Unstable asthma. Severe asthma. What do you need to know? Intermittent bronchial asthma

Severe asthma is a subset of asthma that cannot be effectively treated with standard medications such as inhaled corticosteroids and bronchodilators.

Asthma affects over 26 million people in the United States. Severe asthma is relatively rare - in 5-10% of the total number of people with asthma.

Symptoms of severe asthma are difficult to control, which means that such attacks are very dangerous to health. Patients with severe asthma require the help of a physician to know how to suppress asthma attacks.

In addition to taking medication, it is important to learn to recognize and avoid triggers to prevent asthma attacks.

This article looks at the causes, symptoms, and treatments for severe asthma.

Severe asthma - what is it?

Medicine evaluates the degree of asthma based on how effectively its symptoms respond to treatment. People with severe asthma find it difficult to manage their symptoms with traditional medications.

Severe, persistent asthma manifests itself in symptoms that continue around the clock. Asthma can interfere with both daily activities and at night, while sleeping - nighttime symptoms are common in people with severe asthma.

The more difficult the symptoms are controlled, the higher the risk of complications from this disease.

• symptoms that can occur at any time of the day
• symptoms leading to awakening during sleep, often daily (from the age of 5)
• for the age group up to 4 years old - awakening from symptoms more often than 1 time per week
• symptoms that require repeated use of short-acting beta-2 agonists to suppress
• symptoms that significantly limit a person's daily activities
• FEV1 equal to less than 60% of the norm (at the age of 5 years)

FEV1 stands for "forced expiratory volume". This is the volume of air exhaled by the patient during the first second of a forced expiration. This test helps doctors have a better understanding of a patient's lung function.

In 2014, an article was published where it was argued that severe asthma is confirmed if its symptoms are not controlled by the following medications:

• inhaled corticosteroids and adjuncts, including long-acting inhaled beta-2 agonists, theophylline, or montelukast
• oral corticosteroid treatment lasting at least 6 months per year

Symptoms

People experience asthma symptoms differently. For most of them, the symptoms are impossible to predict, making it difficult to pinpoint severe asthma. However, these symptoms and sensations are common.

Severe asthma makes it difficult for people to carry out daily activities. In the absence of appropriate treatment, the symptoms become debilitating.

Sometimes symptoms occur not only during the day but also at night, leading to awakening.

Asthma symptoms range from minor discomforts to life-threatening attacks where all factors worsen at the same time.

Among the symptoms of asthma are the following:

• labored breathing
• cough
• wheezing
• chest pain
• shortness of breath
• tightness in the chest
• suffocation attacks

Definition of the diagnosis

A doctor can confirm the diagnosis of severe asthma if the standard set of asthma medications fails to cope with the disease.

This means that the diagnosis cannot be made immediately - first, the patient tries various methods of treatment, and the doctor looks at whether they help or not.

When diagnosing asthma in medicine, there are three stages:

• collection and study of the patient's medical history
• medical examination
• breathing tests

Also, the doctor may check for other diseases accompanied by similar symptoms.

The reasons

The exact causes of asthma are still unknown to medicine, but many factors, such as allergies, play an important role here.

A 2013 study found that 75.4% of asthmatics between the ages of 20 and 40 were also diagnosed with allergies.

Additional research has found a link between tobacco use and an increased risk of asthma, in addition to other respiratory conditions. Children who are around adults who smoke may experience the same symptoms.

Numerous environmental factors can also lead to asthma manifestations. A 2017 study found that air pollution is associated with increased relapse and hospitalization due to asthma.

A 2014 report drew a parallel between asthma and obesity. The American Academy of Allergic Diseases, Asthma and Immunology noted that, according to another study, "overall obesity is a contributing factor in asthma."

Treatment

The main goal of asthma treatment is to control its symptoms. This includes preventing airway inflammation, minimizing subsequent attacks, and preventing lung damage.

People with severe asthma need to take their medications more often and at higher dosages than those with moderate asthma. To find the best solution for these special symptoms, you need to see your doctor.

If a severe asthma attack occurs, you should immediately seek medical attention. Asthma attacks can be life-threatening, especially if they don't respond appropriately to medication.

According to asthma experts, the best way to reduce the likelihood of severe asthma attacks is to avoid triggering factors whenever possible and take the necessary medications on time.

