Chronic Obstructive Pulmonary Disease: A New Reality

Data on the prevalence of electronic cigarettes and steam inhalers among children and adolescents and based on real clinical practice, it should be stated that chronic obstructive bronchitis, which is a form of chronic obstructive pulmonary disease (COPD), can make its debut in childhood, which previously seemed impossible.

Today, COPD is understood as an independent disease characterized by a partially irreversible restriction of airflow in the respiratory tract, which, as a rule, is steadily progressive and provoked by an abnormal inflammatory response of the lung tissue to irritation by various pathogenic particles and gases. In response to the impact of external pathogenic factors, the function of the secretory apparatus changes (hypersecretion of mucus, changes in the viscosity of the bronchial secretion) and a cascade of reactions leading to damage to the bronchi, bronchioles and adjacent alveoli develops. Violation of the ratio of proteolytic enzymes and antiproteases , defects in antioxidant protection of the lungs exacerbates the damage.

The prevalence of COPD in the general population is about 1% and increases with age, reaching 10% among people over 40 years of age. In accordance with the forecast of WHO experts, by 2020, COPD will become the third leading cause of morbidity and mortality in the world. COPD is a topical issue, since the consequences of the disease are limiting physical performance and disability of patients, including modern children and adolescents.

Diagnostic criteria for establishing a diagnosis of COPD in practice include characteristic clinical symptoms (prolonged cough and progressive shortness of breath), anamnestic information (presence of risk factors) and functional indicators (progressive decrease in FEV 1, and FEV1/ FVC ratio).

As an illustration, we present the following clinical example:

Patient 16 years old, from a family with no burden allergic historyparents and relatives smoke for a long time, maternal grandfather died of lung cancer. The household history is burdened by living in a damp apartment where cats are kept. From the age of 3, the girl was sick with recurrent bronchitis with a lingering cough, mostly – in the cold season, she repeatedly received outpatient courses of antibiotics and mucolytics. At the age of 7 she was on long-term inpatient treatment for urinary tract infection, and for the first time in the hospital she began to smoke cigarettes with other children. Subsequently, in connection with the frequent episodes of bronchitis and a long-lasting cough, was registered by a pulmonologist at the place of residence. The disease was regarded as the debut of bronchial asthma, basic inhalation treatment was carried out.glucocorticosteroids in gradually increasing doses, due to the lack of effect in the last year before contacting the clinic, she received the combined drug seretid. She was repeatedly hospitalized in a hospital at the place of residence for relief of exacerbations, inhalations with bronchodilators ,mucolytics and antibacterial drugs were added to the therapy.

Between the exacerbations, paroxysmal obsessive cough (in the mornings – with sparse sputum discharge) bothered, she did not suffer from exercise, but the girl often complained of weakness, fatigue and headaches. For the first time sent to the survey to clarify the diagnosis in 16 years. When entering a state of moderate severity; complaints of unproductive cough in the morning with mucous- pus sputum; episodes of exacerbations with febrile temperature and increased cough. On examination, there is no dyspnea at rest, physical development is moderate, harmonious, signs of peripheral osteo- arthropathy are not pronounced; the rib cage is not deformed, percussion sound with a box shade, in the lungs against the background of hard breathing different-sized wet rales are heard. When examining deviations from the indicators of general blood tests, urine, biochemical blood tests were not detected. Immunological study of humoral and cellular immunity, phagocytic activity of neutrophils allowed us to exclude the immunodeficiency state. Allergological examination did not reveal specific sensitization to causal allergens. A morphological analysis of sputum confirmed its mucopurulent character; during sputum culture, colonies of Staphylococcus aureus and epidermal streptococcus were detected . On the radiograph of the lungs there were signs of bronchitis and obstructivesyndrome.

When conducting spirometry, the volume-speed indices were within the limits of proper values, the sample with the measured physical load was reliably after-loading bronchospasm did not reveal. Attention was drawn to the low level of nitric oxide in exhaled air ( FeNO = 3.2 ppb at a rate of 10-25 ppb ), as well as a sharp increase in the content of carbon monoxide in exhaled air (CO = 20 ppm at a rate less than 2 ppm ), which is pathognomonic for regular active smoking. When performing body plethysmography, the presence of obstructive disorders revealed radiographically was confirmed : a sharp increase in the residual lung volume and its contribution to the total lung capacity. Diaskintest was negative, which made it possible to exclude the presence of tuberculosis. The level of sweat chloride was in the normal range, which denied the presence of cystic fibrosis.
Markers of persistent viral-bacterial infections were not identified. Carefully collected history made it possible to clarify that from seven years old to the present, the girl was regularly actively smoking (from ½ to 1 pack of cigarettes per day), i.e. the smoking experience at the time of going to the clinic was 8 years. Her family smoked parents and close relatives, cigarettes were in the public domain.

At the same time, the parents of the girl, knowing about her smoking, did not associate complaints about a prolonged cough and repeated bronchitis in a child with smoking, and were inclined to drug treatment of cough. The girl herself made several unsuccessful attempts to quit smoking, but did not turn to anyone for specialized help. Thus, on the basis of medical history and the results of the survey data presumptive diagnosis of asthma is not found on the confirmation, and the patient was diagnosed: XPO-ethnic obstructive bronchitis. An explanatory conversation was conducted with the parents of the teenager and the girl herself, recommendations were given for improving the health of giving up smoking to all family members (including with the help of specialists from the anti-smoking room at the place of residence) and the treatment tactics of the underlying disease.

