Obstructive bronchitis. Bronchial asthma. Part 1

Bronchial asthma is a chronic relapsing disease that primarily affects the respiratory tract. Characterized by altered bronchial reactivity. A mandatory sign of the disease is an attack of suffocation and status asthmaticus. In most cases, the onset of the disease occurs in childhood and adolescence. However, the disease can begin to develop at any age. To diagnose bronchial asthma, pulmonologists at the Yusupov Hospital conduct a comprehensive examination of patients using modern laboratory and instrumental research methods. Patients are advised by an immunologist-allergist.

If a patient develops broncho-obstructive syndrome for the first time in old age, pulmonologists at the Yusupov Hospital must carry out a differential diagnosis with a number of diseases similar in clinical course (chronic obstructive disease, pulmonary embolism, acute left ventricular failure, lung tumor). To make a diagnosis of bronchial asthma, doctors establish the connection between the appearance of symptoms of the disease after contact with an allergen, the combination with rhinitis, seasonal variability of symptoms, the presence of a genetic, hereditary predisposition to allergic reactions in close relatives and the patient.

Pulmonologists individually select medications to treat each patient. Therapy is carried out with drugs registered in the Russian Federation, which are effective and have a minimal range of side effects.

Bronchial asthma is characterized by:

• Increased or inadequate reaction of the bronchi (hyperreactivity) to the allergen;
• Excessive production of bronchial secretions;
• Chronic and protracted course;
• Recurrent (paroxysmal) nature;
• Shortness of breath;
• wheezing;
• Attacks of dry cough.

Despite numerous studies devoted to this topic, the problem of diagnosing and treating bronchial asthma remains relevant.
The true prevalence and incidence of asthma is difficult to estimate. This may well be due to the fact that different countries use certain diagnostic criteria that are specific only to this region. Rapid urbanization, environmental pollution, chemicalization of agriculture and the constant use of inorganic food additives have all led to a rapid increase in allergization of the world's population. To date, the highest incidence of bronchial asthma has been recorded in the USA, the Russian Federation and Australia. Treatment of bronchial asthma in Moscow is successfully carried out by specialists from the Yusupov Hospital Therapy Clinic. Experienced doctors with extensive experience use modern techniques for diagnosing and treating various diseases of the respiratory system. Thanks to close cooperation with European clinics and the exchange of experience, patients at the Yusupov Hospital Therapy Clinic have a unique opportunity to receive the most effective and safe medications for the treatment of bronchial asthma, which have minimal side effects on the body.

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The main reasons for the development of the disease

Bronchial asthma is a multifactorial disease, that is, it has different causes of development - both external and internal. Traditionally, asthma is believed to be caused by specific allergens:

• Food (honey, citrus fruits, nuts, legumes, seafood, eggs);
• Pollen;
• Fungal;
• Household (feather pillows, house and library dust);
• Animal fur;
• With pincers.

In order for hypersensitivity of the trachea and bronchi to occur, the amount of allergens during contact with them must be very large.
In the future, if the period of sensitization has passed, only a small part of the allergen is enough to trigger an attack of bronchial asthma. In second place after allergens are pharmacological agents:

• Non-steroidal anti-inflammatory drugs;
• Beta blockers;
• Various dyes;
• Aspirin is a classic drug that can provoke acute bronchospasm. A typical attack of aspirin asthma is combined with vasomotor rhinitis and rhinosinusitis.

Environmental factors also play an important role in the occurrence of asthma.
It is most often found in areas with developed heavy industry, high population density, dry climate, frequent temperature changes and stagnant air masses. The fourth reason for the development of AD is considered to be industrial waste. Bronchospasm can be caused by exposure to a variety of compounds used in industry:

• Salts of heavy metals (nickel, chromium, platinum);
• Wood and plant pollen (cedar, oak, cocoa);
• Polymers;
• Household chemicals;
• Various paints and solvents.

Physical activity can provoke the appearance of symptoms of bronchospasm and bronchial obstruction.
The mechanism of development for this type of bronchial asthma involves temperature changes that occur in the bronchi as a result of increased ventilation and subsequent cooling and dryness of the inhaled air. In addition, a well-known factor is that psycho-emotional lability can both aggravate and improve the patient’s condition. This is directly related to changes in the tone of the vagus nerve. The vagus nerve is responsible for the motor activity of the smooth muscles of the tracheobronchial tree.

Why is it difficult to breathe with asthma?

Bronchial asthma is based on chronic inflammation of the airways. With obstruction, a narrowing of the lumen of the bronchi occurs - so much that air cannot pass through, causing shortness of breath and wheezing.

Obstruction occurs due to chronic inflammation. Edema, hyperemia of the mucous membrane, thickening of the bronchial wall. Mucus is released, most often thick, difficult to separate, white.

PHOTO: EVERYDAY HEALTH

Development mechanism

The general mechanism of development, which is inherent in different types of bronchial asthma, is a change in the sensitivity and reactivity of the bronchi, which is determined by the reaction of bronchial patency in response to the influence of pharmacological and physical factors.
In persons suffering from the atonic variant of bronchial asthma, the disease is of hereditary origin. Nonbacterial (plant pollen, house dust, animal hair, bird down and feathers) and bacterial (viruses, bacteria, fungi) allergens play a role in the occurrence of allergic forms of asthma. The mechanisms that underlie different types of inflammation are not well understood.

It is assumed that predominantly eosinophilic inflammation is associated with the activation of Th2 lymphocytes and their increased production of interleukins-5 and 13. Neutrophilic inflammation may be a consequence of the use of inhaled and systemic glucocorticosteroids. With an unexpressed inflammatory process, smooth muscles, fibroblasts and neurons of the respiratory tract play a leading role in the development and progression of the disease. The central role of immunoglobulins E in atopic asthma has been proven.

In bronchial asthma, remodeling of the airways occurs:

• Thickening of the basement membrane;
• Thickening and increase in the number of smooth muscles and goblet cells due to their excessive formation;
• Formation of new vessels.

