more classes about asthma, the risk of sudden death is also high. Among the reasons for fatal asthma, low socio-economic status should be allocated, the unavailability of medical care, depression, conscious refusal to treatment, drug addiction.

2. Chronic Heavy Bronchial Astha
Distinctive features of this form of the disease are the constant presence of symptoms that limit physical activity and sleep, low (less than 60% of the norm) indicators of the volume of forced exhalation, the presence of little reversible bronchial obstruction, despite full-fledged drug therapy using maximum doses of drugs. The factors contributing to the development of the "refractory" asthma are persistent eosinophilic inflammation of the respiratory tract, the effects of tobacco smoke and industrial pollutants, the beginning of asthma in childhood with an early decrease in the function of external respiration, the neatopic nature of asthma and the presence of a chronic respiratory tract infection.

3. Heavy asthma with steroid resistance or steroid dependence
Another form of severe asthma is the "steroid-dependent" and "steroidantistant", or "resistant to therapy", bronchial asthma. In patients with steroid dependence, frequent exacerbations are not always noted or there is a little reversible pronounced respiratory tract. However, to maintain control over Asthma, they constantly need to be taking high doses of corticosteroids in inhalation form or providing a systematic action. Reducing the dose of basic drugs leads to a progressive deterioration in the state of such patients, and an increase can reduce the severity of symptoms and stabilize the course of the disease. It has been proven that this form of severe asthma is more often developing in patients who are ill at an older age and not having signs of atopy.
A possible mechanism for the development of steroid resistance during severe asthma may be a secondary violation of the regulation of glucocorticosteroid recipers due to the uncontrolled long-term assignment of hormones that have a systematic action, or a decrease in the number of steroid receptors. Reducing the efficiency of glucocorticosteroids with severe asthma forms associated with changes in the spectrum of inflammation cells accumulated in the mucous membrane of the respiratory tract. Eosinophilic infiltration is inferior to the preferential neutrophil, which may affect the biological effects of steroids.
Another explanation of the development of resistance may be that glucocorticosteroids not only do not affect hypertrophy of the smooth muscles of bronchi, but also aggravate the myopathy of respiratory muscles (the diaphragm, intercostal muscles and muscles of the upper shoulder belt). The cause of secondary steroid stability can also be a long-term use of β 2 -agonists, viral infection and endogenous violation of the level of female sex hormones. Full steroid immunity during asthma (lack of effect from receiving 40 mg of prednisolone per day for 14 days) is rarely noted and, most likely due to the congenital anomaly of glucocorticosteroid receptors.

Heavy asthma: Causes of lack of control
Not all patients with severe asthma symptoms actually suffer from this form of the disease. In this section, we would like to consider the main reasons for which adequate control over the symptoms of the disease cannot be established.

1. Invalidly established diagnosis
Since the symptoms of asthma (attacks of suffocation, shortness of breath, wheezes in the lungs) are not strictly specific, the possibilities of presence in a particular disease in a patient should not be detected. The list of pathological conditions most frequently disguised as a difficult-controlled asthma is given in Table 1.
A large number of diseases that need to conduct differential diagnosis in the presence of severe asthma symptoms causes care and a large amount of patient surveys (Table 2). The diagnosis of "heavy bronchial asthma" must be confirmed by objective evidence of reversible bronchial obstruction or hyperreactivity of respiratory tract.

2. The presence of concomitant pathology
Some concomitant diseases may determine the increase in the frequency of the occurrence and severity of the aggravation of bronchial asthma (Table 3). Proper diagnosis and treatment for these pathological conditions contributes to improving control over the symptoms of severe asthma.

3. Permanent impact of irritating factors
The constant effect of allergens even at low concentrations contributes to the maintenance of inflammation in the respiratory tract, exacerbating the severity of asthma symptoms. The most common causes of atopy are homemade dust, mold fungus, pets, cockroaches, pollen plants, food allergens.
Inorganic stimuli, such as tobacco smoke, sulfur and nitrogen dioxides, ozone, can also cause insufficient effectiveness of therapy with inhalation corticosteroids.
The reception of some drugs (non-steroidal anti-inflammatory agents, β-adrenoblastors) can cause severe aggravation of bronchial asthma in some patients.
The avoidance of contact with allergens, industrial and household pollutants, the refusal of smoking and controlled therapy significantly improves the condition of patients with bronchial asthma.

4. Inadequate treatment
The cause of persistence of severe asthma symptoms may be underestimated by the severity of the patient's condition and as a result - the insufficient volume of anti-asthma therapy. In 15-20% of cases, the cause of severe asthma is inadequate treatment tactics. An indispensable condition for proper treatment should be sufficient (up to high) dose of inhalation corticosteroids.
A major role in achieving control over Asthma plays the desire and ability of the patient to cooperate. Psychological problems in patients, the irregular treatment of medical care, the lack of faith in traditional treatment methods with excessive drug medicine, is the factors of treatment for medical care, the lack of facilities.
Another reason for poor control over the asthma may be the wrong technique of inhalation of medicinal substances. In this regard, preference should be given to a simpler device with a propeller or powder inhalers.
To eliminate the influence of inadequate treatment, asthma should be followed by a reasonable and clear diagnostic and therapeutic program.

