The basic principles of treatment of bronchial asthma in children

Bronchial asthma is one of the common diseases and is one of the urgent problems of modern pediatrics. In recent years, the whole world, including Ukraine, has a tendency to increase the incidence and more severe course of asthma. Recent epidemiological studies suggest that about 10% of children suffer from bronchial asthma. According to medical institutions, the prevalence of asthma in Kiev in recent years is 4.9-6.06 per 1000 people. The causes of the increase in the incidence of asthma and allergies in children are associated with various factors:

  • a change in the nutrition of children, in particular an increase in the number of children who are breast-fed in the first 4-6 months of life;
  • the desire for comfort, characteristic of a significant part of the population, implies the presence of hermetically sealed windows, air conditioning systems, carpeting, etc., which leads to increased humidity and the creation of conditions for increasing the concentration of house dust and other allergens in the premises;
  • changing stereotypes of child care – a large number of children begin to attend early childhood care facilities, where they are more susceptible to the incidence of viral infection, including respiratory syncytial;
  • increased prevalence of smoking among mothers;
  • exposure to air pollutants (mainly NO2), the source of which is automobile transport, gas stoves, open heat sources.

In connection with the foregoing, the problems of prevention, diagnosis and treatment of bronchial asthma are of paramount importance. The main goal of therapy and prevention of this disease in children is to improve the quality of life of the patient, the successful solution of tasks such as:

  • elimination or reduction of the clinical manifestations of the disease;
  • a decrease in the frequency and severity of exacerbations;
  • preventing the development of life-threatening conditions and deaths;
  • normalization and improvement of external respiration function indicators;
  • restoration and maintenance of vital activity (corresponding to the age of the child), including physical activity;
  • the absence or minimization of side effects from drugs used to treat bronchial asthma;
  • ensuring the normal growth and development of a sick child, preventing disability.

Successful treatment of bronchial asthma is impossible without a trusting relationship between a doctor, a sick child, and his parents. Constant monitoring of sick children makes it possible to monitor the course of the disease, the effectiveness of the therapy, and make appropriate adjustments to the treatment. The control of the disease is carried out in three directions: elimination of trigger factors, specific hyposensitization and pharmacotherapy.

The most effective treatment for asthma is the elimination of a causative allergen (trigger factor). However, in practice this is far from always possible. The basis of drug rehabilitation is basic therapy aimed at eliminating the chronic inflammatory process, restoring patency of the bronchi, preventing the development of repeated exacerbations of the disease and achieving stable remission.

Currently, bronchial asthma is classified based on severity. The stages of intermittent, mild, moderate and severe persistent bronchial asthma are determined depending on the frequency and severity of symptoms, their effect on daytime activity and sleep, bronchial obstruction.

In the treatment of bronchial asthma, a stepwise approach is used (an increase in the number and frequency of medication with increasing severity of asthma). The choice of treatment should be made taking into account the course and period of bronchial asthma. However, an individual approach is required in the choice of means and methods of treatment.

The most preferred for the treatment of patients with bronchial asthma are inhalation forms of drugs, which are characterized by a higher therapeutic index, compared with currently available dosage forms for oral administration. A high concentration of inhaled drugs in the respiratory tract is achieved due to their direct intake. They have a pronounced therapeutic effect with minor side effects. This doctor should be sure to explain to parents, because many of them are afraid to use inhalers for treating a child and prefer tablet dosage forms (aminophylline, No-Shpa).

Children under two years of age should use metered-dose aerosol inhalers with spacers and masks or nebulizers; children from 2 to 5 years – metered-dose aerosol inhalers with spacers or nebulizers. The spacer must necessarily correspond to the inhaler, its size changes, as the child grows and, accordingly, the size of the lungs increases. Patients older than 5 years who find it difficult to use a metered-dose aerosol inhaler need to use metered-dose aerosols with a spacer, metered-dose aerosols that are activated by inhalation, dry powder devices, or nebulizers.

