It belongs to the basic treatment of bronchial asthma. Drugs for bronchial asthma - an overview of the main groups of drugs for effective treatment of the disease. For basic therapy

Preventive drugs used for the basic treatment of bronchial asthma are used to "slow down" the attack and prevent it from developing.

Prophylactic drugs are intended for daily use. They eliminate inflammation, relieve bronchial edema, and reduce the reaction of the bronchi to the action of allergens. Thus, these drugs reduce the frequency and severity of seizures, prevent recurrent seizures, and are intended for continued use. These drugs include antileukotriene drugs, long-acting beta-agonists, cell membrane stabilizers, and corticosteroids. Usually, injectable forms are used, but for complex cases it is recommended to use drugs in tablet form.

Inhaled and systemic glucocorticoids

Recently, inhaled topical glucocorticoids have become widespread, which are available in the form of dispenser inhalers or nebulizers. Currently, they are the main drugs for the basic treatment of bronchial asthma. Inhaled glucocorticoids are prescribed for a long period - up to several weeks. They have a relatively low risk of side effects, therefore they are relatively safe for long-term use, reduce bronchial hypersensitivity, improve lung function, reduce the severity of exacerbations, and therefore improve the quality of life.

Advantages of inhaled glucocorticoids:

1. Inhaled glucocorticoids have the best balance of safety and effectiveness.
2. Powerful anti-inflammatory effect.
3. Regular use allows you to translate the course of bronchial asthma to a milder degree.

Inhaled glucocorticoid hormones, as a rule, do not cause systemic reactions, but with prolonged use at maximum doses, a depressing effect on the hypothalamic-pituitary-adrenal system is possible.

Inhaled glucocorticoids cannot be used to relieve an asthma attack, since the effect develops within one week, while the maximum manifestation appears after 6 weeks from the start of treatment. Currently, the following drugs are used for therapy - fluticasone, budesonide, beclomethasone, triamcinalone acetonide.

Systemic glucocorticoids

Systemic glucocorticoids are used in severe cases, with a progressive deterioration of the patient's condition, with a low efficacy of inhaled bronchodilators. Usually, oral glucocorticoids are taken in one morning dose or on a 2/3 dose schedule in the morning and a smaller portion around noon.

Oral glucocorticoid hormones have side effects:

• Weight gain.
• A reaction from the gastrointestinal tract (inflammation and ulceration).
• Hormonal imbalance.
• Suppression of immunity (tendency to frequent infectious diseases).
• The development of osteoporosis.

Antileukotrienes

These are drugs of a new generation for oral administration with a pronounced anti-inflammatory effect. They help relieve asthma symptoms within 24 hours. They are used in combination with medium and high doses of inhaled glucocorticoids. Antileukotrienes are especially indicated for patients with aspirin bronchial asthma.

Cell membrane stabilizers

Cell membrane stabilizers are used in children under 12 years of age and in adults with mild asthma as an alternative to low doses of inhaled glucocorticoids.

Long-acting beta agonists

Salmeterol and formoterol are currently members of this group. These are drugs that open the airways and reduce inflammation.

It should be remembered that various expectorants and antibiotics should not be used in the treatment of bronchial asthma. Their use is possible only in cases where there are signs of infection along with asthma.

Basic treatment of bronchial asthma is necessary to suppress inflammation in the airways, reduce bronchial hyperreactivity, and reduce bronchial obstruction.

The therapeutic course is developed specifically for each patient, taking into account the severity of the disease, age and other individual characteristics. A patient with asthma is prescribed medications necessary to eliminate the inflammatory process localized in the respiratory tract.

Treatment of pathology is based on the use of drugs that relieve asthmatic attacks, as well as basic therapy drugs. The second group of drugs is designed to affect the pathogenetic mechanism of the disease.

Bronchial asthma is a chronic pathology in which the development of an inflammatory process in the respiratory tract is observed. Asthmatics are faced with narrowing of the bronchi, caused by the influence of external and internal factors. Pathology manifests itself in the form:

• shortness of breath;
• headaches;
• respiratory failure;
• wheezing rales;
• feeling of congestion in the chest area;
• persistent cough.

In total, there are about 230 million asthmatics in the world. In developed countries, similar principles of treatment of pathology are used, which allow many patients to reach the stage of stable remission, subject to all medical recommendations.

Goals and objectives of basic therapy in asthma treatment

For asthmatics, basic therapy is indicated if bronchial asthma causes a deterioration in the general condition of the patient. The main goal in treating the disease is to prevent the pathology from becoming severe when it gets out of control and complications develop.

Possible complications due to the active development of the disease: pneumothorax, emphysema, bettolepsy, atelectasis.

The disease can be of varying severity - each of them has its own therapy regimen. When treating bronchial asthma, doctors must solve the following therapeutic problems:

• assessment of the patient's condition and the impact on the symptoms that appear;
• minimizing the number of attacks (regardless of their intensity);
• minimization of side effects from drugs used for basic treatment;
• teaching asthmatics to self-help skills in the development of attacks;
• monitoring the response of the patient's body to the drugs used, adjusting the appointment, if required.