Treatment of patients with severe asthma
Treatment of patients with symptoms is difficult to controlled asthma should be appointed in specialized pulmonary centers with highly qualified specialists. Only in such medical institutions there is an opportunity for differential diagnosis using laboratory and tool methods of surveys that are not used in routine practice (determining the level of nitrogen oxide in exhaled air, the study of the cell composition of bronchoalveolar lavage, bioptats of mucous membranes, conducting computer tomography, immunological research and genetic examination). In addition, during hospitalization, the effects of allergens and inorganic irritant factors provoking the exacerbation of the disease can be avoided. The algorithm for conducting patients with severe asthma symptoms is presented in the figure.
It is required to compile an individual treatment plan for each patient. After the differential diagnosis, it is important to identify the causal factors of the development of exacerbations and, if possible, to eliminate it: stop smoking, identify causal and significant allergens, carry out the prevention of infections, rehabilitation of infection in the appointment sinuses of the nose, to normalize sleep, affect the gastrooforous reflux, etc.
Be sure to assess and maximize the cooperation between the doctor and the patient. An important point is the formation of patients. The patient should be trained in the elements of self-control (in particular picfloweries) and the tactics of behavior with the developing exacerbation of the disease.
Among other activities to establish control over Asthma, it should be assessed by the correct use of means of delivery and technology of inhalation.
Patients with severe asthma need rehabilitation activities. Many patients are weakened by the disease, suffer from the side effects of anti-inflammatory therapy, are forced to change their lifestyle. The purpose of the physical exercise and psychological correction program contributes to improving the portability of physical exertion and the quality of life of patients.
In medication therapy, the asthma, according to modern recommendations, use a step-up approach, in which the intensity of therapy increases as the severity of the disease increases.
With a severe form of asthma, the basis of therapy is inhalation corticosteroids in high doses (for example, fluticasone, beclametomazone, mobazone). Usually these drugs take 2 times a day, although there are evidence that their four-time use is more efficient. In some cases, the introduction of drugs in high doses through the nebulizer can significantly improve control over asthma. However, it should be remembered that with severe asthma monotherapy in inhalation corticosteroids is not effective enough, and in case of increasing their dose\u003e 800 μg / day increases the likelihood of systemic effects with not always pronounced strengthening of clinical efficiency.
β 2 -Gonists of long-term action (Salmetterol, Formoterol) with severe asthma are necessarily prescribed in addition to inhalation corticosteroids. They contribute to improving the function of external respiration, reduce the frequency of exacerbations, allow you to reduce the use of β 2 short-acting and reduce the dose of inhalation corticosteroids. Combined preparations containing inhaled corticosteroids and β 2-orders of long-term action are considered more efficient and convenient for use (for example, a selender, seroflo, symbicort *).
As with any degree of gravity Ba, with a severe course of β 2, short-acting (salbutamol, phenoterol), only "on demand" is accepted. Their frequent use leads to a decrease in efficiency, and therefore, to the loss of control over ASTMA. With the second phenotype of asthma fragile in extreme situations, parenteral administration of adrenaline is possible.
Corticosteroids that have a systematic action (prednisolone, dexamethasone, triamcinolone) are prescribed with pronounced constant symptoms of severe asthma and a severe exacerbation of the disease with further speed cancellation. Patients who, despite the reception of inhalation corticosteroids in high doses, are developing frequent exacerbations, it may also be recommended that the periodic use of drugs that have a systematic action, in high doses, followed by the transition to supporting minimum doses.
In the case of persistent, despite the constant reception of systemic corticosteroids, severe asthma symptoms should consider increasing their daily dose.
In patients (especially women) receiving corticosteroids with a systemic action, due to pronounced side effects, a correction of mineral exchange and hormonal status is necessary.
Methylxantins (theophylline) in some cases can be appointed in addition to basic drugs. In some patients, their techniques reduce the dose of inhalation and / or systemic corticosteroids. However, due to the toxicity of methylksanthines, under their use, regular control of the level of theophylline in blood plasma is necessary.
Antluicotrienes (Zafirlukast *, Montelukast *) are used with steroid anti-inflammatory means. They are especially effective with aspirin asthma.
The wide use of immunosuppressants and antimetabolites for the treatment of bronchial asthma is limited to their pronounced toxicity. In addition, in clinical trials on the use of inhalation forms, no convincing data is not received about their clinical efficacy.
A promising group of drugs appointed during severe asthma are monoclonal antibodies (omalizumab *). They have proven themselves as an effective addition to traditional basic therapy, which improves the function of the external respiration and the quality of life of patients. When using these drugs, the consumption of β 2 short-acting money is also reduced. Monoclonal antibodies are made to recommendations on the treatment of severe bronchial asthma of the last revision.
Today there are information about the pronounced anti-inflammatory effect of type 2 phosphodiesterase inhibitors (rolleps *, roflumilast *, cylomilast *) during severe asthma.

Conclusion
Heavy bronchial asthma is a multicomponent process that combines pathological conditions with a different sequence of symptoms and exacerbations, chronization rates and the speed of development of attacks. The accurate identification of the clinical variant of the disease makes it possible to better understand the mechanism of its occurrence, which means that it is properly picking treatment for a particular patient.
Not every patient with severe asthma symptoms, the initial diagnosis is confirmed during a detailed examination. Many of them have either the other pathology of respiratory organs, or asthma of moderate gravity and inadequately selected treatment tactics.
Heavy asthma treatment includes a whole complex of non-drug events and multicomponent drug therapy. Clinical studies of recent years have recommended several fundamentally new groups of drugs to achieve control over severe asthma. However, there are still a number of patients with persistent, despite the intensive therapy, symptoms of asthma, and therefore, there is a need to develop new drugs.

Bronchial asthma is classified for species, shapes, phases in several signs (reason, degree of controlling, degree of manifestation of bronchial obstruction). But one of the most important classifications predetermining the treatment of the disease is the classification by the severity of the flow. In accordance with it, four forms of bronchial asthma are distinguished, the most dangerous of which is severe persistent.

Classification of the disease by severity

The severity of the flow of bronchial asthma is determined by:

The number of attacks per week at night;
The number of attacks per week during the daytime;
The frequency and duration of the use of short-acting beta2-agonists;
Indicators of peak speed of exhalation, its daily change;

The patient is diagnosed:

1. episodic bronchial asthma, or asthma of light intermitting flow;

This form of the disease is characterized by episodic short exacerbations (from several hours to several days). The attacks of chunk (shortness of breath or cough) during the day happening no more than 1 time a week, at night - 2 times a month. The peak rate of exhalation is 80% of the proper indicator, it fluctuates no more than 20% during the day.

In the period between exacerbations, bronchial asthma light shape is not manifested by any symptoms, light people function normally.

Unfortunately, to identify the disease in this form is not always. Firstly, its influence on the life of a person is small, he simply can ignore the symptoms and not to contact the doctor. Secondly, the signs of asthma of episodic flow are similar to the signs of other diseases of the respiratory organs, for example, chronic bronchitis. Thirdly, most often an episodic asthma is mixed, that is, allergic and infectious-dependent factors play the same role in its occurrence. Deal may occur in adults in contact with allergens, in children - during infectious diseases of the lower respiratory tract.

To confirm the diagnosis of the patient, examine:

I will take general blood and urine tests.
Make skin allergies;
Radiographic research of the chest organs;
Investigate the function of external respiration with beta2 agonist.

Adequate treatment undertaken when the disease did not gain momentum, helps to keep it and achieve a resistant. It includes the reception of beta2-agonists of short-acting and short-acting theophyllines in order to stop episodic attacks or not allow them (medications are inhaled or orally before physical activity, possible contact with allergens). People with asthma of light intermitting flow should also adhere to the regime established for asthmatic patients. Treatment with anti-inflammatory drugs, it is usually not required.