Basic therapy in children over 5 years of age is carried out under the mandatory control of the function of external respiration (peak flowmetry, FEV1, PEF), taking into account the initial severity of the disease at the time of examination of the patient, it is carried out for a long time, is canceled only when a stable remission is achieved. The choice of treatment methods for the patient is determined by the doctor, taking into account the specific clinical situation.

The methods of basic therapy, designed to influence the inflammatory process, include the appointment of inhaled cromoglycate or sodium nedocromil and corticosteroid drugs, specific immunotherapy.

With long-term (basic) treatment of asthma, it is necessary to adhere to a stepwise approach to therapy, in which the volume and composition of therapy depend on the severity of asthma. The goal is to achieve the effect of therapy using the least amount of drugs. The number of drugs and the frequency of their administration increase if the patient’s condition worsens (step up), and decrease if it improves (step down). In any case, if it is possible to control the course of the disease for three months, the issue of reducing the intensity of therapy, i.e. go to treatment corresponding to a step down, that is, to minimal therapy requiring control of the course of bronchial asthma.

For the medical treatment of bronchial asthma, two types of medicines are used: long-term prophylactic drugs (especially anti-inflammatory ones) that prevent the onset of attacks, and emergency drugs to stop the attacks. Medications for long-term maintenance therapy help to achieve and maintain control over the symptoms of persistent bronchial asthma and prevent its exacerbation. They are used daily. These include anti-inflammatory drugs and prolonged-release bronchodilators.

The group of anti-inflammatory drugs used in children include cromolyn sodium (Intal, Cromolin) and sodium nedocromil (Tyled). They occupy a leading place in the treatment of mild and moderate asthma and are less effective in severe cases. A wide spectrum of activity of drugs of this class is determined by the ability to inhibit both the early phase of the allergic response and the late phase of allergic reactions in chronic inflammation and reduce bronchial reactivity. These drugs are used for at least 2-3 months. Often patients do not want to take the drug for such a long time, which is one of the main reasons for the ineffectiveness of anti-allergic drugs. In case of seizures or bronchial obstruction (according to spirography), combined preparations are prescribed, which include sympathomimetics. Long-term use of cromoglycate or sodium nedocromil alone can provide asthma therapy, so these drugs are especially useful for children in the initial stages of the disease.

The most effective drugs with anti-inflammatory action at all stages of the severity of the disease (according to some reports, including intermittent asthma) are currently inhaled corticosteroids, which are used both in short courses in the treatment of exacerbation and for a long time with continuously recurring asthma. Local inhaled corticosteroids have a pronounced anti-inflammatory activity. They are able to suppress both acute and chronic inflammation, regardless of the reasons that caused its development, contribute to the reduction of edema, the reverse development of inflammation in the mucous membrane of the bronchi, which leads to a decrease in their hyperreactivity, a decrease in the number of attacks and the achievement of remission in patients. Modern inhaled corticosteroids (beclomethasone, budesonide, fluticasone, flunisolid) used in pediatrics have a minimal overall effect, and with short-term administration they have no obvious side effects. One of the causes of widespread phobia when using hormonal drugs is due to the uncontrolled administration of systemic drugs, the use of which is very limited. Inhaled corticosteroids have a significant advantage over systemic ones.

In patients with moderate to severe asthma, an increase in the effectiveness of anti-inflammatory therapy may be

achieved with the inclusion of bronchodilator drugs (prolonged theophyllines or b2-agonists) in therapy. Long-acting theophyllines are used both in the complex of anti-inflammatory therapy, and to prevent the occurrence of attacks of bronchial asthma, especially at night. The daily dose of theophylline of prolonged action is 12-15 mg / kg body weight, for patients with severe bronchial asthma it is slightly lower (11-12 mg / kg body weight).