This leads to irreversible changes in the ventilation function of the lungs and the appearance of ventilation defects. The central place in the mechanism of development of “aspirin” asthma is given to leukotrienes. In physical exertion asthma, heat transfer from the surface of the airways is disrupted.

Bronchial asthma and asthma-like conditions

B

ronchial asthma (BA) is a disease that is sometimes diagnosed in late stages. One of the reasons for late diagnosis is the variety of clinical manifestations of asthma and asthma-like conditions.

The modern concept of asthma is based on the postulate that its occurrence and development is based on a chronic inflammatory process in the mucous membrane of the respiratory tract. Features of the inflammatory process are associated with the nature of the cells migrating into the bronchial mucosa and their biological activity. The products of eosinophils, characteristic of the inflammatory process in asthma, are Charcot-Leyden crystals; Their inflammatory activity is also associated with an increase in the concentration of nitric oxide in exhaled air. Without questioning the inflammatory nature of asthma, it should be emphasized that for the daily practical work of a doctor, the inflammatory theory of the disease has not yet provided reliable and non-burdensome diagnostic methods. The main method remains the study of forced expiratory volume in 1 second (FEV1) and its increase after inhalation of salbutamol. Thus, the diagnosis of asthma is based on evidence of airway obstruction (decreased FEV1) and its reversibility under the influence of a bronchodilator drug (reversible airway obstruction and hyperresponsiveness phenomenon).

In the practice of English doctors, functional methods are widely used for the diagnosis and dynamic monitoring of patients with asthma. So, if a patient comes to an appointment with complaints of cough and signs of airway obstruction, then he is asked to examine the peak expiratory flow (PEF) using a peak flow meter in the morning and evening. At the second meeting, the PSV schedule drawn up by the patient is analyzed. In patients with asthma, the difference between morning and evening PEF values ​​exceeds 15–20%. Peak flowmetry is one of the inexpensive and accessible methods; Subsequently, the doctor uses it to assess the effectiveness of the therapy, and the patient uses it to self-monitor his condition.

It is possible that objective difficulties underlie the early diagnosis of asthma. Modern epidemiological studies reveal a high prevalence of asthma, which, varying depending on the geographical area, exceeds 5% in the general population, and more than 10% among children. There have been no organized epidemiological studies on the heterogeneous group of asthma-like diseases. It can be assumed that they occur several times more often than AD.

Asthma-like diseases

This work aims to analyze modern recommendations for the differential diagnosis of asthma and asthma-like diseases. Most often it is necessary to carry out a differential diagnosis with chronic obstructive bronchitis and pulmonary emphysema in the stages of development of respiratory failure, as well as with a large group of diseases that can be combined on the basis of chronic cough.

The term asthma-like diseases denotes a diverse group of diseases that have different pathogenesis, but whose clinical picture is characterized by the development of suffocation. It undergoes reverse development either spontaneously or under the influence of anti-asthmatic drugs. From a practical point of view, the term asthma-like conditions is used to provide a more thorough differential diagnosis among a large group of diseases.

COPD

Chronic obstructive pulmonary disease (COPD) causes certain difficulties in differential diagnosis. International recommendations place the nature of obstruction in the first place: for COPD, the leading symptom is increasing obstructive breathing disorders, which are only partially reversible with treatment. In patients with COPD, when conducting a diagnostic test with bronchodilators (salbutamol), the increase in FEV1 does not exceed 12%. Another clinical feature of this group of patients is the low effect of therapy with systemic glucocorticosteroids. Thus, the differential diagnosis between BA and COPD requires an indispensable study of the ventilation function of the lungs with an inhalation test with sympathomimetics, the results of which must be evaluated over time.

It should be emphasized that it is necessary to conduct a full clinical examination of this category of patients, including the study of markers of allergic inflammation. The most sensitive tests for diagnosing asthma are an increased level of immunoglobulin IgE, as well as an increasing concentration of nitric oxide in the exhaled air. Eosinophils are not exactly the laboratory test that can be used to solve this clinical problem, since their number may also increase in patients with COPD. However, with additional study of eosinophil mediators (eosinophil cationic protein and others), their diagnostic significance increases significantly. An urgent scientific task is to search for markers of COPD. Of the existing methods, importance is attached to the study of hydrogen peroxide in exhaled air. Thus, crucial importance is attached to the study of the functional parameters of the ventilation function of the lungs, changes in which are noted during the dynamic observation of patients with COPD.

Chronic cough

Chronic cough is another clinical problem that the doctor encounters, one might say, on a daily basis. Epidemiological studies of the prevalence of cough indicate that more than a third of respondents surveyed had complaints of cough. Chronic cough occurs in a large group of diseases. It can be provoked by certain medications: angiotensin-converting enzyme inhibitors, acetylcholinesterase inhibitors, b-adrenergic receptor blockers and others. The most common causes associated with the occurrence of cough are tobacco smoking, viral diseases of the respiratory tract, accumulation of nasal secretions and its aspiration into the lower respiratory tract, gastroesophageal reflux.

Tobacco smoking

very common in Russia. This statement is based on data from epidemiological studies indicating that in more than 70% of the adult population, tobacco smoking is a risk factor for the occurrence of pathological processes in the cardiovascular and respiratory systems. According to the WHO definition, if a person has been bothered by a cough for three months a year for the last two or more years, this indicates that he has chronic bronchitis. In the practice of our doctors, we often encounter patients with cough caused by prolonged smoking.

In the domestic medical literature there is no analogue to the syndrome, which in the English-language literature is called post-nasal drip syndrome

. This category of patients also often seek medical help, as they are concerned about the accumulation of secretions in the nasal passages and its penetration into the pharynx and larynx, which causes a cough. With a long process, cough begins to dominate and becomes the main complaint of the patient. When complaining of a cough, doctors are advised to pay attention to the possibility of its occurrence due to an inflammatory process in the nasal mucosa, which leads to the development of post-nasal drip syndrome.

Gastroesophageal reflux

It is especially common in children and the elderly. In severe cases, they even talk about gastroesophageal reflux disease. It must be remembered that taking certain medications can cause reflux esophagitis. If reflux disease is suspected, pH testing is recommended.