You can resort to both symptomatic and long-term treatment.

The main symptomatic treatment is the use of short-acting beta-2-agonists. This drug should be taken when asthma symptoms appear.

The drugs in this class also include:

• orciprenaline
• albuterol (Ventolin HFA, ProAir, Proventil)
• levosalbutamol (Xopenex)

Inhaled corticosteroids have their own side effectssuch as oral candidiasis or a fungal infection in the mouth. To prevent the development of infection, after using an inhalation aerosol, rinse the mouth.

conclusions

Asthma is a common condition affecting millions of people every day, and its severity can vary.

While in most cases asthma responds adequately to drug use, severe asthma does not respond well to the measures taken.

People with severe asthma should try to avoid triggering factors. Seeing a doctor will also reveal the most effective method treatment.

Asthma is considered severe if it does not respond well to standard treatment regimens such as inhaled corticosteroids or.

Asthma affects tens of millions of people around the planet. About 5 to 10% of them have severe asthma.

Because severe asthma tends to have less controllable symptoms, attacks in this condition pose a greater threat to health and life. In addition, by working closely with a physician, people with severe asthma usually find ways to manage their symptoms.

In addition to taking special medications, it is important for asthma patients to identify the factors that contribute to flare-ups (triggers) and avoid them later. In this way, the development of severe asthma attacks can be prevented.

In this article, we'll look at the causes, symptoms, and treatments for severe asthma.

Severe asthma causes symptoms that recur and are difficult to control

Doctors classify the severity of asthma based on how well the disease responds to treatment. With severe asthma, people find that they find it difficult to control symptoms with conventional therapies.

Severe asthma involves symptoms that recur periodically throughout the day and even night. This type of asthma can interfere with daily activities and make it difficult to sleep as symptoms often worsen at night.

If the disease is difficult to manage, then people are at an increased risk of developing serious complications.

According to the US National Institutes of Health guidelines, severe asthma has the following symptoms:

• symptoms that occur throughout the day;
• nighttime awakenings due to symptoms (often people aged 5 and older wake up 7 nights a week, and children under 5 years old - more than once a week);
• symptoms requiring treatment with short-acting beta-2-agonists several times a day;
• symptoms that significantly limit daily life activity;
• the forced expiratory volume in the first second (FEV1) is less than 60% of the usual one (for people aged 5 and over).

FEV1 is an indicator that reflects the volume of air that a person can exhale with force for one second. By measuring FEV1, doctors get an idea of \u200b\u200bthe quality of lung function.

• inhaled corticosteroids and adjuncts, including long-acting inhaled beta-2 agonists, theophylline and montelukast;
• oral corticosteroids that are taken for at least six months over a one-year period.

Symptoms

Severe asthma can cause chest tightness and pain

Symptoms are different for each patient with asthma. For many people, they can be simply unpredictable. Therefore, it is difficult to name the characteristic signs of severe asthma. And yet there are medical problems that are typical of this condition.

Severe asthma can make it difficult to carry out daily life tasks. If a person is not exposed to effective therapy, then ultimately the disease can limit his ability to work.

Asthma symptoms can occur throughout the day and even at night. In the latter case, people are forced to awaken.

Asthma symptoms can range in severity from minor discomforts to life-threatening attacks, causing all symptoms to flare up.

Symptoms of asthma include the following:

• cough;
• feeling of tightness in the chest;
• dyspnea.

Diagnostics

Doctors diagnose severe asthma if symptoms cannot be controlled by standard asthma treatments.

That is, to make such a diagnosis, some time must pass, during which doctors try to improve the patient's condition using various therapeutic strategies.

Typically, asthma diagnosis consists of the following steps:

• a conversation about the patient's medical history;
• performing a physical examination;
• checking the respiratory function using special tests.

In addition, the doctor may check the patient for other medical conditions that mimic asthma symptoms.

The reasons

The medical community does not yet know the exact causes of asthma, but it is known that several factors, such as allergies, can contribute to this.

In 2013, American scientists conducted a study that showed that more than 75% of asthma patients between the ages of 20 and 40 also suffer from allergies.

Another study confirmed the link between cigarette smoking and an increased risk of asthma and other respiratory problems. Children who spend time with adults who smoke also increase this risk.