It is customary to distinguish 5 main stages of development of bronchial asthma, in accordance with which a treatment regimen is developed:

1. At the initial stage of the development of the pathology, the patient is usually prescribed short-acting beta-adrenergic agonists. These are symptomatic remedies. With their help, the bronchi expand, thereby relieving the attack.
2. At the second stage, at the decision of the doctor, one or more drugs can be used. An asthmatic must take these medications systematically to stop the development of the inflammatory process in the bronchi. Usually, inhaled glucocorticosteroids and beta-adrenergic agonists are prescribed. Treatment begins with minimal doses.
3. At the third stage, in addition to the drugs already prescribed, long-acting beta-adrenergic agonists are used. These drugs dilate the bronchi, making it easier for the patient to breathe and speak.
4. At the fourth stage, patients have a difficult disease, so doctors prescribe systemic hormonal anti-inflammatory drugs. These drugs work well with asthmatic attacks, but their use leads to various side effects: diabetes, metabolic disorders, withdrawal symptoms, etc.

The fifth degree is characterized by an extremely serious condition of the patient. The patient's physical activity is limited, there is severe respiratory failure. Treatment is almost always carried out in a hospital.

What influences the selection of the therapy regimen

Preparations for the basic therapy of bronchial asthma should be prescribed by a doctor, it is forbidden to independently select medicines for yourself. Basic principles of bronchial asthma treatment: immunotherapy and pharmacotherapy.

Regardless of the age and severity of the patient's current condition, treatment begins with small doses of medication. The treatment regimen is usually adjusted by specialists taking into account the following factors:

• the presence of chronic lung pathologies;
• the current state of the asthmatic (while taking medications);
• the intensity of attacks of suffocation at night;
• the presence of characteristic asthmatic manifestations (shortness of breath, wheezing, cough);
• test results;
• duration, frequency, severity of daytime attacks.

With mild, moderate and severe, basic and symptomatic therapy of the disease is carried out.

Beta-adrenomimetics (they are also called "inhaled 2-agonists") and other drugs that stop attacks and reduce their number are necessarily used.

Basic remedies for the treatment of bronchial asthma

Basic therapy for bronchial asthma involves the use of inhaled glucocorticosteroids, systemic glucocorticosteroids, mast cell stabilizers, leukotriene antagonists.

These drugs for the treatment of bronchial asthma are necessary to control the disease, prevent the patient's condition from worsening.

Glucocorticosteroids

Glucocorticosteroids are essential for relieving seizures. They are anti-inflammatory. The use of inhaled glucocorticosteroids allows you to remove bronchial obstruction in a short period of time.

The main advantages of such inhalations include:

• elimination of the inflammatory process in the bronchi;
• decrease in the intensity of the symptoms of the disease;
• the possibility of taking relatively small doses of the drug;
• minimizing the penetration of the active substances of the drug into the general bloodstream;
• improvement of patency in the bronchi.

Systemic glucocorticosteroids

Inhaled glucocorticosteroids can stop attacks, but systemic glucocorticosteroids in the form of tablets are used for the basic therapy of bronchial asthma.

They are prescribed if the patient's condition is assessed as moderate and severe. These drugs:

• eliminate spasms in the bronchi;
• improve airway patency;
• eliminate the inflammatory process;
• reduce the secretion of phlegm.

Systemic glucocorticosteroids can be prescribed in severe stages of the disease, with deterioration of spirometry indicators, in the absence of results of treatment with inhaled drugs and further development of manifestations of bronchial asthma.

It is forbidden to use such medicines independently without a doctor's prescription.

Mast Cell Stabilizers

Anti-inflammatory therapy for bronchial asthma includes the use of mast cell stabilizers. These drugs are prescribed for patients with mild to moderate severity of the disease.

Mast cell stabilizers help:

• prevent and eliminate allergies;
• prevent the occurrence of spasms in the bronchi;
• reduce the inflammatory process;
• reduce bronchial hyperreactivity.

Leukotriene antagonists

Basic therapy for bronchial asthma almost always includes the use of leukotriene antagonists. Their main task is to block leukotriene receptors and inhibit the activity of the 5-lipoxygenase enzyme.

Due to these organic compounds, spasms develop in the bronchi due to allergies to various irritants.

These drugs have a strong anti-inflammatory effect, suppress the cellular and non-cellular components of inflammation in the bronchi, which is caused by exposure to antigens. They also have the following effect:

• elimination of spasms in the bronchi;
• decrease in the formation of phlegm;
• elimination of infiltration and inflammation in the bronchial mucous membranes;
• an increase in the permeability of small vessels in the respiratory organs;
• relaxation of smooth muscles in the respiratory organs.

The use of basic therapy in the treatment of children

Basic therapy for bronchial asthma involves the use of several types of drugs. Treatment is necessarily complex.

Doctors, developing a treatment regimen, must decide how the manifestations of bronchial asthma will be eliminated in the patient. An equally important task is to achieve a stable remission.

When choosing the type of basic therapy for bronchial asthma in children, experts take into account many factors: the age of the child, the age of the first asthmatic symptoms, the presence of other chronic diseases, the current state of the little patient.

Asthma symptoms are also taken into account. They can appear with different intensities. In children diagnosed with bronchial asthma, the following symptoms are observed:

• wheezing during breathing;
• bluish skin tone in the area of ​​the nasolabial triangle (with an attack);
• deterioration of the general condition;
• asthmatic attacks (in the presence of an external stimulus or at night);
• cough, shortness of breath, trouble breathing.

For the treatment of children are used:

• long-acting bronchodilators;
• medicines with anti-inflammatory effect.
• inhaled glucocorticoids.

