Obstructive pulmonary diseases in children: resolved and unresolved issues

Respiratory diseases in children are always in the focus of attention of pediatricians, primarily because of the high incidence. Out of every three children who go to the doctor, two present some kind of respiratory complaint.

In most patients, respiratory diseases occur with bronchial obstructive syndrome, which is understood as a symptom complex of impaired bronchial patency of functional or organic origin, manifested by paroxysmal cough, expiratory dyspnea, asthma attacks. The high frequency of bronchial obstructive syndrome in lung diseases made it possible to single out a group of chronic obstructive pulmonary diseases (COPD) in both adults and children. COPD, starting in childhood, is a common cause of disability and premature disability.

This group of diseases includes congenital (tracheobronchomalacia, tracheobronchomegaly, primary ciliary dyskinesia, cystic fibrosis, malformations of the lung, etc.) and acquired diseases (bronchial asthma, emphysema, obstructive bronchitis, bronchiolitis obliterans, bronchopulmonary dysplasia, etc.). Common to all of them is bronchial obstructive syndrome.

The most common disease of this group is bronchial asthma. Bronchial asthma in children is a disease that develops on the basis of chronic allergic inflammation of the bronchi, their hyperreactivity and is characterized by periodically occurring attacks of difficulty breathing or suffocation as a result of widespread bronchial obstruction due to bronchospasm, mucus hypersecretion, swelling of the bronchial wall. Bronchial hyperreactivity is a term for narrowing of the airways in response to provocative agents.

This definition and concept of asthma as a chronic inflammatory disease of the respiratory tract has developed over the past decade on the basis of histological and immunochemical studies of biopsy samples of the bronchial wall, bronchial fluid and autopsy material from deceased patients suffering from bronchial asthma.

The leading role in the development of bronchial asthma in children belongs to endogenous factors (atopy, heredity, bronchial hyperreactivity), which, in combination with various exogenous factors (allergens, drugs, vaccines, infectious agents, environmental effects, psycho-emotional stress) lead to the clinical manifestation of the disease. It is fundamentally important for the clinical diagnosis of the disease that asthma in children can manifest itself in the form of typical attacks of expiratory dyspnea, shortness of breath, suffocation, wheezing, feeling of constriction in the chest or cough when in contact with house dust, animal hair, plant pollen, inhalation of irritating substances, the effects of pungent odors, physical exertion, the use of certain foods, exposure to cold air, tobacco smoke, the influence of emotional factors, etc., without signs of a cold, more often at night, and in the form of atypical clinical manifestations of bronchial obstruction.

These include:

– unexpected episodes of difficulty breathing (dyspnea);

– prolonged (more than 10 days) dry cough, especially at night and leading to the awakening of the child;

– cough caused by physical exertion associated with inhalation of cold air, change of weather;

– repeated attacks of shortness of breath (3 or more times), provoked by colds;

– recurrent bronchitis or slow recovery after acute bronchitis (cough for more than 2 weeks);

– cough in the presence of concomitant allergic rhinitis, atopic dermatitis.

Obstructive bronchitis is a clinical form of bronchitis, accompanied by the development of bronchial obstruction syndrome. Obstructive bronchitis is more common in children under 4 years old. These, according to the existing “Classification of clinical forms of bronchopulmonary diseases in children” (1996), include acute and recurrent obstructive bronchitis, acute bronchiolitis, and acute and chronic obliterating bronchiolitis.

Obstructive conditions are more often registered against the background of a respiratory viral infection – according to different authors, in 10-30% of infants. It is believed that RS-virus and parainfluenza type III infections account for most obstructive forms of bronchitis, the remaining viruses cause no more than 10-20% of cases. With the development of three episodes of obstructive bronchitis in a child, especially with allergologically burdened heredity, concomitant allergic diseases, and the effects of non-infectious factors, they speak of the formation of bronchial asthma.

Currently, great strides have been made in understanding the mechanisms of development, diagnosis and treatment of obstructive pulmonary diseases in children. This was largely facilitated by the creation of the national program “Bronchial asthma in children. The treatment strategy and prevention ”(1997), the introduction of pathogenically substantiated, unified approaches to the treatment of bronchial asthma and bronchial obstructive syndrome using modern inhaled anti-inflammatory and bronchodilators.

At the same time, hypodiagnosis of bronchial asthma is a fairly common occurrence in pediatric practice, it is far from always possible to achieve complete control of the disease, more often with obstructive bronchitis, considered viral diseases, one has to resort to antibacterial therapy.

In the vast majority of patients with bronchial asthma, the onset of the disease occurs in early childhood. At the same time, quite often the diagnosis of bronchial asthma is established 5 to 10 years after the onset of the first clinical symptoms of the disease. It is estimated that a child visits a pediatrician on average 16 times before he is diagnosed with bronchial asthma, before being observed with such diagnoses as recurrent obstructive bronchitis, asthmatic bronchitis, and ARVI with obstructive syndrome. Only 25% of children are diagnosed within the first year after the onset of the first symptoms of the disease. Untimely diagnosis leads to a later start of basic anti-inflammatory therapy, which worsens the prognosis.

A study of the effectiveness of standard anti-inflammatory therapy therapy regimens in children showed that a three-month course of basic treatment, corresponding to the severity of bronchial asthma, helps to stabilize clinical and functional indicators in only 60% of patients. The above determines the relevance of studying previously unknown, new factors contributing to the development of bronchial obstructive syndrome in children, and the possibilities of therapy for this large group of patients. Infectious agents occupy a special place among them. In recent years, the role of atypical, intracellular pathogens – mycoplasmas and chlamydia – in the development of bronchial asthma and other COPD has been actively studied.

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