Exogenous bronchial asthma, allergic asthma, atopic asthma, occupational asthma, allergic bronchopulmonary aspergillosis, Allergic bronchitis, allergic rhinitis with asthma, exogenous allergic asthma, hay fever with asthma.

Version: MedElement Disease Handbook

Asthma with a predominance of an allergic component (J45.0)

general information

Short description

Listed in accordance with GINA (Global Initiative for Asthma) - 2011 revision.

Bronchial asthma is a chronic inflammatory disease of the airways in which many cells and cellular elements are involved. Chronic inflammation leads to the development of bronchial hyperreactivity, which leads to repeated episodes of wheezing, shortness of breath, chest congestion and coughing, especially at night or in the early morning. These episodes are usually associated with widespread but variable airway obstruction in the lungs, which is often reversible either spontaneously or with treatment.

Bronchial hyperreactivity is an increased sensitivity of the lower respiratory tract to various irritating stimuli, usually contained in the inhaled air. These stimuli are indifferent for healthy people. Hyperreactivity of the bronchi clinically most often manifests itself as episodes of wheezing difficulty breathing in response to an irritant stimulus in persons with a hereditary predisposition. Latent bronchial hyperreactivity is also distinguished, detected only by provocative functional tests with histamine and methacholine.
Bronchial hyperreactivity is specific and nonspecific. Specific hyperreactivity is formed in response to exposure to certain allergens, most of which are found in the air (plant pollen, house and library dust, hair and epidermis of domestic animals, down and feathers of domestic birds, spores and other elements of fungi). Nonspecific hyperreactivity develops under the influence of a variety of stimuli of non-allergenic origin (air pollutants, industrial gases and dust, endocrine disorders, physical activity, neuropsychic factors, respiratory infections, etc.).
This subheading includes the forms of the disease occurring with the formation of specific hyperreactivity. Due to the fact that both forms of hyperreactivity can be present simultaneously and even replace each other in one patient, the terminological clarification "with predominance" has been introduced.
Excluded from the rubric:

J46 Status asthmaticus
J44- Other chronic obstructive pulmonary disease
J60-J70 LUNG DISEASES CAUSED BY EXTERNAL AGENTS
J82 Pulmonary eosinophilia, not elsewhere classified

Classification

The classification of asthma is based on a joint assessment of the symptoms of the clinical picture and indicators of lung function, at the same time, there is no generally accepted classification of bronchial asthma.

According to the severity of the disease according to clinical signs before starting treatment

Mild intermittent bronchial asthma (stage 1):

1. Symptoms less than 1 time per week.
2. Short flare-ups.
3. Nighttime symptoms no more than 2 times a month.
4. FEV1 or PSV> = 80% of the due values.
5. Variability of FEV1 or PSV indicators< 20%.

Mild persistent bronchial asthma (stage 2):

1. Symptoms more often than 1 time per week, but less often than 1 time per day.
2. Nighttime symptoms more often than 2 times a month FEV1 or PSV> = 80% of the proper values.
3. Variability of FEV1 or PSV indicators = 20-30%.

Moderate persistent bronchial asthma (grade 3):

1. Daily symptoms.
2. Flare-ups can affect physical activity and sleep.
3. Nighttime symptoms more often than 1 time per week.
4. FEV, or PSV from 60 to 80% of the due values.
5. Variability of FEV1 or PSV indicators> 30%.

Severe persistent bronchial asthma (grade 4):

1. Daily symptoms.
2. Frequent exacerbations.
3. Frequent nighttime symptoms.
4. Restriction of physical activity.
5. FEV 1 or PSV<= 60 от должных значений.
6. Variability of FEV1 or PSV indicators> 30%.

Additionally, the following phases of the course of bronchial asthma are distinguished:
- aggravation;
- unstable remission;
- remission;
- stable remission (more than 2 years).

GINA 2011. Given the shortcomings, the current classification of asthma severity, according to the consensus, is based on the amount of therapy required to achieve control over the course of the disease. Mild asthma is asthma, the control of which can be achieved with a small amount of therapy (low doses of ICS, antileukotriene drugs, or cromones). Severe asthma is asthma, which requires a large amount of therapy to control (for example, stage 4 according to GINA), or asthma, which cannot be controlled despite a large amount of therapy. It is known that patients with different AD phenotypes have different responses to traditional treatment... As soon as there is a specific treatment for each phenotype, bronchial asthma, which

Previously considered heavy, may become light. The ambiguity of terminology associated with the severity of asthma is due to the fact that the term "severity" is also used to describe the severity of bronchial obstruction or symptoms. Many patients believe that severe or frequent symptoms indicate severe asthma. However, it is important to understand that these symptoms may be the result of inadequate treatment.

Classification according to ICD-10

J45.0 Asthma with a predominance of an allergic component (if there is a connection between the disease and an established external allergen) includes the following clinical options:

• Allergic bronchitis.
• Allergic rhinitis with asthma.
• Atopic asthma.
• Exogenous allergic asthma.
• Hay fever with asthma.

F formulation of the main diagnosis should reflect
- the form of the disease (for example, atopic asthma),
- The severity of the disease (for example, severe persistent asthma),
- The flow phase (for example, exacerbation). In remission with steroid drugs, it is advisable to indicate a maintenance dose of an anti-inflammatory drug (for example, remission at a dose of 800 mcg beclomethasone per day).
- Complications of asthma: respiratory failure and its form (hypoxemic, hypercapnic), especially asthmatic status (AS).

Etiology and pathogenesis

According to GINA-2011, bronchial asthma is a chronic inflammatory disease of the airways in which a number of inflammatory cells and mediators are involved, resulting in characteristic pathophysiological changes.

Atopic asthma begins, as a rule, in childhood and is triggered by household allergens: house dust, six and scales of animal skin and food. Allergic diseases are characteristic of relatives. Asthma itself is preceded by allergic rhinitis, urticaria or diffuse neurodermatitis.
Atopic bronchial asthma (AA) is a classic example of type I (IgE - mediated) hypersensitivity. Trapped in Airways allergens provoke the synthesis of class E immunoglobulins by B cells, the activation and proliferation of mast cells, and the attraction and activation of eosinophils.
Phases of the asthmatic reaction:
-The early phase is caused by contact of sensitized (IgE-coated) mast cells with the same or a similar (cross-sensitivity) antigen and develops within a few minutes. As a result, mediators are released from mast cells, which, either themselves or with the participation nervous system cause bronchospasm, increase vascular permeability (causing tissue edema), stimulate mucus production and, in the most severe cases, cause shock. Mast cells also release cytokines that attract leukocytes (especially eosinophils).
-The late phase develops under the influence of mediators secreted by leukocytes (neutrophils, eosinophils, basophils), endothelial and epithelial cells. It occurs 4-8 hours after exposure to the allergen and lasts 24 hours or more.
The main mediators causing bronchospasm in AA
- Leukotrienes C4, D4, E4 cause prolonged bronchospasm, increase vascular permeability, and stimulate mucus secretion.
- Acetylcholine leads to a contraction of the smooth muscles of the bronchi
- Histamine leads to contraction of the smooth muscles of the bronchi
- Prostaglandin D4 constricts the bronchi and dilates blood vessels,
- Platelet activation factor provokes platelet aggregation and release of histamine and serotonin from their granules.
Morphology.
- At autopsy of patients with status asthmaticus (see J46 Status asthmaticus), swollen lungs are found, although foci of atelectasis are found. The cut shows blockage of the bronchi and bronchioles with thick and viscous mucus (mucous plugs).
- Microscopy reveals layers of bronchial epithelium cells (the so-called Kurshman's spirals), numerous eosinophils and Charcot-Leiden crystals (crystal-like formations of eosinophil proteins) in mucous plugs. The basal membrane of the bronchial epithelium is thickened, the walls of the bronchi are edematous and infiltrated, with inflammatory cells, the bronchial glands are enlarged, the smooth muscles of the bronchi are hypertrophied.

Epidemiology

In the world, bronchial asthma affects about 5% of the adult population (1-18% in different countries). In children, the incidence varies from 0 to 30% in different countries.

The onset of the disease is possible at any age. In about half of patients, bronchial asthma develops before 10 years, in a third - up to 40 years.
Among children with bronchial asthma, there are two times more boys than girls, although the sex ratio levels off by the age of 30.