2. Bronchial asthma persistent (permanent) flow. In turn, the permanent asthma may be lightweight, moderate and severe.

If the disease proceeds in a light persistent form, the peak rate of exhalation in the patient is 80% of the proper, during the day can fluctuate by 20-30%. Cough attacks, shortness of breath, choking happen to him from day to 1 time a week. Attacks at night are repeated more often 2 times a month. Symptoms of the disease during exacerbation affect the quality of the life of the patient, because of them, his daily activity or night sleep may suffer.

A patient with asthma light persistent form is necessary daily treatment. For the prevention of attacks, he needs to use inhaled corticosteroids, sodium cromoglylikat, unoccuping, as well as theophyllins. Initially, corticosteroids are prescribed at a dose of 200-500 μg per day, if bronchial asthma progresses, it is advisable to increase to 750-800 μg per day. Before bedtime, it is recommended to apply a bronchitator of prolonged action, for example, a maplebuterol, salmeterol or formoterol.

The bronchial asthma persistent the medium-free flow is characterized by a frequent manifestation of symptoms that significantly violate the daytime activity of the patient and its night's sleep. At night, coughing attacks, choking, shortness of breath happen 1 time per week and more often. The indicator of the peak feed rate ranges between 60% and 80% of the due.

If a person is diagnosed with this form of asthma, it needs a daily reception of beta2 agonists and anti-inflammatory drugs, only in this way it is possible to control the disease. Biscmethazone is recommended dipropionate or analog inhalation corticosteroid at a dose of 800-2000 μg. Additionally, it is necessary to receive bronchodulators of long-term action, and, especially if the attacks often happen at night. Typically, theophyllins are used, for example, theophile.

How to treat bronchial asthma of hard flow?

The persistent asthma of severe flow is often mixed. Frequent exacerbations, repeating daily and practically every bouts, are provoked by asthma allergic and infectious triggers. The peak rate of exhalation in the patient is less than 60% of the proper, fluctuates by 30% or more. Because of the difficult state, it is forced to limit his own physical activity.

The persistent bronchial asthma of severe flow is controlled with difficulty or is not monitored at all. To assess the severity of the patient's condition, daily picthlometry is needed.

Treatment of this form of the disease is carried out in order to minimize the manifestation of symptoms.

The patient is shown daily high doses of corticosteroids (which is why the persistent asthma of severe flow is sometimes called steroid-dependent). It can take them through an inhaler or spacer.

The spacer is a flask (tank) used in addition to the aerosol inhaler in order to enhance the effectiveness of its impact. Using a pocket can with a spaser, a patient, even with a severe attack, the suffocation will be able to help. He will not need to coordinate inhale and pressing. Children better apply the spacer with a mask.

A person who is diagnosed with a persistent bronchial asthma is severe, recommended:

It is obvious that the patient with a severe degree of constant asthma is forced to make a huge number of the symptoms of drugs. Unfortunately, they are not always effective, but the side effects of their reception are observed quite often. Heavy mixed asthma is mainly treated in the hospital, so medication therapy is selected exclusively by an experienced doctor. Any amateurness in treatment is excluded, since it is fraught with aggravation of the state up to death.

After the treatment has begun, and it gives the result, the patient has a mixed illness clinic, since in response to the therapy of its symptoms are lubricated. But it will be possible to change the diagnosis of a persistent asthma of a heavy flow for a medium-free asthma when the patient begins to obtain drug therapy characteristic of a given severity.

Video: Bronchial asthma in children and adults. Who is in the risk group?

Persisive asthma is a serious pathology. Symptoms can develop in humans for years, which limits its vital activity. However, some patients occur periods of remission.

Asthma persistent - chronic disease. Bronchi spasms occur systematically. This is the most common form of ba. Against the background of inflammation of the respiratory tract, exacerbations are constantly happening. The mucous secret (required to protect the body) is produced in large quantities.

In the presence of such pathology, the patient cannot inhale the air with full breasts. He is also unable to fully exhale it. Some patients face a problem or inhale, or exhalation.

Classification of persistent asthma

Eliminate four forms of the flow of this disease. The degree of gravity establishes, focusing on the symptoms and condition of the patient. The form of pathology flow is established with the goal to assign the most efficient therapy. High-quality treatment helps to achieve a long period of time.

Here are the form of a persistent asthma.

Heavy. Churring happen systematically, arise at night, and the day. It is important to limit physical activity. Only special medicines help.
Average. More often than one or twice a week, attacks at night. In the afternoon they happen less often. Due to respiratory failure, the quality of human life falls.
Light. The attacks happen one or twice a week, preferably during the day. A dream can be broken.

In a timely manner, install the provocateur allergen and take appropriate measures.
Conduct timely vaccination to children.
Scrupulously choose a profession (it is important to reduce the effect of negative external factors to zero).
Feed right.
Lead a healthy lifestyle, and regularly.
To regularly be in the fresh air, for a long time to walk.

Attention! A qualified treatment is of great importance. This will allow prevent complications.

Permanent symptoms during the day. - Frequent exacerbations. - Frequent night symptoms.

Physical activity is limited by the manifestations of asthma.

PSV is less than 60% of due; oscillations more than 30%.

Survey: Common blood test, general urine analysis, definition of a common and specific IHE, chest radiography, a sputum analysis, a study of FVD with a breakdown with beta-2-agonist, daily picoflorometry, if necessary, conducting skin allergic tests.

Treatment: Stage 4. Patients with a difficult course completely controlling asthma fails. The goal of treatment becomes the achievement of the best possible results: the minimum number of symptoms, the minimum need for beta-2-agonists of short-acting, the best possible PSV rates, minimal PSV scatter and minimal side effects from taking drugs. Treatment is usually carried out using a large number of drug control systems.

Primary treatment includes inhaled corticosteroids in high doses (from 800 to 2000 μg per day of the beclometazone of dipropionate or its equivalent).

Oral corticosteroids constantly or long courses.

Prolonged broutine.

You can try to apply an anticholinergic preparation (IPratropium Bromide), especially patients who note side effects when taking beta-2-agonists.

Inhalation beta-2-agonists of short action can be used if necessary to facilitate symptoms, but the frequency of their reception should not exceed 3-4 times a day.

It should be noted that the determination of the severity of asthma for these indicators is possible only before the start of treatment. If the patient already gets the necessary therapy, then its volume should also be taken into account. Thus, if a patient in a clinical picture is determined by a light persistent asthma, but it receives drug treatment with a severe persistent asthma, then the patient is diagnosed with a bronchial asthma of severe flow.

