Modern therapy of chronic obstructive pulmonary disease

Chronic bronchitis in adults: symptoms and treatment at home

Almost every one of us encounters a disease of the respiratory system called bronchitis at least once in our lives. Its main symptom is a severe cough, sometimes with shortness of breath and viscous sputum, as well as headache, general weakness, etc.

But the worst thing is when a similar situation repeats itself at intervals of several months, or even weeks. In this case, we may be talking about a more serious form of the disease, that is, chronic bronchitis, which causes a lot of problems for a person and is difficult to treat. So, what are the signs to recognize the chronic form of the disease, and how to get rid of it forever?

Reasons for the development of the chronic form

The following reasons may be involved in the occurrence of a chronic inflammatory process in the bronchi:

1. Tobacco smoke. The main risk group for the development of chronic bronchitis is smokers;
2. Decreased immunity. It becomes a favorable background for the launch of the microbial factor;
3. Chemical pollutants. All chemical compounds, the vapors of which are regularly inhaled by humans, like dust, cause a reaction in the bronchi in the form of inflammation or bronchospasm;
4. Climatic conditions. Climatic conditions are rarely the root cause. But they provide a general unfavorable background against which all other reasons are realized. These include low air temperatures, high humidity and industrial air pollution;
5. Infections. They are represented by bacterial, viral and atypical pathogens. Very rarely, this factor alone is sufficient to cause a chronic process. There must be a combination of it with other reasons that will support each other’s negative influence. Of utmost importance in this regard are chronic foci of infection in the tonsils, sinuses and carious teeth;
6. Work in conditions of occupational hazards. In such cases, constant inhalation of air contaminated with coal or other types of dust leads to its deposition in the bronchi. The natural reaction of the body to foreign particles is inflammatory. Naturally, under conditions of the continued influx of dust particles, self-cleaning mechanisms cannot have time to remove all accumulated deposits. This is the basis of the chronicity of the process;
7. Hereditary predisposition and congenital characteristics of the bronchial tree. A very important group of reasons why the bronchi are initially susceptible to any harmful environmental factors. Minimal provocateurs cause bronchospasm and increased mucus production. Its obstructed outflow contributes to the activation of infection, maintenance of inflammation with the possibility of developing bronchial obstruction.

The mechanism for triggering a chronic inflammatory process in the bronchial wall is quite complex. It is impossible to single out just one factor that first realizes it. The exception is cases of occupational and chronic bronchitis of smokers.

What are the causes of bronchitis?

All causes of the disease can be divided into three large categories:

Infectious lesions.

The causative agents may be:

• viruses (adenovirus, influenza virus);
• bacteria (usually strepto-, pneumo- and staphylococci);
• atypical microorganisms such as mycoplasma or chlamydia;
• fungal infections.

Exposure to chemical factors.

These include:

• toxic compounds found in the atmosphere of industrial cities;
• increased content of smoke and/or dust in the air;
• occupational hazards in the form of fumes hazardous to health;
• smoking abuse.

Internal factors.

This is, first of all, individual intolerance to certain substances, manifested by an allergic reaction (inflammation) on the bronchial mucosa. Diseases of the cardiovascular and pulmonary systems, as well as chronic infectious and inflammatory disorders in the nasopharynx, oral cavity and tonsils can also provoke the occurrence of pathology.

Classification

Based on the nature of the sputum discharge, the following types of chronic bronchitis are distinguished:

• purulent;
• hemorrhagic (admixture of blood in the discharge from the bronchi);
• fibrinous.

Depending on which part of the bronchial tree is affected, proximal bronchitis (large bronchi) or distal bronchitis (bronchioles are affected) is diagnosed.

In accordance with the presence or absence of a bronchospastic component, bronchitis is divided into obstructive and non-obstructive. The disease can be in remission or exacerbation, uncomplicated or complicated (for example, pulmonary emphysema).

ABSCESS OF THE LUNG

Lung abscess

- a pathological process characterized by the formation of a limited cavity in the lung tissue as a result of its necrosis and purulent melting.

Main pathogens

Development of a lung abscess

binds primarily to anaerobic flora -
Bacteroides
spp.,
F. nucleatum, Peptostreptococcus
spp.,
P. niger
- often in combination with enterobacteria (due to aspiration of oropharyngeal contents).

Choice of antimicrobials

Drugs of choice

: amoxicillin/clavulanate, ampicillin/sulbactam or cefoperazone/sulbactam IV; benzylpenicillin intravenously, then amoxicillin orally (step therapy); benzylpenicillin + metronidazole IV, then amoxicillin + metronidazole orally (stepped therapy).

Alternative drugs

: lincosamides + aminoglycosides of II-III generation; fluoroquinolones + metronidazole; carbapenems.

Duration of therapy

determined individually.

Symptoms of chronic bronchitis

The symptoms of the disease are characterized by pronounced severity and are represented by the following manifestations:

1. Cough. It is the main sign of chronic bronchitis, which determines the course of the disease, as well as the entire clinical picture in general. At the initial stage of the disease, the cough makes itself felt only in the morning with little sputum production. As the disease develops, it becomes wetter and more frequent.
2. Sputum. At the initial stage of the disease, sputum is characterized by the appearance at the end of a coughing attack of a small amount of discharge in the form of mucus, which is transparent or yellowish in color. The development of chronic bronchitis is caused by the appearance of purulent, viscous sputum with a green tint, which indicates the addition of a bacterial infection.
3. Dyspnea. Appears as a result of a very active process of inflammation in the bronchi. Initially occurs when performing any type of physical load. Further, as the disease progresses, it begins to be accompanied by a cough and occurs even at rest.
4. Wheezing. Sputum provokes difficulties with the circulation of air masses, which is caused by the presence of wheezing. If the disease weakens, the wheezing is dry and easy to hear. If there is an exacerbation of the inflammation process, the amount of expectorated sputum increases, and wheezing becomes moist. If the small bronchi are affected, the wheezing begins to have a whistling character, which can be clearly heard from a distance.
5. Cyanosis. The occurrence of this manifestation is not characteristic of the normal course of the disease. A change in the color of the skin indicates the activation of complications when the bronchi become unable to properly supply air masses to the lungs. The result is a bluish tint.
6. Asthma syndrome. The occurrence of asthmatic syndrome may be associated with a prolonged course of inflammation or bronchospasm, which indicates the possibility of the syndrome occurring at any stage of the disease.