Viral respiratory diseases

often provoke the development of cough, which subsequently transforms into a chronic process. Exacerbation of the chronic inflammatory process in the respiratory tract often occurs after an acute viral illness. In recent years, the nature of the chronic persistence of viruses in the epithelial cover of the respiratory mucosa has attracted attention and is being actively studied.

Bronchial asthma

may manifest itself, especially in the early stages, with symptoms of a painful cough. A diagnostic sign that a cough occurs as a manifestation of asthma is its development at night and the awakening of a sick person due to the resulting paroxysm of cough. The asthmatic nature of the cough is also indicated by its occurrence after physical activity (fast walking, running), emotional stress, laughter, crying. Diagnostic criteria for asthma are the establishment of the phenomenon of airway hyperresponsiveness (monitoring of peak expiratory flow for several days, a positive inhalation test with histamine or acetylcholine), as well as an increase in the concentration of nitric oxide in exhaled air, and finally, a positive effect from the administration of bronchodilators.

Hyperventilation syndrome

Hyperventilation syndrome is manifested by the development of a number of vegetative symptoms, among which the most dramatic are dizziness and a feeling of impending fainting; painful feeling of heartbeat and fear of death; difficulty breathing and fear of suffocation. Hyperventilation syndrome always occurs with a pronounced emotional overtones. People around him are involved in the acute negative experiences of a sick person, which often aggravates the manifestations of hyperventilation syndrome. The fact that this syndrome can be reproduced either in a detailed clinical picture, or partially during an arbitrary test for hyperventilation, acquires diagnostic significance. The main criterion for making a diagnosis is establishing the very fact of hyperventilation, which can be done by studying the function of external respiration.

The second classic sign of hyperventilation syndrome is a reduced concentration of carbon dioxide in the blood, i.e. the phenomenon of hypocapnia. This sign was given decisive importance in establishing the diagnosis of hyperventilation syndrome. However, as studies on respiratory physiology have shown, hypercapnia is not always detected with the development of the clinical picture of hyperventilation syndrome. Attention was paid to studies on the level of exhaled CO2 in the final phase of exhalation, which also demonstrated that a direct relationship between hypocapnia and the clinical manifestations of the syndrome could not be established. Varying degrees of sensitivity to gas exchange disturbances in lung function are today the subject of special research in the physiology of breathing.

Thus, despite the long period of research into hyperventilation syndrome, many questions remain for debate about the nature of its occurrence and diagnostic criteria. The defining manifestations of the syndrome are the establishment of the fact of hyperventilation and a bright emotional coloring during its clinical manifestations. In the practical activities of doctors who treat patients with asthma, it is necessary to take into account the role and clinical significance of hyperventilation syndrome, since the tactics of anti-asthmatic therapy largely depend on this. Uncontrolled administration of bronchodilators of the sympathomimetic class can negatively affect the nature and severity of hyperventilation disorders. For many years, Dr. Buteyko’s recommendations have been disseminated in Russia, which are aimed at eliminating the manifestations of hyperventilation syndrome, but cannot be considered as a method of basic therapy for asthma. It should be emphasized that the pathogenetic and clinical aspects of this problem require further development.

Vocal cord dysfunction syndrome

Respiratory disorder in this category of patients is characterized by acutely occurring episodes of respiratory failure, sometimes occurring as suffocation, which resembles suffocation in asthma. Their distinctive feature is the absence of scattered dry rales in the basal parts of the lungs, characteristic of asthma. Wheezing can be heard remotely, which is more typical of stridor, which occurs in a large group of diseases (mainly in acute viral diseases in children).

The ratio of the inhalation and exhalation phases has differential diagnostic significance. In asthma, the expiratory phase dominates. If the stethoscope is placed on the neck, then with asthma a short inhalation and a long exhalation can be recorded, and with vocal cord dysfunction syndrome, on the contrary, a long inhalation and a short exhalation can be heard. Inhalation is accompanied by the appearance of rough respiratory noise, and exhalation is free from spasmodic noise. When externally examining patients during a period of crisis deterioration, attention should be paid to the retraction in the area of ​​the jugular fossa, which appears at the height of inspiration. This sign is typical only for patients with vocal cord dysfunction.

Bronchodilator drugs are not very effective in treating this category of patients, which also makes them significantly different from patients with asthma. Practitioners are advised to consult these patients with ENT doctors in order to confirm the fact of vocal cord dysfunction. Massive inhalation therapy (especially with glucocorticosteroids), which is carried out for asthma, has exacerbated this problem. Hormonal drugs can affect the function of the vocal cords, causing a myopathic effect or fungal infection of the mucous membrane of the upper respiratory tract, including the vocal cords. Sometimes patients are very sensitive to these unwanted side effects of glucocorticosteroids, and for good reason, as they lose the power of their voice. For representatives of many professions (teachers, singers, politicians...) a serious problem arises - the prescription of inhaled steroid drugs leads to the development of weakness of the vocal cords or to more serious processes (such as fungal contamination of the mucous membranes of the respiratory tract).

Breathing disorders in athletes

The topic of respiratory disorders in elite athletes is not discussed in the domestic medical literature. Asthma-like conditions are common mainly among skiers, but they also occur in athletes involved in other sports (runners, track and field athletes). The main pathogenetic mechanism that underlies the occurrence of respiratory disorders is associated with the increased sensitivity of the respiratory tract to the effects of cold air. A study of the characteristics of asthma in athletes did not reveal signs characteristic of asthma, such as infiltration of the mucous membrane of the respiratory tract with eosinophils and an increase in the concentration of nitric oxide in the exhaled air. Histological studies of mucosal biopsies obtained from athletes with symptoms of asthma-like respiratory disorders revealed infiltration predominantly by lymphocytes. After a provocative inhalation test with cold air, the number of granulocytes and macrophages in the respiratory tract mucosa increased, which was especially noticeable in the distal parts of the bronchial tree. It is necessary to take into account that indicators of external respiration function in athletes exceed the required values. However, a high degree of airway hyperresponsiveness is detected, which can be detected by provocative tests with histamine or acetylcholine. Peak expiratory flow monitoring is a sensitive method for assessing airway hyperresponsiveness. When studying the function of external respiration in athletes, it is necessary to take into account the capabilities of this inexpensive and easy research method.

