Bronchial asthma is a controversial, ambiguous and “whimsical” chronic lung disease. This disease is the champion in terms of legends, delusions, myths, alternative approaches to treatment and charlatanry. In this article, we will try to explain clearly about this disease.
Bronchial asthma is described in detail and is known for a long time. But, despite this, to this day remains a mysterious disease. The nature of this disease is not completely clear. The term asthma literally means suffocation. Choking was considered the main, mandatory sign of the disease. Laboratory evidence of the disease was considered eosinophilia and sputum and allergies. But with the development of molecular biology and genetics it became obvious that this is not so.
The modern definition of bronchial asthma is a chronic inflammatory disease of the lower respiratory tract, in the development of which a large number of cells and cellular elements play a role. It is believed that this inflammation leads to the development of hyperreactivity of the bronchi, and the consequence of this hyperreactivity is suffocation, coughing and shortness of breath. The prevalence of bronchial asthma is increasing annually.
According to WHO, about 300 million people suffer from asthma, affecting all age and gender groups. Over the past two decades, the world has experienced a two-fold increase in patients with bronchial asthma. In Russia, from 1998 to 2002, the prevalence of the disease increased by 28.2%. The prevalence of the disease in our country is 6.9% among adults and 10% among children. In the Russian Federation, 7 million people suffer from bronchial asthma.
Question from patient
I got sick with bronchial asthma, will I die soon?
As for mortality, bronchial asthma is rarely the cause of death. As for mortality, bronchial asthma rarely leads to death. In Canada, Australia, some European countries have seen an increase in deaths from asthma. And in England there was a decline in this indicator. Bronchial asthma is not a progressive disease, unlike COPD. The disease does not degenerate into anything.
CAUSES AND RISK FACTORS
Bronchial asthma is a multi-factorial disease. It was established that the family history of allergy (atopy) is the factor of the disease development. The presence of allergies in the family increases the risk of allergic rhinitis and bronchial asthma 5 times! Allergens of house tick, epidermis of animals, plant pollen, cockroach, Alternaria fungi are considered the most common risk factors.
Reducing the concentration of house tick in the home reduces the risk of developing asthma in a child under 8 years old. But in this case, the contact of a child of the first year of life reduces the response to most allergens and the development of asthma in the future.?! According to international studies, more than a dozen circumstances regulate the likelihood of asthma in children and adults.
Infection also plays a controversial role in the development of the disease. Cases that indicate a direct relationship between recurrent childhood respiratory infection and a reduced risk of developing bronchial asthma are described. But it is also known that a viral infection often provokes an exacerbation of asthma. Probably, both those and other observations are correct. Infection plays the role of trigger agent, manifests itself at different stages of human life and affects the stages of the disease.
Deteriorating environmental conditions – bronchial asthma ecologic disease. The level of industrial pollution and the prevalence of the disease are closely and directly interrelated. For example, the prevalence of asthma among urban residents (children, adults) is 1.6-1.8 times higher than in rural areas.
Other factors are small or overweight at birth, mother’s smoking during pregnancy, the presence of animals in the house, obesity, excessive intake of salt.
SYMPTOMS OF BRONCHIAL ASTHMA
Symptoms of bronchial asthma are different and individual. There is no characteristic symptom that unambiguously indicated that a person suffers from asthma. For most people who are sick with asthma – a choking person, constantly coughing and whistling at all frets. However, this is not necessarily so. At the reception, some patients complain of difficulty exhaling, some on difficulty with inhalation. Some complain about coughing at night, in the morning, with physical exertion, and some do not worry about suffocation.
Symptoms of asthma:
- cough with phlegm or without it – a cough with asthma is varied in characteristics. Wet, dry, with phlegm, without phlegm. Sputum is clear, white, gray or similar to bronchi. When you join the infection, sputum is colored in a yellow-green color.
- wheezing, whistling in the chest or noisy breathing – is associated with edema of the bronchial mucosa and a decrease in the diameter of the lumen of the bronchi. It turns out an imitation musical instrument bagpipes.
- suffocation – an attack of suffocation occurs when the airways (bronchi) are sharply narrowed due to inflammation. Choking is a fast process and therefore a person experiences severe panic. Panic results in an even more choking sensation.
