Mixed form of asthma. What is mixed asthma? Mixed asthma: development and features

- clinical and pathogenetic form of asthma, in the development of which both exogenous (allergic) and endogenous (non-allergic) factors take part. It is characterized by prolonged attacks of suffocation, frequent exacerbations, a progressive course, a tendency to the occurrence of pulmonary and extrapulmonary complications. A mixed form of asthma is diagnosed on the basis of an assessment of the allergological and immunological status, data from lung radiography, bronchoscopy, and respiratory function. In the treatment of bronchial asthma, pharmacotherapy is used (bronchodilators, anti-inflammatory, expectorants), rehabilitation methods (massage, breathing exercises, FTL).

Mixed bronchial asthma is a chronic inflammatory disease of the bronchi, occurring with bronchial hyperreactivity and obstruction, combining the signs of atopic and non-atopic bronchial asthma. Bronchial asthma of mixed origin is more common in children older than 4-5 years. Mixed bronchial asthma is more common in industrial areas and areas with a cool, humid climate. The complexity of the diagnosis and treatment of mixed bronchial asthma is due to a wide range of possible causative factors, as well as the participation of several mechanisms in the pathogenesis at once (usually atopic and infection-dependent). Bronchial asthma is interdisciplinary medical problem, on which experts in the field of pulmonology, allergology and immunology, microbiology, etc.

Causes of mixed bronchial asthma

The reasons that determine the originality of the course of mixed bronchial asthma combine various endogenous and exogenous factors. Among the most important internal determinants are genetic predisposition (increased production of IgE, changes in bronchial innervation, inheritance of atopy, ethnic and gender characteristics, etc.). External factors can be represented by infectious agents, non-infectious allergens (pollen, dust, wool, medicines, food, industrial sensitizers), meteorological conditions (fluctuations in temperature, humidity, pressure). In most cases, mixed bronchial asthma is formed from the atopic form by the imposition of infectious sensitization.

The immediate triggers of an asthmatic attack can be stressful situations, physical and psycho-emotional stress, SARS, strong odors, allergens coming from external environment, inhalation of tobacco smoke and air pollutants. All patients with mixed bronchial asthma have foci of chronic infection (tonsillitis, sinusitis, adenoiditis, caries, gastroduodenitis, etc.) and allergic diseases (allergic rhinitis, atopic dermatitis, drug allergy).

The leading pathogenetic links of bronchial asthma are inflammation of the bronchial wall, bronchial hyperreactivity and, as a result, a bronchospastic reaction in response to various nonspecific and specific allergic stimuli.

Classification of bronchial asthma

Bronchial asthma (BA) is subdivided according to the etiological principle, severity and phases of the course, the level of control over the disease. According to ICD-10, it is customary to distinguish between predominantly allergic, non-allergic and mixed forms of bronchial asthma. Each of these forms of bronchial asthma can have a mild, moderate or severe course. In accordance with the criteria for the frequency of attacks and the magnitude of the indicators of bronchial patency, 4 stages of BA are distinguished.

The first stage is mild asthma, episodic (intermittent) course. Attacks of shortness of breath, coughing, suffocation occur less than once a week during the daytime and not more than 2 times a month at night. The values ​​of FEV1 and PSV are more than 80% of the proper values, the daily variability of PSV (peak expiratory flow rate) is less than 20%.

The second stage is mild asthma, persistent course. Symptoms recur weekly (but not daily) during the day and more often than twice a month at night. The values ​​of FEV1 and PSV are less than 80% of the proper values, the daily variability of PSV deviation is less than 20-30%.

The third stage is BA of moderate degree, persistent course. Exacerbation of symptoms occurs daily during the day and more than once a week at night. The values ​​of FEV1 and PSV are 60-80% of the proper values, the daily variability of PSV is more than 30%.

Fourth stage — severe BA, persistent course. During the day, the symptoms are present constantly, night exacerbations occur frequently. The values ​​of FEV1 and PSV outside the attack fall below 60% of the proper values, the daily variability of PSV is more than 30%.

According to the level of control over the manifestations of the disease, controlled, incompletely controlled and uncontrolled bronchial asthma are distinguished; according to the phase of the course - exacerbation and remission.

Symptoms of mixed bronchial asthma

Mixed bronchial asthma in its course resembles infectious-allergic, but unlike the latter, it usually proceeds in moderate and severe form. The most common complaints are paroxysmal cough and asthma attacks, expiratory dyspnea, distant wheezing on expiration, a feeling of heaviness in the chest. Attacks of asthma often occur suddenly, including at night; the frequency and speed of relief of paroxysms depends on the severity of mixed bronchial asthma. At the end of the asthma attack, a small amount of mucous sputum is discharged.

Bronchial asthma of mixed genesis is characterized by a progressive course, frequent and prolonged exacerbations, and the development of attacks that are difficult to stop. Periods of exacerbation of mixed bronchial asthma often occur with subfebrile or febrile temperature, exacerbation of concomitant infectious diseases.

Often there are pulmonary (pneumothorax, emphysema, atelectasis, cardiopulmonary failure) and extrapulmonary complications (cor pulmonale, myocardial dystrophy). If the disease develops in childhood, there may be a lag in the child's physical development as a result of chronic hypoxia and intoxication.

Diagnosis of mixed bronchial asthma

During an attack, the recognition of bronchial asthma is not difficult. It is more difficult to establish the clinical and pathogenetic variant of the disease: for this purpose, the patient should be consulted by a pulmonologist and an allergist-immunologist. Laboratory tests are carried out (blood, sputum, bronchial swabs), X-ray and bronchological examinations, and the study of respiratory function parameters.

When collecting an anamnesis, attention is paid to allergic mood, the presence of chronic infectious foci in the body, the relationship of exacerbations with certain trigger factors, the frequency and severity of attacks. Auscultatory data outside the attack are characterized by dry rales, prolongation of the expiratory phase; during an attack - whistling (buzzing) wheezing, audible at a distance.

During the examination, an allergist performs scarification and intradermal tests with suspected allergens, specific IgE in the blood serum is determined. Sputum microscopy reveals a large number of eosinophils, Kurshman's spirals, Charcot-Leiden crystals. It is also advisable to conduct a bacteriological culture of sputum for pathogenic microflora.

X-ray of the lungs reveals their increased airiness, allows you to identify complications of bronchial asthma. In order to determine the severity of BA, it is necessary to study the parameters of the respiratory function (including spirometry with inhalation tests). To control bronchial obstruction, a patient with mixed bronchial asthma is trained in the skills of independent peak flowmetry. Bronchoscopy is required to exclude other causes of bronchial obstruction, to assess the cellular composition of bronchial lavage.

Differential diagnosis of mixed bronchial asthma is carried out with stenosis of the trachea and bronchi, foreign bodies and tumor lesions respiratory tract, obstructive bronchitis, isolated forms of asthma (atopic, infection-dependent).

Treatment of mixed bronchial asthma

Therapy of mixed bronchial asthma presents certain difficulties due to the need to influence the endogenous component and the exogenous component of the disease. It is imperative to take measures to eliminate the alleged allergen, sanitize foci of chronic inflammation, and avoid contact with factors provoking exacerbation.

Drug treatment of asthma is carried out by several groups of drugs: bronchodilators, anti-inflammatory, anti-asthma, expectorants, antihistamines and other drugs. Basic (anti-inflammatory) therapy is based on the appointment of glucocorticosteroids (inhaled - beclomethasone, budesonide; oral or intravenous - prednisolone, dexamethasone); mast cell membrane stabilizers (nedocromil sodium, sodium cromoglycate), leukotriene receptor antagonists (zafirlukast, montelukast). Inhaled bronchodilators (in the form of aerosols, solutions for nebulizer therapy) are used both for the relief of attacks and for long-term treatment of mixed bronchial asthma. These include salbutamol, fenoterol, ipratropium bromide, theophylline preparations, etc.

Symptomatic treatment of asthma involves the use of expectorants, mucolytics, ultrasonic inhalations with enzymes. Of the non-drug methods for mixed bronchial asthma, respiratory gymnastics, acupuncture, and massage are widely used. chest, climatotherapy. Often patients need psychotherapy. With the predominance of the atopic component, ASIT therapy is recommended.

Forecast and prevention of mixed bronchial asthma

This form of BA is not very favorable in terms of prognosis, since it often leads to disabling complications. However, if the elimination regimen and medical recommendations are followed, a long-term remission can be achieved and the progression of the disease can be delayed for a long time. Prevention of mixed bronchial asthma is to eliminate exogenous influences (contact with potential allergens, stress, physical overwork), increase nonspecific resistance, sanitation of infectious foci.

Bronchial asthma is a common disease of the lower respiratory tract with a variety of manifestations. Mixed asthma - one of them, is formed as a result of the combined influence of internal and external factors on the human body. The disease affects children older than 5 years, less often it occurs in adults.

What is a mixed type of asthma, why it occurs, how to recognize it and what to do when the disease appears, we will consider further.

A mixed form of bronchial asthma is a manifestation of a chronic inflammatory process in the respiratory system, which occurs in moderate and severe forms. It occurs due to the increased sensitivity of the bronchi, which leads to a narrowing of the bronchial lumen under the influence of various stimuli. This condition is caused by contraction of the smooth muscles of the bronchi, swelling of the mucous membrane and the accumulation of excess mucus on its walls.

This pathology is formed under the influence of factors of exogenous (allergic) and endogenous (non-allergic) types. If the disease combines both forms, then it has a mixed nature of origin.

With mixed asthma, there is a direct relationship not only with external stimuli (entering the body through the respiratory tract), but also with hidden infectious diseases (respiratory organs, teeth, stomach, intestines and other internal organs).

The disease is characterized by a relapsing course with multiple exacerbations and intractable attacks.

Classification of bronchial asthma

Mixed bronchial asthma is classified according to the following criteria: according to the severity of the course, the form of the disease, the controllability of the process.