Syndromes RADS, SBS, MCSS

A special group of asthma-like conditions are reactive airway dysfunction syndrome (RADS), multiple chemical sensitivity syndrome (MCSS) and sick building syndrome (SBS).

SBS

– a special syndrome complex that arises in a person from being indoors. It manifests itself in sensations of dry facial skin, eye irritation (red eye syndrome), rhinitis, dry mouth and vocal cords, hoarseness and cough. Typically, such clinical manifestations develop in people in rooms built of concrete and glass and carrying high electrostatic energy.

RADS

as a syndrome complex was isolated in 1985 from individuals who were exposed to massive inhalation effects of toxic substances on the respiratory tract. A classic example of such an impact was the development of cough in persons who were in contaminated areas after the accident at the Chernobyl nuclear power plant. Cough was the most common symptom among those exposed to Chernobyl dust. Canadian researchers who were the first to isolate RADS describe the cellular reactions of the respiratory mucosa: mainly neutrophils and lymphocytes migrate into the bronchial mucosa. However, further research is needed in clinical practice to establish clearer criteria for diagnosing RADS.

Chemical sensitivity syndrome

(or syndrome of idiopathic intolerance to environmental factors - multiple chemical sensitivity/idiopathic environmental intolerance). With this syndrome, several organs and systems are involved in the pathological process. Thus, patients are often bothered by headaches, deterioration of memory and attention, dry throat, sore throat and a feeling of lack of air. The described clinical manifestations are associated with exposure to chemical substances that can be detected in extremely low concentrations. The picture is aggravated by the appearance of a feeling of tightness in the chest and other asthma-like symptoms. Such patients are relatively common in the practice of doctors, and most often they are recommended to seek psychological support from psychiatrists, neurologists and psychologists. Meanwhile, this syndrome has not yet received a complete interpretation - the pathogenetic mechanisms of its development remain unclear.

In specialized clinics where patients are admitted for examination of asthma, asthma-like conditions have begun to be identified in patients with such manifestations as heavy breathing, cough, increased production of bronchial and nasal secretions, and a feeling of pressure on the chest. Trigger factors most often are exposure to irritants (tobacco smoke), physical activity, etc. on the respiratory tract. Some patients are seen by doctors for severe asthma. The basis of the described asthma-like manifestations is the increased sensitivity of sensory nerve endings to the effects of various environmental factors. Hypersensitivity syndrome

(sensor hyperreactivity) is very close in its manifestations to hyperventilation syndrome. However, modern methods of respiratory physiology distinguish between these two conditions, which are similar in their manifestations. Thus, one of the criteria for hypersensitive syndrome is difficulties in performing the necessary maneuvers of the respiratory cycle when studying the function of external respiration. Another feature that distinguishes this category from patients with hyperventilation syndrome is the normal CO2 concentration in the final expiratory phase. Recent studies allow us to conclude that the capsaicin test is specific for patients with manifestations of increased sensitivity of the autonomic nervous system of the respiratory organs. However, practical pulmonology needs a more detailed development of the identified problem.

Charge–Strauss syndrome

Another topic in the differential diagnosis of asthma and asthma-like conditions can be systemic pulmonary vasculitis with predominant damage to the vessels of the pulmonary circulation (Charge-Strauss syndrome). The diagnostic criteria for Charge–Strauss syndrome are allergic rhinitis, asthma, and hypereosinophilia. There are three phases during the course of the disease. The onset of the disease usually manifests itself as allergic rhinitis and asthma. At this stage, the progressive course of the disease attracts attention, and for severe asthma, doctors prescribe systemic glucocorticosteroids relatively early. Typically, this phase of the disease lasts for several years, but the severity of clinical manifestations gradually increases, and when examining this category of patients, persistent hypereosinophilia is revealed. Manifestations of the disease rapidly increase and, with hypereosinophilia, signs of damage to other organs appear: the heart, kidneys, skin, central nervous system, and other forms of the pathological process are possible. The clinical picture is dominated by symptoms of systemic vasculitis with predominant damage to the vessels of the pulmonary circulation. In the diagnosis of Charge–Strauss syndrome, the detection of antibodies to the cytoplasm of neutrophils is of great importance.

Modern classification of asthma

Thanks to an in-depth study of such a unique disease as bronchial asthma, many classifications of this pathology have been developed over time. For example, according to the International Classification of Diseases, Tenth Revision (ICD-10), the following forms of asthma are distinguished:

• Allergic asthma - in this case, the cause of the development of the disease is mainly allergic processes. As a rule, the allergen can be identified during additional diagnostic studies;
• Non-allergic asthma – the disease is not caused by allergic processes;
• Mixed asthma - in which both allergic and non-allergic irritants are combined;
• Unspecified asthma – the cause of the disease cannot be determined.

After doctors determine the type of asthma, they assess the severity of the patient's condition before starting treatment. For this purpose, classification by severity is used. It is based on four simple indicators:

• Frequency of daily exacerbation symptoms per day and per week;
• Frequency of nocturnal exacerbation symptoms per week;
• The impact of an exacerbation on the patient’s quality of life;
• The value of external respiration indicators (PSV and FEV1).

Bronchial asthma occurs in two stages.
The first stage, when symptoms appear from time to time, is called intermittent (episodic) asthma. The second stage, when symptoms are present for a long time or constantly, is called persistent (permanent) asthma. Depending on the severity of symptoms, this stage has three degrees of severity: mild, moderate and severe. Intermittent (episodic) asthma is characterized by short-term episodes of asthma attack, less than once a week. At night, attacks occur no more than twice a month (for at least three months). PEF and FEV1 > 80% of predicted value. Fluctuations in PEF during the day are less than 20%.

Persistent asthma (mild) is characterized by exacerbation of daytime and nighttime attacks (2 times a week). These episodes cause disturbances in sleep and activity. PEF corresponds to 60-80% of the predicted value. Fluctuations in PSV during the day are 20-30%.

