Bronchial asthma - complete information about the disease

Bronchial asthma is a multifactorial disease that is closely associated with chronic inflammation in the respiratory tract, involvement in the pathological process of various cellular elements (mast cells, eosinophils, T-lymphocytes) and a multitude of inflammatory mediators. It is determined by the detection in the anamnesis of clinical manifestations from the respiratory organs, which is manifested by repeated attacks of suffocation, breathing accompanied by hissing sounds, a feeling of compression in the chest, an increasing cough in the night and early morning hours; the severity of these manifestations changes with the passage of time. In addition, there is a variability in the limitation of air flow during exhalation.

Chronic inflammation in the bronchi is very often combined with hyperreactivity of the bronchi.

Epidemiology

Bronchial asthma is characterized by significant prevalence and is accompanied by a significant incidence rate, which makes it a global medical and socioeconomic problem.

Approximately 300 million people suffer from bronchial asthma in the world, but these figures are somewhat understated due to the fact that in many cases the diagnosis of bronchial asthma is established with significant delay. The existing number of affected persons is increased by 50% every subsequent decade.

At present, there is a problem not only of asthma hypodiagnosis, but also its overdiagnosis. In 25-35% of patients with a diagnosis of asthma, established by general practitioners, he is not confirmed with a qualified examination.

Bronchial asthma is affected equally by people of both sexes and different age groups.

In the overwhelming majority of states (mainly with inadequate economic development) an increase in the incidence of bronchial asthma is registered.

In economically developed regions, the prevalence of the disease is stabilized, which is accompanied by a significant reduction in mortality from this disease. To a certain extent, this is due to a decrease in environmental pollution, timely diagnosis and qualified multifaceted and highly effective treatment.

Etiology

The factors leading to the development of bronchial asthma have not been adequately studied. The most important factors include burdened heredity and various inhaled substances that are capable of causing an allergic response of the body or mechanical irritation of the respiratory tract.

The heterogeneous causes of bronchial asthma development are distinguished by a complex combination and influence on each other. This burdened heredity, natural and climatic conditions in which the patient lives, pollution of the environment, socio-economic level, belonging to a particular race.

Risk factors can be divided into those that lead to the formation of bronchial asthma, and the factors that trigger its aggravation.

In addition, there are risk factors for the individual:

  • hereditary (presence in the body of a gene predisposing to atopic reactions and bronchial hyperreactivity);
  • obesity;
  • Sexual accessory (male sex in childhood, female - in adults).

And external factors:

  1. Various allergens (household mites and allergens of various insects (cockroaches), wool of domestic animals, mushrooms (mold, yeast));
  2. infections, mainly viral;
  3. Various chemical factors in production;
  4. smoking (active or passive);
  5. all kinds of air pollution in residential and industrial premises and the environment.

There are different phenotypes of the disease. The most common are:

  • Allergic bronchial asthma, which most often occurs in childhood and is combined with any allergic disease (eczema, allergic rhinitis, food or drug allergy in history).
  • Non-allergic bronchial asthma, in which, as a rule, patients react worse to treatment with inhaled corticosteroids.
  • Bronchial asthma with late onset, which often develops in women in adulthood and when it is treated, it becomes necessary to use higher dosages of inhaled corticosteroids.
  • Bronchial asthma with a fixed airflow rate limitation, which can be a consequence of remodeling of the walls of the bronchial tree.
  • Bronchial asthma on the background of obesity is marked by severe symptoms and minor eosinophilic inflammation of the bronchi.

Pathogenesis

The complex and diverse pathogenesis of bronchial asthma has not been adequately studied. In the inflammatory process with bronchial asthma, a number of inflammatory cells and a large number of inflammatory mediators are involved, which is accompanied by certain pathophysiological processes.

The heterogeneous combination and complex interactions of these etiological factors in predisposed individuals contribute to the emergence and maintenance of chronic inflammation in the respiratory tract, which leads to hyperreactivity of the bronchi, development of asthmatic symptoms, which characterizes the pathological process in bronchial asthma.

