Bronchitis in children - timely diagnosis and successful treatment.

In modern medicine, bronchitis in children and its possible consequences are promptly diagnosed and successfully treated. Repeated, frequent bronchitis can occur in children if they live in conditions with a polluted atmosphere - in cities with developed industry and a small amount of green space. The incidence of bronchitis in children increases if someone smokes in the room where the child lives. Children and adolescents are more likely to suffer from this disease in the cold season, with sudden changes in temperature and humidity in the environment.

Bronchitis is an inflammatory process that occurs in the bronchi. Most often, inflammation in the bronchi affects almost all parts of the bronchial tree. That is, bronchitis is the spread of the inflammatory process in all bronchi, from the large lobar bronchi to the smallest, the internal diameter of which in children under 6 months is no more than 1 mm.

Causes of bronchitis in children

Acute bronchitis most often occurs when a child becomes infected with a viral infection. In such cases, bronchitis is caused by parainfluenza viruses, rhinovirus, and rhinosyncytial virus. Less commonly, viral bronchitis occurs in children when coronavirus, metapneumovirus, or bocaviruses enter the body.

The second most common cause of bronchitis is a bacterial infection. Bacterial bronchitis is caused by pneumococcus, mycoplasma, and chlamydia. Less commonly - Haemophilus influenzae or Moraxella. In a large number of children, the cause of acute bronchitis is a mixed flora, that is, inflammation occurs when both viruses and bacteria enter at the same time.

Another cause of acute bronchitis is the entry of food and stomach contents into the respiratory tract. This most often occurs in children under 6 months of age and occurs when the baby regurgitates and does not feed properly. This type of bronchitis is called aspiration bronchitis. Inflammation in the bronchial mucosa in this situation occurs for several reasons - the gastric contents act aggressively, as they contain hydrochloric acid and enzymes, and the introduction of gastric and intestinal microflora is also possible, which will cause bacterial bronchitis.

Prevention of bronchitis

In general, prevention is the same as for ordinary acute respiratory viral infections - nonspecific: ventilation, hand washing, social distancing, etc. All this became widely known with the spread of Covid-19. There are no specific drugs for the prevention of acute respiratory viral infections, as well as drugs to “strengthen the immune system.” The only exception is the influenza vaccine, but the influenza virus is only one of many causes of bronchitis.

Vaccination against pneumococcal disease may protect against bacterial complications of bronchitis caused by Streptococcus pneumoniae.

Monoclonal antibodies against respiratory syncytial virus (Synagis, palivizumab) can be used in children at risk for severe bronchiolitis (premature children under 6 months born at 35 weeks or earlier). However, this method is only suitable for certain groups of children.

Thus, detecting wheezing in a child’s lungs and diagnosing bronchitis should not cause horror in parents if the child does not belong to a risk group. The child’s own immune system and simple parental care will in most cases ensure a complete recovery in 1–3 weeks. Less commonly, medications or even hospitalization may be required, but the prognosis for bronchitis is almost always favorable.

Forms of bronchitis

There are several forms of bronchitis along the way:

Acute bronchitis is an acute inflammation of the bronchial mucosa.
Recurrent bronchitis – when a child experiences bronchitis 2-3 times a year.
Chronic bronchitis is a chronic widespread inflammatory lesion of the bronchi. In this case, the child experiences 2-3 exacerbations of the disease during the year and this continues for at least two or more years in a row.

Fortunately, chronic bronchitis practically never occurs in children. But there are a number of chronic diseases that occur with similar symptoms.

How does bronchitis manifest?

The main symptom of bronchitis is cough. There may also be an increase in temperature, an accompanying runny nose, nasal congestion, pain and sore throat and other symptoms of a common ARVI. Strictly speaking, simple bronchitis is a type of ARVI.

The vast majority of bronchitis is acute (that is, the cough lasts no more than 2–4 weeks). The terms “recurrent” and “chronic” have little application to children; in most cases they only mask the true cause: bronchial asthma, bacterial protracted bronchitis, cystic fibrosis, primary ciliary dyskinesia, interstitial lung diseases, etc.

In most modern English-language sources, acute bronchitis is not distinguished from other “cold” diseases and is described in the context of ARVI, since it is most often caused by the same respiratory viruses (respiratory syncytial virus, rhinovirus, parainfluenza viruses, influenza, etc.). The only difference is in the main localization of the inflammatory process during ARVI: inflammation in the nose and throat - nasopharyngitis, inflammation in the larynx and vocal folds - laryngitis, in the bronchi - bronchitis. The tradition of considering bronchitis as a serious complication of acute respiratory viral infection, requiring great anxiety and mandatory antibiotic therapy, has no more justification than the automatic prescription of antibiotics on the third day of fever.

Symptoms of bronchitis

When infected with a virus

Acute bronchitis of viral etiology begins with an increase in body temperature, runny nose and cough. A cough may appear immediately, in the absence of breathing problems from the nasopharynx. The cough may be dry and hacking in the first days, and then become unproductive and wet. Some children have a wet cough from the first days, that is, they clear their throat well. Cough and fever can last on average 5-7 days. Depending on the age of the child and the type of virus that has entered the body, cough and fever can persist for up to 2 weeks.