Interaction with patients

Basic asthma therapy is indicated for all patients diagnosed with the disease (except for patients with). But some patients refuse to take anti-inflammatory drugs and any other traditional treatment for bronchial asthma, preferring folk remedies.

It has a right to exist, but asthmatics should in no case refuse to take anti-inflammatory drugs.

Refusal of treatment and lack of control by the attending physician in almost 100% of cases leads to a deterioration in the patient's condition, increased asthmatic attacks, the development of complications (heart problems, headaches, etc.).

Therefore, direct contact should be established between the attending physician and the asthmatic from the very beginning of treatment. It is important that the patient has all the necessary information about his disease:

1. What can trigger the development of an asthmatic attack?
2. How can you quickly stop it?
3. What drugs and in what dosages can be used?
4. When is it necessary to call an ambulance?

Every asthmatic person should know the answers to these questions. If the attending physician did not conduct an appropriate conversation, the patient should independently consult with a specialist, asking him questions of interest.

The presence of direct contact between the doctor and the patient is very important in cases when a small child is being treated for bronchial asthma. Children cannot make their own decisions, so their parents must have all the necessary information about the disease.

Finally

Medicines for the treatment of bronchial asthma, used in basic therapy, are prescribed by a doctor depending on the severity of the disease, the frequency and severity of symptoms, the current state of the patient.

Therapy in each case is strictly individual, therefore, self-medication with the development of bronchial asthma, regardless of its stage, is excluded.

Rational use of drugs, taking into account the routes of their administration (inhalation is preferred);

A stepwise (depending on the severity of the disease) approach to treatment;

In children over 5 years of age, basic therapy is carried out under the control of the function of external respiration (peak flowmetry);

Basic therapy is determined taking into account the initial severity of the disease at the time of examination of the patient, carried out for a long time, canceled when a stable remission is achieved.

Levels of control of bronchial asthma

Specifications	Controlled BA (all of the above)	Partially controlled BA (presence of any manifestation within 1 week)	Uncontrolled BA
Daytime symptoms	No (≤ 2 episodes per week)	> 2 episodes per week	Having 3 or more signs of partially controlled asthma in any week
Activity limitation		Yes - of any severity
Nocturnal symptoms / awakenings due to AD
The need for drugs "first aid"	No (≤ 2 episodes per week)	> 2 episodes per week
Lung function (PSV or FEV1)		<80% от должного или лучшего показателя
Exacerbations		≥ 1 in the last year	... any week with an exacerbation *

* By definition, a flare-up week is a week of uncontrolled asthma.

Step therapy

Stage 1	Stage 2	Stage 3	Stage 4	Stage 5
Patient education
Elimination activities
β2 - short-acting agonists on demand
Supportive therapy options
	Choose one of the following options	Assign one of the following options	Prescribe medium to high doses of ICS	Add one or more options to stage 4
		Low doses of ICS + β2-agonist lasts. actions (preferably)	Add one or more options	The lowest possible dose of oral corticosteroids
		Medium to high doses of ICS	Long-acting β2 agonist
	Low doses of ICS	Low doses of ICS + ALP
		Low doses of ICS + theophylline retarded. release	Sustained release theophylline

Stage 1, which includes the use of drugs to relieve symptoms as needed, is intended only for patients who have not received supportive care. Patients with more frequent onset of symptoms or episodic worsening of the condition should be given regular supportive therapy (see Stage 2 or above) in addition to medications to relieve symptoms as needed.

Steps 2-5 involve a combination of symptom relief medication (as needed) with regular supportive therapy. As the initial maintenance therapy for asthma in patients of any age, at stage 2, corticosteroids are recommended.

It is recommended to assign to 3 steps a combination of low-dose ICS with inhalationbLong-acting 2-agonist in fixed combination... Due to the additive effect of combination therapy, patients usually find it sufficient to prescribe low doses of an inhaled glucocorticosteroid; an increase in the dose of ICS is required only for patients in whom asthma control has not been achieved after 3-4 months of therapy.

Preparations used for basic therapy

Bronchial asthma is a disease of the respiratory tract that is steadily progressing and, as a rule, develops in childhood due to the influence of various factors of an allergic, infectious and genetic nature.

This determines the relevance of preventive methods and the need for the treatment of bronchial asthma in adults and.

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Basic step therapy in adults

Treatment of bronchial asthma is based and depends on the level of control of the disease, and not on its severity, which may change over time due to the therapy. Disease control consists of two components: controlling symptoms and minimizing the risks of exacerbation. However, in patients with different levels of disease control, the severity is a guideline in the appointment of basic therapy for bronchial asthma.

Basic therapy is necessary to reduce the number of exacerbations and hospitalization of patients due to uncontrolled course of bronchial asthma.

The scope of basic therapy is determined individually and has a stepwise approach. There are 5 stages of bronchial asthma treatment. Each step has a preferred therapy option and alternative methods.

How to treat at home

Home asthma treatment in adults is possible with full adherence to the therapy regimen. How to treat this condition in adults is determined by the doctor's prescription. The ineffectiveness of treatment in this case may be due to the lack of technology for using an asthma inhaler. This is due to the fact that the medicine for bronchial asthma does not enter the respiratory tract and is not able to provide the necessary therapeutic effect.

If the symptoms worsen and the condition of the patient being treated at home worsens, a doctor's consultation is necessary to assess the course of the disease and prescribe an effective therapy.