With various manifestations of the disease, differences in pathophysiological processes, chronic inflammation of the respiratory tract is considered the basis for characterizing the disease. Inflammation in the bronchial tree with bronchial asthma progresses even with episodic symptoms, and the relationship between the severity of the disease and the severity of inflammation is far from always distinct.

The inflammatory process develops in all parts of the respiratory tract, encompassing the upper respiratory tract, the mucous membrane of the nose, but is more pronounced in the bronchial tubes of the middle caliber.

The process of inflammation occurs with various clinical forms of bronchial asthma - allergic, non-allergic, aspirin.

The inflammatory process in bronchial asthma has some characteristics peculiar to allergic conditions: activation of mast cells, an increase in the number of activated eosinophils, and an increased number of receptors of unchanged natural killer T cells, as well as type 2 T helper cells that produce inflammatory mediators, leading to the development of symptoms of the disease.

Structural cells of the respiratory tract also have the ability to produce inflammatory mediators, which can support the inflammatory process.

The result of all pathophysiological processes is the development of constriction of the respiratory tract, which leads to a characteristic clinical symptomatology and pathophysiological changes in bronchial asthma.

The mechanism of the appearance of airway hypersensitivity, which is of great importance in the process of maintaining inflammation, has not been studied enough. Hypersensitivity becomes the cause of narrowing when exposed to various irritation factors that do not occur in healthy individuals. Reduction of airway clearance in bronchial asthma is accompanied by a variable restriction of airflow in the bronchi and the emergence of intermittent symptoms.

Bronchial hyperreactivity is caused by an increase in the volume and / or contractility of the structures of the smooth muscles of the respiratory tract, desynchronization of their contractions, changes in the geometry of the bronchi and sensitization of the afferent nerve endings, which in turn is accompanied by excessive contraction of the smooth muscle fibers of the respiratory tract and bronchoconstriction.

Clinical picture

Typical manifestations of bronchial asthma are episodes of attacks of dyspnea, wheezing, coughing (with or without possible sputum), feelings of constriction in the chest.

Individual patients can not assess the severity of their condition, about 10% of patients during an attack do not feel suffocation and shortness of breath, complaining only of coughing and wheezing at breathing. Often develops more than one of these symptoms, which are characterized by a wavy current and varying intensity. Predominantly, the symptomatology occurs or worsens at night, on awakening, is significantly heavier when combined with viral infections.

In the development of an attack, there are usually three periods:

  1. The period of precursors, which is characterized by the appearance of symptoms of conjunctivitis, allergic rhinitis or pharyngitis after exposure to the allergen.
  2. The asthma attack itself develops suddenly, most often at night or in the early morning hours, and lasts from several minutes to several hours. During an attack the patient feels a shortage of air of varying degrees. Develops expiratory dyspnea and cough. The character of the latter can have different qualitative characteristics: most often dry, paroxysmal or with the release of a small amount of viscous vitreous sputum.

The patient usually takes a forced position (sits, leaning his hands on the bed), sometimes rises quickly from the bed and runs up to the window, opens it or the window. The patient makes intensive breaths, the accessory muscles participate in the act of breathing, the intercostal spaces are drawn in.

The facial expression of the patient becomes frightened, pale with a cyanotic shade and a drop of cold sweat. The thorax is enlarged in volume and has the appearance as if it were delayed at maximum inspiration. The frequency of respiratory movements can reach 25-30 per minute, in 25-30% of cases - more than 30; heart rate - up to 120 per minute.

Percutaneously determined boxed sound, the tour of the lower edge of the lungs is significantly limited. Against the background of weakened vesicular breathing with a sharply elongated phase of exhalation, a large number of wheezing sounds are audible, which are audible at a distance.

The period of reverse development begins spontaneously or under the influence of pharmacotherapy. At the same time, separation of vitreous thick sputum begins and a decrease in the symptoms of bronchial obstruction.