Long-acting inhaled b2-agonists (salmeterol, formoterol) provide a bronchodilating effect for 12 hours. Their pharmacotherapeutic effect is associated with the ability to relax the smooth muscles of the bronchi, enhance mucociliary transport, inhibit the release of mediators of the early phase of the allergic response. Prolonged b2-agonists are usually prescribed to patients with signs of insufficient effectiveness of ongoing anti-inflammatory therapy, they can be used as an independent treatment in order to reduce the number of attacks of bronchial asthma, especially in the evening and at night. Oral forms of long-acting b2-agonists (for example, Volmax, Spiropent) are used for mild asthma.

Ketotifen (Zaditen) has the ability to inhibit the synthesis and excretion of allergy mediators, inhibits the development of allergic inflammation in the respiratory tract, skin, gastrointestinal tract, reduces bronchial hyperreactivity. For this reason, ketotifen is used in the treatment of mild to moderate bronchial asthma in children, especially young children, in whom it often proceeds against a background of skin and gastrointestinal allergies.

In the management of patients, questions arise about the place and role of new anti-asthma drugs, such as leukotriene receptor antagonists, new type of inhaled steroids, combination drugs (including prolonged b2-agonists and inhaled steroids), new bronchodilators. The use of antiallergic immunoglobulin, histaglobulin can lead to a reduction in exacerbations and an easier course of asthma in children, and in some patients to achieve clinical remission of the disease, and to reduce the incidence of acute respiratory infection.

Immunostimulating bacterial preparations (IRS-19, Broncho-Munal, Ribomunil, etc.) reduce the incidence of intercurrent acute respiratory diseases and exacerbations of foci of chronic infection and thereby contribute to the reduction of exacerbations of bronchial asthma.

In pediatric allergological practice, specific immunotherapy is a fairly common method of treatment and has been used for over 30 years. This pathogenetically substantiated method for the treatment of bronchial asthma, hay fever, allergic rhinosinusitis and conjunctivitis is to introduce increasing doses of one or more causative allergens into the patient’s body. The effectiveness of this method in asthma is due to many mechanisms. In children with bronchial asthma, specific immunotherapy is carried out with house dust allergens, Dermatophagoides pteronyssimus, Dermatophagoides farinae, pollen, epidermal and fungal allergens. It is indicated for children with atopic bronchial asthma of mild and moderate course with clear evidence of the causative significance of allergens, in cases of low effectiveness of the pharmacotherapy and the inability to eliminate causative allergens from the patient’s environment. Specific immunotherapy improves the clinical condition of patients, promotes the reverse development of allergic inflammation of the mucous membrane of the respiratory tract, reduces bronchial hyperreactivity, and with prolonged (up to 3-4 years) conduction also reduces the overproduction of general and specific IgE. Immunotherapy causes a decrease in the number of intercurrent acute respiratory diseases. For immunotherapy, in addition to the generally accepted parenteral route of administration of therapeutic allergens, endonasal, oral, sublingual can be used. The duration of specific immunotherapy is 3-4 years, it is more effective in cases of bronchial asthma caused by monovalent (especially pollen) sensitization.

Simultaneously with basic therapy in children with bronchial asthma, concomitant pathological processes are treated. To relieve acute violations of bronchial obstruction (relief of an attack of bronchial asthma), emergency drugs (short-acting b2-agonists, anticholinergic drugs, short-acting theophylline) are used. Preference should be given to inhaled forms of drug administration, which allows you to get a quick effect and reduce the overall effect on the child’s body. short-acting b2-agonists (salbutamol, fenoterol), when inhaled, give a quick (after 5-10 minutes) bronchodilating effect. Drugs of this series should be used only for the relief of acute symptoms of bronchial asthma. Short-acting inhaled b2-agonists are prescribed no more than 4 times a day. For mild attacks of bronchial asthma, you can use the oral form of b2-agonists – Ventolin (salbutamol). Preference is given to episodic administration of these drugs. In a situation where b2-agonists are used more than 3-4 times a day, a review and strengthening of basic therapy is necessary. According to the data of long-term studies on the course of bronchial asthma, monotherapy with short-acting b2-agonists has a negative effect. With prolonged uncontrolled use of b2-agonists, bronchial hyperreactivity may increase, which is accompanied by a more severe course of the disease.