• The severity of the disease.

Flow features:

1. Mild degree - characterized by minor exacerbations, which are easily eliminated with the help of bronchodilators.
2. The average severity leads to a decrease in the physical activity of a person, sleep disturbances. With it, the occurrence of more severe and prolonged exacerbations (several per week), sometimes accompanied by asthma attacks, is noted. To reduce negative consequences Asthma requires daily intake of bronchodilators.
3. The severe degree is the most dangerous. It is accompanied by partial or complete limitation of physical activity, difficulty in speech, panic, general weakness, frequent seizures. Attacks during this period can turn into asthmatic status, which poses a serious threat to the life of the patient.

Depending on the severity of the course, the disease can be episodic (developing gradually with rare attacks) or be permanent and proceed in a mild, moderate or severe form.

• Disease control.

According to the controllability of the process, asthma happens:

1. controlled - with the absence of negative manifestations and restrictions for any type of activity;
2. partially controlled - clinical signs appear with a moderate number of exacerbations;
3. uncontrolled - there are multiple symptoms, a significant number of exacerbations, the occurrence of asthmatic attacks.

To establish control over the disease, the patient needs to learn how to independently use a peak flowmeter (to determine top speed exhalation). This will help to determine the onset of an exacerbation, take the prescribed medications in a timely manner and reduce the risk of asthma attacks.

Causes of the disease

The genesis of mixed type bronchial asthma is based on various mechanisms that provoke the disease.

This pathology is the result of the simultaneous influence of allergic and non-allergic causes.

Impact exogenous factors leads to the appearance allergic reaction to certain substances perceived by the body as foreign.

Asthma provocateurs are allergens that enter the respiratory tract from the external environment:

• wool and fluff of pets;
• dry food;
• household cleaning, laundry and dishwashing products;
• dust mites;
• pollen of flowering plants;
• fungal spores;
• insect bites;
• strong odors;
• smoking and inhaling tobacco smoke;
• allergenic foods.

Endogenous (internal) causes are the results of an unstable physiological state of a person:

• complication of viral infections;
• endocrine disorders;
• chronic diseases of internal organs;
• physical and emotional overload;
• hypothermia of the body;
• climatic conditions;
• side effects from taking medications.

Since bronchial asthma of a mixed form develops under the influence of allergens and infection, it belongs to a complicated form of the disease and needs a special approach.

Mixed Asthma Symptoms

Asthma of the mixed form is characterized by periods of exacerbation, remission of inflammatory processes and remission.

The disease is accompanied by certain clinical signs:

• labored breathing;
• the occurrence of suffocation;
• the appearance of an itchy rash;
• violation of sputum excretion;
• feeling of squeezing the chest;
• wheezing wheezing on exhalation;
• coughing (especially at night);
• deterioration in general well-being;
• the appearance of subfebrile temperature;
• allergic manifestations.

The main manifestation of bronchial asthma of mixed genesis are prolonged attacks of suffocation. During an asthma attack, there is a narrowing of the bronchi, coughing and impaired respiratory function.

This condition can last for minutes or hours and can be managed with an inhaler. If the medicine does not work and the attack does not stop, it is necessary to hospitalize the patient.

Diagnostics

Diagnostic measures are the main method for detecting mixed type bronchial asthma.

They include:

A feature of the course of mixed asthma is a combination of allergic and non-allergic manifestations, which implies the use of complex treatment. It includes taking systemic and symptomatic drugs.

Systemic treatment is carried out for a long time (sometimes throughout life). It provides long-term relief by preventing flare-ups and helping to control the condition.

Basic therapy

Basic therapy includes the following medications:

• corticosteroid drugs in tablets or injections - used to thin sputum and discharge it with moderate severity of the disease, as well as with prolonged bronchospasm and status asthmaticus;
• long-term beta-2-agonists - contribute to the expansion of the lumen of the bronchi. In moderate or severe disease, a combination of an inhaled hormone with a beta-agonist is used;
• anticholinergics - contribute to the expansion of the bronchi, reduce the production of mucus, eliminate cough and shortness of breath;
• glucocorticosteroid drugs (inhalation hormones) - relieve inflammation, which reduces bronchial hyperactivity and eliminates bronchospasm, reduces swelling of the mucous membrane. They are prescribed when the disease is severe and difficult to treat. They are used in short courses, as they have serious side effects.

Each person has individual harbingers of an asthma attack, so it is important to learn how to recognize the onset of this moment.

Its main symptoms are:

• chills;
• headache;
• anxiety;
• a sore throat;
• sneezing
• paroxysmal cough;
• weakness.

The use of symptomatic quick response agents - aerosols and inhalers - at the right time will help improve the patient's condition and prevent the development of an attack.

Auxiliary treatment

Physiotherapy is used as an auxiliary treatment:

• massotherapy;
• electrophoresis;
• ultrasound;
• magnetotherapy;
• amplipulse;
• cryotherapy.

Carrying out the procedures improves the functionality of the respiratory tract, reduces inflammation, normalizes blood circulation, and also reduces the body's susceptibility to the effects of allergens.

It should be remembered that all medications must be used strictly according to the doctor's prescription.

It is not recommended to interrupt the treatment on your own with an improvement in general well-being and the disappearance of symptoms of the disease. This can lead to the progression of the disease and the return of all manifestations in a more severe form.

Forecast

It is not possible to predict the result of treatment, since mixed type asthma can provoke serious disturbances in work. respiratory system and cause complications.

However, timely treatment and the implementation of all doctor's prescriptions can stop the development of the disease and lead to prolonged remission.

Prevention of mixed asthma

Preventive measures are an integral part of the fight against a mixed form of bronchial asthma. They help prevent the progression of asthma or alleviate its symptoms.

• the use of protective equipment when using household and construction chemicals;
• frequent exposure to fresh air;
• hardening and increasing the protective properties of the body;
• refusal of heavy physical exertion;
• exclusion from the diet of foods that are allergens;
• daily wet cleaning living quarters;
• limiting or completely refusing contact with pets;
• mastering breathing exercises;
• quitting smoking and excessive alcohol consumption;
• application of methods of self-monitoring of the state of the disease.

Bronchial asthma cannot be completely cured. But proper treatment and the regular implementation of some rules will help to establish control over the disease. This will allow a person to return to a full life.

Version: Directory of Diseases MedElement

Mixed asthma (J45.8)

Gastroenterology

general information

Short description

Bronchial asthma*(BA) is a chronic inflammatory disease of the respiratory tract, which involves many cells and cellular elements. Chronic inflammation causes bronchial hyperreactivity leading to recurrent episodes of wheezing, shortness of breath, chest tightness, 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 spontaneously or with treatment.

Mixed bronchial asthma is diagnosed when the patient has symptoms of both allergic asthma and idiosyncratic asthma.
Diagnostic difficulties can be caused by cases of mixed asthma, when asthma develops in an elderly person or against the background of cardiovascular pathology.
In a number of chronic lung diseases (diffuse pneumosclerosis, emphysema, bronchiectasis, pneumoconiosis, especially silicosis, lung cancer), there is a gradual increase in dyspnea, which is expiratory in nature. Shortness of breath is noted in patients at rest, breathing is accompanied by wheezing.

Bronchial hyperreactivity -increased sensitivity of the lower respiratory tract to various irritating stimuli, which, as a rule, are contained in the inhaled air. These incentives are indifferent to healthy people. Clinically, bronchial hyperreactivity is most often manifested by episodes of wheezing shortness of breath in response to the action of an irritating stimulus in individuals with a hereditary predisposition.
Latent bronchial hyperreactivity is also distinguished, which is detected only by provocative functional tests with histamine and methacholine.
Bronchial hyperreactivity can be specific and nonspecific.

Specific hyperreactivity occurs in response to exposure to certain allergens, mainly contained in the air (plant pollen, house dust, wool and epidermis of domestic animals, fluff and feathers of poultry, spores and other elements of fungi).

Nonspecific hyperreactivity is formed under the influence of various stimuli of non-allergenic origin (aeropollutants, industrial gases and dust, endocrine disorders, physical activity, neuropsychic factors, respiratory infections, etc.).

Note. Excluded from this subsection are:

Asthmatic status - J46;
- Other chronic obstructive pulmonary disease - J44;
- Lung diseases caused by external agents - J60-J70;
- Pulmonary eosinophilia, not elsewhere classified - J82.

* Definition according to GINA (Global Initiative for Asthma) - Revision 2011.

Classification

Classification of asthma is based on a joint assessment of the symptoms of the clinical picture and indicators of lung function. There is no generally accepted classification of bronchial asthma. Below are examples of the most commonly used classifications.

Classification of bronchial asthma (BA) according to Fedoseev G. B. (1982)

1. Stages of BA development:

1.1The state of betrayal- conditions that threaten the onset of asthma (acute and chronic bronchitis, pneumonia with elements of bronchospasm, combined with vasomotor rhinitis, urticaria, vasomotor edema, migraine and neurodermatitis in the presence of eosinophilia in the blood and an increased content of eosinophils in sputum, due to immunological or non-immunological mechanisms of pathogenesis) .

1.2 Clinically diagnosed BA- after the first attack or asthma status (this term is used mainly in screening studies).

2. BA forms(not included in the formulation of the clinical diagnosis):

immunological form.
- non-immunological form

3. Pathogenetic mechanisms of AD:
3.1 Atonic - indicating the allergenic allergen or allergens.
3.2 Infection-dependent - indicating infectious agents and the nature of infectious dependence, which can be manifested by stimulation of an atopic reaction, infectious allergy and the formation of a primary altered bronchial reactivity (if the infection is an allergen, BA is defined as infectious-allergic).
3.3 Autoimmune.
3.4 Dishormonal - indicating the endocrine organ, the function of which is changed, and the nature of dishormonal changes.
3.5 Neuro-psychic - indicating options for neuro-psychic changes.
3.6 Adrenergic imbalance.
3.7 Primarily altered bronchial reactivity, which is formed without the participation of altered reactions of the immune, endocrine and nervous systems. May be congenital or acquired. Manifested under the influence of chemical, physical and mechanical irritants and infectious agents. Attacks of suffocation are characteristic during physical exertion, exposure to cold air, medicines and other things.