Factors and risk groups

Factors affecting the risk of developing AD are divided into:
- factors that determine the development of the disease - internal factors (primarily genetic);
- factors provoking the onset of symptoms - external factors.
Several factors apply to both groups.
The mechanisms of the influence of factors on the development and manifestation of AD are complex and interdependent.

Internal factors:

1. Genetic (for example, genes predisposing to atopy, and genes predisposing to bronchial hyperreactivity).

2. Obesity.

External factors:

1. Allergens:

Room allergens (house dust mites, pet hair, cockroach allergens, fungi, including mold and yeast);

External allergens (pollen, fungi, including mold and yeast).

2.Infections (mainly viral).

3. Professional sensitizers.

4. Smoking tobacco (passive and active).

5. Indoor and outdoor air pollution.

6. Nutrition.

Examples of substances that cause the development of AD in people of certain professions

Profession	Substance
	Animal proteins and vegetable origin
Bakers	Flour, amylase
Farmers-pastoralists	Warehouse pliers
Detergent production	Bacillus subtilis enzymes
Electric soldering	Rosin
Plant farmers	Soy dust
Production of fish products
Food production	Coffee dust, meat softeners, tea, amylase, shellfish, egg whites, pancreatic enzymes, papain
Granary workers	Stock pliers, Aspergillus. Weed particles, ragweed pollen
Medical workers	Psyllium, latex
Poultry farmers	Poultry mites, droppings and bird feathers
Experimental Researchers, Veterinarians	Insects, dandruff and animal urine proteins
Sawmill workers, carpenters	Wood dust
Movers / transport workers	Grain dust
Silk workers	Butterflies and silkworm larvae
	Inorganic compounds
Cosmetologists	Persulfate
Platers	Nickel salts
Refinery workers	Platinum salts, vanadium Organic compounds
Car painting	Ethanolamine, diisocyanates
Hospital workers	Disinfectants (sulfathiazole, chloramine, formaldehyde), latex
Pharmaceutical production	Antibiotics, piperazine, methyldopa, salbutamol, cimetidine
Rubber processing	Formaldegite, ethylenediamide
Plastics industry	Acrylates, hexamethyl diisocyanate, toluine diisocyanate, phthalc anhydride

Elimination of risk factors can significantly improve the course of asthma.

In patients with allergic asthma, elimination of the allergen is of the utmost importance. There is evidence that in urban areas in children with atopic BA, individual complex measures to remove allergens in homes have led to a decrease in pain.

Clinical picture

Clinical diagnostic criteria

Unproductive hacking cough, - prolonged exhalation, - dry, wheezing, usually treble, wheezing in the chest, more at night and in the morning, - attacks of expiratory suffocation, - chest congestion, - dependence respiratory symptoms from contact with provocative agents.

Symptoms, course

Clinical diagnostics bronchial asthma(BA) is based on the following data:

1. Identification of bronchial hyperreactivity, as well as reversibility of obstruction spontaneously or under the influence of treatment (decrease in response to appropriate therapy).
2. Unproductive hacking cough; prolonged exhalation; dry, wheezing, usually treble, wheezing in the chest, noted more at night and in the morning; expiratory shortness of breath, attacks of expiratory suffocation, congestion (stiffness) chest.
3. The dependence of respiratory symptoms on contact with provoking agents.

Are also essential the following factors:
- the appearance of symptoms after episodes of contact with an allergen;
- seasonal variability of symptoms;
- a family history of asthma or atopy.

When diagnosing, you need to find out the following questions:
- Does the patient have episodes of wheezing, including recurring ones?

Does the patient worry about coughing at night?

Does the patient have wheezing or coughing after exercise?

Does the patient have episodes of wheezing, chest congestion, or coughing after exposure to aeroallergens or pollutants?

Does the patient notice that his cold "descends into the chest" or lasts more than 10 days?

Do symptoms improve with appropriate asthma medications?

On physical examination, asthma symptoms may be absent, due to the variability of the manifestations of the disease. The presence of bronchial obstruction is confirmed by wheezing, detected during auscultation.
In some patients, wheezing may be absent or only detected during forced expiration, even in the presence of severe bronchial obstruction. In some cases, patients with severe exacerbations of asthma do not have wheezing due to the strong restriction of air flow and ventilation. Such patients, as a rule, have other Clinical signs indicating the presence and severity of an exacerbation: cyanosis, drowsiness, difficulty speaking, a swollen chest, the participation of auxiliary muscles in the act of breathing and retraction of the intercostal spaces, tachycardia. These clinical symptoms can be observed only when examining the patient during the period of pronounced clinical manifestations.

Clinical manifestations of asthma

1.Cough variant of BA. The main (sometimes the only) manifestation of the disease is cough. Cough AD is most common in children. The severity of symptoms increases at night, and during the day the manifestations of the disease may be absent.
For such patients, it is important to study the variability of indicators of pulmonary function or bronchial hyperreactivity, as well as the determination of eosinophils in sputum.
The cough variant of AD is differentiated from the so-called eosinophilic bronchitis. With the latter, patients have cough and sputum eosinophilia, but at the same time normal performance pulmonary function on spirometry; and normal bronchial reactivity.
In addition, a cough can occur due to the intake ACE inhibitors, gastroesophageal reflux, postnasal leakage syndrome, chronic sinusitis, vocal cord dysfunction.

2. Bronchospasm caused by physical exertion. Refers to the manifestation of non-allergic forms of asthma, when the phenomena of airway hyperresponsiveness dominate. In the majority of cases, physical activity is an important or only cause of the onset of symptoms of the disease. Bronchospasm as a result of physical activity, as a rule, develops 5-10 minutes after the termination of the exercise (rarely - during exercise). Patients have typical AD symptoms or sometimes a prolonged cough that goes away on its own within 30-45 minutes.
Forms of exercise such as running cause AD symptoms more frequently.
Bronchospasm caused by exercise is more likely to develop when dry, cold air is inhaled, more rarely in hot and humid climates.
AD is supported by a rapid reduction in post-exercise bronchospasm symptoms after inhalation of a β2-agonist, as well as prevention of the development of symptoms due to inhalation of a β2-agonist before exercise.
In children, BA can sometimes manifest itself only during exercise. In this regard, in such patients or in the presence of doubts about the diagnosis, it is advisable to conduct a test with physical activity. The diagnosis is facilitated by the 8-minute jogging protocol.

Clinical picture asthma attack typical enough.
With allergic etiology of asthma, before the development of asthma, itching (in the nasopharynx, auricles, in the chin area), nasal congestion or rhinorrhea, a feeling of lack of "free breathing", dry cough may occur. lengthened; the duration of the respiratory cycle increases and the respiratory rate decreases (up to 12-14 per minute).
During listening to the lungs, in the bulk of cases, against the background of a prolonged expiration, a large number of scattered dry rales, mainly whistling, are determined. As an attack of suffocation progresses, wheezing rales on exhalation are heard at a certain distance from the patient in the form of "wheezing" or "bronchial music".

With a prolonged attack of suffocation, which lasts more than 12-24 hours, there is a blockage of small bronchi and bronchioles with inflammatory secretions. General state the patient becomes significantly heavier, the auscultatory picture changes. Patients experience excruciating shortness of breath, aggravated by the slightest movement. The patient takes a forced position - sitting or half-sitting with fixation of the shoulder girdle. In the act of breathing, all the auxiliary muscles are involved, the chest expands, and the intercostal spaces are drawn in when inhaling, cyanosis of the mucous membranes and acrocyanosis occurs and intensifies. It is difficult for the patient to speak, sentences are short and abrupt.
During auscultation, a decrease in the number of dry wheezes is noted, in places they are not heard at all, like vesicular breathing; the so-called zones of the silent lung appear. Above the surface of the lungs, a pulmonary sound with a tympanic shade is determined percussion - a box sound. The lower edges of the lungs are lowered, their mobility is limited.
The completion of an attack of suffocation is accompanied by a cough with the discharge of a small amount of viscous sputum, relief of breathing, a decrease in shortness of breath and the number of heard wheezing. For a long time, a few dry wheezes can be heard while maintaining an extended exhalation. After the seizure stops, the patient often falls asleep. Signs of asthenization persist for a day or more.

Exacerbation of asthma(attacks of asthma, or acute asthma) according to GINA-2011 is divided into mild, moderate, severe and such a point as "respiratory arrest is inevitable." The severity of asthma and the severity of asthma exacerbation are not the same thing. For example, with mild asthma, exacerbations of mild and moderate severity may occur, with asthma of moderate severity and severe, exacerbations of mild, moderate and severe are possible.