- heaviness in the chest during breathing – the origin of this symptom is associated with bronchial obstruction. Increasing obstruction leads to increased severity in the chest. This symptom is equivalent to suffocation.
- shortness of breath is not a typical complaint for bronchial asthma. Shortness of breath is a subjective symptom that describes a person’s feeling of lack of air. The cause of shortness of breath or respiratory failure, as well as concomitant diseases. Symptoms of asthma occur every day, weekly, or extremely rare. The manifestations of these symptoms are of varying severity, from mild to severe. A prolonged severe asthma attack sometimes leads to death!
This range of severity of complaints and blurring of symptoms is characteristic of bronchial asthma. Asthma in the period between exacerbations can not behave itself. In this “quiet” period of time, patients make a mistake – they stop treatment. As a result, the patient has asthma exacerbation.
For bronchial asthma are not required:
- 1. Common symptoms in the form of weakness, poor health. These complaints are typical for a prolonged attack of asthma and the absence of the effect of its treatment. Moreover, the degree of severity of the disease can decrease as quickly with the right treatment, as an attack has occurred.
- 2. Attributed bronchial asthma cyanosis of the hands (acrocyanosis) and skin, lips – arise with a severe, protracted attack and are not characteristic for the disease. This is more evidence in favor of improper therapy or diagnosis.
- 3. Rapid heart rate is a frequent companion in case of exacerbation of asthma. It is the result of excessive use of salbutamol in asthma attacks, and rapid breathing during an attack. Tachycardia worsens the state of health during an attack, increasing panic.
- 4. Often bronchial asthma is attributed to the symptoms of COPD – “watch glass”, “drum sticks”, manifestations of emphysema. This is due to inadequate understanding by some doctors of the essence of these diseases. From this, and confusion.
- 5. Cardiovascular system does not suffer from the presence of bronchial asthma. Rather, we can talk about the medicamental effects of drugs on the cardiovascular system.
Question from patient
I do not choke, but I just cough. And the doctor says that I have asthma! Is it possible?
With a cough version of bronchial asthma (and there are also such), the patient does not suffocate. Moreover, the FVD indices record normal or slightly reduced rates of ventilation. Cough in patients with a cough variant of asthma disturbs at night and in the morning, occurs when walking fast or when playing sports. This question often sounds at the reception in the clinic. Even with special training in the intricacies of diagnosing bronchial asthma, doctors face a diagnostic dilemma – asthma or not? With a thorough questioning of the patient, the analysis of childhood and kinship, the nature of the complaints, the diagnosis of asthma becomes probable. But this is not all the diagnosis of asthma!
DIAGNOSTICS OF BRONCHIAL ASTHMA
The main functional test for the diagnosis of bronchial obstructive syndrome is considered to be spirometry, or the function of external respiration, or FVD. Spirometry shows how the lungs function, narrowed or not the airways (bronchial obstruction), whether the respiratory volumes are altered. The test is painless and bloodless. Carried out in 2 stages. In the first stage of the three attempts to respiratory maneuver (forced expiration), a greater indicator is chosen. Then the doctor suggests to inhale the bronchodilator-expanding drug (Salbutamol) and after 15-20 minutes, the stage number one is repeated. The duration of the procedure is 20-25 minutes. The result is deciphered by the attending physician.
Despite the simplicity of the test, performing a breathing maneuver requires clarity. As the experience of 10 FVDs in other polyclinics and medical centers shows, only two will meet the quality criteria. To avoid mistakes in the diagnosis of asthma, in our clinic, doctors pulmonologists themselves perform this test. The problem becomes more difficult if spirometry is normal, and there is no positive reaction to the drug. In this case, we recommend a bronchoprovacative test. This FVD on the contrary. This expert study confirms or refutes the diagnosis of asthma. Bronchoprotection test is indispensable in the diagnosis of a cough variant of bronchial asthma and asthma of physical effort.
Given the variability of symptoms, functional indices, the variety of causes of development of bronchial asthma for control requires a classification.
Classification of bronchial asthma (according to the recommendations of GINA 2016) in terms of severity:
Step 1: Intermittent bronchial asthma
Manifestations of the disease less than once a week – the patient does not make a complaint. Exacerbations are not prolonged or absent. At night, asthma either does not bother, or nocturnal symptoms occur no more than 2 times a month.
