Leaving aside the indisputable role of endoscopy in the differential diagnosis of diseases manifested by obstructive syndrome, identifying their development with asthma, foreign bodies, neoplasms, congenital defects of the tracheo- bronchial tree, etc., it should be emphasized that opinions about the feasibility of bronchoscopy in patients with asthma diverge.
Some authors, attaching great pathogenetic significance to endobronchial inflammation and already from the 60s using bronchoscopic rehabilitation therapy quite widely , indicate the high efficiency of the method.Others cautiously approach the issue, citing the insecurity of bronchoscopy in bronchial asthma.
Along with this, from the standpoint of the modern understanding of asthma as a chronic Persist ruyuschego airway inflammation, it is extremely important the timely detection and adequate treatment of the inflammatory process in the bronchi.All this justifies the need for a clear definition of the role and place of bronchoscopy, the limits and prospects of its diagnostic and therapeutic possibilities in bronchial asthma.
Bronchoscopy refers to the most informative methods for diagnosing the pathological process in the lower respiratory tract.More than 30 years of experience with bronchological studies in bronchial asthma in children allows us to formulate indications for bronchoscopy in bronchial asthma, in determining which we highlight the diagnostic and therapeutic aspects.
Diagnostic bronchoscopy is indicated:
in therapeutically resistant obstructive syndrome, when it is necessary to exclude the presence of an additional obstacle to ventilation of an irreversible nature (foreign body, neoplasm, malformations of the tracheo- bronchial tree)
Contraindications to bronchoscopy are acute inflammatory and infectious diseases, heart failure, coagulation disorders, intolerance to anesthetics and drugs for general anesthesia.However, these contraindications may be relative if bronchoscopy is used when there is a threat of asphyxiation due to tracheobronchial obstruction (foreign bodies, tumors, congenital lung malformations).
The use of bronchoscopy to diagnose bronchial asthma always raises great doubts, since the visually detectable changes in the mucous membrane are not specific and are present in various obstructive and non-obstructive pulmonary diseases.Our long-term observations indicate that a permanent endoscopic symptom of atopic asthma is edema of the bronchial mucosa;it is detected in 94% of the children surveyed.
The greatest intensity of edema is noted in the early period of the disease, and, as histological studies have shown, exudation is not limited only to the mucous membrane itself, it penetrates deep into the wall of the bronchus, dissecting muscle bundles.
The color of the mucous membrane varies from pale with a slight cyanotic shade to bright red.Redness of the mucous membrane due to the accession of infection.Secretory disorders depend on the phase of the disease and were determined in 88% of patients.
A visible narrowing of the lumen of the bronchi is observed in children in 70% of the examined children with bronchial asthma.The immediate cause of obstructive syndrome in young children should be considered edema and hypersecretion.
For long-term and seriously ill children with bronchial asthma, the thickening of bronchial spurs (the place of division of the bronchi) and pronounced folding of the mucous membrane, which are a manifestation of prolonged bronchospasm and thickening of the hyaline membrane of the bronchi , are characteristic .
In addition to visual assessment, the results of laboratory studies of substrates obtained during endoscopy are crucial in clarifying the nature of endobronchitis .The discovery of a large number of neutrophils and pathogenic microbes in etiologically significant concentrations in aspirate favors an infection that stimulates bronchoconstriction and asphyxiation in bronchial asthma.
A visually detectable diffuse edema, a clear, light, non-admixture of pus, containing a large number of eosinophils, Charcot-Leiden crystals, Kourshman spirals , allow us to speak of allergic, bacterial inflammation with some caution .
A difficult diagnostic problem is bronchial asthma in young children, as many diseases of the lower respiratory tract are accompanied by symptoms similar to bronchial asthma.The study of respiratory function and bronchial hypersensitivity tests in this group of patients are difficult to perform and are not carried out in practice.This leads to delayed diagnosis, delays the timing of anti-asthma therapy and worsens the outcome of the disease, which expands the indications for the bronchoscope and in this category of patients.