In addition, various environmental factors can contribute to the onset of asthma symptoms. In 2017, Argentine researchers proved that polluted air leads to more frequent outbreaks of asthma and increases the frequency of patient visits to the hospital.

A 2014 study found a link between asthma and obesity. Based on the results of this scientific work experts from the American Academy of Allergy, Asthma and Immunology stated that "in general, the increase in obesity can be considered a factor that contributed to the increase in the prevalence of asthma."

Treatment

People should see a doctor immediately if they develop severe asthma attacks.

Asthma treatment involves measures to control symptoms. These include managing the airways, minimizing the risk of developing future asthma symptoms, and preventing lung damage.

People with severe asthma need to take their medications more often than people with regular asthma. In addition, doctors tend to prescribe higher dosages for them. Check with your healthcare professional for management of specific symptoms.

People who develop an attack of severe asthma should go to the hospital immediately, as they can be life threatening, especially if the symptoms are difficult to treat.

Asthma experts point out that the best way to prevent asthma attacks and uncontrollable symptoms is to try as much as possible to avoid triggers, that is, the factors that provoke outbreaks, and take the prescribed drugs in strict accordance with the doctor's recommendations.

Medicines

Your doctor may suggest medications for both rapid relief of symptoms and long-term treatment of asthma.

To relieve symptoms quickly

Short-acting beta-2 agonists are among the main drugs used to rapidly relieve asthma symptoms. These drugs can be taken when symptoms begin to develop.

Examples of short-acting beta-2 agonists include the following drugs:

• orciprenaline;
• albuterol (Ventolin, Proventil, Proair);
• levalbuterol (Xopenex).

For long-term treatment

For long-term treatment of asthma, doctors suggest daily medication to prevent flare-ups. Inhaled corticosteroids are considered the most effective long-acting drugs used to combat asthma.

Inhaled corticosteroids can cause side effects, including oral thrush, which is a yeast infection that develops in the mouth. To reduce the risk of developing this problem, you should rinse your mouth after using inhalers.

Conclusion

Asthma is a common medical condition that affects millions of people around the planet. Asthma can be mild or severe.

While asthma responds well to treatment in most cases, the symptoms of severe asthma cannot be alleviated with standard therapeutic strategies.

People with severe asthma should make every effort to avoid the triggers of the attacks. In addition, you need to work closely with your doctor to find the most effective treatments.

Persistent bronchial asthma is an inflammatory disease of the airways with a chronic course, the only manifestation of which is a reversible narrowing of the lumen of the bronchi. Hyperreactivity of the bronchi occurs against the background of chronic inflammation of the mucous membrane and is manifested by bronchospasm and hyperproduction of thick sputum. All this leads to the appearance of characteristic symptoms.

Persistent asthma

Causes of occurrence

Groups of factors that determine the development of persistent asthma:

• internal;
• external;
• triggers (provoke an exacerbation of the disease).

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

Genetic predisposition

• genetic predisposition (it has been proven that the risk of inheriting bronchial asthma is about 70%);
• atopy (increased IgE titer in response to contact with an allergen);
• high airway activity (severe narrowing of the airway lumen, in response to an allergen or trigger);
• obesity (affects the mechanism of the act of breathing and contributes to the development of an inflammatory reaction).

External factors provoke the appearance of symptoms of the disease:

Factors provoking exacerbation of asthma:

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

Disease manifestations

An exacerbation of the disease occurs after an allergen enters the body and manifests itself in the form of shortness of breath, attacks of unproductive cough, wheezing, and chest congestion. Sometimes an exacerbation can be caused by increased motor activity.

Cough reflex

How symptoms occur:

• irritation of the bronchial cough receptors leads to the onset of a cough reflex;
• spasm of the smooth muscles of the bronchi contributes to the formation of wheezing, due to the turbulent flow of air through the spasmodic airways;
• due to an increase in the work of the respiratory system, shortness of breath occurs.

Severity

According to the severity, persistent asthma is divided into:

1. Mild persistent asthma. Symptoms of the disease occur two or more times a week, but not daily. The onset of seizures that disturb the quality of sleep, more often 2 times a month. Exacerbations have a negative impact on physical activity. FEV in the first second outside the attack is more than 80% of normal values.
2. Persistent asthma of moderate severity. It manifests itself as everyday symptoms, nocturnal manifestations occur more often than once every 7 days, exacerbations reduce physical activity and worsen sleep. Daily intake of short-acting beta-2-adrenergic agonists is required.
3. Severe persistent asthma. It is characterized by regular manifestations of symptoms, more than once a day, frequent exacerbations and disturbances in the quality of sleep, a significant limitation of motor activity.