Note to point 3. A patient may have one pathogenetic mechanism of BA or various combinations of mechanisms are possible (by the time of the examination, one of the mechanisms is the main one). During the development of AD, a change in the main and secondary mechanisms is possible.

The separation of BA according to pathogenetic mechanisms and the isolation of the main one are significantly difficult. Nevertheless, this is justified due to the fact that each of the pathogenetic mechanisms involves a certain, unique nature of drug therapy.

4. Severity of BA(in some cases, such a division is conditional; for example, with a mild course, the patient may die from a suddenly developed asthmatic status, and with a rather severe course, a "spontaneous" remission is possible):

4.1 Easy flow: exacerbations are not long, occur 2-3 times a year. Attacks of suffocation are stopped, as a rule, by taking various bronchodilator drugs inside. In the interictal period, signs of bronchospasm, as a rule, are not detected.

4.2 Moderate course: more frequent exacerbations (3-4 times a year). Attacks of suffocation are more severe and are stopped by injections of drugs.

4.3 Severe flow: exacerbations occur frequently (5 or more times a year), differ in duration. The attacks are severe, often turning into an asthmatic state.

5. Phases of the course of bronchial asthma:

1. Aggravation- this phase is characterized by the presence of pronounced signs of the disease, primarily recurring attacks of asthma or an asthmatic condition.

2. fading exacerbation - in this phase, seizures are more rare and not severe. Physical and functional signs of the disease are less pronounced than in the acute phase.

3. Remission - typical manifestations of BA disappear (no asthma attacks occur, bronchial patency is fully or partially restored).

6. Complications:

1. Pulmonary: emphysema, pulmonary insufficiency, atelectasis, pneumothorax and others.

2. Extrapulmonary: myocardial dystrophy, cor pulmonale, heart failure and others.

Classification of asthma according to the severity of the disease and clinical signs before treatment

Step 1 Mild intermittent asthma:
- symptoms less than once a week;
- short exacerbations;
- nocturnal symptoms no more than 2 times a month;
- FEV1 or PSV>= 80% of the expected values;
- variability in FEV1 or PSV< 20%.

Step 2 Mild persistent asthma:

Symptoms more than 1 time per week, but less than 1 time per day;

- nocturnal symptoms more than 2 times a month FEV1 or PEF>= 80% of the expected values;
- variability of FEV1 or PSV = 20-30%.

Step 3 Persistent moderate asthma:

daily symptoms;
- exacerbations can affect physical activity and sleep;
- nocturnal symptoms more than once a week;
- FEV1 or PSV from 60 to 80% of the proper values;
- variability in FEV1 or PSV > 30%.

Step 4 Severe persistent asthma:
- daily symptoms;
- frequent exacerbations;
- frequent nocturnal symptoms;
- restriction of physical activity;
- FEV 1 or PSV<= 60 от должных значений;
- variability in FEV1 or PSV > 30%.

Additionally, the following are BA course phases:
- exacerbation;
- unstable remission;
- remission;
- stable remission (more than 2 years).

Classification according to the Global Asthma Initiative(GINA 2011)
The classification of asthma severity is based on the amount of therapy required to achieve disease control.

1. Mild asthma - disease control can be achieved with a small amount of therapy (low doses of inhaled corticosteroids, antileukotriene drugs or cromones).

2. Severe asthma - A large amount of therapy is needed to control the disease (eg, GINA grade 4) or control cannot be achieved despite a large amount of therapy.

Patients with different AD phenotypes have different responses to conventional treatment. With the advent of specific treatments for each phenotype, AD that was previously considered severe can become mild.
The ambiguity of the 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. Severe or frequent symptoms do not necessarily indicate severe asthma, as they may be the result of inadequate treatment.

Classification according to ICD-10

J45.0 Asthma with a predominance of an allergic component (in the presence of an association of the disease with an established external allergen) includes the following clinical variants:

allergic bronchitis;

Allergic rhinitis with asthma;

atopic asthma;

Exogenous allergic asthma;

Hay fever with asthma.

J45.1 Non-allergic asthma (when the disease is associated with external factors of a non-allergenic nature or unspecified internal factors) includes the following clinical variants:

Idiosyncratic asthma;

Endogenous non-allergic asthma.

J45.8 Mixed asthma (with signs of the first two forms).

J45.9 Asthma, unspecified, which includes:

asthmatic bronchitis;

Late onset asthma.

J46 Status asthmaticus.

The formulation of the main diagnosis should reflect:
1. The form of the disease (for example, atopic or non-allergic asthma).
2. The severity of the disease (eg, severe persistent asthma).
3. The phase of the course (for example, exacerbation). In remission with steroids, it is reasonable to indicate a maintenance dose of the anti-inflammatory drug (eg, remission at a dose of 800 µg of beclomethasone per day).
4. Complications of asthma: respiratory failure and its form (hypoxemic, hypercapnic), especially asthmatic status.

Etiology and pathogenesis

According to GINA-2011, bronchial asthma (BA) is a chronic inflammatory disease of the respiratory tract, which involves a number of inflammatory cells and mediators, which leads to characteristic pathophysiological changes.

1. Inflammatory cells in the airways in asthma.

1.1 Mast cells. Under the action of allergens with the participation of high-affinity IgE receptors and under the influence of osmotic stimuli, mucosal mast cells are activated. Activated mast cells release mediators that cause bronchospasm (histamine, cysteinyl leukotrienes, prostaglandin D2). An increased number of mast cells in airway smooth muscle may be associated with bronchial hyperreactivity.

1.2 Eosinophils. In the airways, the number of eosinophils is increased. These cells secrete the main proteins that can damage the epithelium of the bronchi. Also, eosinophils may be involved in the release of growth factors and airway remodeling.

1.3 T-lymphocytes. In the respiratory tract, there is an increased number of T-lymphocytes that release specific cytokines that regulate the process of eosinophilic inflammation and the production of IgE by B-lymphocytes. The increase in Th2 cell activity may be partly due to a decrease in the number of regulatory T cells that normally inhibit Th2 lymphocytes. It is also possible to increase the number of inKT cells that secrete Th1 and Th2 cytokines in large quantities.

1.4 Dendritic cells capture allergens from the surface of the bronchial mucosa and migrate to regional lymph nodes, where they interact with regulatory T cells and ultimately stimulate the conversion of undifferentiated T lymphocytes into Th2 cells.

1.5 Macrophages. The number of macrophages in the respiratory tract is increased. Their activation may be associated with the action of allergens with the participation of IgE receptors with low affinity. Due to the activation of macrophages, inflammatory mediators and cytokines are released, which enhance the inflammatory response.

1.6 Neutrophils. In the respiratory tract and sputum of patients with severe asthma and smokers, the number of neutrophils increases. Their pathophysiological role has not been elucidated. It is assumed that an increase in their number may be a consequence of GCS therapy. GCS (glucocorticoids, glucocorticosteroids) - drugs one of the leading properties of which is to inhibit the early stages of the synthesis of the main participants in the formation of inflammatory processes (prostaglandins) in various tissues and organs.
.

2.mediators of inflammation. Currently, more than 100 different mediators are known that are involved in the pathogenesis of asthma and the development of a complex inflammatory response in the airways.

3.Structural changes in the airways - are detected in the airways of patients with asthma and are often considered as a process of bronchial remodeling. Structural changes may result recovery processes in response to chronic inflammation. Due to the deposition of collagen fibers and proteoglycans under the basement membrane, subepithelial fibrosis develops, which is observed in all patients with asthma (including children) even before the onset of clinical manifestations of the disease. The severity of fibrosis may decrease with treatment. The development of fibrosis is also observed in other layers of the bronchial wall, in which collagen and proteoglycans are also deposited.

3.1 Smooth muscle of the bronchial wall. due to hypertrophy Hypertrophy - the growth of an organ, part of it or tissue as a result of cell multiplication and an increase in their volume
and hyperplasia Hyperplasia - an increase in the number of cells, intracellular structures, intercellular fibrous formations due to enhanced organ function or as a result of a pathological tissue neoplasm.
there is an increase in the thickness of the smooth muscle layer, which contributes to the overall thickening of the bronchus wall. This process may depend on the severity of the disease.

3.2Blood vessels. Under the influence of growth factors, such as vascular endothelial growth factor (VEGF), there is a proliferation Proliferation - an increase in the number of cells of a tissue due to their reproduction
vessels of the bronchial wall, contributing to the thickening of the bronchial wall.

3.3 Mucus hypersecretion observed as a result of an increase in the number of goblet cells in the epithelium of the respiratory tract and an increase in the size of the submucosal glands.

4. Narrowing of the airways- universal The final stage pathogenesis of asthma, which leads to the onset of symptoms of the disease and typical physiological changes.

Factors causing narrowing of the airways:

4.1 Contraction of the smooth muscles of the bronchial wall in response to the bronchoconstrictor action of various mediators and neurotransmitters is the main mechanism of airway constriction; almost completely reversible under the action of bronchodilators.

4.2 Airway edema resulting from increased permeability of the microvascular bed, which is caused by the action of inflammatory mediators. Edema can play a particularly important role in exacerbations.

4.3 Thickening of the bronchus wall as a result of structural changes. This factor may have great importance with severe AD. Bronchial wall thickening is not fully reversible with existing drugs.

4.4 Mucus hypersecretion can lead to occlusion Occlusion is a violation of the patency of some hollow formations in the body (blood and lymphatic vessels, subarachnoid spaces and cisterns), due to the persistent closure of their lumen in any area.
bronchial lumen ("mucus plugs") and is the result of increased secretion of mucus and the formation of an inflammatory exudate.