Severity of BA exacerbation according to GINA-2011

	Lung	Middle gravity	Heavy	Stopping breathing is inevitable
Dyspnea	When walking. May lie	When talking; crying in children it becomes quieter and shorter, difficulties in feeding. Prefers to sit	At rest, children stop eating. Sit leaning forward
Speech	Proposals	Phrases	In words
Level wakefulness	May be aroused	Usually agitated	Usually agitated	Inhibited or confused
Breathing rate	Increased	Increased	More than 30 per min.
The participation of auxiliary muscles in the act of breathing and the retraction of the supraclavicular fossae	Usually no	Usually there is	Usually there is	Paradoxical movements chest and abdominal walls
Wheezing	Moderate, often only with exhalation	Loud	Usually loud	Absent
Pulse (in min.)	<100	>100	>120	Bradycardia
Paradoxical pulse	Absent <10 мм рт. ст.	There may be 10-25 mm Hg st	Often available > 25 mm Hg Art. (adults), 20-40 mm Hg Art. (children)	Absence allows assume fatigue respiratory muscles
PSV after the first injection bronchodilator in% of due or the best individual value	>80%	About 60-80%	<60% от должных или наилучших individual values (<100 л/мин. у взрослых) or the effect lasts<2 ч.	Impossible to rate
RaO 2 in kPa (when breathing air)	Normal. Analysis is usually not needed	> 60 mmHg Art.	<60 мм рт. ст. Possible cyanosis
PaCO 2 in kPa (when breathing air)	<45 мм рт. ст.	<45 мм рт. ст.	> 45 mmHg Art. Respiratory failure
SatО 2,% (during breathing air) - oxygen saturation or the degree of saturation of arterial hemoglobin with oxygen	>95%	91-95%	< 90%

Notes:
1. Hypercapnia (hypoventilation) develops more often in young children than in adults and adolescents.
2. Normal heart rate in children:

Breast age (2-12 months)<160 в минуту;

Younger age (1-2 years old)<120 в минуту;

Preschool and school age (2-8 years old)<110 в минуту.
3. Normal respiratory rate in children while awake:

Less than 2 months< 60 в минуту;

2-12 months< 50 в минуту;

1-5 years old< 40 в минуту;

6-8 years old< 30 в минуту.

Diagnostics

Basics of diagnostics of bronchial asthma(BA):
1. Analysis of clinical symptoms dominated by periodic attacks of expiratory suffocation (for more details see the "Clinical picture" section).
2. Determination of pulmonary ventilation parameters, most often using spirography with registration of the forced expiratory flow-volume curve, revealing signs of reversibility of bronchial obstruction.
3. Allergic research.
4. Revealing of nonspecific bronchial hyperreactivity.

Study of indicators of the function of external respiration

1. Spirometry Spirometry - measuring the vital capacity of the lungs and other lung volumes using a spirometer
... Symptoms of bronchial obstruction are often diagnosed in BA patients: a decrease in the parameters - POSevd (peak expiratory flow rate), MOS 25 (maximum flow rate at the 25% FVC point, (FEF75) and FEV1.

To assess the reversibility of bronchial obstruction, pharmacological bronchodilation test with β2-agonists short acting(most often salbutamol). Before testing, you should refrain from taking short-acting bronchodilators for at least 6 hours.
Initially, the patient's original forced-breathing flow-volume curve is recorded. Then the patient makes 1-2 inhalations of one of the short and fast acting β2-agonists. After 15-30 minutes, the flow-volume curves are recorded. With an increase in FEV1 or PIC by 15% or more, airway obstruction is considered reversible or bronchodilator-reactive, and the test is considered positive.

For AD, it is diagnostically important to identify significant diurnal variability of bronchial obstruction. For this, spirography (when the patient is in the hospital) or peak flowmetry (at home) are used. The spread (variability) of FEV1 or PIC indices exceeding 20% ​​during the day is considered to confirm the diagnosis of asthma.

2. Peak flowmetry... It is used to assess the effectiveness of treatment and objectify the presence and severity of bronchial obstruction.
The peak expiratory flow rate (PEF) is estimated - the maximum rate at which air can leave the airways during forced expiration after a full inhalation.
The patient's PSV values ​​are compared with normal values ​​and with the best PSV values ​​observed in this patient. The level of decrease in PSV allows us to draw conclusions about the severity of bronchial obstruction.
The difference in PSV values ​​measured in the daytime and in the evening is also analyzed. A difference of more than 20% indicates an increase in bronchial reactivity.

2.1 Intermittent asthma (stage I). Daytime bouts of shortness of breath, cough, wheezing occur less than 1 time per week. The duration of exacerbations is from several hours to several days. Nocturnal attacks - 2 or less times a month. In the period between exacerbations, lung function is normal; PSV - 80% of the norm or less.

2.2 Mild persistent asthma (stage II). Daytime seizures are observed 1 or more times a week (no more than 1 time per day). Night attacks are repeated more often than 2 times a month. During an exacerbation, the activity and sleep of the patient may be disrupted; PSV - 80% of the norm or less.

2.3 Persistent asthma of moderate severity (stage III). Daily attacks of suffocation, nocturnal attacks occur once a week. As a result of exacerbations, the patient's activity and sleep are disrupted. The patient is forced to use short-acting inhaled beta-adrenomimetics daily; PSV - 60 - 80% of the norm.

2.4 Severe persistent asthma (stage IV). Day and night symptoms are permanent, which limits the patient's physical activity. The PSV indicator is less than 60% of the norm.

3. Allergic research... An allergic history is analyzed (eczema, hay fever, family history of asthma or other allergic diseases). AD is supported by positive skin tests with allergens and increased blood levels of total and specific IgE.

4. Provocative tests with histamine, methacholine, exercise. They are used to detect nonspecific bronchial hyperreactivity, manifested by latent bronchospasm. It is performed in patients with suspected asthma and normal spirographic parameters.

In the histamine test, the patient inhales nebulized histamine in progressively increasing concentrations, each of which is capable of causing bronchial obstruction.
The test is assessed as positive when the air flow rate deteriorates by 20% or more as a result of inhalation of histamine in a concentration one or several orders of magnitude less than that which causes similar changes in healthy people.
The methacholine test is carried out and evaluated in a similar manner.

5. Additional research:
- X-ray of the chest organs in two projections - most often they reveal signs of pulmonary emphysema (increased transparency of the pulmonary fields, depletion of the pulmonary pattern, low standing of the diaphragm domes), while the absence of infiltrative and focal changes in the lungs is important;
- fibrobronchoscopy;

Electrocardiography.
Additional studies are being carried out in patients with atypical asthma and resistance to anti-asthma therapy.

The main diagnostic criteria for asthma:

1. The presence in the clinical picture of the disease of periodic attacks of expiratory suffocation, which have their beginning and end, passing spontaneously or under the influence of bronchodilators.
2. Development of status asthmaticus.
3. Determination of signs of bronchial obstruction (FEV1 or POS issue< 80% от должной величины), которая является обратимой (прирост тех же показателей более 15% в фармакологической пробе с β2-агонистами короткого действия) и вариабельной (колебания показателей более 20% на протяжении суток).
4. Revealing signs of bronchial hyperreactivity (latent bronchospasm) in patients with initial normal parameters of pulmonary ventilation using one of three provocative tests.
5. The presence of a biological marker - a high level of nitric oxide in the exhaled air.

Additional diagnostic criteria:
1. The presence in the clinical picture of symptoms that can be "small equivalents" of an attack of expiratory suffocation:
- unmotivated cough, often at night and after physical exertion;
- repetitive chest tightness and / or wheezing episodes;
- the fact of awakening at night from the indicated symptoms strengthens the criterion.
2. Aggravated allergic history (presence of eczema, hay fever, hay fever, hay fever in the patient) or aggravated family history (BA, atopic diseases in family members of the patient).

3. Positive skin tests for allergens.
4. Increase in the patient's blood level of general and specific IgE (reagins).

Professional BA

Occupational bronchial asthma is often misdiagnosed. Due to the gradual development of occupational asthma, it is often regarded as chronic bronchitis or COPD. This leads to inappropriate or no treatment.

Occupational asthma should be suspected when symptoms of rhinitis, cough and / or wheezing appear, especially in nonsmokers. Making a diagnosis requires the systematic collection of information about the work history and environmental factors in the workplace.

Diagnostic criteria for occupational asthma:
- well-established occupational exposure to known or suspected sensitizing agents;
- the absence of asthma symptoms before hiring or a distinct worsening of asthma after hiring.