Diagnostics

Stages of asthma diagnosis:

Spirometry

1. Collection of patient complaints and anamnesis clarification.
2. Functional diagnostic methods (spirometry, peak flowmetry).
3. Collection of allergic anamnesis.
4. Skin and allergic tests.
5. Test with an allergen for provocation purposes.
6. Laboratory diagnostic methods.

When analyzing complaints, pay attention to:

• shortness of breath on inspiration;
• attacks of unproductive cough;
• heaviness and tightness in the chest;
• wheezing wheezing.

Reversibility of bronchial obstruction is assessed using spirometry. To confirm the diagnosis, the forced expiratory volume in the first second is important. First, this indicator is assessed without the use of drugs, then the patient is administered a bronchodilator drug. After 15-20 minutes, the study is repeated. An increase in FEV1 of more than 12% is in favor of the presumptive diagnosis.

Peak flowmetry

Peak flowmetry is used to determine the peak air velocity. This method is used when it is impossible to conduct spirometry and to monitor the dynamics of the course of the disease. The device is small, so it is convenient to use it to identify the influence of provoking factors at work and at home.

When collecting an allergic anamnesis, it is necessary to establish the presence of allergic diseases in the family, to identify the relationship between the onset of symptoms and the action of allergens (contact with animals, cold season, manifestation of symptoms after being in certain rooms).

To identify a specific allergen, skin tests with allergens are performed. Samples are taken in late autumn or winter to exclude the influence of plant pollen on the test results.

Which doctor to contact

If symptoms of the disease appear, you should contact your local therapist. After a preliminary diagnosis is made, the local doctor will refer the patient to narrow-profile specialists:

• pulmonologist;
• allergist;
• gastroenterologist.

Required analyzes

To confirm the disease, it is necessary to donate blood for the determination of general and specific immunoglobulin E. It is also necessary to donate sputum or bronchoalveolar fluid for analysis for the content of eosinophils.

Sputum examination

Treatment methods

Pharmacotherapy of persistent asthma is divided into 2 types:

• continuous supportive therapy;
• drugs used for exacerbation.

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

Salbutamol

With an exacerbation, drugs are used with the fastest time for the development of effects: Salbutamol, Fenoterol.

Forecast

Provided that the diagnosis is correctly made and effective therapy is prescribed, it is possible to achieve a completely controlled course of the disease. The quality of life of such patients is almost the same as that of healthy people.

Preventive measures

Food allergens

For the prevention of asthma exacerbation, patients are advised to exclude foods that cause an allergic reaction in them. Obese patients need to reduce body weight, which will improve health and reduce the risk of exacerbation. Additionally, active and passive smoking should be excluded to minimize the harmful effects on the lungs. Moderate exercise improves cardiopulmonary function. Patients are advised to engage in swimming to train the muscles involved in the act of inhalation.

Possible complications

The asthmatic condition is the most severe complication of persistent bronchial asthma. It is acute respiratory failure and refractory to bronchodilator drugs. Frequent exacerbations of the disease can lead to the development of pulmonary emphysema, due to overstretching of the lung tissue due to the inability to exhale. Perhaps the development of hypertrophy of the right ventricle of the heart, due to pulmonary hypertension.

Asthma is a formidable disease with the potential for severe complications. But timely diagnosed disease and correctly selected treatment minimize the occurrence of exacerbations and prevent possible complications, while maintaining a high quality of life for patients.

Bronchial asthma, asthma, asthma attacks, choking, asphyxia due to illness, shortness of breath

Version: MedElement Disease Handbook

Asthma (J45)

Pulmonology

general information

Short description

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

Bronchial hyperreactivity -increased sensitivity of the lower respiratory tract to various irritating stimuli, which, as a rule, are contained in the inhaled air. These stimuli are indifferent for healthy people. Clinically, bronchial hyperreactivity is most often manifested by episodes of wheezing shortness of breath in response to an irritant 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 or non-specific.