Persistent asthma (moderate severity) is characterized by daily attacks of asthma. Nighttime symptoms occur once a week. These exacerbations gradually lead to limited physical activity and sleep disturbances. The patient requires daily use of inhaled medications (short-acting beta2-agonists). PSV - 60-80% of the required indicators. The daily fluctuation of the PSV value is more than 30%.

The persistent form (severe) is characterized by frequent nocturnal attacks, exacerbations, and a sharp limitation of physical activity. PSV

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What types of asthma are there?

There are two types of asthma - allergic and non-allergic . Allergists deal with allergic diseases, and pulmonologists deal with non-allergic diseases. Allergies are more common in children, but can debut at any age.

A separate phenotype is virus-induced bronchial asthma : for example, children with obstruction due to ARVI. The child does not react to physical activity, cats, or dust. And as soon as you get sick, obstructions appear. Three or more obstructions in a year are a reason to see a pulmonologist-allergist.

Cough bronchial asthma . Classic symptoms: cough, shortness of breath, asthma attacks. But there are patients in whom bronchial asthma manifests itself only as a lingering cough. Bronchial asthma is among the top three causes of chronic cough in both adults and children.

In such cases, we prescribe anti-inflammatory basic therapy as a diagnosis and look at the effect. If improvement is observed during this treatment, and symptoms reappear during withdrawal, the diagnosis is confirmed.

Main triggers: - Allergies; - Exercise stress; — ARVI.

Bronchial asthma can develop after infections, severe pneumonia, whooping cough. If a person works in hazardous work, occupational bronchial asthma may develop (attacks occur at the workplace). In childhood, bronchial asthma is more common in boys, and in older age - in girls.

Symptoms

The clinical picture of bronchial asthma is described by three main symptoms:

• breathing disorder,
• coughing attacks,
• presence of distant wheezing.

In most cases, attacks occur at night.
Approximately 70% of asthma patients (without taking into account the form of the disease) wake up between one in the morning and five in the morning during an exacerbation episode. The reason for this is increased bronchospasm. This appears to be associated with increased vagal tone, levels of endogenous catecholamines (adrenaline, norepinephrine) and histamine. Histamine is a biologically active substance synthesized by the cells of the human body, which plays a huge role in the cascade of allergic reactions. So, bronchial asthma is characterized by the following manifestations:

• Development of respiratory distress;
• Shortness of breath;
• Heavy breathing;
• Inflating the wings of the nose;
• Cyanosis (blue discoloration of the skin due to low oxygen levels in the blood);
• Participation in the act of breathing of the auxiliary muscles of the chest;
• Excitement, excitement;
• Rapid heartbeat;
• Remote wheezing;
• Sweating.

Before the onset of asthma symptoms, so-called precursors appear.
A clinical picture of conjunctivitis, rhinitis or pharyngitis appears after contact with an allergen. After this, the patient begins to experience a feeling of constriction in the chest. Breathing becomes harsh and expiratory shortness of breath occurs. It is characterized by a rapid and intermittent inhalation, followed by a long, very difficult active exhalation (normally, exhalation is passive). The auxiliary muscles of the upper shoulder girdle and abdominal wall begin to participate in the act of breathing. To facilitate exhalation, the patient takes the most comfortable position for him with the torso tilted forward and emphasis on the hands to fix the shoulder girdle. The attack usually ends with a cough with the discharge of thick, glassy sputum. Often the first manifestation of bronchial asthma is a paroxysmal cough, which is accompanied by expiratory shortness of breath (difficulty exhaling) with the discharge of a small amount of glassy sputum. The developed clinical picture of bronchial asthma is characterized by the appearance of mild, moderate or severe attacks of suffocation. Sometimes an attack begins with the following warning signs:

• Copious discharge of watery secretion from the nose;
• Sneezing;
• Paroxysmal cough.

During an attack of bronchial asthma, the patient takes a short inhalation and an extended exhalation, which is accompanied by wheezing audible from a distance.
The chest is in the position of maximum inspiration. The muscles of the abdominal wall, back, and shoulder girdle take part in breathing. When percussing over the lungs, a box sound is detected; upon auscultation, many dry rales are heard. The attack ends with the release of viscous sputum. One of the most dangerous variants of the course of the disease is the asthmatic state, which can develop into a severe, protracted attack. The asthmatic condition is characterized by a nonproductive cough and increasing resistance to bronchodilator therapy. Pulmonologists distinguish anaphylactic and metabolic forms of the asthmatic condition.

In the anaphylactic form, which is caused by pseudo-allergic or immunological reactions with the release of a large number of mediators of the allergic reaction, an acute severe attack of suffocation occurs.

The metabolic form of bronchial asthma is associated with a functional blockade of beta-adrenergic receptors. It occurs as a result of exposure to adverse meteorological factors, overdose of sympathomimetics during respiratory tract infections, due to rapid withdrawal of corticosteroids, and forms within a few days. Initially, the patient stops producing sputum, and pain appears in the abdominal area, chest, and shoulder girdle muscles. Increased ventilation and loss of moisture with exhaled air lead to an increase in the viscosity of sputum and the closure of the bronchial lumen with a viscous secretion.

The second stage of bronchial status is characterized by the formation of “silent lung” areas in the posterior lower parts of the lungs. There is a clear discrepancy between the severity of distant wheezing and its absence when listening with a stethoscope. The condition of the patients is extremely serious. The chest is emphysematously distended. Pulse is more often than 120 per minute, blood pressure is increased. The ECG shows signs of overload in the right side of the heart. Patients develop respiratory or mixed acidosis (a shift in the body's acid-base balance towards increased acidity).

In the third stage (hypoxic-hypercapnic coma), shortness of breath and cyanosis (bluish color of the skin and visible mucous membranes) increase. The patient's sudden agitation is replaced by loss of consciousness, and convulsions may occur. The pulse is paradoxical (filling decreases during inspiration), blood pressure is reduced.