For obstructive bronchitis

Sometimes bronchitis in a child occurs with signs of obstruction - this is a narrowing of the bronchi due to swelling of the mucous membrane, accumulation of viscous sputum in the bronchi and spasm of the muscles of the bronchi. It is often called obstructive bronchitis. Obstructive bronchitis is accompanied by prolongation of exhalation, which can occur as early as 1-2 days of illness. With obstructive bronchitis, the cough is unproductive and can sometimes be intrusive.

When infected with pulmonary chlamydia

With bronchitis caused by mycoplasma or pulmonary chlamydia, elevated body temperature can persist for up to 2 weeks, while the cough is not pronounced, but lasts a long time, up to 2-3 weeks.

Symptoms and signs of bronchitis

Bronchitis most often manifests itself against the background of an acute respiratory disease. The viruses themselves prefer the upper respiratory tract, but the infection almost always reaches the bronchi4.

Before the child starts coughing and the doctor diagnoses bronchitis, symptoms characteristic of acute respiratory diseases appear. The following symptoms and signs of bronchitis in children may appear:

Heat;
Headache, anxiety;
Weakness, decreased activity, muscle pain, constant fatigue
Runny nose, manifesting itself in the form of nasal congestion, mucous discharge;
Sore throat, sore throat, hoarseness;
The most characteristic symptom is cough and shortness of breath. First dry, then productive with sputum.

Cough is highlighted for a reason; it is the main symptom, after which a treatment plan is developed. A cough can occur even after ARVI has completely subsided. This is often observed due to weakening of general and local immunity when bacterial infection develops. A cough in the acute form of bronchitis can be called persistent; its duration indicates the development of a protracted or chronic disease.

Cough in children can also be caused by other diseases of the respiratory system - laryngitis, tracheitis, and in the worst case, pneumonia. Even more often, the virus affects several areas at once, tracheobronchitis or laryngotracheitis develops.

Cough is a physiological reflex process that occurs due to irritation of the mucous membrane of the respiratory tract. With bronchitis, this is how the body tries to cleanse the bronchi, trachea and larynx from the result of the inflammatory process - phlegm4.

Treatment of bronchitis

Treatment of bronchitis in children is carried out on the basis of clinical recommendations and standards. They summarize the experience of treating children and adolescents, taking into account data accumulated by foreign and Russian specialists.

In case of acute bronchitis, it is better to provide the child with semi-bed rest until the body temperature decreases. In this situation, the baby needs to be given more to drink during the day. If your child wakes up at night, it is better to offer him something to drink at night. It is important to ensure that the sick person has improved sputum discharge and to help the child cough up - this is a light vibration massage (tapping on the chest and breathing exercises, which are carried out in the morning, afternoon and evening. It is better to carry out these procedures on an empty stomach and in a playful way in order to set the sick child up for positivity and recovery .

The room where the sick child is located must have fresh, humidified air. Dry air will cause mucus to dry out, meaning the child will not be able to cough up effectively and efficiently and remove mucus from the bronchi. In this situation, it is necessary to regularly ventilate the room. Use a humidifier, which can sometimes work around the clock during illness. In winter, try to reduce the operation of radiators heating the room, as they make the air dry. If this is not possible, then cover the radiators with a damp cloth. We must try not to make the room hot. The best temperature is 22 degrees. For a child with bronchitis, in the absence of elevated body temperature and intoxication, walks in the fresh air with low physical activity are very useful.

If a child has a dry cough, then centrally acting cough medications can help him, but they are not used for long - 2-3 days.

Sometimes antiviral drugs can help a baby with bronchitis. They are prescribed if there was a viral infection (ARVI) at the onset of the disease.

For mucus that is difficult to clear, mucolytic drugs are prescribed - these are drugs that thin the sputum. Medicines are also prescribed to help move sputum from the lower sections of the bronchi to the upper ones - they enhance the movements of the cilia located in the bronchi. Therefore, sputum moves faster from the lower to the upper sections.

Diagnosis of bronchitis

Bronchitis is a clinical diagnosis, that is, the doctor makes it only on the basis of a survey and examination of the patient. The presence of typical complaints (runny nose, cough, malaise, fever) and typical wheezing when listening to the lungs with a stethoscope, as well as the absence of other reasons that explain these symptoms, is a necessary and sufficient condition for diagnosing bronchitis. Wheezing during bronchitis is symmetrically scattered over the entire surface of the lungs, and not localized only in one area (as happens, for example, with lobar pneumonia). Wheezing can be dry (occur when air passes through narrowed, swollen bronchi without phlegm) and wet (occur when air passes through the bronchi in which phlegm accumulates). Often, both types of wheezing are present at the same time, or dry wheezing is heard in the first days of the disease, then, as the natural course of the disease progresses, they turn into wet wheezing.

Treatment of obstructive bronchitis

In acute bronchitis with obstruction syndrome, it is advisable to prescribe bronchospasmolytic drugs, since the cause of the child’s serious condition is also a spasm of the smooth muscle layer.