Indicators FEV1 or PSV ≥ 80% of the due. Patients with this variant of the flow rarely visit the pulmonologist. The disease does not affect the quality of life.
Stage 2: Light persistent bronchial asthma
The patient feels the manifestations of the disease more than 1 time a week, but less often 1 time per day – in this case, reduced physical activity, occasionally disturbed sleep. The patient notes difficulty breathing at night, more often than twice a month. The patient is concerned about the appearance of regular symptoms.
FEV1 or PSV ≥ 80% of the due. Asthma prevents you from fully living.
Stage 3: Bronchial asthma of medium severity, persistent. Choking, coughing disturb daily. The sleep is broken, usual physical activity is given hardly.
The night becomes a difficult time of the day, several times a week, nightly manifestations of the disease are very disturbing. The need for bronchodilators Salbutamol, Berodual daily.
FEV1 or PSV 60-80% of the due. Such a patient is “heard” everywhere – he wheezes, whistles in the chest. The look is worried, constantly there is not enough air. Patients are very irritable in this condition. Quality of life does not suit them.
Step 4: Severe persistent bronchial asthma. Severe condition – respiratory disorders and symptoms have a pronounced, daily character. Exacerbations change one another. Nocturnal symptoms are daily. Significant decrease in physical activity
FEV1 or PSV ≤ 60% of the due. This is a dangerous condition. Action is required on the part of medical personnel, for the relief of symptoms and the decision to hospitalize in a hospital.
According to this classification, the degree of severity is selected from the most severe manifestation of the symptom or FVD index. And just one symptom or indicator. But because of the variability of the manifestations of asthma, the degree of severity also becomes a variable variable. The severity of asthma is not a static characteristic.
Phenotypes of asthma
Allergic asthma: “classic” for it is characteristic of a beginning in early childhood, as a rule, there are a number of allergic comorbidities. The hereditary factor of an allergy is characteristic. The pathogenesis is based on eosinophilic inflammation. The response to IGKS therapy is good.
Non-allergic asthma: Allergies are not the cause of the development of this variant of asthma. Inflammation is realized due to mixed, neutrophilic, eosinophilic links. The response to IGKS therapy is sometimes absent or incomplete.
BA with a late debut: this option is more common in women, develops in the adult state. In this type of asthma, the allergy is also not characteristic. IGKS is used in doses of more than 1000 micrograms.
BA with fixed airway obstruction: patients suffering from this type of asthma suffer from asthma for a long time. And under the influence of prolonged inflammation, the wall of the bronchi changes so much that the obstruction becomes permanent ..
Asthma in patients with obesity: patients with obesity and asthma suffer from severe respiratory symptoms, not associated with eosinophilic inflammation. The determination of the phenotypes of the disease makes it possible to approach the treatment in person and individually.
Special forms of asthma
GERD induced – gastroesophageal reflux The current problem of protracted cough in patients and GERD is capable of provoking the development of bronchial asthma. The reason for this is the inhalation of an aerosol of acid content from the esophagus.
Aspirin-dependent asthma – the cause of inflammation in the bronchi in this situation is aspirin or other NSAIDs. Usually, the aspirin form is characterized by the so-called. aspirin triad – asthma, polyps of the nasal cavity and reaction to salicylates. The cough variant of bronchial asthma, with the introduction of a bronchoprovascular test into the diagnosis, made it possible to identify this type of disease. Instead of attacks of suffocation, there is a spasmodic cough with an accent at night or in the morning.
Asthma of physical effort – bouts of shortness of breath occur exclusively during physical exertion. With it, there is a variability in ventilation. Sometimes you can hear whistles and wheezing.
Occupational asthma – exclusively factors of the production environment provoke this form of asthma. Other factors, outside the workplace, should not be with this form, the cause of the disease.
Nocturnal asthma is a controversial option. But only night attacks of lack of air are described. Very often correlates with OSAS.
TREATMENT OF BRONCHIAL ASTHMA
Multi factorial disease – multilevel treatment! Successful control of bronchial asthma is possible in a complex of activities:
Drug treatment is correctly prescribed basic (basic) therapy and exacerbation therapy
Prevention of external and internal
Drug treatment is correctly prescribed basic (basic) therapy and exacerbation therapy
Prevention of external and internal factors of exacerbations – antiallergic regimen, diet, control of chronic diseases
Rehabilitation – Patient education, special trainings for patients
Tasks of therapy of bronchial asthma:
1. Ensuring and maintaining control over the symptoms of bronchial asthma, a long time
2. Risk reduction and prevention of future exacerbations of the disease.
Steps are used to solve the problems.