The method of optimizing anti-asthma therapy can be described in the form of blocks in the following way:

Block 1. The first visit of the patient to the doctor, assessment of the degree of gravity, determining the tactics of the patient. If the patient's condition requires emergency care, it is better to hospitalize it. When you first visit, it is difficult to establish the degree of gravity, because For this, the oscillations of PSV are needed during the week the severity of clinical symptoms. Be sure to consider the amount of therapy to the first visit to the doctor. Continue therapy for monitoring. If necessary, you can recommend an additional reception of the beta-2-agonists of a short action.

An introductory weekly monitoring period is assigned if a patient is presumably asthma of light or moderate severity that does not require emergency therapy in full. Otherwise, it is necessary to carry out adequate treatment and monitor the patient within 2 weeks. The patient fills the diary of clinical symptoms and registers PSV indicators in the evening and morning clock.

Block 2. Determining the severity of asthma and the choice of appropriate treatment. It is carried out on the basis of the classification of the severity of bronchial asthma. Provides a visit to the doctor a week after the first visit, if therapy is not appointed in full.

Block 3. Two-week monitoring period on the background of the therapy. The patient, as well as during the introductory period, fills the diary of clinical symptoms and registers PSV.

Block 4. Evaluation of the effectiveness of therapy. Visit in 2 weeks against the background of the therapy.

Stage up: Increase the amount of therapy should be if asthma control fails to be achieved. However, it should be taken into account whether the patient is properly taking medication of the corresponding stage and there is no contact with allergens or other provoking factors. The control is considered unsatisfactory if the patient:

Episodes of cough, whistling or difficult breathing arise

more than 3 times a week.

The symptoms appear at night or in the early morning watches.

The need for the use of broutine

short action.

The variation of PSV indicators is increasing.

Stage down : Reducing supporting therapy is possible if asthma remains under control of at least 3 months. It helps reduce the risk of side effects and increases the susceptibility of the patient to the planned treatment. Reduce therapy follows step-by-step, lowering or canceling the last dose, or additional preparations. It is necessary to observe the symptoms, clinical manifestations and indicators of the function of external respiration.

Thus, although bronchial asthma is an incurable disease, it is quite appropriate to expect that most patients may have to be monitored during the disease.

It is also important to note that the approach to the diagnosis, classification and treatment of asthma, taking into account the severity of its flow, allows you to create flexible plans and special medical programs depending on the availability of anti-asthma drugs, the system of regional health care and the characteristics of a particular patient.

It should be noted once again that one of the central places in the treatment of asthma is currently occupied by the educational program of patients and dispensary observation.

Bronchial asthma

Bronchial asthma (Asthma Bronchiale; Greek. Asthma Heavy breath, suffocation) - a disease, the main sign of which attacks or the periodic states of expiratory choke caused by the pathological hyperreactivity of bronchi. This hyperreactivity is manifested when exposed to various end and exogenous stimuli, both causing an allergic reaction and operating without the participation of allergic mechanisms. The above definition complies with the representation of B. a. As a non-specific syndrome and requires coordination with the tendency to preserve in the medical and diagnostic practice of the prevailing in the USSR in the 60-70s. Allocations from this syndromic concept of allergic B. a. as an independent nosological form.

Classification

There is no generally accepted classification of bronchial asthma. In most countries in Europe and America since 1918 and to the present, B. a. Separed on the caused by external factors (Asthma Extrinsic) and associated with internal causes (Asthma intrinsic). According to modern concepts, the first corresponds to the concept of non-infectious-allergic, or atopic, bronchial asthma, the second includes cases associated with acute and chronic infectious diseases of the respiratory apparatus, endocrine and psychogenic factors. As some options, the so-called aspirin asthma and asthma of physical effort are distinguished. In the classification of A.D. ADO and PK Bulatov adopted in the USSR since 1968, two main forms of B. a.: Atopic and infectious-allergic. Each forms are divided into stages to a betrayal, the stage of attacks and the stage of asthmatic states, and the sequence of stages is not mandatory. In terms of severity, the flows are highlighted with light, moderate gravity and severe B. a. In recent years, in the light of the approach to B. a. As a syndrome, such a classification, as well as the Terminology used, cause objections. In particular, the release of non-immunological form B. a.; The introduction of the term "infectious-dependent form", which will unite all cases of B. a., associated with infection, incl. with non-immunological mechanisms of bronchospasm; Allocation of the dormonal and neuropsychic variants of B. a.

Etiology

Etiology Aspirinova B. a. Not clear. In patients, the intolerance of acetyl-salicylic acid, all pyrazolone derivatives (amidopyrin, analgin, balallin, butadion), as well as indomethacin, mefenamic and fluofenamic acids, ibuprofen, is volitary, i.e. Most non-steroidal anti-inflammatory funds. In addition, some patients (according to various sources, from 10 to 30%) also do not tolerate the yellow food dye tartrazine used in the food and pharmaceutical industry, in particular for the manufacture of yellow shells of dragee and tablets.

Infectious-dependent B. a. It is formed and exacerbated due to bacterial and especially often viral infections of the respiratory unit. According to the work of the school A.D. ADO, the main role belongs to Neisseria Perflava and Staphylococcus aureus bacteria. A number of researchers are greater importance to influenza viruses, paragrippa, respiratory syntial viruses and rhinovirus, mycoplasm.

The predisposing factors of development B., first of all, include heredity, the value of which is more pronounced with atopic B. a., Inherited by recessive type with 50% penetrant. It is assumed that the ability to develop allergic LGE antibodies (immunoglobulins E) in atopic asthma, as at other manifestations of atopy, is associated with a decrease in the number or decrease in the function of T-lymphocyte suppressors. There is an opinion that the development of B. a. Associate some endocrine disorders and dysfunction of the hypophysic system - adrenal bark; Known, for example, exacerbations of the disease in the menopausal period in women. Probably, the predisposing factors include cold raw climates, as well as air pollution.