In addition, seizures can be triggered by increased physical exertion, laughter, inhalation of cold air or the influence of allergens, the adoption of certain pharmaceuticals, tobacco smoking.

The most common symptomatology of bronchial asthma occurs after contact with air-allergens and irritants. In some patients, seasonal exacerbation of the disease due to sensitization to pollen of plants during their flowering is recorded.

The cough variant of bronchial asthma is characterized by a cough, as the predominant (and in some episodes and the only) symptom of the disease.

The "cough" course of bronchial asthma most often develops in young people and children.

Bronchoconstriction, which is caused by physical exertion, is sometimes the only manifestation of the disease. Bronchospasm often develops 5-10 minutes after the termination of physical activity (relatively less often in the process of physical exertion), while patients develop typical symptoms of bronchial asthma, sometimes manifested by persistent cough, self-stopping after 40-45 minutes.

To evaluate the course of bronchial asthma, three parameters are traditionally used: etiology, the severity of the disease and the degree of achievement of its control.

Etiological cause of the disease is often not clear; In addition, the cause of the disease is often several pathogenic factors.

The level of control of bronchial asthma and the risk of complications assesses the patient's response to ongoing pharmacotherapy:

  • controlled bronchial asthma;
  • partially controlled bronchial asthma;
  • Uncontrolled bronchial asthma.

In addition, it is necessary to assess the possible risk (risk of exacerbations, destabilization, rapid reduction in lung function, side effects from the treatment):

Signs associated with a high risk of exacerbations of bronchial asthma:

  1. severe or frequent bouts of bronchial asthma in history, in which there was a need for intensive care and / or intubation;
  2. insufficient control over the course of bronchial asthma;
  3. inadequate inhalation therapy, non-use of inhaled corticosteroids, unscrupulous patient compliance with the doctor's recommendations;
  4. excessive use of short-acting β2-agonists (more than one balloon per 200 doses for a month);
  5. frequent exacerbations over the past year;
  6. any hospitalization for exacerbation of bronchial asthma;
  7. decrease in forced expiratory volume in the first second to 60% and below;
  8. significant psycho-emotional and socio-economic problems;
  9. the effect of tobacco smoke and allergens;
  10. the presence of obesity, rhinosinusitis, food allergy, sputum eosinophilia or blood;
  11. pregnancy.

The presence of the above factors is accompanied by an increased risk of exacerbations even with satisfactory control or absence of symptoms of the disease.

Risk factors for the formation of irreversible obstruction:

  • untimely appointment of inhaled glucocorticoids;
  • the influence of cigarette smoke and aerosolutions;
  • insufficient volume of forced exhalation in the first second;
  • chronic hypersecretion of mucous secretions;
  • presence of eosinophilia of sputum or blood.

Risk factors for side effects of drug therapy:

  1. frequent and long-term courses of pharmacotherapy with tableted forms of glucocorticoids;
  2. long-term use, high dosages of inhaled glucocorticoids;
  3. inclusion in the scheme of pharmacotherapy of inhibitors of cytochrome P450;
  4. improper technique of inhalation.

The severity of the course of bronchial asthma is currently recommended to be considered only retrospectively in terms of the amount of pharmacotherapy used to achieve control of the disease after several months of fully selected basic therapy.

A mild degree of severity is exhibited when control of bronchial asthma is achieved after the use of exceptionally short-acting ?-agonists as needed or low doses of inhaled corticosteroids or antileukotriene pharmacological preparations, which corresponds to 1-2 steps of pharmacotherapy.

The average degree of severity is determined when the control of bronchial asthma is reached in cases of initial dosages of inhaled corticosteroids in combination with prolonged ?-agonists or average dosages of inhaled corticosteroids, which corresponds to the third step of pharmacotherapy.

A severe degree of bronchial asthma flow is established in cases when a significant amount of pharmacotherapy corresponding to 4-5 steps is necessary to achieve sustainable control, or despite the use of intensive pharmacotherapy, it is not possible to control bronchial asthma.