Laboratory diagnostics

Non-invasive determination of markers of airway inflammation.
1. To assess the activity of inflammation in the airways in AD, spontaneously produced or induced by inhalation of a hypertonic solution of sputum can be examined for inflammatory cells - eosinophils or neutrophils.

2. In addition, levels of nitrogen oxide (FeNO) and carbon monoxide (FeCO) in exhaled air have been proposed as non-invasive markers of airway inflammation in AD. In BA patients, an increase in the level of FeNO (in the absence of ICS therapy) is noted as compared with individuals without BA, however, these results are nonspecific for BA. In prospective studies, the value of FeNO for the diagnosis of AD has not been assessed.
3. Skin tests with allergens are the main method for assessing allergic status. They are easy to use, time-saving and cost-effective, and highly sensitive. However, improper testing can lead to false positive or false negative results.
4. Determination of specific IgE in blood serum does not exceed skin tests in terms of reliability and is a more expensive method. The main disadvantage of methods for assessing the allergic status is that positive test results do not necessarily indicate the allergic nature of the disease and the relationship of the allergen with the development of AD, since in some patients specific IgE can be detected in the absence of any symptoms and play no role in the development of AD. The presence of the corresponding exposure to the allergen and its relationship with AD symptoms should be confirmed by the history data. Measuring the level of total IgE in serum is not a method for diagnosing atopy.
Clinical analyzes
1. UAC. Eosinophilia is not determined in all patients and cannot serve as a diagnostic criterion. An increase in ESR and eosinophilia are determined during an exacerbation.
2. General analysis of sputum. Microscopy in sputum can detect a large number of eosinophils, Charcot-Leiden crystals (shiny transparent crystals that form after the destruction of eosinophils and have the shape of rhombuses or octahedrons), Kurshman spirals (formed due to small spastic contractions of the bronchi and look like casts of transparent mucus in the form spirals). The release of Creole bodies during an attack is also noted - these are rounded formations consisting of epithelial cells.

3. A biochemical blood test is not the main diagnostic method, since the changes are of a general nature and such studies are prescribed to monitor the patient's condition during an exacerbation.

Differential diagnosis

1. Differential diagnosis of BA variants.

The main differential diagnostic signs of atopic and infectious-dependent BA variants(according to Fedoseev G.B., 2001)

Signs	Atopic variant	Infection-dependent variant
Allergic diseases in the family	Often	Rarely (except for asthma)
Atopic diseases in a patient	Often	Rarely
Relationship of an attack with an external allergen	Often	Rarely
Features of an attack	Acute onset, rapid development, usually short duration and mild course	Gradual onset, long duration, often heavy course
Pathology of the nose and paranasal sinuses	Allergic rhinosinusitis or polyposis without signs of infection	Allergic rhinosinusitis, often polyposis, signs of infection
Bronchopulmonary infectious process	Usually absent	Often chronic bronchitis, pneumonia
Eosinophilia of blood and sputum	Usually moderate	Often high
Specific IgE antibodies to non-infectious allergens	Present	Absent
Skin tests with extracts of non-infectious allergens	Positive	Negative
Exercise test	More often negative	More often positive
Elimination of the allergen	Possible, often effective	Impossible
Beta-adrenostimulants	Very effective	Moderately effective
Anticholinergics	Ineffective	Are effective
Euphyllin	Very effective	Moderately effective
Intal, tiled	Very effective	Less effective
Corticosteroids	Are effective	Are effective

2. Perform differential diagnosis of BA with chronic obstructive pulmonary disease(COPD), which is characterized by more persistent bronchial obstruction. In patients with COPD, spontaneous lability of symptoms typical of BA is not observed, there is no or significantly less daily variability of FEV1 and POS, complete irreversibility or less reversibility of bronchial obstruction is determined in the sample with β2-agonists (FEV1 increase is less than 15%).
Sputum in COPD is dominated by neutrophils and macrophages, rather than eosinophils. In patients with COPD, the effectiveness of bronchodilator therapy is lower; anticholinergics are more effective bronchodilators than short-acting β2-agonists; pulmonary hypertension and signs of chronic cor pulmonale are more common.

Some features of diagnosis and differential diagnosis (according to GINA 2011)

1.In children aged 5 and under episodes of wheezing are common.

Types of wheezing in the chest:

1.1 Transient early wheezing, which children often "outgrow" in the first 3 years of life. Such wheezing is often associated with prematurity and parental smoking.

1.2 Persistent wheezing with early onset (before the age of 3 years). Children usually have recurrent episodes of wheezing associated with acute respiratory viral infections. However, children have no signs of atopy and no family history of atopy (unlike children in the next age group with late onset wheezing / bronchial asthma).
Wheezing episodes tend to persist at school age and still occur in a significant proportion of children aged 12 years.
The cause of episodes of wheezing in children under 2 years old is usually a respiratory syncytial viral infection, in children 2-5 years old - other viruses.

1.3 Late-onset wheezing / bronchial asthma. AD in these children often lasts throughout childhood and continues into adulthood. Such patients are characterized by a history of atopy (often manifested as eczema) and airway pathology typical of AD.

With repeated episodes of wheezing, it is necessary to exclude other causes of wheezing:

Chronic rhinosinusitis;

Gastroesophageal reflux;

Recurrent viral infections of the lower respiratory tract;

Cystic fibrosis;

Bronchopulmonary dysplasia;

Tuberculosis;

Foreign body aspiration;
- immunodeficiency;

Syndrome of primary ciliary dyskinesia;

Malformations causing narrowing of the lower respiratory tract;
- Congenital heart defect.

The possibility of another disease is indicated by the appearance of symptoms in the neonatal period (in combination with insufficient weight gain); wheezing associated with vomiting, signs of focal lesions of the lungs or cardiovascular pathology.

2. Patients over 5 years old and adults. Differential diagnosis should be carried out with the following diseases:

Hyperventilation syndrome and panic attacks;

Upper airway obstruction and foreign body aspiration;

Other obstructive pulmonary diseases, especially COPD;

Non-obstructive lung disease (for example, diffuse lesions of the lung parenchyma);

Non-respiratory diseases (eg, left ventricular failure).

3. Elderly patients. BA should be differentiated from left ventricular failure. In addition, AD underdiagnosis occurs in old age.

Risk factors for asthma underdiagnosis in elderly patients

3.1 From the patient's side:
- depression;
- social isolation;
- impaired memory and intelligence;


- a decrease in the perception of shortness of breath and bronchoconstriction.

3.2 From the side of the doctor:
- the misconception that asthma does not start in old and old age;
- difficulties in the study of lung function;
- Perception of asthma symptoms as signs of aging;
- accompanying illnesses;
- underestimation of shortness of breath due to decreased physical activity of the patient.

Complications

Complications of bronchial asthma are divided into pulmonary and extrapulmonary.

Pulmonary complications: chronic bronchitis, hypoventilation pneumonia, pulmonary emphysema, pneumosclerosis, respiratory failure, bronchiectasis, atelectasis, pneumothorax.

Extrapulmonary complications: pulmonary heart, heart failure, myocardial dystrophy, arrhythmia; in patients with hormone-dependent BA, complications associated with prolonged use of systemic corticosteroids may occur.

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Treatment

Objectives of the treatment of bronchial asthma(BA):

Achieving and maintaining symptom control;

Maintaining a normal level of activity, including physical activity;

Maintaining lung function at normal or as close to normal levels;

Prevention of BA exacerbations;

Prevention of undesirable effects of anti-asthma drugs;

Prevention of deaths from asthma.

BA control levels(GINA 2006-2011)

Specifications	Controlled BA(all of the above)	Partially controlled BA(presence of any manifestation within a week)	Uncontrolled BA
Daytime symptoms	No (≤ 2 episodes per week)	> 2 times a week	3 or more signs of partially controlled asthma in any week
Activity limitation	No	Yes - of any severity
Nocturnal symptoms / awakenings	No	Yes - of any severity
Need for emergency medications	No (≤ 2 episodes per week)	> 2 times a week
Lung function indicators (PSV or FEV1) 1	Norm	< 80% от должного (или от наилучшего показателя для данного пациента)
Exacerbations	No	1 or more times a year 2	Any exacerbation week of 3

1 Pulmonary function testing is not reliable in children 5 years of age and younger. Periodic assessment of the level of control over asthma in accordance with the criteria indicated in the table will allow individual selection of the pharmacotherapy regimen for the patient.
2 Each exacerbation requires an immediate review of maintenance therapy and an assessment of its adequacy
3 By definition, the development of any exacerbation indicates that asthma is not controlled

Drug therapy

Medicines for AD treatment:

1. Drugs that control the course of the disease (maintenance therapy):
- inhalation and systemic GCS;
- antileukotriene agents;
- inhaled β2-agonists long acting in combination with inhaled corticosteroids;
- sustained-release theophylline;
- cromones and antibodies to IgE.
These drugs provide control over the clinical manifestations of asthma; they are taken daily and for a long time. The most effective for maintenance therapy are inhaled corticosteroids.