Drug overview

A wide range of drugs are used to treat bronchial asthma. Their combinations and doses are selected by the doctor, taking into account the dynamics of the disease and the patient's condition.

The use of ICS in the form of inhalers (sprays)

Inhaled glucocorticosteroids (ICS) are the most effective drugs in the basic therapy of bronchial asthma. ICS are able to reduce the severity of symptoms, improve external respiration and minimize the phenomena of bronchial hyperreactivity.

The following drugs are widely used in clinical practice:

• Budesonide;
• Flunisolide;
• Beclomethasone dipropionate;
• Fluticasone propionate.

The mechanism of action of glucocorticoids in bronchial asthma is based on their anti-inflammatory effect. With the help of inhalers used for bronchial asthma, glucocorticosteroid molecules are found on the epithelium of the respiratory tract. Then they penetrate the membrane and find themselves in the area where reactions occur that stimulate the release of anti-inflammatory molecules.

Some inhalers used for asthma are:

• Budiair;
• Foster;
• Salmecort.

The clinical effect of glucocorticosteroids is achieved with the appointment of various doses and depends on the degree of the disease. Low doses of ICS reduce the frequency of exacerbations, improve external respiration, reduce inflammation and airway hyperresponsiveness. High doses of ICS are used to reduce bronchial hyperreactivity and better control the course of the disease.

Antileukotriene

Antileukotriene drugs for the treatment of bronchial asthma inhibit cysteinyl leukotriene receptors in eosinophils and neutrophils. This is responsible for their anti-inflammatory effect. They also have a bronchodilatory effect. This group of drugs has found especially widespread use in aspirin bronchial asthma and polypous rhinosinusitis.

The use of antileukotriene drugs in bronchial asthma helps to reduce the prescribed doses of inhaled glucocorticosteroids.

Bronchodilators (Euphyllin and others)

Bronchodilators for bronchial asthma are widely used to eliminate bronchospasm. Bronchodilators are available in the form of inhalers, sprays, syrups, solutions and tablets for bronchial asthma.

Pharmacological groups that have a bronchodilator effect include:

• beta-2 adrenergic receptor agonists, which are subdivided into short-acting and long-acting agonists (formoterol and salmeterol);
• antagonists of M-cholinergic receptors;
• adrenalin;
• myotropic antispasmodics;
• glaucine.

Eufillin, a phosphodiesterase inhibitor, is also actively used in this disease, it relaxes the muscles of the bronchi, relieves spasm of the bronchi, and has a stimulating effect on the contraction of the diaphragm and the respiratory center. In addition, the use of aminophylline leads to the normalization of the respiratory function and oxygenation of the blood.

It is impossible to select the best pills for the treatment of bronchial asthma, the list of drugs is compiled by the doctor based on the current state of the sick person.

Glucocorticoids (Prednisolone and others)

Prednisolone is actively used in the glucocorticoid group. It does not have a bronchodilator effect, but it has a strong anti-inflammatory effect. Glucocorticoids are prescribed for seizures in which treatment with bronchodilators is ineffective. The action of prednisolone does not occur immediately - it develops within 6 hours after taking the drug.

The dose of prednisolone is up to 40 mg per day. Its reduction should occur gradually, since otherwise the risk of exacerbations will be high.

Cromones

Cromones are drugs used in bronchial asthma and have anti-inflammatory effects. This group of drugs has found wider application in pediatric practice due to their safety and minimal side effects. Cromones are used in the form of inhalation and spray for bronchial asthma. In case of broncho-obstructive syndrome, it is recommended to prescribe short-acting beta-2 agonists before use.

Cough in asthma occurs against the background of expiratory dyspnea and is stopped together with bronchial spasm by the drugs discussed above. To treat a cough that is not associated with an attack should be based on its nature with the use of antibiotics, mucolytic, antitussive and other agents.

List of the most effective medicines

The list of the most effective medicines for bronchial asthma is presented below:

1. Omalizumab is a monoclonal antibody drug. It is able to provide hormone-free asthma treatment even in severe adults. The use of omalizumab can successfully control the symptoms of bronchial asthma.
2. Zafirlukast is a drug that has anti-inflammatory and bronchodilatory effects. The mechanism of action of Zafirlukast is based on blocking leukotriene receptors and preventing bronchial contractions. The main indications for the appointment: asthma of mild to moderate severity.
3. Budesonide is a glucocorticosteroid with anti-inflammatory anti-allergic effects. Budesonide for asthma is used in inhalation form.
4. Atrovent (ipratropium bromide) is an inhaled anticholinergic that has a bronchodilating effect. The mechanism of action is based on inhibition of receptors of the muscles of the tracheobronchial tree and suppression of reflex bronchoconstriction.

With bronchial asthma, patients without a confirmed disability can count on free medicines. The conditions for their provision change over time, and also depend on the region of residence, therefore, the question of obtaining them should be addressed to the doctor.

Non-drug methods

Non-drug treatment of bronchial asthma acts as an adjunct to the main treatment and, as a rule, is prescribed by the attending physician if indicated. The procedures are selected individually and according to the recommendations of a specialist.

Massage

Massage for bronchial asthma improves blood circulation, activates the respiratory muscles and increases tissue oxygen saturation. Also, massage helps to eliminate congestion in the lungs and improve airway patency in obstructive syndrome.