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

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

Note. Excluded from this subheading:

Status asthmaticus - J46;
- Another chronic obstructive pulmonary disease - J44;
- Diseases of the lung caused by external agents - J60-J70;
- Pulmonary eosinophilia, not elsewhere classified - J82.

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

Classification

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

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

1. Stages of asthma development:

1.1 Pre-asthma condition - conditions posing a threat 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 increased content of eosinophils in the sputum, caused by immunological mechanisms or non-immunological mechanisms) ...

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

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

Immunological form.
- non-immunological form

3. Pathogenetic mechanisms of AD:
3.1 Atonic - indicating the allergenic allergen or allergens.
3.2 Infection-dependent - indicating the infectious agents and the nature of the infectious dependence, which can be manifested by the 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 Dyshormonal - indicating the endocrine organ, the function of which is changed, and the nature of dyshormonal changes.
3.5 Neuropsychic - indicating the options for neuropsychic 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. It can be congenital or acquired. It manifests itself under the influence of chemical, physical and mechanical irritants and infectious agents. Attacks of suffocation are characteristic during physical exertion, exposure to cold air, medications and other things.

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

The division of BA by pathogenetic mechanisms and the isolation of the main one is significantly difficult. Nevertheless, this is justified due to the fact that each of the pathogenetic mechanisms presupposes a certain character of drug therapy peculiar only to it.

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

4.1 Light current:exacerbations are not long-term, occur 2-3 times a year. Asthma attacks are stopped, as a rule, by taking various bronchodilators 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). Asthma attacks are more severe and are stopped by injections of drugs.

4.3 Heavy course:exacerbations occur often (5 or more times a year), differ in duration. Severe attacks, often turn 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 recurrent attacks of asthma or an asthmatic state.

2. Fading aggravation -in this phase, attacks are more rare and less severe. Physical and functional signs of the disease are less pronounced than in the acute phase.

3. Remission -typical manifestations of asthma disappear (asthma attacks do not occur, bronchial patency is fully or partially restored).

6. Complications:

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

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

Classification of asthma by the severity of the disease and by clinical signs before starting treatment

Step 1. Mild intermittent BA:
- symptoms less than 1 time per week;
- short exacerbations;
- nighttime symptoms no more than 2 times a month;
- FEV1 or PSV\u003e \u003d 80% of due values;
- variability of FEV1 or PSV indicators< 20%.

Stage 2.Mild persistent asthma:

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

- night symptoms more often than 2 times a month FEV1 or PSV\u003e \u003d 80% of the proper values;
- variability of FEV1 or PSV indicators \u003d 20-30%.

Stage 3. Moderate persistent asthma:

Daily symptoms;
- exacerbations can affect physical activity and sleep;
- nocturnal symptoms more often than 1 time per week;
- FEV1 or PSV from 60 to 80% of the due values;
- variability of FEV1 or PSV\u003e 30%.

Stage 4.Severe persistent asthma:
- daily symptoms;
- frequent exacerbations;
- frequent nighttime symptoms;
- limiting physical activity;
- FEV 1 or PSV<= 60 от должных значений;
- variability of FEV1 or PSV\u003e 30%.

The following are additionally highlighted BA flow phases:
- aggravation;
- 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 control over the course of the disease.

1. Mild BA - 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 required to control the disease (for example, GINA stage 4) or control cannot be achieved despite a large amount of therapy.

Patients with different AD phenotypes have different responses to traditional treatment... With the advent of specific treatments for each phenotype, AD, which was previously considered severe, may 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 result from inadequate treatment.

Classification according to ICD-10

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

Allergic bronchitis;

Allergic rhinitis with asthma;

Atopic asthma;

Exogenous allergic asthma;

Hay fever with asthma.

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

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 wording 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 steroid drugs, it is advisable to indicate a maintenance dose of an anti-inflammatory drug (for example, remission at a dose of 800 mcg beclomethasone per day).
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 airways, in which a number of inflammatory cells and mediators are involved, leading to characteristic pathophysiological changes.

1. Inflammatory cells in the airways in AD.

1.1 Mast cells. Under the influence of allergens, with the participation of receptors for IgE with high affinity and under the influence of osmotic stimuli, the 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 hyperresponsiveness.