Important importance is given to differentiation of the severe course of bronchial asthma from insufficiently controlled.

In addition to the typical symptoms of bronchial asthma, it is necessary to pay attention to certain pathophysiological features of the disease in certain specific situations:

  • Exacerbations of asthma or transient worsening of bronchial asthma with loss of disease control, provoked by significant physical exertion, air pollution or naturally caused factors. Prolonged worsening, as a rule, is supported by a viral infection of the respiratory tract, as well as the influence of allergens, aggravating inflammation in the lower respiratory tract.
  • Nocturnal asthma, which is characterized by worsening during the night period of time and depends on circadian rhythms of hormone circulation and neurogenic activation (increased cholinergic tone in the night period), decreased activity of endogenous anti-inflammatory mechanisms.
  • Bronchial asthma, difficult to treat, often develops for unknown reasons. Individual patients experience reduced sensitivity to glucocorticoid pharmaceuticals and are practically uncontrolled. Sometimes this is due to an unfair attitude towards their treatment, in some episodes such a course has a dependence on the genetic characteristics of the individual.
  • Irreversible bronchial obstruction is characterized by a progressive violation of external respiration, which is irreversible under the influence of treatment.

Diagnostics

To confirm the diagnosis of bronchial asthma, important attention is given to a detailed history. When polling a patient, it is necessary to find out the occurrence of a wheezing in the past, an indomitable night cough, the appearance of wheezing soon after physical exertion or after contacting allergens and pollutants, prolonged for more than 10 days, colds with a gradual involvement of the lower respiratory tract.

The diagnosis of bronchial asthma is based on a combination of typical clinical symptoms and evidence in favor of a variable rate limit for exhaled airflow. This should be recorded with a bronchodilator reversibility test using a bronchodilator or other instrumental studies. Bronchial asthma, as a rule, is associated with inflammation of the bronchi and their hyperreactivity, but to verify the diagnosis, these symptoms are not mandatory or sufficient.

An additional value for diagnostics also has research methods that reveal the relationship with sensitization and the eosinophilic nature of inflammation in the airways.

In patients with unexpressed clinical symptoms and the absence of a reliable effect of risk factors, instrumental techniques do not have a significant diagnostic value because of the high probability of false positive and false negative results.

Identification of signs of reversible bronchial obstruction in spirometric studies or significant differences in the parameters in determining the peak air velocity throughout the day allows to confirm with high confidence the diagnosis of bronchial asthma.

The increase in the number of eosinophils in sputum and blood, the increase in the fraction of nitric oxide in the exhaled air, the detection of allergic sensitization allows us to conclude that a possible development of bronchial asthma. Negative results of the above indicators do not provide a reliable opportunity to exclude bronchial asthma.

Other methods of investigation (X-ray, endoscopic) can be used for differential diagnosis.

To diagnose and control the course of bronchial asthma, the following instrumental studies are used:

  1. spirometry and bronchodilation test;
  2. peakflowmetry;
  3. assessment of bronchial hyperreactivity;
  4. non-invaliive detection of markers of airway inflammation;
  5. Assessment of allergic status.

Differential diagnostics

Bronchial asthma must be differentiated from the following disease states:

  • hyperventilation syndrome and panic attack;
  • obstruction of the upper respiratory tract and aspiration of foreign bodies;
  • dysfunction of the vocal cords;
  • cystic fibrosis;
  • gastroesophageal reflux disease;
  • other obstructive pulmonary diseases, especially chronic obstructive pulmonary disease;
  • non-obstructive pulmonary diseases (interstitial lung diseases);
  • non-respiratory diseases (left ventricular heart failure);
  • Congenital heart disease;
  • pulmonary embolism.

Moreover, bronchial asthma can occur in combination with any of these conditions or a combination of them, which greatly complicates the diagnosis, assessment of the severity and level of its control.