In a situation of acute bronchitis with bronchial obstruction syndrome, inhalation procedures using special drugs are prescribed. It is necessary to choose the type of inhaler for a sick child with a doctor who, based on the clinical manifestations of this disease and the characteristics of your child’s body, will select the tactically correct route of inhalation therapy and dose. Antibacterial therapy, that is, the use of antibiotics in this case is not indicated. But if the baby’s temperature remains above 38° for more than 5 days, it is necessary to conduct a laboratory test and, possibly, take a chest x-ray. The results of these examinations will decide on further treatment and the use of antibiotics. The doctor will prescribe the necessary antibacterial drug based on the characteristics of the clinical manifestations of bronchitis in a given patient and the results of the examination.

How does an obstruction form?

The wall of the bronchi consists of cartilaginous tissue, which changes its structure and becomes thinner as it moves away from the trachea. The volume of smooth muscle cells increases as their caliber decreases, and their sensitivity to carbon dioxide (the more of it, the wider the diameter) increases.

The decrease in bronchial lumen is caused by three mechanisms:

swelling of their mucous membrane, resulting from the ingress of allergens or microbial antigens;
accumulation of viscous thick sputum in the lumen;
contraction of small-caliber smooth muscles of the bronchi.

These are three links of one process that potentiate each other.

Prevention

In the modern situation, it is necessary to pay great attention to the prevention of bronchitis. Prevention in children is vaccination against various infections. It is important that not only the child is vaccinated, but that everyone around him is also vaccinated. A big role for children is played by hardening, fresh indoor air, adherence to a daily routine, constant physical education, active walks in the fresh air, proper and regular healthy nutrition appropriate for the child’s age, and the use of vitamins.

Treatment of the disease

Effective therapy of broncho-obstructive syndrome is impossible without the use of inhalers. Steam inhalation is not suitable in this case: under the influence of moist heat, even more blood flows to the mucous membrane, resulting in increased swelling. You can use:
- ultrasonic inhalers (these are usually available only in medical institutions);
spacers, that is, containers into which the medicine is injected and then inhaled by the patient in the form of an aerosol.

In case of acute obstructive bronchitis, inhalations are carried out with drugs that dilate the bronchi (Berodual, Ventolin, Eufillin, Hydrocortisone), and drugs that dilute sputum are also used (Lazolvan, Fluimucil). The latter are not used from the first day of illness.

Antibiotic therapy is not indicated in every case, but only if bronchitis was caused by a bacterial agent.
Antiallergic treatment (“Erius”, “Zodak”) is a mandatory component of the treatment of bronchial obstruction.
It is imperative to ensure that the child is sufficiently hydrated, as otherwise it will be impossible to facilitate the removal of thick and viscous mucus through the bronchi.
During treatment, a strict hypoallergenic diet is observed. Children under 3 years old should not be given foods that are new to them.

Thus, obstructive bronchitis is a common pathology of the respiratory system. It is dangerous due to the development of tissue hypoxia, so it must be diagnosed in time. The main component of treatment is inhalation therapy with bronchodilator solutions.

Causes of prolonged cough not related to bronchitis:

sinusitis and postnasal drip syndrome (this is the flow of nasal mucus along the back wall of the pharynx into the respiratory tract). Most patients have mucous or mucopurulent nasal discharge.
postnasal drip can occur with general cooling of the body, allergic and vasomotor rhinitis, irritating environmental factors;
Various foreign bodies can enter the child’s bronchi - through swallowing, choking, inhalation;
oncology, pleurisy - here the diagnosis will be correctly made when additional types of examination are carried out;
a prolonged cough can be due to heart failure (in this situation, the cough often occurs at night when the child is sleeping); the diagnosis is helped by examination of the chest organs and echocardiography.
a child may be allergic to various irritants (food, household or plant allergens, taking certain medications, the presence of some animals in the house).
If a child has a prolonged cough, it is necessary to exclude the infectious disease whooping cough.

Cough syrups and bronchitis. How do syrups affect the symptoms of bronchitis in a child?

In general, all cough medications can be divided into three main groups:

A – centrally acting drugs, that is, those that suppress the cough reflex in the brain. They don't solve problems, but they create the appearance of improvement. Although in some rare cases it is difficult to do without them, for example, when a child has whooping cough;
B – herbal preparations (mucaltin, pertussin, sinupret, and many others) mainly stimulate the secretion of secretions by the goblet glands of the respiratory tract, that is, they, on the contrary, increase the cough. The older the child, the higher the effectiveness of these drugs, but not earlier than 3 years! And in life there are, excuse the jargon, “nerds” who cannot cough themselves up even at 14–15 years old;
B – drugs that dilute sputum. These are basically all synthetic mucolytics: ACC, carbocisteine, ambroxol, erespal. Although a lot of things are written in the instructions for these drugs, in the end, when a small child has bronchitis, and the doctor prescribes any syrup from group B or C, the result is always the same: the cough gets worse, but the result of this cough worsens. A small child does not have enough strength to cough up large amounts of mucus. This is especially noticeable in infants: while he is lying on his back, he screams until he is “blue,” he is picked up, begins to cough little by little and calm down, and may fall asleep in his arms “in a column”;

It should be clarified that an experienced pediatrician prescribes an antihistamine (Zyrtec or Fenistil) together with cough syrups, since their flavorings often cause allergies in a child, especially if he already had dermatitis on the skin.