Features of the pathogenesis are described for the following forms of AD:
- exacerbation of BA;
- night BA;
- irreversible bronchial obstruction;
- BA, difficult to treat;
- BA in smokers;
- aspirin triad.

Epidemiology

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. Approximately half of the patients develop bronchial asthma before the age of 10 years, in a third - up to 40 years.
Among children with bronchial asthma, there are twice as many boys as 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 causing the development of the disease - internal factors (primarily genetic);
- factors that provoke the onset of symptoms - external factors.
Some factors belong to both groups.
The mechanisms of influence of factors on the development and manifestations 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 molds and yeasts).

2. Infections (mainly viral).

3. Professional sensitizers.

4. Tobacco smoking (passive and active).

5. Air pollution indoors and outdoors.

6. Nutrition.

Examples of substances that cause the development of asthma in certain occupations

Profession	Substance
	Proteins of animal and vegetable origin
Bakers	Flour, amylase
Cattle farmers	Warehouse tongs
Detergent production	Bacillus subtilis enzymes
Electrical soldering	Rosin
Crop farmers	soy dust
Production of fish products
Food production	Coffee dust, meat tenderizers, tea, amylase, shellfish, egg whites, pancreatic enzymes, papain
Granary workers	Warehouse mites, Aspergillus. Weed particles, ragweed pollen
Medical workers	Psyllium, latex
poultry farmers	Poultry mites, bird droppings and feathers
Researchers-experimenters, veterinarians	Insects, dander and animal urine proteins
Sawmill workers, carpenters	wood dust
Movers/transport workers	grain dust
Silk workers	Butterflies and silkworm larvae
	inorganic compounds
Beauticians	Persulfate
Platters	Nickel salts
Oil refinery workers	Salts of platinum, vanadium organic compounds
Car painting	Ethanolamine, diisocyanates
Hospital workers	Disinfectants (sulfathiazole, chloramine, formaldehyde), latex
Pharmaceutical production	Antibiotics, piperazine, methyldopa, salbutamol, cimetidine
Rubber processing	Formaldehyde, ethylenediamide
Plastics production	Acrylates, hexamethyl diisocyanate, toluine diisocyanate, phthalic anhydride

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

In patients with allergic asthma, elimination of the allergen is of paramount importance. There is evidence that in urban areas in children with atopic asthma, individual complex measures for the removal of allergens in the homes led to a decrease in soreness.

Clinical picture

Clinical Criteria for Diagnosis

Unproductive hacking cough, prolonged expiration, dry, wheezing, usually treble, wheezing in the chest, more at night and in the morning, attacks of expiratory choking, chest congestion, dependence of respiratory symptoms on contact with provoking agents.

Symptoms, course

Clinical diagnosis of 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, whistling, usually treble, rales in the chest, more marked at night and in the morning; expiratory dyspnea, attacks of expiratory suffocation, congestion (stiffness) of the chest.
3. Dependence of respiratory symptoms on contact with provoking agents.

Also of great importance are the following factors :
- the appearance of symptoms after episodes of contact with the 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 have a cough at night?

Does the patient have wheezing or cough after exercise?

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

Does the patient report that the cold "goes down to the chest" or continues for more than 10 days?

Does the severity of symptoms decrease after the use of appropriate anti-asthma drugs?

On physical examination, there may be no symptoms of asthma, due to the variability in the manifestations of the disease. The presence of bronchial obstruction is confirmed by wheezing that is detected during auscultation.
In some patients, wheezing may be absent or detected only during forced exhalation, even in the presence of severe bronchial obstruction. In some cases, patients with severe exacerbations of asthma do not wheeze due to severe limitation of airflow and ventilation. In such patients, as a rule, there are other clinical signs indicating the presence and severity of an exacerbation: cyanosis, drowsiness, difficulty in speaking, swollen chest, participation of auxiliary muscles in the act of breathing and retraction of the intercostal spaces, tachycardia. These clinical symptoms can only be observed when examining the patient during the period of pronounced clinical manifestations.

Variants of clinical manifestations of AD

1.Cough variant of BA. The main (sometimes the only) manifestation of the disease is a cough. Cough asthma 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 lung function or bronchial hyperreactivity, as well as the determination of eosinophils in sputum.
The cough variant of asthma is differentiated from the so-called eosinophilic bronchitis. In the latter, patients present with cough and sputum eosinophilia, but have normal lung function on spirometry and normal bronchial reactivity.
In addition, cough can occur due to the use of ACE inhibitors, gastroesophageal reflux, postnasal drip syndrome, chronic sinusitis, dysfunction of the vocal cords.

2. Bronchospasm induced by physical activity. Refers to the manifestation of non-allergic forms of asthma, when the phenomena of airway hyperreactivity 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 cessation of exercise (rarely - during exercise). Patients have typical symptoms of asthma or sometimes a prolonged cough that resolves on its own within 30-45 minutes.
Forms of exercise such as running cause asthma symptoms more frequently.
Exercise-induced bronchospasm often develops when inhaling dry, cold air, more rarely in hot and humid climates.
In favor of asthma is evidenced by the rapid improvement in the symptoms of post-exercise bronchospasm after inhaled β2-agonist, as well as the prevention of the development of symptoms due to inhaled β2-agonist before exercise.
In children, asthma 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. Diagnosis is facilitated by a protocol with an 8-minute run.

Clinical picture of an asthma attack quite characteristic.
In case of allergic etiology of BA, before the development of suffocation, itching (in the nasopharynx, auricles, in the chin area), nasal congestion or rhinorrhea, feelings of lack of "free breathing", dry cough can be observed. lengthened; the duration of the respiratory cycle increases and the respiratory rate decreases (up to 12-14 per minute).
While listening to the lungs in the majority of cases, against the background of an extended exhalation, a large number of scattered dry rales, mostly whistling. As the asthma attack progresses, wheezing wheezes on expiration 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 the small bronchi and bronchioles with an inflammatory secret. The general condition of the patient is significantly aggravated, 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. All auxiliary muscles participate in the act of breathing, the chest expands, and the intercostal spaces are drawn in during inspiration, cyanosis of the mucous membranes, acrocyanosis, arises and intensifies. It is difficult for the patient to speak, the sentences are short and jerky.
During auscultation, there is a decrease in the number of dry rales, in some places they are not heard at all, as well as vesicular breathing; so-called silent lung zones appear. Above the surface of the lungs, percussion is determined by a pulmonary sound with a tympanic shade - a box sound. The lower edges of the lungs are lowered, their mobility is limited.
The completion of an asthma attack is accompanied by a cough with a discharge of a small amount of viscous sputum, easier breathing, a decrease in shortness of breath and the number of auscultated wheezing. Even for a long time, a few dry rales can be heard while maintaining an elongated exhalation. After the cessation of the attack, the patient often falls asleep. Signs of asthenia 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 an item as "breathing is inevitable." The severity of the course of BA and the severity of exacerbation of BA are not the same thing. For example, with mild asthma, exacerbations of mild and moderate severity can occur; with asthma of moderate severity and severe, exacerbations of mild, moderate, and severe are possible.

The severity of BA exacerbation according to GINA-2011

	Lung	Middle gravity	heavy	Stopping breathing is inevitable
Dyspnea	When walking. May lie	When talking; children crying getting quieter and shorter having difficulty feeding. Prefers to sit	At rest, children stop eating. Sitting leaning forward
Speech	Offers	Phrases	words
Level wakefulness	May be aroused	Usually aroused	Usually aroused	Inhibited or confused mind
Breathing rate	Increased	Increased	More than 30 min.
Participation of auxiliary muscles in the act of breathing and retraction of the supraclavicular fossae	Usually no	Usually there	Usually there	Paradoxical movements chest and abdominal walls
wheezing	Moderate, often only exhale	Loud	Usually loud	Missing
Pulse (in min.)	<100	>100	>120	Bradycardia
Paradoxical pulse	Absent <10 мм рт. ст.	May have 10-25 mmHg st	Often available >25 mmHg Art. (adults) 20-40 mmHg 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
PaO 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. Possible respiratory failure
SatO 2,% (when breathing air) - oxygen saturation or the degree of saturation of arterial blood 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:

Infant (2-12 months)<160 в минуту;

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

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

Under 2 months< 60 в минуту;

2-12 months< 50 в минуту;

1-5 years< 40 в минуту;

6-8 years old< 30 в минуту.

Diagnostics

Fundamentals of diagnosing bronchial asthma(BA):
1. Analysis of clinical symptoms, which are dominated by periodic attacks of expiratory suffocation (for more details, see the "Clinical picture" section).
2. Determination of indicators of pulmonary ventilation, most often with the help of spirography with registration of the "flow-volume" curve of forced expiration, identification of signs of reversibility of bronchial obstruction.
3. Allergological research.
4. Identification of nonspecific bronchial hyperreactivity.

The study of indicators of the function of external respiration

1. Spirometry Spirometry - measurement of vital capacity of the lungs and other lung volumes using a spirometer
. In patients with asthma, signs of bronchial obstruction are often diagnosed: a decrease in indicators - PEF (peak expiratory volumetric velocity), MOS 25 (maximum volumetric velocity at the point of 25% FVC, (FEF75) and FEV1.

To assess the reversibility of bronchial obstruction is used pharmacological bronchodilation test with short-acting β2-agonists (most often salbutamol). Before the test, you should refrain from taking short-acting bronchodilators for at least 6 hours.
Initially, the initial curve "flow-volume" forced breathing of the patient 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 curve is recorded. With an increase in FEV1 or FOS ex by 15% or more, airway obstruction is considered reversible or bronchodilator-reactive, and the test is considered positive.