To confirm or eliminate the allergic etiology of endobronchial inflammation can bronchoscopy with biopsy of the mucous membrane of the lower respiratory tract with differential diagnostic purposes.Histological and histochemical Bron hobioptatov study, to our knowledge, most typical for asthma changes appeared mucosal edema, and muscular bundles and thickening of the basement membrane homogenisation, its shirring.
Electron microscopic and histochemical studies revealed an increase in the content of collagen in the basement membrane.Later our studies showed that the cellular composition of mucosal infiltration in bronchial asthma is characterized by a significantly higher number of 1 mm 2 of IgE , IgA producing cells , degranulated mast cells and eosinophils than in non-obstructive bronchitis.
The main objectives of bronchoscopy in the treatment of asthma are:
- elimination of obstructive violations of bronchial patency;
- suppressing the activity of infectious-inflammatory process in the lower respiratory tract by direct exposure to antibiotics on the etiologically significant microbial flora
Tactics of therapeutic effects, the volume and nature of bronchological benefits depend on the phase of the disease, the severity of obstructive syndrome and respiratory failure due to them.
During exacerbation of mild to moderate asthma, bronchial lavage is sometimes performed — bronchial lavage, fractional injections of 15–20 ml (or more, depending on the age of the child) of warm saline into lobar and segmental bronchi, followed by aspiration of the contents.
- At the end of the procedure, intrabronchial administration of antibiotics is logically justified, if the role of the infectious factor in maintaining bronchoconstriction in asphyxiation is proved .
- Optimization of endobronchial antibiotic therapy is achieved by the original, developed in our clinic, the mode of administration of antibiotics .
- With purulentEndobronchitis with a high degree of bronchial infection activity The treatment course includes 3-5 procedures for 3 weeks.
Extremely difficult is the question of the effectiveness and safety of bronchoscopy in severe exacerbation of bronchial asthma, which becomes asthmatic. On the one hand, in the development of the terminal state and the genesis of death in patients with asthmatic status, acute respiratory failure, caused by blockage of the terminal bronchi with thick clots of mucus, comes to the fore. On the other hand, instrumental intervention at certain stages precisely in this category of patients may be complicated by bronchospasm and laryngism, therefore the risk of hypoxic disorders representing a threat to the patient’s life is high. In this regard, the use of BL in prolonged attacks of asphyxiation and severe respiratory failure is a therapeutic dilemma, which should be addressed by qualified anesthesiology and resuscitation specialists, bronchologists and clinicians experienced in the treatment of patients with bronchial asthma.
The accumulation of experience on the use of bronchoscopy in patients in status asthmaticus is still ongoing. Therefore, issues of improving the efficiency and safety of bronchoscopy, as well as clarifying the indications and contraindications for its use in asthmatic statistics remain relevant.
Methodological aspects of bronchoscopy in bronchial asthma.
In order to increase therapeutic efficacy and reduce the risk of possible complications, certain principles must be followed.
First, it concerns the choice of apparatus and method of anesthesia. With the exacerbation of a mild degree in school-aged children, emotionally stable and contact in communication with a doctor, bronchoscopy can be performed under local anesthesia with a fibrobroscope.
When exacerbation of moderate and severe asthma, regardless of the patient’s age, optimal conditions for the implementation of full bronchial lavage, good oxygenation and sufficient elimination of carbon dioxide throughout the procedure are provided only with a rigid injection bronchoscope and anesthesia with myo-relaxants during continuous artificial ventilation of the lungs.
Secondly, before the forthcoming bronchoscopy, it is advisable to saturate the patient’s body with fluid, rehydration, since this helps to soften the bronchial clots and increases the effectiveness of bronchoaspiration.
Patients who are in severe exacerbation and in asthmatic status should undergo intensive drug and infusion therapy, since even a temporary weakening of bronchospasm and hypoxemia reduces the risk of bronchological intervention. Lavage of the bronchi in this group of patients is a resuscitation manual and should be carried out in an intensive care unit by experienced specialists.