In pediatric practice, asthma attacks are treated with inhaled anticholinergics (ipratropium bromide, oxytropium bromide) that block the M-cholinergic receptors involved in the development of cGMP-mediated spasm of the smooth muscles of the bronchi. The purpose of these drugs in children is promising, taking into account the anatomophysiological characteristics of the child’s body. Due to its low absorption, inhaled anticholinergics from the mucosa of the bronchial tree have good tolerance. The combination with sympathomimetics (Berodual, Combivent) provides a synergistic effect in connection with the impact on various mechanisms of bronchospasm. The most effective inhaled anticholinergics during seizures that occur against the background of an acute respiratory viral infection when exposed to irritants.

Along with drug treatment, a special place in the treatment of bronchial asthma is occupied by non-drug methods, which are aimed at eliminating causally significant external factors and training systems, providing compensation for biological disorders, which allows them to be used in the early stages of the disease. These methods of training therapy should be carried out in phases of subsiding exacerbation and remission of bronchial asthma with moderate and mild course. When combining non-pharmacological methods with standard treatment regimens, it is necessary to take into account the safety, safety and non-invasiveness of the method, conduct it under conditions of monitoring the patient’s condition and only under the supervision of a doctor. The effectiveness of rehabilitation therapy depends on the condition of the child, especially the course of the disease and its etiology. The methods of non-pharmacological treatment of bronchial asthma include: wellness regimen, diet therapy, physical education (breathing training, massage and vibration massage, physiotherapy exercises, breathing exercises), speleotherapy and mountain climatic treatment, physiotherapy methods (laser therapy, acupuncture, herbal medicine) and psychotherapy.

I would especially like to dwell on the issues of psychotherapy for children with bronchial asthma. The psychological characteristics of patients, timely diagnosis and psychotherapeutic correction of the patient’s neuropsychiatric status are necessary components of therapy in children. The goals of psychotherapy are the formation of parents’ views on the disease and the change in the life position of the child, the ability to overcome emotional stress, conflict situations. The effectiveness of therapy in children is closely related to the careful implementation of medical recommendations by parents. The lack of parental awareness of the main etiological factors underlying the development and exacerbation of asthma, as well as existing modern treatment methods, leads to the fact that many of them ignore the prescription of doctors, independently stop treatment or use the services of non-specialists.

In recent years, the direction of psychological assistance to patients with bronchial asthma has been developing successfully – the training of patients with asthma schools (clubs). The main tasks of the pediatric asthma school are to increase the effectiveness of therapy for bronchial asthma and to control the course of the disease of the parents or patients themselves. The family of a sick child receives the necessary information about the causes of development and the basics of the pathogenesis of bronchial asthma, the principles of anti-relapse, anti-inflammatory and bronchodilator therapy.

The main topics of the classes are: what is bronchial asthma, the causes of its occurrence and the importance of allergic diagnostics, the organization of elimination measures and hypoallergenic diets, the principles of drug therapy, the need for anti-inflammatory therapy with non-steroid and steroid drugs, non-drug methods of treating asthma. In school classes, it is discussed how to avoid contact with airborne pollutants indoors, what is the role of family rehabilitation and chronic focal infection of the rhinopharyngeal zone in the prevention of attacks, and other issues are considered.

Effective comprehensive treatment of patients with bronchial asthma will help many of them get rid of the development of symptoms of the disease, prevent severe exacerbations, minimize the need for medications to stop attacks and improve the quality of life. To achieve this, a long interaction and compliance of the patient, his parents and the doctor are required.

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