2. Emergency medications (to relieve symptoms):
- inhaled fast acting β2-agonists;
- anticholinergics;
- short-acting theophylline;
- short-acting oral β2-agonists.
These drugs are taken to relieve symptoms as needed. They have a quick action, eliminate bronchospasm and relieve its symptoms.

Drugs for the treatment of AD can be administered in different ways - by inhalation, oral administration, or injection. Advantages of the inhalation route of administration:
- delivers drugs directly to the respiratory tract;
- a locally higher concentration of the medicinal substance is achieved;
- the risk of systemic side effects is significantly reduced.

For maintenance therapy, inhaled corticosteroids are most effective.

The drugs of choice for the relief of bronchospasm and for the prevention of exercise-induced bronchospasm in adults and children of any age are rapid-acting inhaled β2-agonists.

The growing use (especially daily) of emergency medications indicates a deterioration in asthma control and the need for a revision of therapy.

Inhaled corticosteroids are most effective for the treatment of persistent asthma:
- reduce the severity of asthma symptoms;
- improve the quality of life and lung function;
- reduce bronchial hyperreactivity;
- inhibit inflammation in the airways;
- reduce the frequency and severity of exacerbations, the frequency of deaths in asthma.

Inhaled corticosteroids do not cure asthma, and when they are canceled, some patients experience worsening of their condition within weeks or months.
Local undesirable effects of inhaled corticosteroids: oropharyngeal candidiasis, dysphonia, sometimes - cough due to irritation of the upper respiratory tract.
Systemic side effects of long-term therapy with high doses of inhaled corticosteroids: a tendency to bruise, suppression of the adrenal cortex, a decrease in bone mineral density.

Calculated equipotent daily doses of inhaled corticosteroids in adults(GINA 2011)

A drug	Low daily allowance doses(mcg)	Average daily allowance doses(mcg)	High daily allowance doses(mcg)
Beclomethasone dipropionate CFC *	200-500	>500-1000	>1000-2000
Beclomethasone dipropionate HFA **	100-250	>250-500	>500-1000
Budesonide	200-400	>400-800	>800-1600
Cyclesonide	80-160	>160-320	>320-1280
Flunisolide	500-1000	>1000-2000	>2000
Fluticasone propionate	100-250	>250-500	>500-1000
Mometasone furoate	200	≥ 400	≥ 800
Triamcinolone acetonide	400-1000	>1000-2000	>2000

* CFCs - chlorofluorocarbon (freon) inhalers
** HFA - hydrofluoroalkane (CFC-free) inhalers

Calculated equipotent daily doses of inhaled corticosteroids for children over 5 years old(GINA 2011)

A drug	Low daily allowance doses(mcg)	Average daily allowance doses(mcg)	High daily allowance doses(mcg)
Beclomethasone dipropionate	100-200	>200-400	>400
Budesonide	100-200	>200-400	>400
Budesonide Neb	250-500	>500-1000	>1000
Cyclesonide	80-160	>160-320	>320
Flunisolide	500-750	>750-1250	>1250
Fluticasone propionate	100-200	>200-500	>500
Mometasone furoate	100	≥ 200	≥ 400
Triamcinolone acetonide	400-800	>800-1200	>1200

Antileukotriene drugs: antagonists of cysteinyl leukotriene receptors of the 1st subtype (montelukast, pranlukast and zafirlukast), as well as a 5-lipoxygenase inhibitor (zileuton).
Action:
- weak and variable bronchodilatory effect;
- reduce the severity of symptoms, including cough;
- improve lung function;
- reduce the activity of inflammation in the airways;
- reduce the frequency of BA exacerbations.
Antileukotriene drugs can be used as second-line drugs for the treatment of adult patients with mild persistent asthma. Some patients with aspirin BA also respond well to therapy with these drugs.
Antileukotriene drugs are well tolerated; few or no side effects.

Long-acting inhaled β2 -agonists: formoterol, salmeterol.
Should not be used as monotherapy for asthma, since there is no evidence that these drugs inhibit inflammation in asthma.
These drugs are most effective in combination with inhaled corticosteroids. Combination therapy is preferable in the treatment of patients in whom the use of medium doses of inhaled corticosteroids does not allow achieving BA control.
With regular use of β2-agonists, the development of relative refractoriness to them is possible (this applies to both short and long-acting drugs).
Long-acting inhaled β2-agonist therapy is characterized by a lower frequency of systemic adverse effects (such as stimulation of cardio-vascular system, skeletal muscle tremor and hypokalemia) compared with long-acting oral β2-agonists.

Long-acting oral β2-agonists: slow-release dosage forms of salbutamol, terbutaline and bambuterol (a prodrug that converts to terbutaline in the body).
Used in rare cases when additional bronchodilator action is required.
Undesirable effects: stimulation of the cardiovascular system (tachycardia), anxiety and tremors of skeletal muscles. Adverse cardiovascular reactions can also occur with the use of oral β2-agonists in combination with theophylline.

Rapid-acting inhaled β2-agonists: salbutamol, terbutaline, fenoterol, levalbuterol HFA, reproterol and pirbuterol. Due to the rapid onset of action, formoterol (a long-acting β2-agonist) can also be used to relieve asthma symptoms, but only in patients receiving regular maintenance therapy with inhaled GCS.
Rapid-acting inhaled β2-agonists are emergency drugs and are the drugs of choice for relieving bronchospasm during exacerbation of asthma, as well as for preventing exercise-induced bronchospasm. Should be used only as needed, with the lowest possible doses and frequency of inhalations.
The growing, especially daily, use of these drugs indicates a loss of control over asthma and the need to revise therapy. In the absence of a rapid and stable improvement after inhalation of a β2-agonist during an exacerbation of asthma, the patient should also be monitored and, possibly, a short course of therapy with oral corticosteroids should be prescribed.
The use of oral β2-agonists in standard doses is accompanied by more pronounced undesirable systemic effects (tremor, tachycardia) than when using inhaled forms.

Short-acting oral β2-agonists(referred to as an emergency) can be prescribed to only a few patients who are unable to receive inhalation drugs. Side effects are observed more often.

Theophylline is a bronchodilator and, when administered in low doses, has a slight anti-inflammatory effect and increases resistance.
Theophylline is available as dosage forms sustained-release that can be taken once or twice a day.
According to the available data, sustained-release theophylline has little efficacy as a first drug for the maintenance treatment of bronchial asthma.
Theophylline addition can improve the results of treatment of patients in whom monotherapy with inhaled corticosteroids does not allow achieving control over asthma.
The efficacy of theophylline as monotherapy and therapy prescribed in addition to inhaled or oral corticosteroids has been shown in children over the age of 5 years.
When using theophylline (especially in high doses - 10 mg / kg of body weight per day or more), significant side effects are possible (usually decrease or disappear with long-term use).
Undesirable effects of theophylline:
- nausea and vomiting - the most common side effects at the beginning of use;
- violations by gastrointestinal tract;
- loose stools;
- heart rhythm disturbances;
- convulsions;
- death.

Sodium cromoglycate and sodium nedocromil(cromones) are of limited value in long-term BA therapy in adults. There are known examples of the beneficial effect of these drugs in mild persistent asthma and exercise-induced bronchospasm.
Cromones have a weak anti-inflammatory effect and are less effective than low doses of inhaled corticosteroids. Side effects(cough after inhalation and sore throat) are rare.

Anti-IgE(omalizumab) are used in patients with increased level Serum IgE. Indicated for severe allergic asthma, control over which is not achieved with the help of inhaled corticosteroids.
In a small number of patients, the appearance of an underlying disease (Churge-Strauss syndrome) was observed upon discontinuation of GCS due to anti-IgE treatment.