The main principle of stepwise therapy is an increase in the volume of therapy in the absence of proper control over asthma (with its aggravation) and a corresponding decrease in this volume when the stabilization of the condition, the subsidence of the symptoms of the disease, is achieved. The steps contain information on treatment options that differ in their effectiveness. The degree and extent of therapy are chosen by the attending physician and depend on the degree of asthma symptoms in the patient. The use of stepwise therapy allows, with its correct application, to evaluate the effectiveness of the chosen treatment regimen. For example, if you can not stabilize the exacerbation of asthma, you need to check the technique of using inhalers. Check whether the patient is doing the appointments and recommendations. Perhaps attention was not paid to concomitant diseases? And having evaluated these factors, a decision is made to change the amount of treatment.
Reducing the amount of therapy, for example multiplicity or dosage of inhalers, also requires caution. The severity of the disease is necessarily taken into account when changing the therapy. Patients often make mistakes by abolishing medication at early stages of asthma stabilization.
Drugs for treatment are divided into two groups:
1. Quick-acting, high-speed drugs (Ventolin, Salbutamol). Berodual). These drugs quickly for 5 to 15 minutes ease the patient’s condition, take off the attack of suffocation. These drugs are available in the form of pocket inhalers or suspensions for inhalation through a nebulizer. Almost every patient with an asthmatic illness in his pocket has an inhaler for quick relief during an attack. Most patients need these inhalers 1 or 2 times a week – or much less often. But when the symptoms of bronchial asthma are severe and severe, the need for rapid-action inhalers increases. It is possible to overdose them and worsen overall health. Drugs of basic therapy
2. For the basal therapy of asthma, combinations of anti-inflammatory drugs – IGKS (inhaled glucocorticosteroids – budesonide, mometasone, beclazone) and long-acting bronchodilators (Foradil, Formoterol, Salmeterol) are used. The purpose of this group of drugs is to prevent the asthma symptoms from exacerbating and controlling the disease. The anti-inflammatory effect is achieved by the action of corticosteroid hormones on inflammatory mediators – eosinophils, cytokines and other inflammatory cells.
Pocket metered-dose inhalers are means of delivering medicines to the bronchi. They are specifically designed to inhale a medicinal product in the form of an aerosol or powder.
Nebulizers are inhalers, but stationary – they are a means of delivering drugs in the form of suspensions or solutions in the bronchi. It is used for exacerbation of bronchial asthma, especially severe course.
For successful treatment it is important to take all the medications that the doctor prescribes. Patients should learn the proper use of inhalers. You may have to take the medication several times a day and at the same time, the absence of symptoms is not an excuse to introduce corrections into the therapy scheme yourself. Our specialists pay special attention to the correct use of inhalers. After all, there are a lot of modifications of drugs for inhalation therapy, and we know the peculiarities of using all drugs. The patient may think that the recommended drug does not work, but this does not mean that it does not help. If you have such doubts, contact a pulmonologist. It is important to know that improper treatment of asthma leads to changes in the lungs. Incorrect medication can lead you to a hospital bed.
Leukotriene Receptor Antagonists
(anti-leukotriene agents – Montelukast and Zafirlukast). These drugs are less effective than IGKS for asthma control. The drug is effective in atopic form of bronchial asthma, as well as patients with aspirin form of asthma and asthma physical effort. These drugs suppress the narrowing of the bronchi in response to inhalation of leukotrienes, reduce the asthmatic response to cold and physical effort.
Cromones are sodium cromoglycate (“Intal”) and nedocromil (“Taileed”). The effectiveness and safety of modern inhaled steroids, the production of new antileukotriene drugs led to the displacement of cromoglycate and nedocromil from the arsenal of pulmonologists.
Therapy with humanized antibodies to IgE – Omalizumab. This is a monoclonal antibody that can bind the IgE circulating in the blood of the patient, having a pronounced mediated effect on allergens, reducing inflammation in the bronchi. This drug is most useful in severe forms of asthma, with eosinophilic inflammation, with an ineffective response to IGCC therapy. The efficiency of application is about 30%.