For asthma, it is diagnostically important to identify a significant daily variability in bronchial obstruction. For this, spirography (when the patient is in the hospital) or peak flowmetry (at home) is used. The spread (variability) of FEV1 or POS ex more than 20% during the day is considered to confirm the diagnosis of BA.

2. Peakflowmetry. It is used to evaluate the effectiveness of treatment and to objectify the presence and severity of bronchial obstruction.
Peak expiratory flow rate (PEF) is estimated - the maximum speed at which air can exit the respiratory tract during a forced exhalation after a full breath.
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 between PSV values ​​measured during the day 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 attacks of shortness of breath, cough, wheezing occur less than 1 time per week. Duration of exacerbations - from several hours to several days. Night attacks - 2 or less times a month. In the period between exacerbations, lung function is normal; PSV - 80% of normal or less.

2.2 Mild persistent asthma (stage II). Daytime attacks are observed 1 or more times a week (not 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 disturbed; PSV - 80% of normal or less.

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

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

3. Allergological study. Allergological history is analyzed (eczema, hay fever, family history of asthma or other allergic diseases). Positive skin tests with allergens and elevated blood levels of total and specific IgE testify in favor of AD.

4. Provocative Tests with histamine, methacholine, physical activity. They are used to detect nonspecific bronchial hyperreactivity, manifested by latent bronchospasm. Performed in patients with suspected asthma and normal spirography.

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 if the air flow rate deteriorates by 20% or more as a result of histamine inhalation at a concentration one or more orders of magnitude lower than that which causes similar changes in healthy people.
Similarly, a test with methacholine is carried out and evaluated.

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

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

Main diagnostic criteria for AD:

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 vyd< 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. Identification of signs of bronchial hyperreactivity (hidden bronchospasm) in patients with initial normal indicators 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 may be "small equivalents" of an attack of expiratory suffocation:
- unmotivated cough, often at night and after exercise;
- recurring sensations of chest tightness and / or episodes of wheezing;
- the fact of awakening at night from the indicated symptoms strengthens the criterion.
2. Aggravated allergic history (presence of eczema, hay fever, pollinosis in a patient) or aggravated family history (BA, atopic diseases in the patient's family members).

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

Professional BA

Bronchial asthma due to professional activity is often not diagnosed. Due to the gradual development of occupational asthma, it is often regarded as chronic bronchitis or COPD. This leads to incorrect treatment or its absence.

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

Criteria for the diagnosis of occupational asthma:
- well-established occupational exposure to known or suspected sensitizing agents;
- the absence of symptoms of asthma before employment or a clear worsening of the course of asthma after employment.

Laboratory diagnostics

Non-invasive determination of markers of airway inflammation

1. The study of spontaneously produced or induced by inhalation of hypertonic sputum solution on inflammatory cells - eosinophils or neutrophils. It is used to assess the activity of inflammation in the airways in asthma.

2. Determination of levels of nitric oxide (FeNO) and carbon monoxide (FeCO) in exhaled air. In patients with BA, there is an increase in the level of FeNO (in the absence of inhaled corticosteroids) compared with individuals without BA, however, these results are not specific for this disease. The role of FeNO in the diagnosis of AD has not been evaluated in prospective studies.

3. Skin tests with allergens - are the main method for assessing allergic status. Such samples are highly sensitive, easy to use and do not require much time. It should be borne in mind that incorrect sample performance can lead to false positive or false negative results.

4. The determination of specific IgE in blood serum is a more expensive method than skin tests, which does not surpass them in reliability.
In some patients, specific IgE may be detected in the absence of any symptoms and play no role in the development of AD. Thus, positive test results do not necessarily indicate the allergic nature of the disease and the association of the allergen with the development of asthma.
The presence of allergen exposure and its association with asthma manifestations should be supported by history data. The measurement of total IgE in serum is not a method of diagnosing atopy.

Clinical Tests

1. Complete blood count: during the period of exacerbation, an increase in ESR and eosinophilia are noted. Eosinophilia is not determined in all patients and cannot serve as a diagnostic criterion.

2. General sputum analysis:
- a large number of eosinophils;
- Charcot-Leiden crystals;
- Kurshman's spirals (formed due to small spastic contractions of the bronchi);
- neutral leukocytes - in patients with infectious-dependent BA in the stage of an active inflammatory process;
- release of Creole bodies during an attack.

3. Biochemical analysis of blood: changes are of a general nature. BAC is not the main diagnostic method and is prescribed to monitor the patient's condition during an exacerbation.

Differential Diagnosis

1. Differential diagnosis of BA variants.

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

signs	Atopic variant	infection dependent variant
Allergic diseases in the family	Often	Rare (except asthma)
Atopic disease in a patient	Often	Rarely
Connection of an attack with an external allergen	Often	Rarely
Features of an attack	Acute onset, rapid onset, usually of short duration and mild course	Gradual onset, long duration, often severe
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	Missing
Skin tests with extracts of non-infectious allergens	Positive	Negative
Exercise test	More often negative	More often positive
Allergen Elimination	Possible, often effective	Impossible
Beta-agonists	Very effective	Moderately effective
Cholinolytics	Ineffective	Effective
Eufillin	Very effective	Moderately effective
Intal, Thailed	Very effective	Less effective
Corticosteroids	Effective	Effective

2. Differential diagnosis of BA is carried out with chronic obstructive pulmonary disease(COPD), which is characterized by more permanent bronchial obstruction. In patients with COPD, there is no spontaneous lability of symptoms typical of BA, there is no or significantly less daily variability in FEV1 and POS exud, complete irreversibility or less reversibility of bronchial obstruction is determined in the test with β2-agonists (increase in FEV1 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, more effective bronchodilators are anticholinergics, and not 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 years and younger wheezing episodes 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 of children and smoking parents.

1.2 Persistent wheezing with early onset (under 3 years of age). Children usually have recurrent episodes of wheezing associated with acute respiratory viral infections. At the same time, children do not have signs of atopy and there is no family history of atopy (in contrast to children of the next age group with late onset wheezing/bronchial asthma).
Wheezing episodes typically continue into school age and are still detected in a significant proportion of children as young as 12 years of age.
The cause of wheezing episodes in children under 2 years of age is usually a respiratory syncytial virus infection, in children 2-5 years of age - other viruses.

1.3 Late-onset wheezing/asthma. Asthma 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 asthma.

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;

Aspiration of a foreign body;
- 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 lung damage or cardiovascular pathology.

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

Hyperventilation syndrome and panic attacks;

Obstruction of the upper respiratory tract and aspiration of foreign bodies;

Other obstructive pulmonary diseases, especially COPD;

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

Non-respiratory diseases (for example, left ventricular failure).

3. Elderly patients. BA should be differentiated from left ventricular failure. In addition, BA is underdiagnosed in the elderly.

Risk Factors for Underdiagnosis of AD in Elderly Patients

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


- Decreased perception of dyspnea and bronchoconstriction.

3.2 From the doctor's point of view:
- misconception that asthma does not start in old age;
- difficulties in examining lung function;
- perception of asthma symptoms as signs of aging;
- accompanying illnesses;
- underestimation of dyspnea due to a decrease in the patient's physical activity.

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 a hormone-dependent variant of BA, complications associated with prolonged use of systemic corticosteroids may occur.

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Treatment

Objectives of the treatment of bronchial asthma(BA):

Achieve and maintain control of symptoms;

Maintaining a normal level of activity, including physical activity;

Maintaining lung function at a normal or as close to normal level as possible;

Prevention of asthma exacerbations;

Prevention of unwanted effects of anti-asthma drugs;

Prevention of deaths from AD.

BA control levels(GINA 2006-2011)

Characteristics	controlled BA(all of the above)	Partially controlled asthma(presence of any manifestation within a week)	uncontrolled asthma
daytime symptoms	None (≤ 2 episodes per week)	> 2 times a week	3 or more signs of partially controlled asthma in any week
Activity restriction	No	Yes - any expression
Night symptoms/ awakenings	No	Yes - any expression
Need for emergency medicines	None (≤ 2 episodes per week)	> 2 times a week
Pulmonary function tests (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 week with aggravation 3

1 Pulmonary function testing not reliable in children 5 years of age and younger. Periodic assessment of the level of control over BA in accordance with the criteria indicated in the table will allow you to individually select a 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

Medical therapy

Medications for the treatment of AD:

1. Drugs that control the course of the disease (maintenance therapy):
- inhalation and systemic corticosteroids;
- anti-leukotriene 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 AD; they are taken daily and for a long time. The most effective for maintenance therapy are inhaled corticosteroids.

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

Drugs for the treatment of asthma can be administered in various ways - inhalation, oral 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;
- Significantly reduces the risk of systemic side effects.

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 fast-acting inhaled β2-agonists.

Increasing use (especially daily) of rescue drugs indicates worsening asthma control and the need to reconsider therapy.

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

Inhaled corticosteroids do not cure BA, and when they are canceled in some patients, a worsening of the condition is observed 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 bruising, 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(µg)	Medium daily allowance doses(µg)	High daily allowance doses(µg)
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

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

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

A drug	Low daily allowance doses(µg)	Medium daily allowance doses(µg)	High daily allowance doses(µg)
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: subtype 1 cysteinyl leukotriene receptor antagonists (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 respiratory tract;
- reduce the frequency of asthma exacerbations.
Anti-leukotriene drugs can be used as second-line drugs for the treatment of adult patients with mild persistent asthma. Some patients with aspirin asthma also respond well to therapy with these drugs.
Antileukotriene drugs are well tolerated; side effects are few or absent.

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

Oral long-acting β2-agonists: sustained-release formulations of salbutamol, terbutaline, and bambuterol (a prodrug that is converted 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 skeletal muscle tremor. Undesirable cardiovascular reactions can also occur when oral β2-agonists are used in combination with theophylline.