Evaluation of bronchial asthma

In all patients, assessment of bronchial asthma should include an assessment of the control of bronchial asthma (both control of symptoms and possible risks of adverse future outcomes), assessment of problems associated with treatment - especially with regard to the correctness of the technique of inhalation and compliance with the recommended regimen (adherence to treatment) - as well as an assessment of various co-morbidities that can worsen the tolerability of symptoms and quality of life. Determination of the parameters of the function of external respiration, especially the volume of forced expiration at the 1st second in the form of a percentage calculated from the proper index, is an important part of the assessment of the possible risk of worsening of the course of the disease in the future.

The level of control of bronchial asthma indicates how severe the symptomatology of bronchial asthma is in a particular patient or how much their severity (up to complete absence) as a result of treatment has changed.

Treatment

The main goals and objectives in the treatment of bronchial asthma:

  1. elimination of symptoms of the disease and their subsequent prevention;
  2. achievement of a satisfactory quality of life;
  3. decrease in the need for β2-agonists;
  4. if possible, the preservation of pulmonary function, close to normal;
  5. prevention of exacerbations;
  6. reducing thli risk of adverse effects of ongoing pharmacotherapy;
  7. Decrease in the level of lethality.

The patient is assigned individual stepwise treatment, which corresponds to one of the stages of pharmacotherapy (in accordance with the recommendations of GINA 2014):

1 st stage - if necessary, the use of short-acting β2-agonists, the question of the use of low doses of inhaled corticosteroids is considered individually;

2 nd stage - low doses of inhaled corticosteroids are necessarily prescribed, antileukotriene medications, low doses of theophylline may be used;

Stage 3 - low doses of inhaled corticosteroids in combination with prolonged β2-agonists are necessarily prescribed; additional pharmaceuticals include medium or high dosages of inhaled corticosteroids or their combination with anti-leukotriene drugs;

4th stage - mandatory - medium or high dosages of inhaled corticosteroids in combination with prolonged β2-agonists; to additional pharmaceuticals include high dosages of inhaled corticosteroids in combination with antileukotriene pharmaceuticals or theophylline;

5th stage - other pharmaceuticals (for example, anti-IgE antibodies), systemic corticosteroid therapy with low dosages are additionally assigned to the 4th stage treatment regimen.

At any stage of pharmacotherapy, if short-term β2-agonists are required to rapidly relieve the symptoms of the disease and alleviate the condition of the patient as an emergency drug.

In separate episodes (3-5 stages of pharmacotherapy in patients with frequent exacerbations), it is more preferable to use inhaled corticosteroids in combination with formoterol (SMART-therapy) as an emergency aid.

For the treatment of bronchial asthma, pharmaceuticals and various non-pharmacological treatment methods are used.

Pharmaceuticals used to treat bronchial asthma are divided into "basic", with which it is necessary to achieve control over the course of the disease, and "symptomatic", by which short-term attacks of exacerbation of the disease are arrested.

Basic pharmacotherapy provides for daily intake of pharmaceuticals indefinitely for clinical control of bronchial asthma, which are mainly characterized by anti-inflammatory effect. Symptomatic therapy - the use of high-speed pharmaceuticals to eliminate bronchospasm and related disorders in other organs and systems.

The administration of drugs is carried out by inhalation, oral and parenteral routes. More preferable is the inhalation route of administration, since the drug directly enters the respiratory tract, creating an effective local concentration, and thus reduces the risk of development or severity of the side effects of pharmaceuticals.

Devices, through which the delivery of pharmaceutical means by inhalation, are divided into metered aerosol inhalers, their versions and metered powder inhalers. It is necessary to pay attention to delivery devices of a certain type, which, without the use of a propellant, produce a "slow" cloud containing finely dispersed pharmaceutical means, which greatly facilitates delivery.

It should be borne in mind that in some patients with severe bronchial asthma and a reduced inspiratory reserve, the effectiveness of the use of metered-dose powder inhalers may decrease.