Physiotherapy

Physiotherapy for bronchial asthma is represented by various methods that vary depending on the period of the disease. For example, during an exacerbation of asthma, aerosol therapy can be performed using ultrasound. In addition, electroaerosol therapy is also used.

Aerosol inhalations are carried out with euphyllin, heparin, propolis, atropine.

In order to restore the patency of the bronchi, electrophoresis of bronchodilators is used on the interscapular region.

Non-specific methods include ultraviolet irradiation in order to increase the resistance of the body's immune system.

In the interictal period, electrophoresis of calcium ions is used, as well as phonophoresis of hydrocortisone on the segmental zones of the chest.

To date, magnetotherapy and low-frequency ultrasound have proven their effectiveness in the treatment of bronchial asthma.

Spa treatment

Spa treatment for bronchial asthma is a combination of climatic therapy, thalasso and balneotherapy. The sanatoriums are located in the Crimea, Kislovodsk, Gorny Altai and are popular among patients with respiratory diseases. Only those patients who are in the phase of stable remission and those who have undergone a thorough examination undergo rehabilitation in such centers.

However, it is worth considering the fact that the patient needs time to adapt to climatic conditions, therefore, when choosing a sanatorium, the doctor should prefer resorts with a climate close to that in which the patient is used to living.

Folk remedies

The use of folk remedies is not particularly effective and has only a minimal effect. The most effective folk remedy for treating bronchial asthma is herbal medicine. It involves the use of medicinal plants in the form of inhalation and in tablet forms.

• garlic juice can be used for aerosol inhalation;
• tea made from lingonberry berries and leaves;
• a decoction of viburnum berries and honey.

Herbal medicine has a number of side effects (allergic reactions) and contraindications, which requires mandatory consultation with a specialist before use.

Respiratory gymnastics refers to physiotherapy exercises and includes the performance of exercises, accompanied by holding the breath.

The purpose of this method is to relieve and prevent an attack of bronchial asthma.

The diet for bronchial asthma does not differ much from the diet of a healthy person. However, doctors recommend adhering to certain principles in compiling your diet:

1. Limiting daily salt intake.
2. Consumption of a sufficient amount of liquid per day (at least 1.5 liters).
3. Limiting the consumption of fatty, fried and spicy foods.
4. Steamed and boiled food is preferred.
5. It is recommended to eat food in small portions many times a day (5-6 times).
6. The diet should be balanced in protein, fat and carbohydrates.
7. The diet should contain both vegetables and fruits, as well as meat and fish.

Status asthmaticus is a condition characterized by an attack of a protracted course of asthma, which is not stopped by bronchodilators for several hours. In order to treat bronchial asthma in this case, it is important to remember that the purpose of the assistance provided during an exacerbation of bronchial asthma is to limit the action of the trigger and stop the asthma attack.

The drugs used to treat the seizure are preferably inhaled or infused.

Bronchodilator therapy for an attack is represented by rapid-acting beta-2 agonists. Then, an hour later, the patient's condition is monitored and, when symptoms are relieved, the beta-2 agonist is continued for every 3 hours throughout the day or 2 days.

With moderate severity, the doses of inhaled glucocorticosteroids are increased, their oral forms, an inhaled anticholinergic are added, and therapy with beta-2 agonists is also continued every 3 hours for 1-2 days.

For severe severity, higher doses of oral and inhaled glucocorticosteroids are also added. Shown hospitalization in the inpatient department.

In case of asthmatic status, the patient is urgently hospitalized in the intensive care unit and immediate intensive care is started:

1. Systemic glucocorticosteroids (prednisolone) are urgently administered intravenously, and inhaled through a nebulizer.
2. Epinephrine (adrenaline) is administered subcutaneously or intramuscularly when breathing is threatened.
3. Artificial ventilation of the lungs and resuscitation measures are carried out in the presence of clinical indications for these procedures.

Bronchial asthma is a respiratory disease that cannot be completely cured. Asthma medications are used to provide relief.

The possibilities of modern medicine are limited by the ability to minimize risk factors, alleviate symptoms and improve the quality of the patient's health and life.

Preventive methods for both children and adults are of particular importance. In childhood, they are aimed at eliminating risk factors and the primary development of asthma.

Conclusion

- an inflammatory disease with allergic, infectious and non-infectious genesis, depending on the etiological factor.

Treatment of bronchial asthma involves the use of both medication and non-medication methods.

The severity of the course and the clinical picture of the disease determine the medical tactics and the required amount of therapy for the patient.

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Bronchial asthma is a disease that doctors are increasingly faced with in recent years. This is not surprising, because, according to international studies, in the developed countries of the world about 5% of the adult population and almost 10% of children suffer from this disease. In addition, in recent decades, there has been a clear tendency towards an increase in the incidence of allergic diseases, including bronchial asthma.

It is this circumstance that has caused the appearance in recent years of a number of policy documents, guidelines on the diagnosis and treatment of bronchial asthma. These fundamental documents are the Joint Report of WHO and the National Heart, Lung, and Blood Institute (USA) “Bronchial asthma. Global Strategy (GINA) ", 1996 and" Bronchial Asthma (Formulary System). A guide for doctors in Russia ", 1999. These guidelines are intended for practitioners and serve one purpose - the formation of a unified concept of bronchial asthma, its diagnosis and treatment.

In turn, modern therapy of bronchial asthma is based on the above concept, on the basis of which the form and severity of the disease are determined.