Rapidly acting inhaled β2-agonists: salbutamol, terbutaline, fenoterol, levalbuterol HFA, reproterol and pirbuterol. Due to its 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 corticosteroids.
Fast-acting inhaled β2-agonists are emergency medicines and are the drugs of choice for the relief of bronchospasm during exacerbation of asthma, as well as for the prevention of 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 reconsider 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 continue to 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 than when using inhaled forms, undesirable systemic effects (tremor, tachycardia).

Short-acting oral β2-agonists(refer to emergency medicines) can be prescribed to only a few patients who are not able to take inhaled drugs. Side effects are observed more often.

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

Sodium cromoglycate and nedocromil sodium(cromones) are of limited value in the long-term treatment of asthma in adults. There are known examples of the beneficial effects 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 elevated serum IgE levels. 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 (Churg-Strauss syndrome) was observed when glucocorticosteroids were discontinued due to anti-IgE treatment.

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

Oral antiallergic drugs(tranilast, repyrinast, tazanolast, pemirolast, ozagrel, celatrodust, amlexanox and ibudilast) are offered for mild treatment and moderate allergic asthma in some countries.

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

Comprehensive treatment program BA (according to GINA) includes:

Patient education;
- clinical and functional monitoring;
- elimination of causative 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 the patient from coming into contact with allergens and irritants. The approach to the treatment of the patient is determined by his condition and the goal currently facing the doctor.

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

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

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 systemic intravenous glucocorticoids (SGK) and bronchodilators in the correction of acid-base metabolism and blood gas composition with the help of medications and non-drugs.

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 step therapy, where each step includes therapy options that can serve as alternatives when choosing maintenance therapy for asthma. The effectiveness of therapy increases from stage 1 to stage 5.

Stage 1
Includes the use of rescue drugs as needed.
It is intended only for patients who have not received maintenance therapy and occasionally experience short-term (up to several hours) symptoms of asthma during the daytime. Patients with more frequent onset of symptoms or episodic worsening of the condition are indicated for regular maintenance therapy (see step 2 or higher) in addition to rescue drugs as needed.

Rescue medications recommended in Step 1: Rapid-acting inhaled β2-agonists.
Alternative drugs: inhaled anticholinergics, short-acting oral β2-agonists, or short-acting theophylline.

Stage 2
Relief drug + one disease control drug.
Drugs recommended as initial maintenance therapy for asthma in patients of any age at stage 2: low-dose inhaled corticosteroids.
Alternative agents for asthma control: antileukotriene drugs.

Step 3

3.1. Emergency drug + one or two drugs to control the course of the disease.
At step 3, children, adolescents and adults are recommended: a combination of a low dose of inhaled corticosteroids with a long-acting inhaled β2-agonist. Reception is carried out using one inhaler with a fixed combination or using different inhalers.
If control over BA 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 in the management of children) is to increase the doses of inhaled corticosteroids to medium doses.

3.3. Step 3 treatment option: Combination of low dose inhaled corticosteroids with an antileukotriene drug. A low-dose extended-release theophylline may be used instead of an antileukotriene (these options have not been fully investigated in children 5 years of age and younger).

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

If asthma control is not achieved with a combination of a medium-dose inhaled glucocorticosteroid and a β2-agonist and/or a third maintenance drug (eg, antileukotriene or sustained-release theophylline), high-dose inhaled glucocorticosteroids are recommended, but only as trial therapy. duration 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 increases by adding a long-acting β2-agonist to medium and low doses of inhaled corticosteroids, as well as the addition of antileukotriene drugs (less compared to a long-acting β2-agonist).
The addition of low doses of sustained release theophylline to inhaled corticosteroids in medium and low doses and a long-acting β2-agonist may increase the effectiveness of therapy.

Step 5
Emergency drug + additional options for the use of drugs to control the course of the disease.
The addition of oral corticosteroids to other maintenance drugs may increase the effect of treatment, but is accompanied by severe adverse events. Due to this this option considered only in patients with severe uncontrolled asthma on treatment at the appropriate stage 4, if the patient has daily symptoms that limit activity, and frequent exacerbations.

The use of anti-IgE in addition to other maintenance drugs improves the control of allergic asthma if it is not achieved during treatment with combinations of other maintenance drugs that include high doses of inhaled or oral corticosteroids.

Well antibiotic therapy indicated in the presence of purulent sputum, high leukocytosis, accelerated ESR. Taking into account antibiograms appoint:
- spiramycin 3,000,000 IU 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 IV drip.

Forecast

The prognosis is favorable with regular dispensary observation (at least 2 times a year) and rationally selected treatment.
The lethal outcome may be associated with severe infectious complications, progressive pulmonary heart failure in patients with cor pulmonale, 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 dysfunctions 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 go into a more severe form;

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

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

In asthma that began in childhood, about long-term prognosis is favorable. As a rule, by puberty, children "outgrow" asthma, but they still have impaired lung function, bronchial hyperreactivity, and deviations in the immune status.
For asthma that started at adolescence possible adverse course of the disease.
In asthma that 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 prognostically more favorable;
- "pollen" asthma, as a rule, has a milder course compared to "dust";
- in elderly patients, a primary severe course is noted, especially in patients with aspirin BA.

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

Hospitalization

Indications for hospitalization:
- severe attack of bronchial asthma;

There is no rapid response to bronchodilator drugs and the effect lasts less than 3 hours;
- no improvement within 2-6 hours after the start of 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 increase in the risk of intubation during subsequent exacerbations;
- who have Last year have already been hospitalized or treated for emergency care against the background of bronchial asthma;
- taking or recently discontinued oralglucocorticosteroids;
- using inhaled fast-acting β2-agonists in excess, especially more than one pack of salbutamol (or equivalent) per month;
- With mental illness, a history of psychological problems, including the abuse of sedatives;
Poor adherence to the asthma treatment plan.

Prevention

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

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

Patients should be educated on proper drug administration and proper use of drug delivery devices and peak flow meters to monitor peak expiratory flow (PEF).

The patient must be able to:
- control PSV;
- to understand the difference between drugs of basic and symptomatic therapy;
- avoid asthma triggers;
- identify signs of deterioration of the disease and independently stop attacks, as well as timely apply for medical care for the relief of severe seizures.
The control of asthma over a long period requires a written treatment plan (algorithm of patient actions).

List of preventive measures:

Termination of contact with cause-dependent allergens;
- termination of contact with non-specific irritating environmental factors (tobacco smoke, exhaust gases, etc.);
- exclusion of occupational hazard;
- with aspirin form of BA - refusal to use aspirin and other NSAIDs, as well as compliance with a specific diet and other restrictions;
- refusal to take beta-blockers, regardless of the form of asthma;
- adequate use of any medicines;
- timely treatment of foci of infection, neuroendocrine disorders and other concomitant diseases;
- timely and adequate therapy of asthma and other allergic diseases;
- timely vaccination against influenza, prevention of respiratory viral infections;
- Carrying out therapeutic and diagnostic measures 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 (dexamethasone, prednisolone), methylxanthines (aminophylline) 20-30 minutes before the procedure. The dose should be determined taking into account age, body weight, severity of asthma and the extent of intervention. Before carrying out such an intervention, a consultation with an allergist is indicated.

Information

Sources and literature

1. Global Strategy treatment and prevention of bronchial asthma (revised 2011) / ed. Belevsky A.S., M.: Russian Respiratory Society, 2012
2. Russian therapeutic reference book / edited by acad.RAMN Chuchalin A.G., 2007
   1. pp 337-341
3. http://www.medkursor.ru/biblioteka/help/u/6147.html
4. http://lekmed.ru
5. http://pulmonolog.com

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74 years old

Clinical diagnosis:

Bronchial asthma, mixed form, moderate severity,

Aggravation.

Accompanying illnesses:

Cholecystitis, otitis, sinusitis, chronic bronchitis.

Immunological diagnosis:

SARS 3-4 times a year, chronic bronchitis.

Curator: Mulyugina Ekaterina Nikolaevna

Curation period: 07.05.2015-21.05.2012

Passport data

Age: 72 years old

Year of birth: 11/26/1941

Occupation: school teacher

Place of residence: Orenburg, st. New, 17, apt. 49

Marital status: Married

Date of receipt: 05/05/15

Curation start date: 05/07/15

Diagnosis at admission: Bronchial asthma of mixed form, moderate severity, exacerbation.

Complaints at the time of admission

For daily asthma attacks, up to 6 times a day, including at night.

Shortness of breath of a mixed nature, which occurs with slight physical exertion, when walking at a slow pace at a distance of 100-150 m, when climbing 1 flight of stairs, disappears after rest.

Medical history

He considers himself ill since the autumn of 2007, when for the first time there were attacks of suffocation, at night, on cold air, during exercise, on dust. She did not go to the hospital, she inhaled Berotek on her own (1-2 doses situationally). Also, suffocation was accompanied by a dry, paroxysmal cough. Exacerbation since July 2008 after a community work day at work (grass and hay were removed), asthma attacks intensified, began to appear almost every night, coughing attacks became more frequent, she was treated on her own, then she went to the district clinic, she was diagnosed with Bronchial asthma, DN 0, referred to the pulmonologist of the regional polyclinic, 05.05.08 was hospitalized in the pulmonology department of the Regional Clinical Hospital for diagnosis and treatment.

Anamnesis of life

She grew and developed well, did not lag behind her peers in mental and physical development. Graduated from 10 classes high school, studied to be a mathematics teacher at the OGPU. After university, she went to work as a school teacher.

Past illnesses:

Chr. Bronchitis from youth; suffered from pneumonia of various localization, including bilateral (in childhood), the last time in October 2007; colds.

She denies tuberculosis, sexually transmitted diseases, hepatitis in herself and her relatives.

There were no operations, injuries, blood transfusions.

allergic history.