The effectiveness of drug delivery to the lower respiratory tract depends on the design of the inhaler and the form of the drug, the particle size, the speed of the aerosol flow or the "cloud" and the correct use of the device. In this regard, it is very important to select an effective delivery device and teach the patient how to apply it effectively.

Inhaled glucocorticoids in the present period of time are the most effective pharmaceuticals for the treatment of bronchial asthma.

In patients suffering from smoking, the therapeutic effect of inhaled glucocorticoids is reduced, so a dose adjustment upward, categorical refusal of smoking is necessary.

Antileukotriene pharmacological preparations in separate episodes can be used instead of inhaled glucocorticoids (in patients of advanced age with a mild persistent disease course, with aspirin asthma).

This group of pharmaceuticals is less effective in achieving control of bronchial asthma, therefore, replacing them with inhaled glucocorticoids is not recommended.

Prolonged β2-agonists, tiotropium, theophylline, and cromona are usually used as an additional therapy in combination with inhaled glucocorticoids.

Anti-IgE antibodies are used in patients with severe bronchial asthma with a significant increase in IgE in the blood and inadequate effect of inhaled corticosteroids.

Systemic glucocorticoid therapy, which does not refer to symptomatic therapy, is used in case of severe exacerbations of bronchial asthma.

Symptomatic therapy is aimed at the rapid arrest of bronchoconstriction with bronchodilator drugs mainly characterized by influence on smooth muscles.

At the present time, pharmaceutical preparations of the group of β2-agonists, anticholinergics and theophylline are used. The most effective are β2-agonists.

Allergen-specific therapy is used infrequently and only after the determination of clinically significant antigens in a particular patient.

Control over the effectiveness of treatment provides a cyclical approach, which makes it possible to reduce overdiagnosis and timely to conduct adequate correction of pharmacotherapy based on a regular reassessment of the severity of the course of the disease.

Exacerbation of bronchial asthma is the development of acute or subacute episodes of the progression of clinical symptoms (shortness of breath, coughing, wheezing, chest stiffness or a combination of them) in comparison with the patient's usual condition.

Such episodes have fundamental differences from the unsatisfactory control of bronchial asthma: exacerbation of bronchial asthma is not accompanied by significant changes in airflow rate during the day (the main sign of unsatisfactory control of bronchial asthma), but their decrease compared to the state before exacerbation.

It must be taken into account that it is very difficult to differentiate the slight exacerbation of bronchial asthma from the temporary loss of control of bronchial asthma.

Treatment of exacerbations of bronchial asthma should ensure:

  • maintenance of adequate oxygen saturation,
  • improvement of the function of external respiration,
  • cupping of inflammation in the bronchi for faster resolution of bronchial obstruction and prevention of exacerbation.

The oxygen supply must be carried out through the nasal cannula or mask, maintaining oxygen saturation at a level of 93-95%.

When suppressing asthma exacerbation, high doses of short-acting β2-agonists are used, which allows to overcome significant anatomical obstacles (edema of the bronchial mucosa, spasm of smooth muscle fibers, congestion of mucus in the bronchus lumen), and also the dose-dependent character of the effectiveness of short-acting β2-agonists.

A sufficient dose of an inhaled corticosteroid applied within 1 hour after treatment reduces the need for hospitalization in patients who have not received systemic corticosteroids.

Patients who, after initial therapy, have severe bronchial obstruction, it is recommended that inhalations of ipratropium bromide be added to treatment.

Systemic use of glucocorticoids is the main method of arresting the inflammatory reaction in the bronchi during exacerbation of bronchial asthma, with the exception of episodes with very mild exacerbation of asthma.

The rate of entry and severity of the effect for oral and intravenous administration of glucocorticoids in the vast majority of patients is equivalent, so intravenous glucocorticoids are reserved primarily for patients with very severe obstruction and swallowing.

After restoring bronchial conductivity, it is recommended to continue taking glucocorticoids for 5-7 days to prevent exacerbation.