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

1.3 T lymphocytes... There is an increased number of T-lymphocytes in the airways, which 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 in part be due to a decrease in the number of regulatory T cells, which 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 to 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 low affinity IgE receptors. 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 smoking patients, the number of neutrophils increases. Their pathophysiological role has not been clarified. It is assumed that an increase in their number may be a consequence of GCS therapy. GCS (glucocorticoids, glucocorticosteroids) - medications one of the leading properties of which is to suppress the early stages of the synthesis of the main participants in the formation inflammatory processes (prostaglandins) in various tissues and organs.
.

2. Inflammatory mediators.Currently, more than 100 different mediators are known that are involved in the pathogenesis of AD and the development of a complex inflammatory response in the respiratory tract.

3.Structural changes in the airways - are detected in the airways of BA patients and are often considered as a process of bronchial remodeling. Structural changes can be the result of repair processes in response to chronic inflammation. Due to the deposition of collagen and proteoglycan fibers under the basement membrane, subepithelial fibrosis develops, which is noted in all BA patients (including children) even before the onset clinical manifestations diseases. The severity of fibrosis may be reduced 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 muscles of the bronchial wall... Due to hypertrophy Hypertrophy - the proliferation of an organ, its part or tissue as a result of cell proliferation and an increase in their volume
and hyperplasia Hyperplasia - an increase in the number of cells, intracellular structures, intercellular fibrous formations due to increased organ function or as a result of pathological tissue neoplasm.
there is an increase in the thickness of the smooth muscle layer, which contributes to the general thickening of the bronchial wall. This process can depend on the severity of the disease.

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

3.3 Hypersecretion of mucusobserved 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 submucous glands.

4. Airway narrowing - the universal final stage of AD pathogenesis, which leads to the onset of symptoms of the disease and typical physiological changes.

Factors contributing to the narrowing of the airways:

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

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

4.3 Thickening of the bronchial wall as a result of structural changes. This factor can be of great importance in severe asthma. The thickening of the bronchial wall is not completely reversible under the influence of 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.
the lumen of the bronchi ("mucous plugs") and is the result of increased mucus secretion and the formation of an inflammatory exudate.

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

Epidemiology

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

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

Factors and risk groups

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

Internal factors:

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

2. Obesity.

External factors:

1. Allergens:

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

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

2.Infections (mainly viral).

3. Professional sensitizers.

4. Smoking tobacco (passive and active).

5. Indoor and outdoor air pollution.

6. Nutrition.

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

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

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

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

Clinical picture

Clinical diagnostic criteria

Unproductive hacking cough, - prolonged exhalation, - dry, wheezing, usually treble, wheezing in the chest, more at night and in the morning, - attacks of expiratory suffocation, - chest congestion, - the 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, wheezing, usually treble, wheezing in the chest, more noted at night and in the morning; expiratory dyspnea, attacks of expiratory suffocation, chest congestion (stiffness).
3. The dependence of respiratory symptoms on contact with provoking agents.

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

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

Does the patient worry about coughing at night?

Does the patient have wheezing or coughing after exercise?

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

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

Are symptoms relieved by appropriate asthma medications?

On physical examination, AD symptoms may be absent due to the variability of the disease manifestations. The presence of bronchial obstruction is confirmed by wheezing, detected during auscultation.
In some patients, wheezing rales may be absent or only detected during forced expiration, even in the presence of severe bronchial obstruction. In some cases, in patients with severe exacerbations of asthma, wheezing is absent due to a strong restriction of air flow and ventilation. In such patients, as a rule, there are other clinical signs indicating the presence and severity of an exacerbation: cyanosis, drowsiness, difficulty speaking, bloating. rib cage, the participation of auxiliary muscles in the act of breathing and retraction of the intercostal spaces, tachycardia. These clinical symptoms can be observed only when examining the patient during the period of pronounced clinical manifestations.