Patients with bronchial status are hospitalized in the intensive care unit on any day of the week, regardless of the time of day. They are observed by resuscitators using monitors and given therapy aimed at stopping an attack of bronchial asthma. Severe cases of bronchial status are discussed at a meeting of the Expert Council with the participation of candidates and doctors of medical sciences, doctors of the highest category. Leading specialists in the field of pulmonology, immunology and allergology develop patient management tactics. A multidisciplinary approach to the treatment of bronchial asthma allows you to quickly relieve the bronchial status and achieve sustainable remission.

The course of bronchial asthma is largely determined by the age of the patient at which the disease developed. In the vast majority of cases, signs of bronchial asthma in children disappear spontaneously at puberty.

Symptoms of asthmatic bronchitis

During the course of the disease, there are two periods: a period of exacerbations and periods of remission. The main sign of an exacerbation period is a cough at low-grade or normal temperatures, as well as noisy exhalations with a whistling and forced character.

The harbingers of coughing attacks in asthmatic bronchitis are: nasal congestion and sore throat, serous-mucous runny nose and mild malaise. The cough is paroxysmal and intrusive, bothering patients only at night. At the very beginning of the period, the cough is dry and can easily be provoked by laughter. From time to time, the cough with asthmatic bronchitis changes from dry to wet.

The general condition of the patient is not impaired; symptoms of asthmatic bronchitis can also be intoxication, pale skin and loss of appetite, there is no lethargy. Upon examination, it is clear that the chest is not enlarged, but characteristic wheezing in the bronchi is present in some patients. The level of immunoglobulins and histamine in the blood is increased.

A characteristic feature of asthmatic bronchitis is the recurrence of symptoms. Periods of exacerbation of asthmatic bronchitis last from a couple of hours to 30 days . Most children suffering from asthmatic bronchitis may also suffer from various allergic diseases. Children who are prone to asthmatic bronchitis have neurodermatitis, as well as frequent manifestations of allergic diathesis on the skin (especially in children in the first years of life).

Diagnostics

The diagnosis of bronchial asthma is made by pulmonologists at the Yusupov Hospital based on the following indicators:

• Complaints, medical history and life of the patient;
• Clinical and functional examination with assessment of the reversibility of bronchial obstruction;
• Specific allergy examination (skin tests with allergens and determination of specific immunoglobulin class E in blood serum);
• Exceptions for other diseases.

The following clinical signs increase the likelihood of having bronchial asthma:

• The presence of more than one of the following symptoms: wheezing, shortness of breath, chest tightness and cough, especially when the patient's condition worsens at night and early in the morning;
• The occurrence of symptoms when exposed to cold air and allergens, physical activity, after taking or β-blockers and acetylsalicylic acid;
• A history of atopic diseases, asthma or atopic diseases in relatives;
• Widespread dry wheezing when auscultating;
• Low peak expiratory flow or forced expiratory volume in 1 second that cannot be explained by other reasons;
• An increase in the number of eosinophils in the peripheral blood, unexplained by other reasons.

To establish a diagnosis of bronchial asthma, pulmonologists at the Yusupov Hospital use special diagnostic methods:

• Studies of the ventilation function of the lungs with assessment of the reversibility of bronchial obstruction;
• Detection of increased bronchial reactivity;
• Conducting a specific allergy examination.

When performing spirometry, an important parameter is FEV1 (forced expiratory volume in the first second of the maneuver).
It indicates the degree of bronchial obstruction. In patients with spirometry within normal limits, a methacholine inhalation test is performed. In bronchial asthma, sputum tests reveal eosinophils, Kurshman spirals, and Charcot-Leyden crystals. Eosinophilia is understood as an increase in the number of eosinophils (leukocyte blood cells) of more than 5%. In parallel, the level of IgE in the blood serum increases, which is a specific mediator of allergic inflammation in the human body. When examining sputum under a microscope, one can detect Courshmann spirals (casts of small bronchi) and Charcot-Leyden crystals (shiny, smooth formations formed from the eosinophil enzyme).

All patients with suspected asthma undergo a study of external respiratory function in order to establish the presence, level and degree of obstruction of the tracheobronchial tree. Tests for assessing physical function include:

• Spirometry;
• Pneumotachometry;
• Recording a flow-volume curve.

A decrease in FEV1 of less than 65% of vital capacity and an increase in residual lung volume of more than 25% of vital capacity indicates a serious problem with airway patency.
To establish the reversibility of changes in the respiratory tract, functional tests with bronchodilators are performed. An improvement in spirometry by 25%, as well as complete restoration of bronchial patency after inhalation of these drugs, indicates the reversibility of bronchospasm.

To identify a specific allergen, an allergological study is performed - skin tests with various antigens. Such tests can only be carried out during remission. In the therapy clinic of the Yusupov Hospital, the scope of the planned examination for the patient is determined by a highly qualified specialist.

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Symptoms of lung diseases

Most pulmonary diseases are accompanied by the following symptoms:

• Chest pain. Constant or occurring with a deep breath. It can radiate to the shoulder, shoulder blade, neck. Chest pain can have various causes, so it is important to correctly diagnose its source.
• Cough. Dry and wet, varying intensity. The duration of the cough, as well as the presence of expectorated purulent sputum, should be especially alarming. In some pathological processes, blood may be present in the sputum.
• Dyspnea. It is observed both during physical activity and exercise, and at rest, and even during sleep. In some cases it turns into suffocation. Shortness of breath can be a consequence of smoking, high body weight, and also accompanies many diseases (not only pulmonary ones). Therefore, timely diagnosis is extremely important.
• Snore. Despite the fact that many people do not pay much attention to snoring as a symptom of the disease, it may indicate the progression of lung disease. One of them is obstructive sleep apnea syndrome (OSA). If left untreated, it can lead to a heart attack or stroke.

If even one of these symptoms occurs, it is important to immediately make an appointment with a therapist. The doctor at our clinic will help determine the source of unpleasant symptoms and prescribe appropriate treatment.