According to modern concepts, bronchial asthma, regardless of the severity of its course, is a chronic inflammatory disease of the respiratory tract, in the formation of which many cells are involved: mast cells, eosinophils and T-lymphocytes. If predisposed, this inflammation leads to repeated episodes of wheezing, shortness of breath, chest tightness, and coughing, especially at night and / or in the early morning. These symptoms are usually accompanied by widespread but variable bronchial obstruction that is at least partially reversible spontaneously or with treatment. Inflammation leads to the formation of an increased sensitivity of the respiratory tract to a variety of stimuli, which do not cause any reaction in healthy individuals. This condition is bronchial hyperreactivity, which can be specific and nonspecific. Specific hyperreactivity is an increased sensitivity of the bronchi to certain, specific allergens that have caused the development of asthma. Nonspecific hyperreactivity is understood as an increased sensitivity to a variety of nonspecific stimuli of a non-allergenic nature: cold air, exercise, pungent odors, stress, etc. component of 20% or more.

Allergic mechanisms cause asthma in 80% of children and in about 40-50% of adults, therefore the European Academy of Allergology and Clinical Immunology (EAACI) suggests using the term "allergic asthma" as the main definition of asthma caused by an immunological mechanism, and in those cases, when the participation of antibodies of the immunoglobulin E class in this mechanism is proven, hence the term "IgE-mediated asthma". In our country, the term "atopic asthma" is used to refer to this option. The definition fully reflects the essence of the process in which IgE antibodies are involved. Other non-immunological types of asthma EAACI are proposed to be called non-allergic asthma. Apparently, this form can be attributed to asthma, which develops due to impaired metabolism of arachidonic acid, endocrine and neuropsychiatric disorders, impaired receptor and electrolyte balances of the respiratory tract, exposure to non-allergenic aeropollutants and occupational factors.

Establishing the form of bronchial asthma is of fundamental importance for its therapy, because the treatment of any allergic disease begins with measures to eliminate the allergen (or allergens) that is guilty of the development of the disease. It is possible to completely remove the allergen, if we are talking about a pet, food or medicine, and only thanks to this to achieve remission of bronchial asthma. But more often the development of asthma is provoked by a house dust mite, which cannot be removed completely. However, the number of dust mites can be significantly reduced by using special non-allergenic bedding and acaricidal products, and by regularly wet cleaning with a deep vacuum cleaner. All these measures, as well as measures to reduce the pollen content in the air of residential premises during the flowering season and measures to minimize contact with spores of non-domestic and intra-household non-pathogenic molds, lead to a significant weakening of bronchial asthma symptoms in patients sensitive to these allergens.

Pharmacotherapy is an integral and most important component of a comprehensive treatment program for bronchial asthma. There are several key provisions in the treatment of bronchial asthma:

• asthma can be effectively controlled in most patients, but it cannot be cured;
• inhalation method of administration of drugs for asthma is the most preferable and effective;
• basic asthma therapy involves the use of anti-inflammatory drugs, in particular inhaled glucocorticosteroids, which are currently the most effective drugs for controlling asthma;
• bronchodilators (β 2 -agonists, xanthines, anticholinergics) are emergency drugs that relieve bronchospasm.

So, all drugs that are used to treat bronchial asthma are usually divided into two groups: basic or therapeutic, that is, with an anti-inflammatory effect, and symptomatic, with predominantly rapid bronchodilator activity. However, in recent years, a new group of anti-asthma drugs has appeared on the pharmacological market, which are a combination of anti-inflammatory and bronchodilators.

The basic anti-inflammatory drugs include glucocorticosteroids, mast cell stabilizers - cromones and leukotriene inhibitors.

Inhaled glucocorticosteroids (beclomethasone dipropionate, fluticasone propionate, budesonide, flunisolide) are currently the drugs of choice for the treatment of moderate to severe asthma. Moreover, according to international recommendations, inhaled glucocorticosteroids (ICS) are indicated for all patients with persistent asthma, including those with mild asthma, because even with this form of asthma, all elements of chronic allergic inflammation are present in the respiratory tract mucosa. Unlike systemic steroids, which, in turn, are the agent of choice in acute severe asthma, ICS do not have severe systemic side effects that pose a threat to the patient. Only in high daily doses (above 1000 mcg) can they inhibit the function of the adrenal cortex. The multifactorial anti-inflammatory effect of inhaled glucocorticosteroids is manifested in their ability to reduce or even completely eliminate bronchial hyperreactivity, restore and increase the sensitivity of β 2 -adrenergic receptors to catecholamines, including β 2 -agonist drugs. It has been proven that the anti-inflammatory efficacy of ICS depends on the dose; therefore, it is advisable to start treatment with medium and high doses (depending on the severity of asthma). When a stable state of patients is reached (but not earlier than 1-3 months after the start of ICS therapy) and an improvement in the FVD parameters, the dose of ICS can be reduced, but not canceled! In the event of a worsening asthma course and a decrease in pulmonary functional parameters, the dose of ICS should be increased. The occurrence of such harmless, but undesirable side effects of ICS, such as oral candidiasis, dysphonia, irritating cough, can be avoided by using spacers, as well as rinsing the mouth and throat with a weak solution of soda or just warm water after each inhalation of the drug.