Therapy of acute obstructive syndrome in children with acute respiratory diseases

Despite modern advances in medicine, in the 21st century the prevalence of infections not only does not decrease, but is increasingly increasing. For a long time, the first place in the structure of infectious morbidity in children is occupied by acute respiratory diseases (ARI) [1, 2]. According to the state report of Rospotrebnadzor, in Russia the incidence of acute respiratory infections in children in 2012 was more than 28 million (28,423,135), or 19,896.3 cases per 100 thousand children [3]. Such a high prevalence of acute respiratory infections in childhood is due to both the contagiousness of the infectious factor and the anatomical and physiological characteristics of the child’s body. A significant place in the etiological structure of acute respiratory infections is given to viral infections. Over the past decades, new viruses have been identified that determine the severe course of acute respiratory infections with airway obstruction, especially in children in the first years of life. Particular attention is paid to the role of metapneumovirus, coronovirus, bocavirus, rhinovirus, influenza virus reassortants, and respiratory syncytial virus in the development of obstructive airway syndrome. Their role in the development of acute obstructive airway syndrome (AOOS) in children is undeniable; at the same time, there is evidence indicating their possible role in the development of bronchial asthma (BA) in genetically predisposed individuals [1, 4].

Acute obstructive conditions of the respiratory tract in children are quite common and sometimes severe, accompanied by signs of respiratory failure. The most common of them is acute stenosing laryngotracheitis (croup), caused by inflammation of the mucous and submucosal space of the larynx and trachea, involving the tissues and structures of the subglottic space in the process and the development of laryngeal stenosis. Also quite often the cause of acute obstructive conditions of the respiratory tract against the background of acute respiratory viral infection (ARVI) in children are acute obstructive bronchitis, bronchiolitis and asthma [5].

The term “croup” refers to a clinical syndrome accompanied by a hoarse or hoarse voice, a rough “barking” cough and difficulty (stenotic) breathing. In the domestic literature, this disease is described under the name “stenosing laryngotracheitis”, in the International Classification of Diseases, 10th revision (ICD-10) - “acute obstructive laryngitis”. However, in practical work, the most widely used term is “croup”, which is recommended by leading pediatric infectious disease specialists to be used as a general terminology.

Broncho-obstructive syndrome is a symptom complex of functional or organic origin, the clinical manifestations of which consist of prolonged exhalation, whistling, noisy breathing, attacks of suffocation, coughing, etc. The terms “broncho-obstructive syndrome” and “croup” cannot be used as an independent diagnosis.

The prevalence of obstructive conditions of the respiratory tract due to acute respiratory viral infections is quite high, especially in children in the first 6 years of life. This is due to the anatomical and physiological characteristics of the respiratory tract in young children. Thus, the frequency of development of bronchial obstruction against the background of acute respiratory diseases in children of the first years of life is, according to various authors, from 5% to 50%. Most often, obstructive conditions are observed in children with a family history of allergies. The same trend exists in children, who often suffer from respiratory infections more than 6 times a year. In Western literature, the term “wheezing” is currently accepted - “noisy breathing” syndrome, combining laryngotracheal causes of OSDP and broncho-obstructive syndrome. It has been noted that 50% of children experience wheezing and shortness of breath at least once in their lives, and recurrent bronchial obstruction is typical for 25% of children [2, 6, 7].

Our analysis of the prevalence of obstructive syndrome in children with acute respiratory infections, which is the reason for hospitalization in the respiratory infections department of the St. Vladimir Children's City Clinical Hospital in Moscow, indicates an increase in patients with obstructive respiratory tract syndrome in recent years. According to our data, in 2011, 1348 children were admitted to the respiratory department, of which 408 children had a fairly severe course of OSDP due to acute respiratory infections. In subsequent years, we observed an increase in the role of NSDP, which determines the severity of acute respiratory infections; for example, in 2012, the number of hospitalizations reached 1636, and children with NSDP increased to 669. It should be noted that in 90% of cases, the age of children with NSDP was less than 5 years. An analysis was carried out of the reasons for the lack of effectiveness of treatment for obstructive conditions in children at the prehospital stage. It has been established that the main ones are inadequate assessment of the severity of NSDP and, accordingly, the lack of timely and rational therapy for NSDP, late prescription of anti-inflammatory therapy, and lack of control over the inhalation technique.

The high incidence of OSDP in children is due to both the characteristics of the infectious factor in the modern world and the anatomical and physiological characteristics of the child’s body. It is known that the immune system of children in the first years of life is characterized by immaturity and insufficient reserve capabilities. Thus, the response of the innate immune system of children in the first years of life is characterized by limited secretion of interferons (IFN), insufficient complement activity, and decreased cellular cytotoxicity. The features of adaptive immunity in this age group of patients are due to the Th2 direction of the immune response, which often contributes to the development of allergic reactions, the immaturity of the humoral part of the immune response with a decrease in the level of secretory immunoglobulin (Ig) A on the mucous membranes, and the predominant production of IgM to infectious pathogens. The immaturity of the immune response contributes to frequent acute respiratory infections and often determines the severity of their course [1].