Pathogenesis

The pathogenesis of any form B. a. It consists in the formation of the hyperreactivity of bronchi, which manifests the spasm of bronchial muscles, the penetration of the bronchi mucous membrane (due to the increase in the vascular permeability) and the hypersection of the mucus, which leads to bronchial obstruction and the development of choking. Bronchial obstruction may occur both as a result of an allergic reaction and in response to the impact of non-specific stimuli - physical (inhalation of cold air, inert dust, etc.), chemical (for example, ozone, sulfur gas), sharp odors, weather changes (especially drop barometric pressure, rain, wind, snow), physical or mental load, etc. Specific mechanisms for the formation of the hyperreactivity of the bronchi are not sufficiently studied and, probably, unequal for different etiological variants of B. a. With a different ratio of the role of congenital and acquired violations of the control of the bronchial tone. The defect of B-adrenergic regulation of the tone of the bronchial wall is attached, the role of hyperency of A-adrenoreceptors and the bronchi cholinoreceptors, as well as the so-called nonadenergic neholinergic system, is not excluded. Acute bronchial obstruction in the case of atonic B. a. Developed when exposed to the bronchial walls of the mediators of the allergic reaction I type (see Allergy ). A possible pathogenetic role in the immunoglobulin reaction G (subclass LGG 4) is discussed. With the help of inhalation provocative tests with atopic allergens, it is established that they can induce as a typical immediate response (after 15-20 min.after contact with the allergen), and the late, which begins after 3-4 c.and reaches a maximum after 6-8 c.(about 50% of patients). The genesis of the late reaction is explained by the inflammation of the bronchial wall with the involvement of neutrophils and eosinophils by chemotactic factors of the allergic reaction I type. There is reason to believe that it is the late reaction to the allergen significantly enhances the hyperreactivity of the bronchi to nonspecific stimuli. In some cases, it is the basis for the development of asthmatic status, but the latter can be due to other reasons, arising, for example, after taking non-steroidal anti-inflammatory drugs in patients with Aspirinov B. A., under the overdose of adrenomimetics. After improperly abolition of glucocorticoids, etc. In the pathogenesis of asthmatic status, the blockade of B-adrenoreceptors and mechanical obstruction of bronchi (viscous mucus, as well as due to edema and cell infiltration of their walls) are considered to be the most significant.

Pathogenesis Aspirinova B. a. Not quite clear. In most cases there is pseudo-Allergy to A number of non-steroidal anti-inflammatory funds. It is believed that the leading importance is the violation of the metabolism of arachidonic acid.

Pathogenesis of infectious-dependent B. a. does not have a generally accepted explanation. Proof of LGE-due to allergies on bacteria and viruses are not received. Theories are discussed - the adrenoblocating action of a number of viruses and bacteria, as well as a vagus bronchokonstrictor reflex during damage to the virus of afferent zones. It has been established that the lymphocytes of patients B. a. Special substance is isolated in elevated amounts that can cause the liberation of histamophies and, possibly, other mediators from basophils and fat cells. Microbes that are in respiratory tract of patients, as well as bacterial allergens manufactured for practical use stimulate the release of this substance with lymphocytes of patients with infectious-dependent B. a. It follows from this that the final pathogenetic links of the formation of an attack of choking can be similar to both basic forms of bronchial asthma.

Pathogenetic mechanisms of asthma of physical effort are not established. There is a point of view that the leading in the pathogenesis is irritation of the effector endings of the vagus nerve. The reflex can be caused, in particular, the heat loss is light due to the forced breathing. The effect of cooling through the media mechanism is more likely. It is noted that asthma of physical effort is easier to be carried out inhalation of dry air than moisturized.

In many patients, B. a. Psychogenic attacks of choking arising, for example, with the emotions of fear or anger, with false information of the patient about the inhalation of it allegedly increasing doses of allergen (when in fact the patient has inhaled the saline), etc. Sharp, heavy stressful situations are more likely to cause a temporary remission of B. A., whereas chronic psychotrams usually deteriorate its current. Mechanisms for the effects of psychogenic influences for B. a. remain unclear. A different type of neurosis, found in patients B. a., Is more often a consequence, and not the cause of the disease. Currently, there is no sufficient basis to allocate psychogenic asthma in a separate form, but in the complex treatment of patients B. a. The value of psychogenation should be considered.

Clinical picture

In the stage, many patients are detected allergic or polypose rhinosinusitis. The manifestations of actually addresses the parole cough (dry or with the release of a small amount of mystery of viscous sputum), which is not facilitated by conventional antitussive preparations and is eliminated by means of treatment B. a. Cough attacks usually arise at night or in the early morning watches. Most often, cough remains after transferred respiratory viral infection or exacerbation of chronic bronchitis, pneumonia. The difficulty of breathing is not yet experienced. With auscultation of the lungs, hard breathing is sometimes determined, very rarely dry wheezes with a forced exhale. Eosinophilia is detected in the blood and sputum. In the study of the functions of external respiration (FVD) before and after the inhalation of B-adrenomimetics (IZADRINA, BERRETEK, etc.), a significant increase in the power of exhalation may be established, indicating the so-called hidden bronchospasm.

In subsequent stages of development B. a. The main manifestations become the attacks of suffocation, and with a serious flow also the state of the progressive choke, denoted as an asthmatic status (Status AsthMaticus).

Bronchial asthma attack It develops relatively suddenly, in some patients following certain individual precursors (sore throat, skin itching, nasal congestion, Rinorea, etc.). There is a feeling of mortgage in the chest, difficulty breathing, the desire to pump out, although cough during this period, mostly dry and exacerbates shortness of breath. The difficulty of breathing, which the patient is experiencing at the beginning only in exhalation, increases, which forces the patient to take a sedentary position to include auxiliary respiratory muscles ( cm. Respiratory system ). Wildrs appear in the chest, which first feels only the patient himself (or listening to his light physicians), then they become heard at a distance (remote wheezes) as a combination of different height of the votes of the harmony (musical wheems). At the height of the attack, the patient is experiencing severe suffocation, the difficulty is not only exhaled, but also inhale (due to installation in the breathing pause of the chest and the diaphragm into the position of deep breath).

The patient sits, leaning on his hands on the edge of the seating. Chest expanded; Exhaust is significantly elongated and achieved by the visible tension of the muscles of the chest and the body (expiratory shortness of breath); The intercostal on the breath is drawn; The cervical veins are sweeping on the breath, in the breath fall, reflecting significant drops of intrathore pressure in the phases of inhalation and exhalation. When the percussion of the chest is determined by the box sound, the omission of the lower boundary of the lungs and the restriction of the respiratory movement of the diaphragm, which is also confirmed with a radiographic study that detects a significant increase in the transparency of the pulmonary fields (acute swelling of the lungs). Auscultation over the lungs detect rigid breathing and abundant different tones of dry wheezing with the predominance of buzzes (at the beginning and at the end of the attack) or whistling (at the height of the attack). Heartbeats are rapidly. Heart tones are often poorly determined due to the swelling of the lungs and the muffled volume of hearing dry wheels.