Systemic GCS in severe uncontrolled asthma, are indicated as long-term therapy oral medications(it is recommended to use it for a longer period than with the usual two-week course of intensive therapy with systemic corticosteroids - usually 40 to 50 mg of prednisolone per day).
The duration of the use of systemic corticosteroids is limited by the risk of developing serious undesirable effects (osteoporosis, arterial hypertension, suppression of the hypothalamic-pituitary-adrenal system, obesity, diabetes, cataracts, glaucoma, muscle weakness, stretch marks and a tendency to bruise due to thinning of the skin). Patients taking any form of systemic corticosteroids for a long time require the prescription of drugs for the prevention of osteoporosis.

Oral anti-allergic drugs(tranilast, repirinast, tazanolast, pemirolast, ozagrel, celatrodast, amlexanox and ibudilast) - suggested for treatment of mild and moderate allergic asthma in some countries.

Anticholinergics - ipratropium bromide and oxitropium bromide.
Inhaled ipratropium bromide is less effective than inhaled rapid-acting β2-agonists.
Inhaled anticholinergics are not recommended for long-term treatment of asthma in children.

Comprehensive treatment program BA (according to GINA) includes:

Patient education;
- clinical and functional monitoring;
- elimination of causal factors;
- development of a long-term therapy plan;
- prevention of exacerbations and drawing up a plan for their treatment;
- dynamic observation.

Drug therapy options

Treatment for AD is usually lifelong. It should be borne in mind that drug therapy does not replace measures to prevent patient contact with allergens and irritants. The approach to the patient's treatment is determined by his condition and the goal that the doctor currently faces.

In practice, it is necessary to distinguish between the following therapy options:

1. Relief of an attack - carried out with the help of bronchodilators, which can be applied by the patient himself situationally (for example, in case of mild breathing disorders - salbutamol in the form of a metered aerosol device) or by medical personnel through a nebulizer (in case of severe respiratory disorders).

Basic anti-relapse therapy: a maintenance dose of anti-inflammatory drugs (the most effective are inhaled glucocorticoids).

3. Basic anti-relapse therapy.

4. Treatment of status asthmaticus - is carried out using high doses of intravenous systemic glucocorticoids (IVC) and bronchodilators in the correction of acid-base metabolism and gas composition blood with the help of medication and non-medication.

Long-term maintenance therapy for asthma:

1. Assessment of the level of control over BA.
2. Treatment aimed at achieving control.
3. Monitoring to maintain control.

Treatment aimed at achieving control is carried out according to stepwise therapy, where each step includes therapy options that can serve as alternatives in the choice of BA maintenance therapy. The effectiveness of therapy increases from stage 1 to stage 5.

Stage 1
Includes the use of emergency drugs as needed.
It is intended only for patients who have not received maintenance therapy and who occasionally experience short-term (up to several hours) BA symptoms during the day. Patients with more frequent symptoms or episodic deterioration of the condition should receive regular supportive therapy (see step 2 or above) in addition to emergency medications as needed.

Recommended emergency drugs in Step 1: Inhaled, rapid-acting β2-agonists.
Alternative drugs: inhaled anticholinergics, short-acting oral β2-agonists, or short-acting theophylline.

Stage 2
Emergency drug + one drug to control the course of the disease.
Drugs recommended as initial maintenance therapy for asthma in patients of any age at stage 2: inhaled corticosteroids in a low dose.
Alternative means for controlling asthma: antileukotriene drugs.

Stage 3

3.1. Emergency drug + one or two drugs to control the course of the disease.
At stage 3, children, adolescents and adults are recommended: a combination of a low dose of inhaled corticosteroids with an inhaled long-acting β2-agonist. Reception is carried out using one fixed combination inhaler or using different inhalers.
If BA control has not been achieved after 3-4 months of therapy, an increase in the dose of inhaled corticosteroids is indicated.

3.2. Another treatment option for adults and children (the only one recommended for the management of children) is to increase the doses of inhaled corticosteroids to medium doses.

3.3. Treatment option at stage 3: a combination of low-dose inhaled corticosteroids with an antileukotriene drug. Instead of an antileukotriene drug, a low-dose sustained-release theophylline may be prescribed (these options have not been fully investigated in children aged 5 years and younger).

Stage 4
Emergency drug + two or more drugs to control the course of the disease.
The choice of drugs in Stage 4 depends on the previous appointments in Stage 2 and 3.
Preferred option: a combination of medium to high dose inhaled corticosteroids with a long-acting inhaled β2-agonist.

If BA control is not achieved using a combination of inhaled corticosteroids in a medium dose and a β2-agonist and / or a third drug for maintenance therapy (for example, an antileukotriene drug or sustained-release theophylline), the use of high doses of inhaled corticosteroids is recommended, but only as a trial therapy lasting 3-6 months.
With prolonged use of high doses of inhaled corticosteroids, the risk of side effects increases.

When using medium or high doses of inhaled corticosteroids, drugs should be prescribed 2 times a day (for most drugs). Budesonide is more effective when the frequency of administration is increased up to 4 times a day.

The effect of treatment is increased by the addition of a long-acting β2-agonist to medium and low doses of inhaled corticosteroids, as well as the addition of antileukotriene drugs (less in comparison with a long-acting β2-agonist).
Can increase the effectiveness of therapy and the addition of low doses of sustained-release theophylline to inhaled corticosteroids in medium and low doses and a long-acting β2-agonist.

Stage 5
Emergency drug + additional options for using drugs to control the course of the disease.
Adding oral corticosteroids to other supportive therapy drugs can increase the effect of treatment, however, it is accompanied by severe adverse events. In this regard, this option is considered only in patients with severe uncontrolled asthma on the background of therapy corresponding to stage 4, if the patient has daily symptoms that limit activity and frequent exacerbations.

Prescribing anti-IgE in addition to other supportive therapy drugs improves control over allergic asthma, if it is not achieved against the background of treatment with combinations of other supportive therapy drugs, which include high doses of inhaled or oral corticosteroids.

Well antibacterial therapy indicated in the presence of purulent sputum, high leukocytosis, accelerated ESR. Taking into account antibiotics, they are prescribed:
- spiramycin 3,000,000 U x 2 times, 5-7 days;
- amoxicillin + clavulanic acid 625 mg x 2 times, 7 days;
- clarithromycin 250 mg x 2 times, 5-7 days;
- ceftriaxone 1.0 x 1 time, 5 days;
- metronidazole 100 ml intravenous drip.

Forecast

The prognosis is favorable with regular dispensary observation(at least 2 times a year) and rationally selected treatment.
The lethal outcome can be associated with severe infectious complications, progressive pulmonary heart failure in patients pulmonary heart, untimely and irrational therapy.

The following points should be kept in mind:
- in the presence of bronchial asthma (BA) of any severity, the progression of impaired functions of the bronchopulmonary system occurs faster than in healthy people;

With a mild course of the disease and adequate therapy, the prognosis is quite favorable;
- in the absence of timely therapy, the disease can turn into a more severe form;

In severe and moderate asthma, the prognosis depends on the adequacy of treatment and the presence of complications;
- concomitant pathology can worsen the prognosis of the disease.

NS The nature of the disease and the long-term prognosis depend on the patient's age at the time of the onset of the disease.

With BA that began in childhood, about The long-term prognosis is favorable. As a rule, by puberty, children "outgrow" asthma, but they still have impaired pulmonary function, bronchial hyperreactivity, and abnormalities in the immune status.
With BA that began in adolescence, an unfavorable course of the disease is possible.
With AD, which began in adulthood and old age, the nature of the development and prognosis of the disease is more predictable.
The severity of the course depends on the form of the disease:
- allergic asthma is easier and more favorable prognostically;
- "pollen" asthma, as a rule, has a lighter course compared to "dusty";
- in elderly patients, the course is primarily severe, especially in patients with aspirin BA.

AD is a chronic, slowly progressive disease. With adequate therapy, asthma symptoms can be eliminated, but treatment does not affect the cause of their occurrence. Periods of remission can last for several years.

Hospitalization

Indications for hospitalization:
- severe attack of bronchial asthma;

There is no quick response to bronchodilator drugs and the effect lasts less than 3 hours;
- no improvement within 2-6 hours after starting oral corticosteroid therapy;
- there is a further deterioration - an increase in respiratory and pulmonary heart failure, "silent lung".