Often the development of OSDP in children of the first years of life is due to the anatomical and physiological features of the structure of the respiratory tract of this age group of patients. Among them, especially important are the presence of hyperplasia of glandular tissue, secretion of predominantly viscous sputum, relative narrowness of the respiratory tract, smaller volume of smooth muscles, low collateral ventilation, and structural features of the larynx. The development of croup in children with ARVI is due to the small absolute size of the larynx, the softness of the cartilaginous skeleton, and the loose and elongated epiglottis. All this creates special preconditions for the components of stenosis: spasm and edema. In addition, due to the fact that the plates of the thyroid cartilage in children converge at a right angle (in adults it is sharp), the vocal cords (folds) become disproportionately short, and up to 7 years the depth of the larynx exceeds its width. The smaller the child, the greater the relative area occupied by loose connective tissue in the subglottic space, which increases the volume of swelling of the laryngeal mucosa. In children of the first three years of life, the larynx, trachea and bronchi have a relatively smaller diameter than in adults. The narrowness of all parts of the breathing apparatus significantly increases aerodynamic resistance. Young children are characterized by insufficient rigidity of the bone structure of the chest, which freely reacts by retracting compliant places to increase resistance in the airways, as well as features of the position and structure of the diaphragm. The differentiation of the nervous apparatus is also insufficient due to the fact that the 1st and 2nd reflexogenic zones are fused along their entire length and the 3rd reflexogenic zone, the receptors of which are abundantly branched throughout the mucous membrane of the subglottic space, is not formed, which contributes to the occurrence of prolonged spasm of the glottis and laryngeal stenosis. It is these features that contribute to the frequent development and recurrence of airway obstruction in children of the first years of life, especially against the background of acute respiratory infections [1, 5, 8].

The prognosis for the course of OSDP can be quite serious and depends on the form of the disease that caused the development of obstruction, and the timely implementation of pathogenetically determined treatment and prevention regimens.

The main directions of therapy for OSDP in children are the actual treatment of respiratory infection and treatment of airway obstruction.

According to modern data, the main place in the mechanism of development of OODP is attributed to inflammation. The development of inflammation of the mucous membrane of the upper and lower respiratory tract contributes to hypersecretion of viscous mucus, the formation of edema of the mucous membrane of the respiratory tract, disruption of mucociliary transport and the development of obstruction. Accordingly, the main directions of therapy for OSDP are anti-inflammatory therapy [9–11].

Inflammation is an important factor in bronchial obstruction in young children and can be caused by various factors. As a result of their influence, a cascade of immunological reactions is triggered, promoting the release of type 1 and type 2 mediators into the peripheral bloodstream. It is with these mediators (histamine, leukotrienes, prostaglandins) that the main pathogenetic mechanisms of obstructive syndrome are associated - increased vascular permeability, the appearance of edema of the bronchial mucosa, hypersecretion of viscous mucus, and the development of bronchospasm.

In children of the first years of life, it is edema and hyperplasia of the mucous membrane of the respiratory tract that is the main cause of airway obstruction at different levels. The developed lymphatic and circulatory systems of the child’s respiratory tract provide him with many physiological functions. However, under pathological conditions, edema is characterized by thickening of all layers of the bronchial wall (submucosal and mucous layers, basement membrane), which leads to impaired airway patency. With recurrent bronchopulmonary diseases, the structure of the epithelium is disrupted, its hyperplasia and squamous metaplasia are noted.

Another equally important mechanism of OSDP in children of the first years of life is a violation of bronchial secretion, which develops with any adverse effect on the respiratory system and in most cases is accompanied by an increase in the amount of secretion and an increase in its viscosity. The function of the mucous and serous glands is regulated by the parasympathetic nervous system; acetylcholine stimulates their activity. This reaction is initially defensive in nature. However, stagnation of bronchial contents leads to disruption of the ventilation and respiratory function of the lungs. The thick and viscous secretion produced, in addition to inhibiting ciliary activity, can cause bronchial obstruction due to the accumulation of mucus in the respiratory tract. In severe cases, ventilation disorders are accompanied by the development of atelectasis.

A significant role in the development of broncho-obstructive syndrome (BOS) is played by bronchial hyperreactivity. Bronchial hyperreactivity is an increase in the sensitivity and reactivity of the bronchi to specific and nonspecific stimuli. The cause of bronchial hyperreactivity is an imbalance between excitatory (cholinergic, noncholinergic and α-adrenergic systems) and inhibitory (β-adrenergic system) influences on bronchial tone. It is known that stimulation of β2-adrenergic receptors by catecholamines, as well as increasing the concentration of cAMP and prostaglandins E2, reduces the manifestations of bronchospasm. According to the classical theory of A. Szentivanyi (1968), patients with bronchial hyperreactivity have a defect in the biochemical structure of β2 receptors, which is reduced to adenylate cyclase deficiency. These patients have a reduced number of β-receptors on lymphocytes, there is an imbalance of adrenergic receptors towards hypersensitivity of α-adrenergic receptors, which predisposes to smooth muscle spasm, mucosal edema, infiltration and hypersecretion. Hereditary blockade of adenylate cyclase reduces the sensitivity of β2-adrenergic receptors to adrenergic agonists, which is quite common in patients with asthma. At the same time, some researchers point to the functional immaturity of β2-adrenergic receptors in children in the first months of life.