Sodium cromoglycate and sodium nedocromil (cromones) suppress the release of mediators from the mast cell by stabilizing its membrane. These drugs, prescribed before exposure to the allergen, can inhibit early and late allergic reactions. Their anti-inflammatory effect is significantly inferior to that of ICS. A decrease in bronchial hyperreactivity occurs only after prolonged (at least 12 weeks) treatment with cromones. However, the advantage of cromons is their safety. These drugs have virtually no side effects and are therefore successfully used to treat childhood asthma and asthma in adolescents. Mild atopic asthma in adults is sometimes also well controlled with cromoglycate or nedocromil sodium.

Antileukotriene drugs, including cysteinyl (leukotriene) receptor antagonists and leukotriene synthesis inhibitors, represent a relatively new group of anti-inflammatory drugs used to treat asthma. In Russia, the drugs zafirlukast (acolat) and montelukast (singular) - leukotriene receptor blockers, presented in a form for oral administration, are currently registered and approved for use. The anti-inflammatory effect of these drugs is to block the action of leukotrienes - fatty acids, the breakdown products of arachidonic acid involved in the formation of bronchial obstruction. In recent years, there have been many works devoted to the study of the clinical efficacy of antileukotriene drugs in various forms and varying degrees of severity of bronchial asthma. These drugs are effective in the treatment of patients with the aspirin form of bronchial asthma, in which leukotrienes are the main mediators of inflammation and the formation of bronchial obstruction. They effectively control exercise asthma and nocturnal asthma, as well as intermittent asthma caused by allergen exposure. Particular attention is paid to the study of antileukotriene drugs used in the treatment of childhood asthma, since they are convenient to use and cause a relatively low risk of serious side effects compared to ICS. In the latest American guidelines for the diagnosis and treatment of asthma, leukotriene receptor antagonist drugs are considered as an alternative to ICS for the control of mild, persistent asthma in children 6 years of age and older, as well as in adults. However, there are currently a lot of studies demonstrating the effectiveness of these drugs in persons suffering from moderate to severe asthma, to whom leukotriene receptor antagonists are prescribed as an adjunct to ICS. This combination of drugs, potentiating each other's action, enhances anti-asthma therapy and avoids increasing the dose of ICS in some patients, and sometimes even reducing it.

Thus, new anti-asthma drugs - leukotriene receptor antagonists can be used for anti-inflammatory (basic) asthma therapy in the following situations:

• mild, persistent asthma;
• childhood asthma;
• exercise asthma;
• aspirin asthma;
• nocturnal asthma;
• acute allergen-induced asthma;
• moderate to severe asthma;
• GCS phobia;
• asthma, which is not satisfactorily controlled by safe doses of GCS;
• treating patients who have difficulty using the inhaler;
• treatment of patients diagnosed with asthma in combination with allergic rhinitis.

Bronchodilator drugs are used to relieve an acute asthma attack in chronic asthma, and to prevent exercise asthma, acute allergen-induced asthma, as well as to relieve severe bronchospasm during exacerbation of bronchial asthma.

Key provisions in bronchodilator therapy of bronchial asthma:

• Short-acting β 2 -agonists are the most effective bronchodilators;
• inhaled forms of bronchodilators are preferred over oral and parenteral forms.

Selective β 2 -agonists of the first generation: albuterol (salbutamol, ventolin), terbutaline (bricanil), fenoterol (berotec) and others - are the most effective bronchodilators. They are able to quickly (within 3-5 minutes) and for a fairly long period (up to 4-5 hours) have a bronchodilator effect after inhalation in the form of a metered aerosol for mild and moderate asthma attacks, and when using solutions of these drugs through a nebulizer - and with severe attacks in case of exacerbation of asthma. However, short-acting β 2 -agonists should only be used to relieve asthma attacks. They are not recommended for continuous, basic therapy, since they are not able to reduce airway inflammation and bronchial hyperreactivity. Moreover, with their constant and long-term intake, the degree of bronchial hyperreactivity may increase, and the indicators of the function of external respiration may deteriorate. The second generation β 2 -agonists, or long-acting β 2 -agonists: salmeterol and formoterol, are devoid of these disadvantages. Due to the lipophilicity of their molecules, these drugs are very close to β 2 -adrenergic receptors, which, first of all, determines the duration of their bronchodilator action - up to 12 hours after inhalation of 50 μg or 100 μg of salmeterol and 6 μg, 12 μg or 24 μg of formoterol. At the same time, formoterol, in addition to a long-term effect, simultaneously has a rapid bronchodilatory effect, comparable to the time of the onset of the action of salbutamol. All β 2 -adrenomimetic drugs have the ability to inhibit the release of mediators of allergic inflammation, such as histamine, prostaglandins and leukotrienes, from mast cells, eosinophils, and this property is maximally manifested in long-acting β 2 -agonists. In addition, the latter have the ability to reduce the permeability of the capillaries of the mucous membrane of the bronchial tree. All this allows us to speak about the anti-inflammatory effect of long-acting β 2 -agonists. They are able to suppress both early and late asthmatic reactions that occur after inhalation of the allergen, and reduce bronchial reactivity. These drugs are the treatment of choice for mild to moderate asthma and for patients with nocturnal symptoms of asthma; they can also be used to prevent exercise asthma. In patients with moderate and severe asthma, it is advisable to combine them with ICS.