Patients at high risk of death:
- having a history of conditions close to lethal;
- requiring intubation, artificial ventilation, which leads to an increased risk of intubation with subsequent exacerbations;
- who have already been hospitalized or applied for emergency care against the background of bronchial asthma;
- taking or recently discontinued oralglucocorticosteroids;
- using inhaled rapid-acting β2-agonists in excessive amounts, especially more than one package of salbutamol (or equivalent) per month;
- with mental illness, psychological problems a history of sedation abuse;
- poorly adhering to the treatment plan for bronchial asthma.

Prophylaxis

Preventive measures in bronchial asthma (BA) depend on the patient's condition. If necessary, it is possible to increase or decrease the activity of the treatment.

Asthma control should begin with a thorough study of the causes of the disease, since the simplest measures can often have a significant effect on the course of the disease (it is possible to save the patient from the clinical manifestations of atopic AD variant by identifying the causative factor and eliminating contact with him in the future).

Patients should be trained in proper drug intake and proper use of drug delivery devices and peak flow meters to control peak expiratory flow (PEF).

The patient should be able to:
- control PSV;
- to understand the difference between drugs of basic and symptomatic therapy;
- avoid triggers of asthma;
- to determine the signs of worsening of the disease and to stop the seizures on their own, as well as to apply for medical help for relief of severe attacks.
BA control over a long period requires a written treatment plan (patient action algorithm).

List of preventive measures:

Termination of contact with causal allergens;
- termination of contact with nonspecific irritating factors of the external environment (tobacco smoke, exhaust gases, etc.);
- exclusion of professional harm;
- in the case of aspirin BA - refusal to use aspirin and other NSAIDs, as well as adherence to a specific diet and other restrictions;
- refusal to take beta-blockers, regardless of the form of BA;
- adequate application of any medicines;
- timely treatment foci of infection, neuroendocrine disorders and other concomitant diseases;
- timely and adequate therapy for asthma and other allergic diseases;
- timely vaccination against influenza, prevention of respiratory viral infections;
- carrying out medical and diagnostic activities using allergens only in specialized hospitals and offices under the supervision of an allergist;
- carrying out premedication before invasive examination methods and surgical interventions - parenteral administration of drugs: GCS (dexametozone, prednisolone), methylxanthines (aminophylline) 20-30 minutes before the procedure. The dose should be determined taking into account the age, body weight, asthma severity and the volume of intervention. Before carrying out such an intervention, an allergist consultation is indicated.

Information

Sources and Literature

1. Damianov I. Secrets of pathology / translation from English. ed. Kogan E.A., M.: 2006

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Prevention takes a special place infectious diseases respiratory tract. People with COPD are more prone to lung infections. Such patients are shown annual influenza vaccination. In addition, the use of pneumococcal vaccine can reduce the frequency of exacerbations of COPD and the development of community-acquired pneumonia, in this regard, vaccination is recommended for patients of older age groups over 65 years old and patients with severe COPD, regardless of age. If, nevertheless, COPD patient falls ill with pneumonia, then in vaccinated patients pneumonia proceeds much easier. While at home, you should follow some rules that will help prevent exacerbations and progression of COPD: avoid contact with various chemicals that can irritate the lungs (smoke, exhaust fumes, polluted air). In addition, cold or dry air can provoke an attack; it is better to use an air conditioner or an air filter in the house; during the working day it is necessary to take rest breaks; exercise regularly physical exercise to stay in good physical shape for as long as possible; eat well so as not to be deficient in nutrients. If weight loss does occur, then you need to see a doctor or nutritionist who will help you choose a diet to replenish the daily energy costs of the body.

Medical services for the prevention of disease Asthma with a predominance of an allergic component

Medical service	Average price by country
Psychological rehabilitation school for patients and relatives	There is no data
Tobacco Quitting School	There is no data
Patient Care School	There is no data
Group preventive counseling for the correction of risk factors for the development of noncommunicable diseases	There is no data
Individual in-depth preventive counseling on the correction of risk factors for the development of non-communicable diseases repeated	There is no data
Individual in-depth preventive counseling on the correction of risk factors for the development of non-communicable diseases, primary	There is no data
Individual short preventive counseling on the correction of risk factors for the development of non-communicable diseases	There is no data

The purpose of the lecture is based on the knowledge gained, to diagnose bronchial asthma, formulate a diagnosis, carry out a differential diagnosis with a syndromic-similar pathology, prescribe a personalized treatment for a particular patient, determine preventive measures and prognosis for this disease.

Lecture plan

Clinical case

Definition of BA

Epidemiology of asthma

AD etiology

Pathogenesis, pathomorphology, pathophysiology of AD

BA clinic

Diagnostic criteria for asthma

Differential diagnosis of asthma

BA classification

BA treatments

Prognosis, prevention of asthma

Patient A, 52 years old, economist by profession.

Delivered to the clinic with an attack of suffocation. Due to significant difficulty in breathing, she could answer questions in abrupt phrases. She complained of choking, not relieved with salbutomol, and an unproductive cough.

Medical history. Since childhood, she was prone to colds, which manifested themselves as coughs, difficulty in nasal breathing, and a runny nose. In the last 5 years, episodes of acute respiratory viral infections have become frequent, accompanied by prolonged cough, difficult "wheezing" breathing, especially at night. I began to react to tobacco smoke, cold air, physical activity - difficulty breathing and coughing appeared. I went to the doctor and was diagnosed with chronic bronchitis. On the recommendation of a doctor, he began to use salbutamol, which stopped coughing and shortness of breath. Worsening condition for about a week, associated with "cold". There was a cough with viscous sputum, shortness of breath with difficult exhalation, constant wheezing and a feeling of heaviness in the chest, nasal congestion, the temperature rose to 37.5 grams. S. Did not go to the doctor, took paracetamol, inhalation of salbutamol every 2-3 hours. A severe attack of suffocation, not relieved by salbutamol, the cessation of coughing up sputum caused an emergency emergency call.

Anamnesis of life. Professional activity is not related to harmful factors, living conditions are good. Gynecological history is not burdened, menopause is about a year. There are two pregnancies and childbirth. I do not smoke.

Allergic history. WITH childhood there were signs of food intolerance - urticaria when eating seafood. During the flowering season of wormwood and ragweed, nasal congestion, sneezing and lacrimation appeared, for which she took antihistamines. Recently reacts to contact with house dust. Heredity is aggravated: the maternal grandmother had bronchial asthma, the mother had hay fever.

Objective status. The patient's condition is serious due to a pronounced attack of suffocation. Forced sitting position with shoulder girdle fixation. The skin is pale with a slight diffuse cyanosis, the respiratory rate is 15 per minute, the exhalation is lengthened, there is no apnea phase. The chest is in a state of deep inspiration, the muscles of the neck and shoulder girdle are actively involved in breathing, the supraclavicular spaces bulge out. On palpation, the voice tremor is evenly carried out in all parts of the lungs, with percussion over the upper parts of the lungs, a boxed tone of sound. During auscultation, uneven ventilation is determined, areas of weakened and hard breathing alternate, exhalation is lengthened, an abundance of wheezing dry wheezing, intensifying with forced exhalation. The pulse is rhythmic, 105 beats / min. Heart sounds are rhythmic, muffled due to the abundance of wheezing. BP 140/85 mm Hg. Art. The abdominal organs were normal. Peak flowmetry revealed signs of bronchial obstruction: a decrease in PSV to 47% of the required values, an increase in the post-bronchodilation test was less than 10%, followed by a deterioration in the indicator within an hour. Pulse oximetry revealed hypoxemia - oxygen saturation -SaO92%. Laboratory data without deviations from the norm. On ECG signs overload of the right ventricle of the heart. The chest x-ray showed increased airiness mainly in the upper parts of both lungs.

So, the severity of the patient's condition is determined by the syndromes: asthma - asthma, bronchial obstruction and respiratory failure.

"Asthma" translated from Greek means "suffocation" - this is a paroxysmal onset of shortness of breath . Asthma in the classical sense is bronchial asthma. However, there is paroxysmal suffocation of another nature. Consequently, the main diagnostic task of the doctor at the stage of preliminary diagnosis is to establish the origin of suffocation, to establish what factors underlie bronchial obstruction. For the implementation of the diagnostic process, it is necessary to consider the main provisions of AD, which determine its nosological independence.

Definition

The modern concept of bronchial asthma considers AD as

chronic inflammatory disease the respiratory tract, in which many cells and cellular elements take part. Chronic inflammation leads to the development of bronchial hyperreactivity, which leads to repeated episodes of wheezing, shortness of breath, chest congestion and coughing, especially at night or in the early morning. These episodes are usually associated with widespread but variable airway obstruction in the lungs, which is often reversible either spontaneously or with treatment.