It has been established that in young children, M-cholinergic receptors are quite well developed, which, on the one hand, determines the characteristics of the course of broncho-obstructive diseases in this group of patients (tendency to develop obstruction, production of very viscous bronchial secretions), on the other hand, explains the pronounced bronchodilator effect They have M-anticholinergics.

Thus, the anatomical and physiological characteristics of young children determine both the high prevalence of OSDP in children of the first years of life and the mechanisms of its development with the corresponding clinical picture of “wet asthma”.

Therapy for OSDP should be started immediately after symptoms are identified at the patient's bedside. It is necessary to immediately begin emergency therapy and at the same time find out the causes of bronchial obstruction.

The main directions of emergency treatment of OSDP include measures for bronchodilator, anti-inflammatory therapy, improvement of bronchial drainage function and restoration of adequate mucociliary clearance. A severe attack of bronchial obstruction requires oxygenation of inhaled air, and sometimes artificial ventilation.

Emergency treatment of OSDP in children should be carried out taking into account the pathogenesis of obstruction in different age periods. In the genesis of BOS in young children, inflammatory edema and hypersecretion of viscous mucus predominate, and bronchospasm is slightly expressed. With age, bronchial hyperreactivity increases and along with this the role of bronchospasm increases.

The main directions of treatment for acute obstructive conditions of the upper and lower respiratory tract in children with acute respiratory infections are the treatment of the respiratory infection itself and the treatment of airway obstruction [12]. Of course, treatment of acute respiratory infections should be comprehensive and individual in each specific case.

Etiotropic therapy for the most common viral infections is currently difficult due to the narrow spectrum of action of antiviral drugs, the age limit for their use in children in the first years of life, and the insufficient evidence base for the effectiveness of this group of drugs. Currently, recombinant interferon preparations and drugs that stimulate the synthesis of endogenous interferon are actively used in the treatment of acute respiratory infections of viral etiology. The prescription of antibacterial drugs is indicated in the case of prolonged fever (more than 3-4 days), and/or the presence of signs of respiratory failure in the absence of biofeedback, and/or suspected pneumonia, and/or pronounced changes in the clinical blood test.

Modern standards for the treatment of obstructive conditions of the respiratory tract are defined in international and national program documents [5, 9, 13], according to which the main drugs in the treatment of OSDP are bronchodilators and drugs with anti-inflammatory effects. The widespread use of inhaled glucocorticosteroids (ICS) is recommended as an effective anti-inflammatory therapy. ICS are the most effective treatment for acute stenosing laryngotracheitis, bronchial asthma and acute obstructive bronchitis. The mechanism of their therapeutic action is associated with a powerful anti-inflammatory effect. The anti-inflammatory effect of ICS is associated with an inhibitory effect on inflammatory cells and their mediators, including the production of cytokines (interleukins), pro-inflammatory mediators and their interaction with target cells. ICS have an effect on all phases of inflammation, regardless of its nature, and the key cellular target may be epithelial cells of the respiratory tract. ICS directly or indirectly regulate the transcription of target cell genes. They increase the synthesis of anti-inflammatory proteins (lipocortin-1) or reduce the synthesis of pro-inflammatory cytokines - interleukins, tumor necrosis factor, etc. With long-term therapy with ICS in patients with bronchial asthma, the number of mast cells and eosinophils on the mucous membranes of the respiratory tract is significantly reduced, cell membranes are stabilized, membranes of lysosomes and vascular permeability decreases.

In addition to reducing inflammatory swelling of the mucous membrane and bronchial hyperreactivity, ICS improve the function of β2-adrenergic receptors both by synthesizing new receptors and increasing their sensitivity. Therefore, ICS potentiate the effects of β2-agonists.

Inhaled use of GCS creates high concentrations of drugs in the respiratory tract, which ensures the most pronounced local anti-inflammatory effect and minimal manifestations of systemic (undesirable) effects.

However, the effectiveness and safety of ICS in the treatment of OSDP in children is largely determined by the method of delivery directly to the respiratory tract and the inhalation technique [14, 16]. Delivery systems currently available include metered dose aerosol inhalers (MDIs), MDIs with a spacer and face mask (Aerochamber, Babyhaler), breath-activated MDIs, powder inhalers and nebulizers. It is now recognized that the optimal system for delivering drugs to the respiratory tract for acute respiratory depression in young children is a nebulizer. Its use contributes to the best positive dynamics of clinical data, a sufficient bronchodilator effect of the peripheral sections of the bronchi, and the technique of its use is almost error-free. The main goal of nebulizer therapy is to deliver a therapeutic dose of the desired drug in aerosol form in a short period of time, usually 5–10 minutes. Its advantages include: an easily performed inhalation technique, the ability to deliver a higher dose of the inhaled substance and ensure its penetration into poorly ventilated areas of the bronchi. In young children, it is necessary to use a mask of the appropriate size; from 3–4 years of age, it is better to use a mouthpiece than a mask, since the use of a mask reduces the dose of the inhaled substance due to its sedimentation in the nasopharynx.

Currently, the following ICS can be used in the practice of a doctor: beclomethasone, budesonide, fluticasone propionate, mometasone furoate and ciclesonide. It is necessary to note the age-related aspects of prescribing ICS in children. Thus, in children from 6 months of age, the drug budesonide suspension is approved for use in inhalation through a compressor nebulizer, from 12 months - fluticasone propionate through a spacer, beclomethasone propionate is approved for use in pediatric practice from 4 years, ciclesonide from 6 years, and mometasone furoate from the age of 12.