Theophyllines are the main methylxanthines used in the treatment of asthma. Theophyllines have bronchodilator and anti-inflammatory effects. By blocking the enzyme phosphodiesterase, theophylline stabilizes cAMP and reduces the concentration of intracellular calcium in smooth muscle cells of the bronchi (and other internal organs), mast cells, T-lymphocytes, eosinophils, neutrophils, macrophages, endothelial cells. As a result, the smooth muscles of the bronchi are relaxed, the release of mediators from the inflammatory cells is suppressed and the increased vascular permeability is reduced. Theophylline largely suppresses both the early and late phases of the asthmatic reaction. Prolonged theophyllines have been successfully used to control nocturnal asthmatic manifestations. However, the efficacy of theophylline in acute asthma attacks is inferior (both in the speed of the onset of the effect and in its severity) to β 2 -agonists used by inhalation, especially through a nebulizer. Therefore, intravenous administration of aminophylline should be considered as a backup measure for those patients with acute severe asthma, for whom the administration of β 2 -agonists through a nebulizer is not effective enough. This limitation is also due to the high risk of adverse reactions to theophylline (cardiovascular and gastrointestinal disorders, excitation of the central nervous system), developing, as a rule, when the concentration of 15 μg / ml in the peripheral blood is exceeded. Therefore, long-term use of theophylline requires monitoring of its concentration in the blood.

Anticholinergic drugs (ipratropium bromide and oxytropium bromide) have a bronchodilator effect by blocking M-cholinergic receptors and reducing the tone of the vagus nerve. One of these drugs, ipratropium bromide (atrovent), has long been registered in Russia and has been successfully used. In terms of the strength and speed of the onset of the effect, anticholinergic drugs are inferior to β 2 -agonists, their bronchodilator effect develops 30-40 minutes after inhalation. However, their combined use with β 2 -agonists, mutually reinforcing the effect of these drugs, has a pronounced bronchodilator effect, especially in moderate and severe asthma, as well as in patients with asthma and concomitant chronic obstructive bronchitis. Such combined preparations containing ipratropium bromide and a short-acting β 2 -agonist are berodual (contains fenoterol) and combivent (contains salbutamol).

A fundamentally new step in modern pharmacotherapy of bronchial asthma is the creation of combined drugs with a pronounced anti-inflammatory and long-term bronchodilator effect. It is a combination of inhaled corticosteroids and long-acting β 2 -agonists. Today, on the pharmacological market in Europe, including Russia, there are two such drugs: seretide, containing fluticasone propionate and salmeterol, and symbicort, which contains budesonide and formoterol. It turned out that in such compounds a corticosteroid and a prolonged β 2 -agonist have a complementary effect and their clinical effect significantly exceeds that in the case of monotherapy with ICS or a long-acting β 2 -agonist. Prescribing such a combination can serve as an alternative to increasing the dose of ICS in patients with moderate to severe asthma. Prolonged β 2 -agonists and corticosteroids interact at the molecular level. Corticosteroids increase the synthesis of β 2 -adrenergic receptors in the bronchial mucosa, reduce their desensitization and, conversely, increase the sensitivity of these receptors to the action of β 2 -agonists. On the other hand, prolonged β 2 -agonists stimulate the inactive glucocorticoid receptor, which as a result becomes more sensitive to the action of inhaled glucocorticosteroids. The simultaneous use of ICS and a prolonged β 2 -agonist not only facilitates the course of asthma, but also significantly improves functional performance, reduces the need for short-acting β 2 -agonists, and significantly more effectively prevents asthma exacerbations compared to therapy with ICS alone.

The undoubted advantage of these drugs, especially attracting asthmatic patients, is the combination of two active substances in one inhalation device: a metered aerosol inhaler (seretide AIM) or a powder inhaler (seretid multidisc) and turbuhaler containing preparations in the form of powder (symbicort-turbuhaler) ... The drugs have a convenient two-fold dosing regimen; for symbicort, a single dose is also possible. Seretide is available in forms containing various doses of ICS: 100, 250 or 500 mcg of fluticasone propionate with a constant dose of salmeterol - 50 mcg. Symbicort is available in a dosage of 160 mcg of budesonide and 4.5 mcg of formoterol. Symbicort can be prescribed 1 to 4 times a day, which allows you to control the variable course of asthma using the same inhaler, reducing the dose of the drug when adequate asthma control is achieved and increasing when symptoms worsen. This circumstance allows you to choose an adequate therapy, taking into account the severity of asthma for each individual patient. In addition, symbicort, due to the fast-acting formoterol, quickly relieves asthma symptoms. This leads to an increase in adherence to therapy: seeing that treatment helps quickly and effectively, the patient is more willing to comply with the doctor's prescription. It should be remembered that combination drugs (ICS + long-acting β 2 -agonists) should not be used to relieve an acute asthma attack. For this purpose, short-acting β 2 -agonists are recommended for patients.

Thus, the use of combined preparations of ICS and prolonged β 2 -agonists is advisable in all cases of persistent asthma, when it is not possible to achieve good control over the disease only by the appointment of ICS. The criteria for well-controlled asthma are the absence of nocturnal symptoms, good exercise tolerance, no need for emergency care, the daily need for bronchodilators of less than 2 doses, the peak expiratory flow rate of more than 80% and its daily fluctuations of less than 20%, and the absence of side effects from the therapy.

Of course, it is advisable to start treatment with ICS with a combination of them with salmeterol or formoterol, which will achieve a quick clinical effect and make patients believe in the success of treatment.

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