1. Allergic diseases in the family: bronchial asthma in grandmother, aunt, uncle.

2. Past diseases: hr. bronchitis, pneumonia.

3. Reactions to the introduction of sera, vaccines, drugs denies.

4. Marks seasonality (deterioration in late summer, autumn)

5. The course of the disease is influenced by such factors as: cold, physical activity. Attacks occur in the morning after sleep, in the afternoon when going out into fresh air.

6. Notes a reaction to hay dust, to strong odors (ammonia), a reaction to bee stings (fever, rash, itching), when eating watermelon, grapes - difficulty breathing.

7. The patient associates the exacerbation of the disease with the cold and with the flowering period.

Conclusion: from the allergic history it is clear that this disease is hereditary and has a mixed nature, because. an allergic factor (dust, flowers) and a non-allergic factor (physical activity, weather) were identified.

Status praesens communis

The general condition of the patient is satisfactory. Consciousness is clear, the position in bed is active. The patient's behavior is normal, answers questions adequately, easily comes into contact. The physique is correct, the constitution is normosthenic, satisfactory nutrition. Height 176 cm, weight 74 kg. The skin is of normal color, clean, moist. Muscular system well developed, normal tone, atrophy, developmental defects, no pain on palpation. Bones of the skull, spine, limbs, chest without curvature, with good resistance. The movements in the joints are free, there are no restrictions.

Respiratory system

Nasal breathing is difficult. Chest of the correct form; both halves are symmetrical, equally involved in the act of breathing. Breathing is rhythmic, abdominal type. RR = 18 movements per minute. Palpation: the chest is painless, elastic. On percussion - a clear pulmonary sound. Topographic percussion revealed no pathology. Auscultation - vesicular breathing, dry rales in all lung fields.

The cardiovascular system

When examining the region of the heart, no defigurations were found. The apex beat was not visually determined. The heartbeat is not visible. Systolic retraction in the area of ​​the apex beat, pulsations in the II intercostal space, IV intercostal space on the left side of the sternum is not observed. Pulsations in the extracardiac region are not determined. Palpation: apical impulse of 5 m/r along the midclavicular line. Percussion: Boundaries unchanged. Auscultation: the tones are muffled, the rhythm is correct, heart rate = 92 per minute, blood pressure = 130/90 mm Hg.

urinary system

When examining the lumbar region, swelling and edema were not found. Kidneys and bladder not palpable. Urination is not difficult, painless, 3-4 times a day. Pasternatsky's symptom is negative on both sides.

Preliminary diagnosis

Based on the patient's complaints about asthma attacks that occur upon contact with pungent odors, when entering cold air, also at night, stopped by Berotek; shortness of breath of the expiratory type when walking, climbing stairs, physical exertion; cough with hard-to-remove sputum of a mucous nature more often in the morning after sleep, it can be assumed that the respiratory system is involved in the pathological process.

Thus, based on complaints and data from an objective examination, syndromes can be distinguished:

1. Syndrome of bronchial obstruction, because the patient has asthma attacks that occur upon contact with pungent odors, when entering cold air, at night; shortness of breath of the expiratory type when walking, climbing stairs, physical exertion; cough with difficult expectoration in the morning. Auscultatory: whistling dry rales.

2. Bronchial hyperreactivity syndrome, because the patient has a cough with mucus sputum difficult to separate, expiratory dyspnea. Auscultatory: wheezing.

3. Syndrome of bronchial irritation, because. The patient has an unproductive cough. Auscultatory: dry rales.

4. Syndrome of respiratory failure, tk. shortness of breath expiratory type with severe physical exertion.

Based on the history data, risk factors can be identified: heredity, hypothermia, contact with hay dust, smoking.

Thus, a preliminary diagnosis can be made: Bronchial asthma, mixed form, moderate severity, exacerbation, DN0.

Bronchial asthma, because syndromes were identified: bronchial obstruction, bronchial hyperreactivity, bronchial irritation, respiratory failure. Shortness of breath of the expiratory type, asthma attacks, unproductive cough, dry rales on auscultation in all lung fields.

Mixed form, because history revealed allergic and non-allergic factors.

Moderate severity, tk. attacks of suffocation daily, night attacks 1 time per week. Daily use of medicines.

The phase of exacerbation, because. shortness of breath increased, asthma attacks, coughing became more frequent.

DN 0, because shortness of breath occurs with heavy physical exertion.

Case management plan

General clinical studies of OAC (eosinophilia, leukocytosis, ESR acceleration), BAC, TAM, feces for I/g, immunogram)

study of the function of external respiration (SPG, provocative test with beta-2-agonists, peak flowmetry.)

general sputum analysis (eosinophilia, a large amount of epithelium, Kurshman spirals, Charcot-Leiden crystals)

ECG, ECHOCG.(expansion of the right heart)

X-ray in two projections

Consultation with an immunologist, an allergist.

Results of paraclinical studies.

Complete blood count dated 6.05.15.

Erythrocytes - 4.9

Hemoglobin -152 g/l

ESR - 16 mm/h

Conclusion: leukocytosis, accelerated ESR

Sputum analysis dated 8.05.15.

Quantity - meager color - green-gray. Character - slimy. Eosinophils - neg. Leukocytes - 8-10-15 in the field of view. Alveolar macrophages 6-10 per field of view.

Conclusion: increased number of leukocytes, alveolar macrophages.

Active enzymes of blood serum 8.09.08.

ALT - 0.15 (0.1-0.7), AST - 0.18 (0.1-0.5)

Conclusion: biochemical parameters are normal.

Biochemical blood test dated 5.05.15.

Bilirubin total - 16.0, urea - 6.4

Conclusion: tests are normal.

Analysis of feces for eggs of worms dated 8.05.15.

Eggs were not found.

Urinalysis dated 8.05.15

Color - saturated, transparency - cloudy, protein - negative.

ECG dated 05/09/15.

Conclusion: sinus rhythm with a heart rate of 69 per minute, vertical EOS.

X-ray dated 6.05.15.

Conclusion: Focal and infiltrative shadows were not revealed, the pulmonary pattern is enhanced, the roots are structural, the sinuses are shortened.

FBS from 05/06/15

Conclusion: no pathology was detected.

FVD study

Conclusion: Violation of the function of external respiration by obstructive type - obstruction is generalized, moderately pronounced, with normal volume and capacitance indicators. The test with a bronchodilator (berotek 2 doses) was positive, after the test, bronchial patency at all levels significantly improved, FEV1 increased, and respiratory resistance decreased. The obstruction is reversible.

Clinical diagnosis

Thus, based on the data of an objective examination (auscultatively: dry rales are heard in all lung fields), data on an allergological anamnesis (an allergic factor (flower dust, pungent odors) and a non-allergic factor (weather, physical activity)), performed laboratory and instrumental diagnostic methods : in the KLA - leukocytosis, a slight increase in ESR indicates an acute inflammatory process; In the analysis of sputum - leukocytosis, an increase in the number of alveolar macrophages - an inflammatory process in the respiratory system; radiograph - increased lung pattern; in the study of the function of external respiration - obstructive type, VC is not changed, moderate violation of bronchial patency, the test with berotek is positive.

Based on the above data, a clinical diagnosis can be made: Bronchial asthma, mixed form, moderate severity, exacerbation, DN0.

bronchial asthma complaint

Differential Diagnosis

Mixed bronchial asthma can be differentiated from chronic obstructive pulmonary disease. In COPD, there is no allergic factor, the obstruction is irreversible or partially reversible, when in BA it is reversible, BA is more common at a young age, COPD, mainly in people over 40 years old, the course in BA is undulating, in COPD it is progressive, in BA eosinophilia of blood, sputum; FEV1, FEV1 / FVC in BA - reduced or normal, in COPD - always reduced; daily variability of PSV in BA - more than 20%, in COPD - less than 20%, peak flow: increase in BA - more than 15%, in COPD - less than 15%.

Thus, it is possible to make a diagnosis: Bronchial asthma, mixed form, moderate severity, DN0.

Management of a patient with bronchial asthma involves six main components: 1) educational program; 2) assessing and monitoring the severity of the disease; 3) exclusion of factors that provoke an exacerbation of the disease, or control over them; 4) development of an individual scheme drug treatment; 5) development of a treatment plan for exacerbation of the disease, emergency treatment for an asthma attack and (or) status asthmaticus; 6) dispensary observation.

The general education program involves the sanitary education of a patient with asthma: he masters methods of preventing asthma, which significantly improve his quality of life, evaluates and writes down the main symptoms of his disease in a diary, and conducts individual control over the peak expiratory flow rate using a portable peak flowmeter. The changes discovered by him in the course of the disease allow him to consult a doctor in a timely manner.

Drug therapy: Based on the pathogenesis of bronchial asthma, bronchodilators (beta-2-adrenergic agonists, M-anticholinergics, xanthines) and anti-inflammatory anti-asthma drugs (GCs, mast cell membrane stabilizers and leukotriene inhibitors) are used for treatment.

Anti-inflammatory anti-asthma drugs (basic therapy) - Beclomethasone or Cromolyn sodium 800 mcg per day. It is recommended to use an inhaler with a spacer.

Bronchodilator drugs: Berotek 500 mcg - it relaxes the smooth muscles of the bronchi and blood vessels, blocks the release of inflammatory mediators and bronchoconstriction from mast cells. It is applied before an expected asthma attack (for example, contact with an allergen, exercise stress) prevent it from occurring.

Long-acting theophylline preparations. Eufillin 2.4% - 10.0 IV drip per 200 ml of saline.

For more severe exacerbations, a course of oral corticosteroids should be given.