To carry out nebulizer therapy, only drug solutions specially designed for these purposes are used, approved by the Pharmacological Committee of the Russian Federation for nebulizers. At the same time, even a small particle of a solution in an aerosol retains all the medicinal properties of the substance; the solutions themselves for nebulizer therapy do not cause damage to the mucous membrane of the bronchi and alveoli, and packaging in the form of bottles or nebulas allows for convenient dosing of drugs both in hospital and at home.

More recently, a whole line of drugs intended for nebulizer therapy was registered in our country, including ICS - budesonide (Budenit Steri-Neb) and 3 bronchodilators: salbutamol (Salamol Steri-Neb), ipratropium bromide (Ipratropium Steri-Neb) and the combination salbutamol/ ipratropium bromide (Ipramol Steri-Neb).

The drug Budenit Steri-Neb (budesonide) is a generic version of the original drug budesonide Pulmicort suspension. According to the definition of the Food and Drugs Administration of the United States (FDA), a generic drug is a drug comparable to the original drug in dosage form, strength, route of administration, quality, pharmacological properties and indications for use. Generic drugs that meet this definition are characterized by: compliance with pharmacopoeial requirements, production under GMP (Good Manufacturing Practice) conditions, almost complete compliance with the original product in composition (excipients may be different) and effects produced, lack of patent protection , a more affordable price than the original drug.

All of the above characteristics can be attributed to Steri-Heaven. The preparations in nebulas are created using advanced 3-stage “hot sealing” technology, which allows you to achieve maximum sterility. Each Steri-Sky contains one dose of the drug, and the drug is completely ready for use (does not require dilution), which eliminates dosing errors [15]. Steri-Sky plastic ampoules are easy to open. Medicines found in Steri-Sky do not contain benzalkonium chloride and other preservatives, which makes them safer, and this is very important when used, especially in pediatric practice.

Thus, the main principles of treatment of bronchial obstruction are anti-inflammatory treatment and the use of bronchodilators. It is ICS that are an important component of anti-inflammatory therapy for BOS. Currently, nebulized budesonide for exacerbation of asthma is considered as an alternative to systemic glucocorticosteroids [13]. The advantage of budesonide when administered by inhalation is the faster action of GCS (within 1–3 hours), maximum improvement of bronchial patency after 3–6 hours, reduction of bronchial hyperreactivity and a much higher safety profile.

Taking into account the fact that the majority of clinical studies of nebulized budesonide therapy used the original drug Pulmicort (suspension), a comparison of the pharmaceutical equivalence of these drugs was performed to assess the comparability of the results of these studies in relation to Budenitis Steri-Neb.

A direct comparison of the therapeutic efficacy and safety of Budenit Steri-Neb (TEVA, Israel) and Pulmicort (suspension) (AstraZeneca, UK) was conducted in a multicenter randomized placebo-controlled study in a cohort of children (from 5 years to 11 years 8 months) delivered to emergency departments for asthma exacerbation (Phase III parallel group study; 23 study sites recruited patients in 6 countries—Estonia, Israel, Latvia, Poland, Colombia, and Mexico). The study included 302 children. Budenit Steri-Neb (0.5 mg/2 ml and 1 mg/2 ml) and Pulmicort suspension (0.5 mg/2 ml and 1 mg/2 ml) did not differ significantly in component composition, suspension particle size, particle distribution generated aerosol by size, amount of budesonide in the inhaled mixture. Thus, chemical and pharmacological studies of Budenit Steri-Neb and the original drug Pulmicort revealed the equivalence of the budesonide suspension of the two manufacturers in terms of the main indicators affecting the therapeutic effect of ICS. Therapeutic equivalence and similar safety profile of Budenit Steri-Neb and the original drug Pulmicort (suspension) have been demonstrated, which allows extrapolation of data obtained in studies of nebulized budesonide [16].

Thus, according to international and national recommendations, the most optimal, affordable and effective anti-inflammatory drug for the treatment of acute stenosing laryngotracheitis, broncho-obstructive syndrome in children over 6 months of age is a budesonide suspension with inhalation use through a nebulizer. The appearance on the pharmaceutical market of high-quality generics in the form of Steri-Sky, including budesonide (Budenit Steri-Neb), expands the choice of pediatricians in the treatment of acute stenosing laryngotracheitis and broncho-obstructive syndrome in children. Early administration of this drug for OSDP is the key to a favorable prognosis and prevention of complications.

Data from regulatory documents [5, 9, 13] and the results of our own clinical observations indicate that the use of modern ICS is a highly effective and safe method of treating severe OADP. In children from 6 months of age and older, the best is inhalation of budesonide through a nebulizer at a daily dose of 0.25–1 mg/day (the volume of the inhaled solution is adjusted to 2–4 ml by adding saline). The drug can be prescribed once a day, however, as our experience shows, at the height of a severe attack of broncho-obstruction or laryngeal stenosis of 2-3 degrees in children of the first years of life, inhalations of the drug 2 times a day are more effective. In patients who have not previously received ICS, it is advisable to start with a dose of 0.5 mg every 12 hours, and on days 2–3, with a good therapeutic effect, switch to 0.25–0.50 mg once a day. It is advisable to prescribe IGS 15–20 minutes after inhalation of a bronchodilator, but it is also possible to use both drugs simultaneously in the same nebulizer chamber. The duration of therapy with inhaled corticosteroids is determined by the nature of the disease, the duration and severity of the obstruction, as well as the effect of the therapy. In children with acute obstructive bronchitis with severe bronchial obstruction, the need for ICS therapy is usually 5-7 days, and in children with croup - 2-3 days.