Epidemiology

BA is currently one of the most common human diseases in all age groups. There are about 300 million BA patients in the world. The incidence of asthma is about 5%, the mortality rate is 0.4-0.8 per 100,000. The prevalence of asthma is different and depends on many factors: climatogeographic zone, lifestyle, genetic characteristics, environmental factors, socio-economic factors. The highest prevalence of symptoms is recorded in Australia, New Zealand, Great Britain, the lowest - in Indonesia, Turkey, Taiwan, Albania. A sharp increase in the incidence of asthma, 7-10 times higher than the incidence in previous decades, occurred from the 30s to the 80s of the XX century and continues in the last 20 years, both among children and adults. V Of Russia Until 1900 AD was a relatively rare disease. In Russian medical journals of that time, isolated cases of the disease in adults and children were described. In the modern period, according to official statistics, the total number of BA patients in the Russian Federation is about 1 million, however, according to experts, the estimated number of BA patients is about 7 million. BA is the cause of death of 250 thousand deaths per year (GINA.2011).

Modern features of the BA course:

BA began to proceed much easier;

there are more BA patients;

BA is common among both adults and children;

AD is characterized by significant heterogeneity and variability of symptoms;

there is an underdiagnosis of asthma, which is associated with an underestimation of the lungs and rare episodes of the disease.

• AD etiology

The nosological affiliation of AD is based on the specific etiology, pathomorphology, mechanisms of the disease, clinical manifestations and treatment, prevention and educational programs. The concept of the disease distinguishes predisposing, etiological and resolving factors. Throughout the entire time of the formation of the theory of the mechanisms of AD development, the role of resolving factors that cause the development of the first attack or exacerbation of the disease in a previously sensitized organism is considered.

Factors influencing the risk of AD onset and manifestation, subdivided into factors that cause the development of the disease (internal) and factors that provoke the appearance of symptoms (external). External factors can be viewed as:

A) causal (initiating) - inflammation inducers, cause the onset of the disease and its exacerbation;

B) aggravating - triggers, increase the possibility of asthma onset and exacerbations. Several factors apply to both groups.

Asthma is an intermittent narrowing of the airways that causes shortness of breath and wheezing. It can develop at any age, but up to half of all new cases are now diagnosed in children under the age of 10. More common in men. In most cases, asthma is a family disorder. The risk factor for the development of the disease is smoking.

The severity and duration of seizures can vary greatly from time to time. Some asthmatics experience mild and rare attacks, while others suffer from prolonged and debilitating symptoms each time. In most patients, the manifestations of the disease are between these two extremes, but each time it is impossible to predict the severity and duration of the attack. Some severe asthma attacks can be life threatening if not treated urgently.

Allergic form

During attacks, the muscles of the bronchi contract, which causes them to narrow. The mucous membrane of the bronchi becomes inflamed, produces a lot of mucus, which clogs the small airways. In some people, these airway changes are triggered by an allergic reaction.

Allergic asthma tends to start as early as early age and then develop along with other allergic manifestations such as eczema and hay fever. The predisposition is often familial and can be inherited from the parents. It is known that attacks of allergic asthma can be triggered by certain substances called allergens. These include: pollen, dandruff, hair and saliva of domestic animals (mainly dogs and cats); some asthmatics are very sensitive to aspirin, and taking it can also trigger an attack.

In the case of a disease already in adults, no allergens have been found that provoke an inflammatory reaction of the respiratory tract. The first attack is usually associated with a respiratory infection. The factors that trigger an asthma attack can be cold air, exercise stress, smoking, sometimes emotional stress. Although industrial waste and exhaust fumes do not usually cause seizures, they can worsen symptoms in asthmatics and cause illness in susceptible people.

Professional uniform

In some cases, prolonged inhalation of a substance at work can cause illness in healthy person... This form of the disease is called occupational asthma and is a form of occupational lung disease.

If during working hours attacks of shortness of breath begin and wheezing occurs, but these symptoms disappear upon returning home, then the patient has occupational asthma. This disorder is very difficult to diagnose because It takes weeks, months, and sometimes years of constant contact with an allergen for a person before they develop the first symptoms of the disease. More than 200 different chemicals have now been identified that, when present in the air in the workplace, can cause disease.

Symptoms

They can develop gradually, so the person does not pay attention to them until the first attack. For example, contact with an allergen or a respiratory infection can cause the following symptoms:

• wheezing;
• painless chest tightness;
• difficulty breathing out;
• dry persistent cough;
• feeling of panic;
• sweating

These symptoms are severely exacerbated at night and in the early morning hours.

Some people experience wheezing during a cold or other respiratory tract infection, and in most cases this symptom is not indicative of the onset of illness.

With severe asthma, the following symptoms develop:

• wheezing becomes inaudible because too little air passes through the airways;
• the person cannot finish the phrase due to shortness of breath;
• due to lack of oxygen, lips, tongue, fingers and toes turn blue;
• confusion and coma.

The goal of any drug treatment is the elimination of symptoms and a decrease in the frequency and severity of attacks. There are 2 main forms of therapy - fast-acting drugs that relieve symptoms and control drugs. These medicines are mainly produced in the form of inhalers that spray a strictly metered dose. In acute asthma attacks, for some patients, inhalers with aerosol cans or in the form of special nebulizers are more convenient. They create a thin suspension of the drug in the air, which is inhaled through a tube or face mask. Balloons are also used when it is difficult to accurately measure the dose of medication. Children should only use aerosol cans.

If asthma develops in an adult, then it is necessary to prescribe fast-acting medications that relieve symptoms. Control drugs are gradually added if the patient has to take fast-acting drugs several times a week.

Wheezing attacks are usually treated with fast-acting medications (bronchodilators). There are several types of bronchodilators that relax the muscles of the bronchi and thereby expand their lumen and at the same time eliminate the violation of respiratory activity. The effect usually occurs within a few minutes after inhalation, but only lasts for a few hours.

If a sudden and severe asthma attack develops, you should immediately take a fast-acting agent prescribed by your doctor. The patient should take a comfortable position and remain calm. Put your hands on your knees to support your back, do not lie down, try to slow down your breathing rate so as not to lose strength. If the drug does not work, you need to call an ambulance.

When treated in a hospital, the patient is prescribed oxygen and corticosteroids. In addition, a high dose of a bronchodilator is administered or delivered through a nebulizer. In rare cases, when urgent medical treatment does not have an effect, the patient is connected to the device. artificial respiration which pumps air with a high oxygen content into the lungs. After stabilization of the condition, chest physiotherapy is prescribed (to facilitate coughing up accumulated mucus).

Control and prevention

The most important aspects successful disease control is a careful selection of drug treatment and regular monitoring of the patient's condition. Severe and life-threatening asthma attacks rarely develop when symptoms are regularly monitored.

Most medicines for the control and prevention of seizures belong to the corticosteroid group. They slow down the production of mucus, relieve inflammation of the airways, thereby reducing the likelihood of subsequent narrowing under the action of provoking substances. In some cases, NSAIDs are used to reduce the allergic reaction and prevent the narrowing of the airways. Controlling medications must be taken daily for several days to be effective. Patients with chronic and severe asthma are prescribed low-dose oral control medications (instead of inhalation).

Precautions and Diagnostics

If the patient develops a severe asthma attack or the symptoms continue to worsen, an ambulance should be called urgently.

In case of breathing problems that are absent at the time of the medical appointment, the doctor should examine the patient and write down the symptoms from his words. The patient will be referred to various tests (such as spirometry) to determine how well the lungs are working.

If the attack has developed directly at the doctor's appointment, then the patient is measured with a pneumotachometer the rate of exhalation and inhaled a bronchodilator (a drug that widens the airways). A doctor can diagnose asthma if the rate of expiration of air increases sharply while taking a bronchodilator.

If severe shortness of breath develops, the patient should be referred to a hospital for examination, during which the oxygen level in the blood will be measured, fluorography will be done to exclude other severe pulmonary dysfunctions (such as pneumothorax) that have symptoms similar to asthma.

Once a diagnosis is made, the patient should have skin tests done to identify allergens that can cause seizures.

Some asthmatics do not need treatment as long as they avoid any triggering factors, follow the advice of their doctors, and take their medications according to a treatment plan.

In about half of cases, childhood asthma resolves by the age of 20. The prognosis for adult asthmatics, who are generally in good health, is also very favorable if they strictly monitor their condition.