Note: If asthma control cannot be achieved, as evidenced by more frequent symptoms, an increased need for bronchodilators, or a drop in PEF, then step 4 treatment should be given.

symptomatic treatment. Expectorants are used to improve the drainage function of the bronchial tree and reduce the viscosity of sputum. Secretolytic preparations are recommended, Potassium iodide is the most powerful expectorant, prescribed 1 tbsp. spoon of 3% solution 5-6 times a day after meals, no more than 5 days in a row. Infusion of thermopsis - 0.8-1 g per 200 ml of water - is prescribed before meals, 1 tbsp. spoon 5-6 times a day. A good effect is observed from ultrasonic inhalations of trypsin, chymopsin and other enzymes.

exercise therapy. Effective non-drug methods of symptomatic treatment of patients with asthma are breathing exercises, chest massage, postural drainage, and acupuncture. Respiratory gymnastics includes such exercises as sipping, swinging movements of the arms (“chopping firewood”), and when spreading or raising the arms, one should take the deepest possible breath, and when lowering the arms, a forced deep exhalation. In some cases, shallow breathing according to Buteyko, paradoxical breathing exercises according to Strelnikova are used (inhalation is done when the body is tilted forward, exhalation is done when unbending). Nebulators are widely used - devices that create resistance to breathing.

In order to prevent inflammatory and infectious diseases of the respiratory system, you can prescribe an immunostimulating drug - IRS-19, 2 injections / day in each nostril for 2 weeks.

In terms of health, favorable, because. following the recommendations of the doctor, you can bring the disease to a long-term stable remission. Favorable for life and working capacity, tk. shortness of breath occurs only during an exacerbation of the disease, with heavy physical exertion.

The purpose of therapeutic and preventive measures is not to delay the process, since the exacerbation of the inflammatory disease, hypothermia involuntarily worsens the condition of the patient's body and, as a result, can lead to the stage of decompensation of the disease.

observation diary

07.05.15 The patient's condition is of moderate severity, complaints of shortness of breath with little physical exertion. Objectively: the skin and visible mucous membranes are of normal color, moderately moistened, body temperature is 36.5 C, respiratory organs: the chest is painless on palpation, dullness of percussion sound, auscultatory - weakening of vesicular breathing , dry wheezing, BH - 18 beats. V. min. Cardiovascular system: There is no cardiac impulse. Auscultatory: muffled heart sounds, emphasis II tone on the aorta. There are no noises. BP 140/100 mm Hg.

9.05.15 The patient's condition is satisfactory, no complaints. Objectively: the skin and visible mucous membranes are of normal color, moderately moistened. body t 36.6 C, respiratory organs: painless on palpation, percussion-clear pulmonary sound, auscultatory - vesicular breathing is weakened, no wheezing, respiratory rate - 18 beats. V. min. Cardiovascular system: There is no cardiac impulse. Ausk: the heart sounds are muffled, the emphasis of the second tone is on the aorta. There are no noises. BP 130/90 mmHg.

05/12/15 The patient's condition is satisfactory, no complaints at the present time. Objectively: the skin and visible mucous membranes are of normal color and normal humidity. body t 36.6 C, respiratory organs: the chest is painless on palpation, percussion-clear pulmonary sound, auscultatory - vesicular breathing, no wheezing, respiratory rate - 17 beats. V. min. Cardiovascular system: There is no cardiac impulse. Auscultatory: muffled heart sounds, emphasis II tone on the aorta. There are no noises. BP 120/80 mmHg

Bibliography

1. R.M. Khaitov "Immunology", 2009

2. Diagnosis and treatment of immunopathological diseases” A.P. Kolesnikov, A.S. Khobarov.

3. Mashkovsky M.D. “ Medicines” part 1 and 2. Moscow, “Medicine”, 2012.

4. A.I. Martynov. "Internal Diseases" in two volumes. Moscow "GOETAR - MED", 2013.

4. Vidal's Handbook, 2003. M.: AstraPharmService, 2011. 1488 pp.

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Complaints of the patient at admission, anamnesis of his life. Assessment of the general condition of the patient. Plan of examination of the patient and its results. Substantiation of the diagnosis - endogenous bronchial asthma infection-dependent with symptoms of atopy of moderate severity.

case history, added 09/08/2012


Complaints of the patient, examination data of organs and systems, laboratory and instrumental studies. Plain radiography of the chest. Sputum analysis for Mycobacterium tuberculosis. Substantiation of the clinical diagnosis. Treatment plan, discharge summary.

case history, added 10/30/2011


Diagnosis: bronchial asthma, mixed form, moderate course, period of remission. Data from laboratory and instrumental studies. Allergist consultation. The development of acute community-acquired pneumonia. Individual bronchial hyperreactivity.

medical history, added 06/22/2009


Based on the patient's complaints, life history, results of laboratory and instrumental studies, a preliminary diagnosis of bronchial asthma of a mixed form of moderate severity was made. Substantiation of the clinical diagnosis. Treatment of the disease.

presentation, added 08/26/2015


Complaints of the patient at the time of admission. History of disease and life. Preliminary, clinical, differential and immunological diagnoses. Treatment of non-allergic bronchial asthma. Immunopathogenesis, observation diary and disease prognosis.

case history, added 03/10/2009


Complaints upon admission of the patient to inpatient treatment. Examination of organs and systems of the patient, data from laboratory and additional studies. Substantiation of the clinical diagnosis: adenovirus infection, medium form. Therapeutic treatment plan.

Bronchial asthma is considered a very dangerous disease, and mixed asthma is one of the most complex forms of asthma pathology. Fear due to an unexpected attack of suffocation is the lot of the patient. The disease is quite common throughout the world and can affect a person at any age, even a small child. Modern methods of treatment allow you to effectively deal with the disease, it is important to start such treatment in a timely manner, without bringing the condition to severe stages.

What is this disease?

Bronchial asthma is a lesion of the respiratory tract of a recurrent nature with a violation of bronchial reactivity and the presence of asthmatic status - a mandatory clinical sign in the form of asthma attacks. A mixed form of the disease is a type of bronchial asthma, the etiology of which combines atopic (allergic) and non-allergic factors. Most often, mixed-type asthma arises according to an atopic mechanism, but with the imposition of bacterial sensitization. Other non-allergic causes can serve as reinforcing factors: poisoning, stress, endocrine disease, etc.

Any bronchial asthma is caused by the appearance of bronchial hyperreactivity as a result of the development of an inflammatory reaction in their wall. This anomalous property causes an extreme increase in the sensitivity (sensitization) of the walls of the respiratory canals to the effects of various provoking factors that are safe for healthy people. Inflammation is usually caused by allergens or non-specific (non-allergic) exposures, but in mixed form asthma, both of these mechanisms are combined.

Bronchial asthma refers to chronic pathologies, but has a pronounced aggressive recurrent character. It includes two main phases: exacerbation (attack) and remission (interictal period). Sometimes the phase of subsiding exacerbation is singled out separately. In the case when the exacerbation cannot be stopped within 20-30 hours, an asthmatic condition may develop. This phenomenon is a long period of a serious condition, which is characterized by an increase in resistance to therapy, persistent cough, development of respiratory failure, pulmonary obstruction with a transition to a coma.

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Clinical picture

The mixed form of the disease is characterized by exacerbation polymorphism, progressive development, attacks of increased frequency and duration with a high probability of transition to an asthmatic state, and problems with stopping attacks. The likelihood of complications increases: pneumothorax, pulmonary heart failure, atelectasis. The clinical picture of mixed asthma most often indicates the predominance of the bacterial nature of bronchial sensitization. There is a direct connection with hypothermia and exacerbation of background infectious diseases, and the exacerbation itself has signs of infectious type asthma (subfebrile temperature, general intoxication of the body).

At the same time, additional sensitization caused by allergens not associated with infection leaves its mark on the course of the disease. In the interval between prolonged suffocation of an infectious nature, allergic acute, but short-lived manifestations appear in the form of severe shortness of breath without a change in temperature. Such exacerbations are easily eliminated by taking bronchodilators.

In people affected by a mixed type of asthma, numerous foci-sources of infection are found: in the pulmonary system, ENT system, and digestive organs. At the same time, the causes of the atopic type are determined: genetic predisposition, allergic diseases (allergic rhinitis, dermatitis), drug and other types of allergies. The composition of peripheral blood shows the features of this type of disease. In the analysis of blood serum, an increased level of Ig E and the content of specific antibodies are detected, a decrease in the content and activity of T-lymphocytes, T-suppressors is recorded.

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Classification of pathology

It is produced taking into account the severity of the course of the disease and the severity of the main symptom (suffocation). The degree of respiratory failure () is divided into 3 phases:

1. light phase. Shortness of breath is manifested only when walking, speech is not difficult.
2. Middle phase. Shortness of breath is noticeable when talking, discomfort in the supine position, which makes it necessary to sit, only a short sentence is pronounced without additional inspiration.
3. hard phase. Respiratory insufficiency at rest, the need to inhale occurs after 1-2 spoken words, forced posture - sitting with an inclination forward.

The severity of the disease is divided into the following categories:

1. Stage 1. Episodic (intermittent) form. Attacks occur during the day no more than 4 times a month, and at night - 2 times a month, the exacerbation is of a short duration.
2. Stage 2. Mild persistent type, in which daytime exacerbation occurs 2-7 times a week, attacks at night - more than 2 times a month, insomnia due to breathing, problems with motor activity appear.
3. Stage 3. Persistent bronchial asthma of a mixed form of moderate severity, in which daytime attacks occur daily, nighttime - more than 1 time in 4 days, there is a decrease in motor activity.
4. Stage 4. Severe persistent bronchial asthma (repeated exacerbations during the day, frequent nocturnal attacks, significant deterioration in general condition and reduced ability to work).

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Diagnosis of the disease

The doctor easily establishes the primary diagnosis by characteristic suffocation and respiratory failure after examination and study of the anamnesis. Differentiation of the disease according to the type of pathology is carried out with the participation of a therapist, an allergist and a pulmonologist. To establish the final diagnosis, radiography, ultrasound, electrocardiogram, spirometry, peak flowmetry (peak expiratory flow rate) are performed. It is mandatory to conduct laboratory tests of blood and sputum. Skin tests are sometimes performed to determine the type of allergen.