In routine clinical practice, portable gas analyzers for determining the level of carbon monoxide in exhaled air have been well recommended for detecting active smokers . Thus, in our clinic, 100 patients with bronchial asthma (BA) of varying severity of 6–18 years (68 boys, 32 girls) were examined for the content of carbon monoxide in the exhaled air using Smokerlyzer ( Bedfont , England ).
The simplicity of the breathing maneuver (15 second breath hold at inspiratory height followed by expiration through the mouthpiece of the gas analyzer) makes the procedure for non-invasive measurement of carbon monoxide levels in exhaled air accessible to most children over 6 years old.Among those examined, 14 active smokers aged 13 to 18 years were identified: the average level of carbon monoxide in the exhaled air was 7.9 ppm (4-16 ppm ) (1 ppm – 1 particle of gas per 106 air particles); all of them were in the clinic due to the severe course of asthma, and smoking was denied. Nineteen patients belonging to the category of passive smokers (in their families, parents or close relatives smoked at home) had an average level of carbon monoxide in the exhaled air = 1,3ppm (0-2 ppm ), which did not reliably distinguish them from the group of children not exposed to tobacco smoke (67 patients, average CO = 1.4 ppm (0-2 ppm )). However, among patients prone to passive smoking, children with more severe asthma prevailed . The results indicate the potential practical importance of using carbon monoxide analyzers in a children’s pulmonary clinic to identify active smokers in order to conduct targeted anti-treating programs and monitor their effectiveness.

In addition, the most widely used biomarker for determining the effect of cigarette smoke on humans is cotinine , the main nicotine metabolite detected by gas chromatography or radioimmunoassay of the blood or, preferably, urine, reflecting the level of nicotine absorption through the lungs.After stopping smoking, cotinine is stored in the urine longer than nicotine, and is detected within 36 hours after smoking the last cigarette. In addition, it was found that, the level of cotinine in the urine is significantly increased in passive smokers. To date, there are special test strips for determining cotinine in the urine using the immunochromatographic method.

A particular problem is patients using vaping as an alternative to smoking (from the English vapor – vapor, vaporization). This invention is only 14 years old: in 2003, the smoker Hong Lik from Hong Kong, whose father died of COPD, patented the first electronic cigarette-vaporizer, designed to quit smoking. However, the further fate of this invention went along the path of improving various devices and creating flavoring mixtures, the benefits of which raise more and more questions.

To date, more than 500 brands of devices intended for “floating”, and almost 8,000 kinds of liquids with and without nicotine, are sold in the world, the vapors of which are inhaled. It is established that in the period between 2013-2014. passion for high school students of electronic cigarettes and steam inhalers has tripled. It is believed that the number of teenagers vapers already exceeds the number of adolescents who smoke regular cigarettes.

It is known that the composition of liquids for vaping includes glycerin, propylene glycol , distilled water and various flavors . Propylene glycol and glycerin – two- and triatomic alcohols, viscous, colorless liquids; widely used in household chemicals, cosmetics, allowed as additives for food (E1520 and E422). When heated, propylene glycol (Bp = 187 ° C) and glycerin ( Bp = 290 ° C) evaporate to form a number of carcinogens: formaldehyde, propylene oxide , glycidol , etc. It has been proven that lung tissue cells react to vaping water vapor , as well as cigarette smoke exposure, which increases the likelihood of developing lung cancer (compared to non-smokers). To date, some US states equate vapers to smokers, they are forbidden to soar on board aircraft, in public places and in stores.

According to the FDA (Food and Drug Administration, USA), electronic device fluids can contain 31 toxic chemicals, including acrolein, diacetyl, and formaldehyde, which levels increase with temperature and device type. So, liquids in these devices can heat up to 300 ° С (for example, bp . acrolein = 52.7 ° C), which entails the release of hazardous substances. In addition, in experiments on animals after vaping , the development of acute pulmonary insufficiency lasting up to half an hour was recorded. In addition, in only 8 months of 2016, 15 people were treated with burns of the face, hands, thighs and groin, which were obtained as a result of the explosion of electronic cigarettes and vapor devices;

Electronic cigarettes and vapor-inhalers today are certified as electronic devices — neither their effectiveness in quitting smoking, such as nicotine replacement preparations (chewing gum, patches), nor the composition of cartridges and liquids is tested. Electronic cigarettes and devices forvaping are available for sale ( including in large shopping centers and on the Internet).

Therefore, an important task of modern pediatricians and pulmonologists is the creation of effective barriers to the “rejuvenation” of COPD. To this end, it is advisable to recommend an anonymous questioning of children and adolescents to identify the prevalence of smoking, the use of electronic cigarettes and steam inhalers , regular monitoring using portable spirometers, CO-analyzers and determining cotinine levels . Active educational position of the medical community can contribute to the amendment to the existing legislation on mandatory certification of electronic cigarettes and paroingalyatoro in, as well as fluids to them as medical devices; their free sale to persons under 18 should also be restricted. In addition, it is necessary to attract the media to discuss this topic, including through the use of Internet resources and television.

Before it is too late, every effort must be made to ensure that COPD does not have a chance to become a reality in childhood!

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