The attack can continue from a few minutes to 2-4 c.(depending on the treatment applied). The permission of the attack is usually preceded by cough with a small amount of sputum. The difficulty of breathing decreases, and then disappears.

Astmatic status Determined as life-threatening increasing bronchial obstruction with progressive ventilation disorders and gas exchange in the lungs, which is not usually effective in this patient with bronchodiolitics.

Three options for the start of asthmatic status are possible: the rapid development of the coma (sometimes observed in patients after the abolition of glucocorticoids), the transition to the asthmatic status of an asthma attack (often on the background of an overdose of adrenomimetics) and the slow development of the progressive choking, most often in patients with infectious-dependent B. A . According to the severity of the state of patients and the degrees of violations of gas exchange, there are three stages of asthmatic status.

The stage of the stage is characterized by the appearance of sustainable expiratory shortness, against the background of which the frequent seizures of the suffocation arise, forcing patients to resort to repeated inhalations of adrenomimetics, but the last only briefly facilitate the capture (not eliminating completely expiratory breath), and after a few hours it is lost and this is their action. Patients are somewhat excited. Percussion and auscultation of the lungs reveal changes similar to those in the attack B. A., but dry wheezing are usually less abundant and tremendous wheezing of high tone. As a rule, tachycardia is determined, especially sharply pronounced with adrenomimetics into intoxication, when the tremors of the fingers of the brushes, pallor, an increase in systolic blood pressure, sometimes extrasystolia, expansion of pupils are also detected. Oxygen voltage (PO 2) and carbon dioxide (RSO 2) in arterial blood close to normal, there may be a tendency to hindeling.

The II stage of asthmatic status is distinguished by the severe degree of expiratory choking, the fatigue of the respiratory muscles with a gradual decrease in the minute respiratory volume of increasing hypoxemia. The patient either sits, leaning on the edge of the bed, either head. The excitement is replaced by increasingly extensive periods of apathy. Language, leather face and body cyanotic. Breathing remains rapidly, but it is less deep than in stage I. The picture of an acute lung blinking, auscultative - weakened rigid breathing, which over certain parts of the lungs may not listen at all (the zones of the "silent" lung). The number of hearing dry wheezes is significantly reduced (non-delicate and soft whistling wheezing are determined). There is tachycardia, sometimes extrasystole; on ECG - signs of pulmonary hypertension (see Hypertension of a small circle of blood circulation ), Reducing the tissue T in most instruments. PO 2 arterial blood drops to 60-50 mm RT. Art.Moderate hypercupnia is possible.

ILL Stage of Astmatic Status is characterized by sharply pronounced arterial hypoxhemia (PO 2 in the range of 40-50 mm RT. Art.) and increasing hypercapper (RSO 2 above 80 mm RT. Art.) with the development of respiratory and acidotic coms. There is a pronounced diffuse cyanosis. Frequently determined dryness of mucous membranes, decreased tissue turgora (signs of dehydration). Breathing gradually penetrates and becomes less and less deep that, with auscultation, it affects the disappearance of wheezing and a significant weakening of respiratory noise with the expansion of the "silent" lights. Tachycardia is often combined with various heart arrhythms. Death may occur from stopping the breath or sharp heart rate disorders due to myocardial hypoxia.

Separate forms of brocal Asthma have features of the history, clinical manifestations and flows.

AtopicB. a. More often starts in childhood or in youthful age. In a family history of more than 50% of cases, asthma or other atonic diseases are detected, a history of the patient is an allergic rhinitis, atopic dermatitis. Attacks of suffocation with atopic B. a. Often, prudent symptoms are preceded: itching in the nose and the nasopharynk, the nasal congestion, sometimes itching in the field of chin, neck, inter-pumping area. The attack often begins with dry cough, then a typical picture of expiratory suffocation with remote dry wheels is quickly deployed. Usually the attack quickly manages to stop using B-adrenomimetics or euphilline; The selection of a small amount of bright viscous sputum ends. After the attack, auscultative symptoms of asthma are completely eliminated or remain minimal.

For atopic B. a. Characterized by a relatively easy course, later the development of complications. A severe course, the development of asthmatic status is rare. In the first years of the disease, remission is typical when contacting allergens. Frequently spontaneous remission. Complete recovery with atopic B. a. Adults are rare.

Infectious-dependent B. a. It is observed in persons of different ages, but adults are more painful. The family history relatively often marks asthma, rarely - atopic diseases. Characterized by a combination of B. a. with polypose rhinosinusitis. The beginning of the disease is usually associated with acute, more often with viral infections or with exacerbations of chronic diseases of the respiratory apparatus (sinusitis, bronchitis, pneumonia). The attacks of suffocation differ less than with atopic B. a., Acute development, greater duration, less clear and rapid resolution in response to the use of adrenomimetics. After the binding of the attack at auscultation of the lungs, hard breathing with an elongated exhalation, dry buzzes, in the presence of inflammatory exudate in bronchi - wet wipes. With this form B. a. More often it is a serious flow with repeated asthma status, complications are developing faster.

Aspirin asthma In typical cases, it is characterized by a combination of B. a. With recurrent polypose of the nose and its apparent sinuses and intolerance of acetylsalicylic acid (the so-called aspirin triad, which is sometimes denoted as an asthmatic triad). However, the polyposis of the nose is sometimes absent. Adult women are more often ill, but the disease meets in children. It usually begins with polypose rhinosinusitis; Polyps after their removal quickly recur. At some stage of the disease after the next polypectomy or admission of aspirin, Analgin is joined by B. a., The manifestations of which are preserved subsequently and without receiving non-steroidal anti-inflammatory funds. The reception of these drugs invariably causes exacerbation of the disease of various severity - from the manifestations of rhinitis to the hardest asthmatic status with death. Polypectomy is also often accompanied by heavy exacerbations of B. a. Most clinicians believe that for Aspirinov B. a. Characterized by a difficult course. Atopia among these patients is rare.

Asthma physical effort, or post-load-loaded bronchospasm, does not seem to be an independent form of B. a. It has been established that in 50-90% of patients with any form B. a. The physical effort is able to cause an attack of a suffocation after 2-10 min.after the end of the load. Attacks are rarely heavy, 5-10 continue min Sometimes up to 1. c.; Pass without the use of drugs or after inhalation of B-adrenomimetics. In children, asthma, physical effort is more common than adults. It is noted that some kind of physical efforts (run, playing football, basketball) especially often cause post-load-loaded bronchospasm. Lifting weights less dangerous; Relatively well tolerated swimming and rowing. It also matters the duration of physical exertion. Under the conditions of provocative test, loads are usually provided for 6-8 min.; with a longer load (12-16 min.) The severity of post-load-loaded bronchospasm can be less - the patient seems to jump through bronchospasm.