Treatment

Bronchial asthma refers to a certain type of disease that cannot be completely cured, but it can be controlled. Treatment goals set by the doctors at the Yusupov Hospital:

• Achieving and maintaining seizure control;
• Preventing exacerbations;
• Maintaining respiratory function indicators as close to normal levels as possible;
• Elimination of restrictions on the physical activity of patients, including physical education and sports;
• Minimizing side effects and adverse events from the use of medications;
• Preventing the formation of irreversible bronchial obstruction.

Treatment of asthma is based on two stages: symptomatic therapy to provide emergency assistance and preventive or basic treatment to control the course of asthma.

What to do during an attack?

When children develop bronchial asthma, parents experience fear and often panic, but they need to calm down and take measures such as:

• place the child on something solid;
• tilt your torso forward, ask to rest your elbows on your knees;
• open the window, but without overcooling the room;
• Give your child an inhaler prescribed by your doctor;
• Until the unpleasant symptoms go away, calm the child down, distract him by talking or reading aloud.

Even if you are worried and worried, do not show it, do not provoke fear in the child - this will significantly aggravate his condition.

If the child’s condition does not change while taking the drug and the measures taken, it is necessary to call an ambulance.

Basic therapy

Today, first-line medications for the preventive treatment of asthma in patients of any age include inhaled glucocorticoid drugs (ICS):

• Beclomethasone dipropionate;
• Flunisolide;
• Fluticasone propionate;
• Triamcinolone acetonide;
• Mometasone furoate.

Experts prescribe this group of medications to almost all patients with asthma, including those with mild severity of the disease.
ICS are the most powerful anti-inflammatory drugs. Having a wide spectrum of action, they exert their effect on both cellular and humoral mechanisms of the development of allergic (immune) inflammation. These drugs are the choice for patients with persistent asthma of any severity. In addition, ICS is prescribed to all patients with bronchial asthma who take short-acting β2-agonists more than once a day.

In second place in basic therapy are cromones (mast cell membrane stabilizers):

• Sodium cromoglycate;
• Undercut.

These drugs belong to the group of inhaled non-steroidal anti-inflammatory drugs.
Used in the treatment of patients with mild persistent asthma. In addition, they can be prescribed for prophylactic purposes to prevent bronchospasm during physical activity, inhalation of cold air, and possible contact with an allergen. Antileukotriene drugs (leukotriene receptor antagonists): zafirlukast, montelukast. These drugs are recommended to be taken mainly by patients with aspirin-induced bronchial asthma, as well as to prevent bronchospasm provoked by allergens and physical activity.

Systemic glucocorticoid drugs:

• Prednisolone;
• Methylprednisolone.

If a patient is diagnosed with severe bronchial asthma, in which high doses of inhaled glucocorticoids in combination with regular use of bronchodilators are ineffective, systemic glucocorticoids are prescribed.

Treatment of asthma in adults

Pulmonologists at the Yusupov Hospital, when conducting pharmacotherapy for bronchial asthma, direct all efforts to achieving and maintaining clinical control of the disease over a long period.
If current therapy does not provide control of bronchial asthma, increase the volume of therapy until control is achieved. If partial control of bronchial asthma is achieved, the possibility of increasing the volume of therapy is collectively considered. If control of bronchial asthma is maintained within three months of treatment, the volume of maintenance therapy is reduced in order to establish the minimum number of drugs and the lowest doses of drugs that are sufficient to maintain control. For the treatment of bronchial asthma, 2 types of pharmacological agents are used: emergency medications (to relieve bronchospasm) and medications for basic (“maintenance”) therapy. The first group of drugs includes short- and long-acting β2-agonists (fenoterol, salbutamol, formoterol) and inhaled anticholinergic drugs (tiotropium bromide, ipratropium bromide).

For the basic treatment of bronchial asthma, the following drugs are used:

• Inhaled glucocorticosteroids and systemic corticosteroids;
• Combined drugs (long-acting β2-agonists + inhaled glucocorticosteroids);
• Extended-release theophyllines;
• Leukotriene receptor antagonists;
• Antibodies to IGE.

At the beginning of 2015, the drug Salmecort was registered in the Russian Federation.
This is a fixed combination of salmeterol with fluticasone in the form of a metered dose aerosol inhaler. It is used for maintenance therapy of bronchial asthma. Emergency care for an attack of bronchial asthma:

• Reassure the patient;
• Free yourself from restrictive clothing, unbutton your shirt collar;
• Provide access to fresh air;
• Use the patient’s existing pocket inhaler (can be repeated three times with an interval of 20 minutes);
• Give a comfortable sitting position (the patient’s arms should rest on the table or chair rails, elbows spread to the sides).

If there is no effect or the patient’s condition worsens (threat of status asthmaticus), it is necessary to immediately call an ambulance.

Nebulizer therapy

Nebulizer therapy is a modern method of eliminating severe exacerbation of asthma.
The nebulizer operates on the principle of delivering a therapeutic dose of the drug in aerosol form directly into the patient’s bronchi to obtain a rapid clinical effect. The use of this device during exacerbation of asthma allows local administration of high doses of bronchodilators, while the drug is practically not absorbed into the blood and does not have side effects on other organs and systems, as is often the case when taking tablets or using injections. Thus, nebulizer therapy can not only effectively reduce the manifestation of bronchospasm, but also significantly reduce the frequency of systemic side effects of drugs.

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Recommendations for therapy

The treatment of bronchial asthma is based on basic therapy. It has a stepped base. The severity level is determined based on the number of symptoms that bother the patient. There are 5 stages - degrees of severity of bronchial asthma: 1) mild intermittent; 2) mild persistent; 3) moderate severity persistent; 4) severe persistent; 5) extremely heavy.

All therapy is aimed at achieving control—the absence of symptoms.

● First-line drugs are inhaled glucocorticosteroids.

● The second group of drugs is leukotriene receptor blockers (Montelukast). They are used less frequently and can be combined with inhaled glucocorticosteroids or prescribed separately.

Where to start therapy depends on the severity. All risks must be weighed. The FDA* issued a letter warning doctors to be more careful when prescribing Montelukast. (*FDA—Food and Drug Administration, is an agency of the U.S. Department of Health and Human Services).