With exacerbation of bronchial asthma with anaphylaxis and / or angioedema, in addition to standard therapy, intramuscular injection of epinephrine is indicated. The routine use of epinephrine in other types of exacerbations of bronchial asthma is not shown.

Intravenous administration of magnesium sulphate improves the ventilation function in patients with severe and life-threatening exacerbation of bronchial asthma, but is not indicated with a mild exacerbation of asthma.

The use of euphyllin is significantly inferior to inhaled short-acting β2-agonists, so the standard undifferentiated use of euphyllin in asthma exacerbation is unacceptable.

It is often necessary to repeatedly reassess the clinical state and oxygen saturation, and the amount of subsequent pharmacotherapy is regulated in accordance with the response to treatment. The parameters of the function of external respiration should be measured after 1 hour, and patients who develop deterioration despite intensive bronchodilator and glucocorticoid medication should be re-examined in order to assess the need for transfer to the intensive care unit or resuscitation.

Severe exacerbation of bronchial asthma (asthmatic status) is a seizure of bronchial asthma characterized by severe severity and resistance to standard or routine bronchodilator therapy, which, if not adequately treated, may result in death.

A severe exacerbation develops in approximately 30% of patients with bronchial asthma, mortality according to various authors is from 1 to 10%.

Severe exacerbation of asthma with a slow rate of development

Etiopathogenesis

Quite often, such a form of exacerbation is caused by infection of the tracheobronchial tree (bacterial and especially viral) and various treatment defects.

The most frequent cause of an exacerbation is inadequate illness severity, patient treatment, insufficient use of basic pharmaceuticals, primarily inhaled glucocorticosteroids. In some episodes, the abuse of β2-agonists is accompanied by damage to the mucous membrane of the respiratory tract by gas freon, which is used in metered-dose inhalers, which leads to difficulty in separating the sputum, reducing receptor susceptibility to β2-agonists.

Progressing bronchial obstruction leads to disruption of gas exchange and acid-base state, water-electrolyte metabolism.

Increasing hyperventilation with an increase in the work of the respiratory musculature, profuse sweating and limited fluid intake is accompanied by an even greater viscosity of sputum, a decrease in the volume of circulating blood is accompanied by circulatory hypotension.

Clinical picture and diagnosis

This aggravation is accompanied by an ineffective, unproductive cough that is practically not accompanied by sputum production, and a rapidly growing picture of acute respiratory failure, dyspnea, progressive cyanosis.

The patient is in a forced position (orthopnea), profuse sweating is noted, difficulty in talking because of dyspnea, participation in the act of respiration of the auxiliary muscles of the neck, and pulling over- and subclavian spaces. The frequency of respiratory movements exceeds 25 per minute, the heart rate is over 110 per minute, audible at a distance noisy wheezing on exhalation.

In the absence of adequate treatment, the patient's condition deteriorates steadily, the disturbances from the central nervous system are added (periodic excitation or, conversely, apathy, contact with the patient is difficult), formal mental disorders (hallucinations and delusions, hallucinations) followed by loss of consciousness and coma.

The diagnostic criterion for severe exacerbation is the absence of improvement in the patient's condition after a 3-fold every 20 minutes of inhalation of high-dose β2-agonists in high doses (including through the nebulizer), and peak expiratory flow is less than 60% of the proper or best individual indicator.

The severity of the condition is estimated by oxygen saturation and peak expiratory flow rate.

Treatment

Medical measures should be carried out in the intensive care unit without delay.

The therapeutic measures of the first line include the use of a high-speed β2-agonist, previously prescribed systemic glucocorticoid pharmaceuticals and oxygen.

Second-line therapy includes the use of anticholinergic fast-acting pharmaceuticals, theophylline preparations and parenteral forms of β2-agonists, and posidrome therapy.

In extremely severe conditions, the patient is transferred to the artificial ventilation of the lungs.