Complications

Strongly flowing by B. a. Completed by emphysemic lungs, often chronic nonspecific bronchitis, pneumosclerosis, the development of the pulmonary heart, with the formation of in the subsequent chronic pulmonary heart failure. Significantly faster these complications occur with infectious-dependent than with the atopic form of the disease. At the height of the attack of suffocation or a protracted batch of cough, a short-term loss of consciousness is possible ( bettoleppsia ). With severe attacks, light breaks are sometimes noted in the plots of bullous emphysema with development pnemothorax and pneumomediastinum (see Mediastinum ). It is often observed complications due to long-term therapy B. a. glucocorticoids: obesity, arterial hypertension, pronounced osteoporosis, which can cause the occurrence during the bouts of B. a. Spontaneous fractures of ribs. With the continuous use of glucocorticoids in a relatively short time (sometimes for 3-5 weeks), hormone-dependent flow B. a.; Cancellation of glucocorticoids can cause severe asthmatic status threatening.

Analysis of the clinical picture and purposeful examination of the patient make it possible to solve three main diagnostic tasks: confirm (or reject) the presence of B. a., To determine its form, to establish a spectrum of allergens (with allergic B. a.) Or pseudo-allergenov (see) Pseudo-Allergy ), having etiological significance for B. a. In this patient. The last task is solved with the participation of allergists.

The diagnosis of bronchial asthma is based on the following criteria: the characteristic attacks of expiratory suffocation with remote wheezes; Significant differences in the power of the exhalation during the attack (sharp decline) and outside the attack: the effectiveness of B-adrenomimetics in the relief of the bonuses of choking; blood eosinophilia and especially sputum; The presence of concomitant allergic or polypose rhinosinusopathy. Confirm the presence of B. a. characteristic changes of the FVD; Less than specific X-ray data outside the attack of asthma. From the latter in favor of the possible presence of B. a. may indicate signs of chronic emphisms of the lungs and pneumosclerosis (more often found in infectious-dependent ASTME) and changes in the apparent sinuses of the nose - signs of edema of the mucous membrane, polypose, sometimes purulent process. With atopic B. a. Radiographic changes in the lungs outside the attack of choking may be absent even years later from the beginning of the disease.

From the FVD studies, the main value for the diagnosis of B. a. It has the detection of bronchial obstruction (as a leading type of ventilation disorders at B. a.) and, the main thing that is characteristic of B. a. The hyperreactivity of the bronchi, determined by the dynamics of the FVD in provocative samples with the inhalation of physiological active substances (acetylcholine, histamine, etc.), hyperventilation, physical activity. Bronchial obstruction is determined to reduce the forced vital capacity in the first second of the exhalation (Ferez 1) and the power of the exhalation according to pneumotometry. The latter method is very simple and can be used by a doctor on the usual outpatient reception, incl. To identify the so-called hidden bronchospasm, often detected in patients B. a. If the power of the exhalation, measured before and after 5, 10 and 20 min.after the inhalation of the patient with one dose of Alupent (or other B-adrenomimetics in a dosage manual inhaler), increases by 20% or more, then the test is considered positive, testifying to the imaginary bronchospasm. At the same time, the negative test in the remission phase at normal source power of the exhalation does not give grounds to reject the diagnosis of B. a.

The degree of non-specific hyperency of the bronchi is estimated in the Phase of Remissions B. a. With the help of provocative inhalation tests with acetylcholine (carbocholy), sometimes histamine, PGF 2A, B-adrenobloculous drugs. These studies, sometimes necessary for the dubious diagnosis of B. a., Are carried out only in the hospital. The provocative test is considered positive if after inhalation of the solution of the acetylcholine freak, and (or) the power of the exhalation is reduced by more than 20%; In some cases, a clinically deployed attack B. a was provoked. A positive acetylcholine test confirms the diagnosis of B. a., Negative allows you to reject it with a great degree of probability.

Diagnosis of individual forms B. a. The extent is based on clinical data, the analysis of which, if necessary, is complemented by special tests and allergological examination.

Aspirin asthma is assumed to be highly likely in the case of a clear connection of attacks with the admission of aspirin or other non-steroidal anti-inflammatory funds, as well as if asthma is the first manifestation of the intolerance of these drugs, especially in women over 30 years old who do not have an atopy in a personal and family history and pansynusitis suffering Polyposis of the nose that complements the aspirin triad. The diagnosis is more reliable if during the bouts of B. a. The normal level of LGE in the blood is found in the presence of blood eosinophilia. In doubtful cases, specialized agencies sometimes conduct a provocative oral test with acetylsalicylic acid (in minimal doses), but the widespread use of this test cannot be recommended due to the possibility of severe reactions.

The asthma of physical efforts are established according to the history of the history and the results of a provocative test with dosage (using a bicycle ergometer) with a physical activity, which is usually carried out in a hospital in the phase of the disease remission and in the absence of contraindications (heart disease, thrombophlebitis of the lower extremities, high degree of myopia, etc.) . The test is considered positive if within 20 min.after performing the physical force of Ferzha) and (or), the power of the exhalation is reduced by 20% and the clinically pronounced attack of suffocation (usually not heavy). A positive test is an objective indicator of the hyperreactivity of the bronchi and can be used to confirm the diagnosis of B. a. A negative result does not exclude this diagnosis.

Atopic B. a. Recognize the characteristics of the clinical course, the presence of concomitant manifestations of atopy (pollinosis, atopic dermatitis, food allergies, etc.), the data of family and allergological anamnesis. Reaffirm the diagnosis of reactive sensitization in the patient (see Allergy ) and positive results of eliminational tests (termination of contact with suspected allergens), as well as provocative samples with certain allergens. For atonic B. a. Characterized by the increased content of general LGE in serum, as well as the presence of allergenspecific LGE. Relatively often notes a decrease in the number of T-lymphocytes, especially T-suppressors.