Clinical manifestations of asthma

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

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

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

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

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

Severity of BA exacerbation according to GINA-2011

	Lung	Middle gravity	Heavy	Breathing is inevitable
Dyspnea	When walking. May lie	When talking; crying in children it becomes quieter and shorter, difficulties in feeding. Prefers to sit	At rest, children stop eating. Sit leaning forward
Speech	Proposals	Phrases	In words
Level wakefulness	May be aroused	Usually excited	Usually excited	Inhibited or confused
Breathing rate	Increased	Increased	More than 30 per min.
Participation of auxiliary muscles in the act of breathing and retraction of the supraclavicular fossae	Usually no	There is usually	There is usually	Paradoxical movements chest and abdominal walls
Wheezing rales	Moderate, often only when exhalation	Loud	Usually loud	Absent
Pulse (in min.)	<100	>100	>120	Bradycardia
Paradoxical pulse	Absent <10 мм рт. ст.	There may be 10-25 mm Hg st	Often available \u003e 25 mm Hg Art. (adults), 20-40 mm Hg. Art. (children)	Absence allows assume fatigue respiratory muscles
PSV after the first injection bronchodilator in% of due or 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.	Unable to rate
RaO 2 in kPa (when breathing air)	Normal. Analysis is usually not needed	\u003e 60 mmHg Art.	<60 мм рт. ст. Possible cyanosis
PaCO 2 in kPa (when breathing air)	<45 мм рт. ст.	<45 мм рт. ст.	\u003e 45 mm Hg Art. Respiratory failure
SatО 2,% (during breathing air) - oxygen saturation or the degree of saturation of arterial hemoglobin with oxygen	>95%	91-95%	< 90%

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

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

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

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

Less than 2 months< 60 в минуту;

2-12 months< 50 в минуту;

1-5 years old< 40 в минуту;

6-8 years old< 30 в минуту.

Diagnostics

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

Study of function indicators external respiration

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

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

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

2. Peak flowmetry... It is used to assess the effectiveness of treatment and objectify the presence and severity of bronchial obstruction.
The peak expiratory flow rate (PEF) is estimated - the maximum rate at which air can leave the airways during a forced expiration after a full inhalation.
The patient's PSV values \u200b\u200bare compared with normal values \u200b\u200band with the best PSV values \u200b\u200bobserved in this patient. The level of PSV reduction allows drawing conclusions about the severity of bronchial obstruction.
The difference in PSV values \u200b\u200bmeasured 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 bouts of shortness of breath, coughing, wheezing occur less often than 1 time per week. The duration of exacerbations is from several hours to several days. Nighttime attacks - 2 or less times a month. In the period between exacerbations, lung function is normal; PSV - 80% of the norm or less.

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

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

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

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

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

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

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

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

The 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 issue< 80% от должной величины), которая является обратимой (прирост тех же показателей более 15% в фармакологической пробе с β2-агонистами короткого действия) и вариабельной (колебания показателей более 20% на протяжении суток).
4. Revealing signs of bronchial hyperreactivity (latent bronchospasm) in patients with baseline normal parameters of pulmonary ventilation using one of three provocative tests.
5. The presence of a biological marker - a high level of nitric oxide in the exhaled air.

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

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

Professional BA

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

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

Diagnostic criteria for occupational asthma:
- well-established occupational exposure to known or suspected sensitizing agents;
- no BA symptoms before hiring or a distinct worsening of asthma after hiring.

Laboratory diagnostics

Non-invasive determination of markers of airway inflammation

1. Study of spontaneously produced or induced by inhalation of hypertonic sputum solution for inflammatory cells - eosinophils or neutrophils. It is used to assess the activity of inflammation in the airways in AD.

2. Determination of levels of nitric oxide (FeNO) and carbon monoxide (FeCO) in exhaled air. Patients with asthma have an increase in the level of FeNO (in the absence of therapy with inhaled GCS) compared with persons without asthma, but these results are nonspecific for this disease. In prospective studies, the value of FeNO for the diagnosis of AD has not been assessed.

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

4. 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 can 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 relationship of the allergen with the development of AD.
The presence of exposure to the allergen and its relationship with BA manifestations should be confirmed by the history data. Measuring the level of total IgE in serum is not a diagnostic method for atopy.

Clinical analyzes

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 analysis of sputum:
- 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 asthma in the stage of an active inflammatory process;
- Isolation of Creole bodies during an attack.

3. Biochemical blood test: changes are general. LHC is not the main diagnostic method and is prescribed for monitoring the patient's condition during an exacerbation.