Broncholytic therapy

β2-adrenergic agonists, anticholinergic drugs and their combination, as well as short-acting theophyllines can be used as bronchodilator therapy for BOS.

According to national recommendations, short-acting β2-agonists (salbutamol, terbutaline, fenoterol) are the first choice drugs. The effect of this group of drugs begins 5–10 minutes after inhalation and lasts 4–6 hours. A single dose of salbutamol inhaled through a MDI is 100–200 mcg (1–2 doses); when using a nebulizer, the single dose can be significantly increased and is 2.5 mg (nebulas of 2.5 ml of 0.1% solution). The emergency treatment algorithm for severe BOS involves three inhalations of a short-acting β2-agonist over 1 hour with an interval of 20 minutes. Drugs in this group are highly selective and therefore have minimal side effects. However, with long-term uncontrolled use of short-acting β2-agonists, it is possible to increase bronchial hyperreactivity and reduce the sensitivity of β2-adrenergic receptors to the drug.

Anticholinergic drugs (ipratropium bromide) can be used as bronchodilator therapy, taking into account the pathogenetic mechanisms of BOS. This group of drugs block muscarinic M3 receptors for acetylcholine. The bronchodilator effect of the inhaled form of ipratropium bromide develops 15–20 minutes after inhalation. Through a MDI with a spacer, 2 doses (40 mcg) of the drug are inhaled once, through a nebulizer - 8-20 drops (100-250 mcg) 3-4 times a day. Anticholinergic drugs in cases of BOS arising from a respiratory infection are somewhat more effective than short-acting α2-agonists.

It has now been established that a physiological feature of young children is the presence of a relatively small number of adrenergic receptors; with age, there is an increase in their number and an increase in sensitivity to the action of mediators. The sensitivity of M-cholinergic receptors, as a rule, is quite high from the first months of life. These observations served as a prerequisite for the creation of combination drugs. Most often in the complex therapy of biofeedback in young children, a combination drug is currently used that combines 2 mechanisms of action: stimulation of adrenergic receptors and blockade of M-cholinergic receptors. When ipratropium bromide and fenoterol are used together, the bronchodilator effect is achieved by acting on various pharmacological targets [9, 11, 13].

Mucolytic and expectorant therapy

Mucolytic and expectorant therapy for children with OSDP of infectious origin is carried out taking into account the age of the child, the severity of the respiratory infection, the amount of sputum produced and its rheological properties. The main goal is to thin the mucus, reduce its adhesiveness and increase the effectiveness of the cough.

If children have an unproductive cough with viscous sputum, it is advisable to combine the inhalation (via nebulizer) and oral route of administration of mucolytics, the best of which are ambroxol preparations (Lazolvan, Ambrobene, Ambrohexal, etc.). These drugs have proven themselves well in the complex treatment of broncho-obstructive syndrome in children. They have a pronounced mucolytic and mucokinetic effect, a moderate anti-inflammatory effect, increase the synthesis of surfactant, do not increase bronchial obstruction, and practically do not cause allergic reactions. Ambroxol preparations for respiratory infections in children are prescribed 7.5–15 mg 2–3 times a day in the form of syrup, solution and/or inhalation.

For children with an obsessive, unproductive cough and lack of sputum, it is advisable to prescribe expectorant medications: alkaline drinks, herbal remedies, etc. Herbal medicines should be prescribed to children with allergies with caution. We can recommend preparations created from natural plant materials using modern technologies (ivy leaf extract - Prospan, Bronchipret, etc.). A combination of expectorants and mucolytic drugs is possible.

Thus, a feature of the course of acute respiratory infections in children in the first years of life is the frequent development of acute obstructive conditions of the respiratory tract. The main causes of acute obstructive conditions of the respiratory tract in children with ARVI are acute stenosing laryngotracheitis, acute obstructive bronchitis, bronchiolitis and bronchial asthma. These conditions require urgent treatment. The main method of drug delivery during an exacerbation of the disease is inhalation using nebulizers. The main directions of therapy for OSDP are the prescription of anti-inflammatory drugs, bronchodilators and mucolytics. The drugs of choice for anti-inflammatory therapy for OSDP are ICS. Timely prescribed rational therapy for OSDP is the key to rapid relief of OSDP and prevention of life-threatening conditions.

With information support from TEVA LLC

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S. V. Zaitseva, Candidate of Medical Sciences S. Yu. Snitko O. V. Zaitseva, Doctor of Medical Sciences, Professor E. E. Lokshina, Candidate of Medical Sciences

State Budgetary Educational Institution of Higher Professional Education MGMSU named after A. I. Evdokimov Ministry of Health of the Russian Federation, Moscow

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