Infectious-dependent B. a. It is assumed primarily in cases of the manifestation of attacks of suffocation against the background of already formed chronic bronchitis, chronic pneumonia or in the presence of chronic foci of infection in the upper respiratory tract. However, in all cases it is necessary to differentiate the infectious-dependent and atopic forms of B. a. In favor of infectious-dependent B. a. Slow start and greater duration of the attacks of suffocation, the inclusive relationship of their participation with a transferred acute or aggravated chronic respiratory infection, a tendency to the development of asthmatic status, the absence of sensitization patients with reactive sensitization, positive skin and provocative inhalation tests with bacterial allergens. The main differences in the atopic and infectious-dependent forms of B. a. Posted table .

The persistent bronchial asthma is an inflammatory disease of the air pathways with a chronic flow, the only manifestation of which is the reversible narrowing of the lumen of the bronchi. The hypereactivity of the bronchi occurs against the background of chronic inflammation of the mucous membrane and manifests itself with bronchospasm and hyperproduction of thick sputum. All this leads to the appearance of characteristic symptoms.

Persistent asthma

Causes of occurrence

Groups of factors causing the development of persistent asthma:

internal;
external;
triggers (provoke the aggravation of the disease).

Internal factors determine the development of the disease. These include:

Genetic predisposition

genetic predisposition (it has been proven that the risk of inheritance of bronchial asthma is about 70%);
atopia (increasing the IgE titer in response to contact with an allergen);
high activity of airways (strong narrowing of the enlightenment of airways, in response to the action of allergen or trigger);
obesity (effect on the mechanism of respiratory act and contributes to the development of an inflammatory response).

External factors provoke the appearance of symptoms of the disease:

Factors provoking the aggravation of asthma:

student breathing;
natural factors (high or low air temperature, wind);
pharmacological preparations (NSAIDs, beta receptor antagonists);
the smell of paints and varnishes;
psycho-emotional tension.

Manifestations of the disease

The aggravation of the disease occurs after the allergen hit in the body and manifests itself in the form of shortness of shortness of breath, attacks of an unproductive cough, whistling wheezing, plowing in the chest. Sometimes the aggravation can be caused by increased motor activity.

Cough reflex

The mechanism of symptoms:

the irritation of the cough receptors of the bronchi leads to the occurrence of cough reflex;
the spasm of the smooth muscles of the bronchi contributes to the formation of a whistling breathing, due to the turbulent air current through the spasmated airways;
due to the increase in the operation of the respiratory system, shortness of breath arises.

Severity

According to the severity, persistent ASTMU is divided into:

Little persistent ba. The symptoms of the disease arises two or more times a week, but not daily. The emergence of attacks that violate the quality of sleep, more often 2 times a month. The exacerbations are negatively reflected on motor activity. OFV for the first second outside the attack more than 80% of normal indicators.
Assistant medium gravity. Manifested by everyday symptomatomy, night manifestations occur more often than once in 7 days, exacerbations reduce motor activity and worsen sleep. Daily reception of Beta-2-adreminomimetics of short action is required.
Heavy persistent ba. It is characterized by regular manifestations of symptoms, more than once a day, frequent exacerbations and a breakdown of sleep quality, a significant limitation of motor activity.

Diagnostics

Asthma Diagnostics Stages:

Spirometry

Collection of patient complaints and refinement of anamnesis.
Functional methods of diagnostics (spirometry, picoflorometry).
Collect allergic.
Skin-allergic samples.
Test with an allergen for the purpose of provocation.
Laboratory diagnostic methods.

When analyzing complaints, pay attention to:

breath, arising on the breath;
attacks of an unproductive cough;
the severity and feeling of squeezing in the chest;
whistling wheezes.

An assessment of the reversibility of briefcase is carried out with spirometry. To confirm the diagnosis, an indicator of the volume of forced exhalation in the first second is important. At first, this indicator is estimated without the use of medicines, then the patient is introduced the preparation of broncholics. After 15-20 minutes, the study repeat. An increase in FEV1 by more than 12% testifies in favor of the alleged diagnosis.

Picoflorometry

Using picofloumetria, the peak air velocity is determined. This method is used with the impossibility of conducting spirometry and to control the dynamics of the course of the disease. The device has small sizes, so it is convenient to use it to identify the influence of provoking factors at work and at home.

When assessing allergianamnese, it is necessary to establish the presence of allergic diseases in the family, to identify the connection between the occurrence of symptoms and the action of allergens (contact with animals, the cold season, the manifestation of symptoms after the presence in certain premises).

To identify specific allergens, skin samples with allergens are carried out. Samples are carried out in late autumn or in winter to eliminate the effect of pollen plants on the test results.

To which doctor to turn

With the appearance of symptoms of the disease, it is necessary to refer to the precinct therapist. After the preliminary diagnosis of the district doctor will send the patient to narrow-profile specialists:

pulmonologist;
allergist;
gastroenterologist.

Required analyzes

To confirm the disease, it is necessary to donate blood for the definition of a common and specific immunoglobulin E. It is also necessary to hand over the wet or bronchoalveolar fluid for analysis on the content of eosinophils.

Survey study

Treatment methods

Pharmacotherapy of persistent asthma is divided into 2 types:

constant supporting therapy;
preparations used in exacerbation.

Supporting (basic) therapy is aimed at reducing the frequency of attacks, up to their complete absence. For this purpose, drugs are prescribed with anti-inflammatory activity (inhalation and systemic corticosteroids), prolonged beta-2-agonists.

Salbutamol.

During exacerbation, drugs are used with the highest possible effects of effects: salbutamol, phenoterol.

Forecast

Subject to the facilitated diagnosis and appointment of effective therapy, it is possible to achieve a fully controlled course of the disease. The quality of life of such patients has almost no difference from healthy people.

Preventive measures

Food allergens

For the prevention of asthma exacerbation, it is recommended to exclude food products that cause them a manifestation of an allergic reaction. Purchase patients need to be reduced by body weight, which will improve the state of health, and reduce the risk of exacerbation. Additionally, it is necessary to exclude active and passive smoking to minimize the harmful effects on the lungs. Moderate physical exertion improve the cardiovascular function. Patients are recommended to engage in swimming, to train muscles participating in the act of inhalation.

Possible complications

Astmatic condition is the hardest complication of the flow of persistent bronchial asthma. It is an acute respiratory failure and immunity to broncholy preparations. Frequent exacerbations of the disease can lead to the development of the emphysema of the lungs, due to the extracts of lung tissue due to the impossibility of exhalation. The development of hypertrophy of the right ventricular heart is possible due to pulmonary hypertension.

Asthma is a formidable disease, with the possibility of developing severe complications. But in time the diagnosed disease and correctly selected treatment reduces the emergence of exacerbations to a minimum and prevent possible complications, while maintaining the high quality of life of patients.