Differential diagnosis

1. Differential diagnosis of BA variants.

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

Signs	Atopic variant	Infection-dependent variant
Allergic diseases in the family	Often	Rarely (except for asthma)
Atopic diseases in a patient	Often	Seldom
Relationship of an attack with an external allergen	Often	Seldom
Features of an attack	Acute onset, rapid development, usually 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	Typically moderate	Often high
Specific IgE antibodies to non-infectious allergens	Present	Absent
Skin tests with extracts of non-infectious allergens	Positive	Negative
Exercise test	More often negative	More often positive
Elimination of the allergen	Possible, often effective	Impossible
Beta-adrenostimulants	Very effective	Moderately effective
Anticholinergics	Ineffective	Effective
Euphyllin	Very effective	Moderately effective
Intal, tiled	Very effective	Less effective
Corticosteroids	Effective	Effective

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

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

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

Types of wheezing in the chest:

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

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

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

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

Chronic rhinosinusitis;

Gastroesophageal reflux;

Recurrent viral infections of the lower respiratory tract;

Cystic fibrosis;

Bronchopulmonary dysplasia;

Tuberculosis;

Foreign body aspiration;
- immunodeficiency;

Syndrome of primary ciliary dyskinesia;

Malformations causing narrowing of the lower respiratory tract;
- congenital heart disease.

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

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

Hyperventilation syndrome and panic attacks;

Upper airway obstruction and foreign body aspiration;

Other obstructive pulmonary diseases, especially COPD;

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

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

3. Elderly patients.It is necessary to differentiate BA from left ventricular failure. In addition, AD underdiagnosis occurs in old age.

Risk factors for asthma underdiagnosis in elderly patients

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


- reduced perception of shortness of breath and bronchoconstriction.

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

Complications

Complications of bronchial asthma are divided into pulmonary and extrapulmonary.

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

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

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Treatment

Objectives of bronchial asthma treatment(BA):

Achieving and maintaining symptom control;

Maintaining a normal level of activity, including physical activity;

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

Prevention of BA exacerbations;

Prevention of undesirable effects of anti-asthma drugs;

Prevention of deaths from asthma.

BA control levels(GINA 2006-2011)

Characteristics	Controlled BA(all of the above)	Partially controlled BA(presence of any manifestation during the week)	Uncontrolled BA
Daytime symptoms	No (≤ 2 episodes per week)	\u003e 2 times a week	3 or more signs of partially controlled AD in any week
Activity limitation	No	Yes - of any severity
Night symptoms / awakenings	No	Yes - of any severity
Need for emergency medications	No (≤ 2 episodes per week)	\u003e 2 times a week
Lung function indices (PSV or FEV1) 1	Norm	< 80% от должного (или от наилучшего показателя для данного пациента)
Exacerbations	No	1 or more times a year 2	Any exacerbation week of 3

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

Drug therapy

Medicines for AD treatment:

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

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

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

For maintenance therapy, inhaled corticosteroids are most effective.

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

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

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

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

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

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

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

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

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

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

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

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

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

Short-acting oral β2-agonists (referred to as emergency drugs) can be prescribed to only a few patients who are unable to take inhaled drugs. Side effects are more common.

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

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

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

Systemic GCSin severe uncontrolled asthma, they are indicated in the form of long-term therapy with oral drugs (it is recommended to use it for a longer period than with the usual two-week course of intensive therapy with systemic corticosteroids - typically 40 to 50 mg of prednisolone per day).
The duration of the use of systemic corticosteroids is limited by the risk of developing serious undesirable effects (osteoporosis, arterial hypertension, suppression of the hypothalamic-pituitary-adrenal system, obesity, diabetes mellitus, 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 anti-allergic drugs (tranilast, repirinast, tazanolast, pemirolast, ozagrel, celatrodast, amlexanox and ibudilast) - are offered for the treatment of mild to moderate allergic asthma in some countries.

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

Comprehensive treatment programBA (according to GINA) includes:

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

Drug therapy options

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

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

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

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

3. Basic anti-relapse therapy.

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

Long-term maintenance therapy for asthma:

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

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

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

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

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

Stage 3

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

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

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

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

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

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

The effect of treatment is increased by the addition of a long-acting β2-agonist to medium and low doses of inhaled GCS, as well as the addition of antileukotriene drugs (less in comparison with 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 can also increase the effectiveness of therapy.

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

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

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

Forecast

The prognosis is favorable with regular dispensary observation (at least 2 times a year) and rationally selected treatment.
The lethal outcome can be associated with severe infectious complications, progressive pulmonary heart failure in patients 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 impaired functions of the bronchopulmonary system occurs faster than in healthy people;

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

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

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

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