Methotrexate and gold preparations – have a corticosteroid sparing effect in the treatment of asthma. However, the use is limited by adverse reactions.
Theophyllines have been used since the middle of the last century to treat asthma. Their big advantage is their cheapness. Therefore, the drug is readily used in countries with a low economic level. However, theophylline revealed new properties that are being studied. And we will see the revival of this group of medicines.
Specific immunotherapy (SIT or ASIT). It is used in the proven relationship between asthma and allergen (allergens). A one-time and dangerous way of treating asthma, but the only way to treat asthma is to give a long-term remission in 70% of cases, with a full three-year cycle of treatment. The effect is achieved by reducing the immune response to gradually and periodically increasing doses of the administered allergen into the human body. It turns out something like an inoculation against allergies. The method has many contraindications and limitations.
NON-TREATMENT OF TREATMENT
Rehabilitation of patients with bronchial asthma
It is formed from the strict observance of the patient’s drug treatment plan, the training of control over his condition, symptoms of asthma. The developed individual plan fits in recommendations for correct behavior in case of exacerbation of the disease. Physical exercises and simulators help keep the respiratory muscles in a trained state, providing tolerance to physical exertion, improve cardiopulmonary function. Regular physical training will reduce the severity of exacerbations.
Prevention of patients with bronchial asthma
In patients with asthmatics, there is a perception that if factors of provoking seizures are avoided, drug treatment is not necessary or at least to reduce the amount of drug support. Evidence on this score is not enough. But, nevertheless, it is possible to offer with confidence as preventive measures the following:
do not cancel independently, prescribed therapy
elimination of risk factors for the development of bronchial asthma. This is the case when it is easier said than done. For example – the ecological state of the environment is not subject to the patient. Regret sometimes the factors causing asthma exacerbation, are found only at work. Then the patient faces a difficult question of choosing between asthma and earning money.
air purifiers in the apartment, the correct anti-allergic regime during the flowering period of plants
exclusion of tobacco smoking.
climate in the apartment and at work – the presence and absence of rooms exceeding the doses of formaldehyde, phenols, etc.
sanation of foci of chronic infection in the patient. For example, chronic infections of the nose, larynx, pharynx or the organs of the digestive tract.
Salt caves or halotherapy is a safe method of preventing diseases of the upper and lower respiratory tract and psycho-emotional unloading of the body. Consider this technique as an asthma treatment is not worth it. During the passage of the spa treatment, the salt caves are useful.
Bronchial asthma and diet
A patient with asthma should eat regularly! There are no recommendations confirmed by clinical studies on the need for a diet. International studies have proven that initiating asthma can be an excess of salt intake and a risk factor is obesity. If you eat less salt and monitor calories, there will be no problems. The diet for asthma is used when there is an allergy to food. Here the recommendation is one – exclude these products from the diet and allergic reaction to them will not. Also, in the presence of GERD and asthma, it is necessary to observe the diet prescribed by the doctor for the prevention of GERD.
The prognosis of bronchial asthma is favorable. According to our observations, 70% of patients are “afraid” of asthma, but they ignore obstructive bronchitis. And this is misleading. the forecast of COPD is more tragic and more dangerous. If you follow the recommendations of doctors, asthma will not change your usual rhythm of life. Bronchial asthma of obesity, bronchial asthma with a fixed load, atopic asthma or smoker’s asthma are difficult options for treatment. The prescribed therapy does not bring relief of breathing and well-being. In 10% of cases, inpatient care, right up to the intensive care unit, can not be avoided.
What is the difference between the division of pulmonology “ItgraMedservice” from other clinics and departments in the treatment of bronchial asthma?
This is a multi-disciplinary approach to the problem of bronchial asthma in each individual patient. Because asthma is a multi factorial disease. The disease can not be approached by simply appointing an aerosol inhaler. We possess all methods of therapy of bronchial asthma. Asthma school and rehabilitation NN Meshcheryakova, popular in Moscow. When choosing a treatment regimen, doctors assess the possible undesirable effects of the drugs used and honestly discuss this with patients.
Every year we update information on new drugs at the Congress on Respiratory Problems and at the European Congress on Respiratory Diseases.
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