The outcome of a severe exacerbation of asthma can be a fatal outcome, the cause of which is most often asphyxia due to obturation of bronchi viscous sputum and swelling of bronchial mucosa, to a lesser extent - bronchospasm.

Severe exacerbation of asthma with sudden onset

This form is marked by the marked development of a decrease in the sensitivity of mucosal receptors to β2-agonists and, as a rule, occurs unexpectedly in massive contact with allergens, more often at the time of administration (or soon thereafter) of antibiotics, sulfonamides, proteolytic enzymes, vaccines, serums.

In essence, this form is an anaphylactic shock associated with sensitization by pharmaceuticals or other allergens. In addition to generalized bronchial obstruction, mainly due to bronchospasm, patients have a rapid decrease in blood pressure, a threadlike frequent pulse, a cold sweat. The state deteriorates catastrophically quickly.

Progression of suffocation of an expiratory character, the widespread cyanosis of the skin and mucous membranes, there is motor excitation, followed by apathy and a violation of consciousness. After a short time, convulsions develop, and within a few minutes (less often after 1-3 hours) a hypoxemic-hypercapnic coma develops.

The genesis of such an exacerbation of bronchial asthma is not always allergic.

Generalized bronchospasm may develop with the use of certain pharmaceuticals (non-steroidal anti-inflammatory drugs, ?-adrenoblockers), inhalation of cold air, sharp odors acting as nonspecific irritants, with neuro-emotional stress.

Severe exacerbation of bronchial asthma with a sudden onset presents a real threat to the life of the patient and requires vigorous urgent measures.

These include:

  • restriction of the intake of substances that provoked this exacerbation;
  • intravenous fluid administration of sympathomimetics, glucocorticosteroids, euphyllin;
  • intravenous injection of anti-shock solutions;
  • if there is no clinical effect in the first minutes, the patient must be transferred to artificial ventilation.

Mortality with sudden severe exacerbation of bronchial asthma is much higher than with exacerbation with slow development.

Complications

Complications of bronchial asthma are divided into local (pulmonary) and general (extrapulmonary):

  • Pulmonary: emphysema, respiratory failure, atelectasis, pneumothorax, pneumosclerosis, bronchiectasis, asthmatic status.
  • Extrapulmonary: myocardial dystrophy, pulmonary heart, heart failure, cardiac arrhythmias.

Forecast

alert
With the control of asthma, the prognosis of patients with bronchial asthma is optimistic.

Prevention

Primary prophylaxis is aimed at adequate treatment of acute and chronic respiratory diseases, sanation of foci of chronic nasopharyngeal and sinus infection, hardening of the body to improve its resistance to catarrhal diseases, as well as elimination or minimization of exposure to occupational hazards, non-smoking, exclusion of passive smoking.

Elimination of potentially dangerous allergens from the environment with a hypoallergenic diet, excluding contact with animal hair, house dust and others.

Secondary prevention is not only in the treatment of bronchial asthma, but also in the implementation of rehabilitation measures at various clinical stages of the course of the disease.

All patients should be provided with a written plan of activities for bronchial asthma that corresponds to their current level of control of bronchial asthma and their medical literacy so that they know how to recognize the exacerbation of asthma and how to respond to it.

It is necessary to identify patients with an increased risk of death related to bronchial asthma and to make notes in their medical records as individuals in need of more frequent observation.

After any aggravation it is necessary to organize follow-up at an early stage, regardless of where the treatment was performed.

It is necessary to evaluate the control of symptoms in the patient and the risk factors for exacerbations that he has in the future.

In the overwhelming majority of cases, in order to reduce the risk of exacerbations in the future, it is necessary to prescribe a permanent pharmacotherapy with a drug for controlling the disease.

The patient needs to monitor the correctness of the inhalation and adherence to therapy.

Tertiary prevention (rehabilitation) is a complex of psychological, pedagogical, social measures aimed at eliminating or compensating for life limitations, restoring lost functions with the aim of possibly recovering social and professional status as completely as possible.