Montelukast can indeed have side effects - changes in behavior, aggression, agitation, sleep disturbance. This does not mean that the doctor should not prescribe it, but should warn about possible side effects and discontinue the drug if symptoms appear.

The minimum period of basic therapy is 3 months. If all is well, treatment continues for another 3 months (either at the same dosage or at a reduced dose). The doctor may even try to stop the basic therapy.

If bronchial asthma is not controlled (treatment has been prescribed, but symptoms still persist), the volume of treatment may be insufficient. You need to go up a notch and prescribe a slightly larger volume of basic therapy. Or prescribe combination drugs.

If asthma is severe and difficult to treat, maximum therapy is prescribed: high doses of hormones, systemic steroids, biological or targeted therapy. GINA emphasizes that hormones in tablets on a continuous basis should be prescribed as late as possible. Before this, the patient is referred to determine the asthma phenotype.

Also, the reason for the lack of control may be the patient's low adherence to treatment . Patients are often anxious. As Dr. House said: “All patients lie.” And patients with bronchial asthma too. They do not take basic therapy, reduce doses, and skip days. Patients are often scared that we offer them not pills, but an inhaler.

Complications

The most serious complication of bronchial asthma is the development of status asthmaticus. This is a prolonged attack, characterized by severe obstruction, severe respiratory failure, and impaired bronchial drainage function. During such an attack, the patient’s usual inhaled medications do not help. Only inpatient treatment is required. One of the causes of status asthmaticus may be an overdose of inhaled sympathomimetics or rapid withdrawal of glucocorticoid drugs. There are three stages in the mechanism of formation of this complication of asthma:

• The first stage is similar to a protracted attack (can last more than 12 hours), which is not controlled by conventional inhaled drugs;
• The second stage - at this stage the patient develops tachycardia, lethargy is noted, the skin becomes bluish and becomes covered with sticky sweat. Shortness of breath is significantly pronounced;
• Third stage - at this stage the patient develops a sharp disturbance in the activity of the central nervous system up to coma, which causes death.

Another rather rare complication of asthma is spontaneous pneumothorax. With a long and persistent course of asthma, pulmonary emphysema and cor pulmonale develop, which leads to pulmonary heart failure.

Treatment of asthma complications

Since status asthmaticus (AS) is an extremely dangerous complication of asthma, which can potentially threaten the patient’s life, its treatment must be carried out within the walls of a medical institution. The first measure in the treatment of AS is the intravenous administration of large doses of glucocorticoid drugs, in parallel with sympathomimetics and drugs that promote the rapid expansion of spasmodic bronchi. In addition, the patient needs infusion and symptomatic therapy. If it was not possible to stop AS at the first stage, then the patient is transferred to artificial ventilation and undergoes sanative bronchoscopy.

Nutrition for asthma in adults

To prevent recurrence of asthma attacks and alleviate the course of the disease, the patient is recommended to follow a diet. The following are excluded from the diet:

• Seafood;
• Citrus fruits (except lemons);
• Beekeeping products;
• Nuts;
• Chocolate;
• Alcohol and cigarettes;
• Dairy products;
• Baking and white bread.

Meals should be divided into 4-5 small portions, and try to avoid overeating. With the right approach, avoiding contact with allergens and a favorable psycho-emotional environment, the patient can minimize the frequency of asthmatic attacks and improve their general condition.

Prevention of asthma

Prevention of bronchial asthma is divided into primary and secondary.
The goal of primary prevention is to prevent the development of sensitization in patients at risk. The risk group for the development of allergic diseases includes people with a hereditary predisposition to atopy. Secondary prevention is carried out in a group of people with established sensitization who do not have asthma symptoms. These include children with atopic dermatitis or allergic rhinitis, with a family history of bronchial asthma. For effective prevention, it is necessary to minimize the harmful effects of external factors, which often cause the development of bronchial asthma in adults:

• Lead a healthy and active lifestyle;
• Avoid contact with allergens (ventilate the room, do wet cleaning, etc.);
• Eat properly.

What does an asthma attack look like in children?

An attack can develop in different ways, but usually has a fairly typical clinical picture. It begins with a cough, which may be accompanied by a skin rash and rhinitis. The baby's breathing becomes uneven, there are short inhalations, and exhalations are clearly difficult. Breathing is accompanied by wheezing; from the outside, the attack looks as if the child is gasping for air. This may cause pale skin and blue lips. Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6591438/ Shyamali C. Dharmage, Jennifer L. Perret and Adnan Custovic Epidemiology of Asthma in Children and Adults // Front Pediatr. 2019; 7:246

Disability in AD in adults

The fact that a patient has asthma does not necessarily mean that he is undeniably disabled.
For example, if the severity of the disease is mild or moderate, in most percent of cases he will be refused. The fact is that this disease develops slowly, and from minor restrictions causing the patient can develop into a fairly complex degree, accompanied by other diseases that appear as a result of asthma. Therefore, at the initial stage of its manifestation, disability is not considered. Doctors at the therapeutic department of the Yusupov Hospital provide first-class examination and treatment of patients with respiratory diseases, including bronchial asthma. All studies are performed by specialists using modern medical equipment from leading European countries. Innovative research and therapy methods are used at the hospital. Bronchial asthma is no longer a problem for patients at the Yusupov Hospital. Anyone can make an appointment with a clinic doctor by calling the phone number located on the website. Online consultation is also available 24 hours a day.

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About asthmatic bronchitis

Asthmatic bronchitis is a pathological disease that occurs in the bronchi of large and medium calibers. The disease occurs as a result of hypersecretion of the bronchial mucosa. Asthmatic bronchitis, to a greater extent, affects children of preschool and early age .

Asthmatic bronchitis is most often caused by various allergens, both of viral origin (fungal, viral, bacterial) and food (milk, strawberries, citrus fruits, etc.). The disease can also be initiated by other allergens that enter the body through the stomach or through breathing.

Asthmatic bronchitis can easily develop against the background of a protracted illness such as bronchopneumonia, or other viral infections. In cases where the nature of the disease is not viral, the attacks may stop. And if the disease is infectious, the disease will develop slowly and gradually.