PNEUMONIA

Pneumonia

- an acute infectious disease characterized by focal damage to the respiratory parts of the lungs with intra-alveolar exudation, detected by objective and x-ray examination, expressed in varying degrees by a febrile reaction and intoxication.

Clinically significant is the division of pneumonia into community-acquired

and
nosocomial (hospital, in-hospital)
. This division of pneumonia has nothing to do with the severity of their course. The main and only criterion for differentiation is the environment in which pneumonia developed.

Nosocomial pneumonia

- pneumonia that develops in a patient no earlier than 48 hours after hospitalization and was not in the incubation period.

Main pathogens

Community-acquired pneumonia

Pneumococcus remains the most common causative agent of community-acquired pneumonia (Table 2). Two other microorganisms are M.pneumoniae

and
C.pneumoniae
- often occur in young and middle-aged people (up to 20-30%), and their etiological role in patients of older age groups is less significant (1-3%).
L.pneumophila
is a rare causative agent of community-acquired pneumonia, but legionella pneumonia ranks second (after pneumococcal) in terms of mortality.
H.influenzae more often causes pneumonia in smokers, as well as against the background of chronic bronchitis. E.coli
and
K.pneumoniae
(less commonly other representatives of the
Enterobacteriaceae
) are found, as a rule, in patients with risk factors (diabetes mellitus, congestive heart failure, etc.).
The likelihood of staph pneumonia ( S. aureus
) increases in older people or in people who have had the flu.

Table 2. Etiology of community-acquired pneumonia

Nosocomial pneumonia

The etiology of nosocomial pneumonia is dominated by gram-negative microflora of the Enterobacteriaceae family, P.aeruginosa

(Table 3).

Table 3. Etiology of nosocomial pneumonia

There is a special type of nosocomial pneumonia - ventilator-associated pneumonia, the etiology of which depends on the length of the patient's stay on mechanical ventilation. With the so-called early VAP (development in the first 4 days of being on a ventilator), the most likely pathogens are S.pneumoniae, H.influenzae, S.aureus

(MSSA) and other representatives of the normal microflora of the oral cavity.
The development of late VAP (more than 4 days on mechanical ventilation) is associated with P.aeruginosa, Acinetobacter
spp., members of the
Enterobacteriaceae
, and less commonly MRSA.

Choice of antimicrobials

When treating patients with community-acquired pneumonia, a differentiated approach should be taken to the choice of antimicrobial agents, taking into account age, severity of the condition, the presence of concomitant diseases, location of the patient (at home, in the general ward of a hospital, in the ICU), previous antimicrobial therapy, use of glucocorticoids, etc. (Table . 4).

Table 4. Choice of antibiotics for community-acquired pneumonia

Prognostically, the rapid initiation of antimicrobial therapy, no later than 4 hours after diagnosis, is very important.

When choosing AMPs in a patient with nosocomial pneumonia

the nature of the department in which he is located (general profile or ICU), the use of mechanical ventilation and the time of development of VAP are taken into account (Table 5). Empirical therapy is planned based on local data on the sensitivity of likely pathogens. Sputum examination is mandatory, and it is desirable to obtain material by invasive methods with quantitative assessment of the results, and blood culture.

Table 5. Choice of antibiotics for nosocomial pneumonia

Risk factors: recent abdominal surgery, aspiration - anaerobes; coma, head injury, diabetes, chronic renal failure, influenza, “IV drug addicts” - S.aureus

;
large doses of glucocorticoids, cytostatics, neutropenia - Legionella
spp.,
P.aeruginosa, Aspergillus
spp.;
long stay in the ICU, treatment with corticosteroids, antibiotics, bronchiectasis, cystic fibrosis - P.aeruginosa
,
Enterobacter
spp.,
Acinetobacter
spp.

Routes of administration of antimicrobial drugs

In the treatment of outpatient forms of community-acquired pneumonia, preference should be given to oral antibiotics. However, in severe infections, AMPs must be administered intravenously. In the latter case, stepwise therapy is also highly effective, which involves switching from parenteral to oral administration. The transition should be made when the course of the disease stabilizes or the clinical picture improves (on average 2-3 days from the start of treatment).

Duration of therapy

For uncomplicated community-acquired pneumonia, antibiotic therapy can be completed once stable normalization of body temperature is achieved. The duration of treatment is usually 7-10 days.

If there are clinical and/or epidemiological data on mycoplasma, chlamydial or legionella pneumonia, the duration of antibacterial therapy should be longer due to the risk of relapse of infection - 2-3 weeks.

Duration of AMP use for complicated community-acquired pneumonia

and
nosocomial pneumonia
are determined individually.

In any case, the persistence of individual clinical, laboratory and/or radiological signs is not an absolute indication for continuation of antibacterial therapy or its modification. In most cases, these signs resolve spontaneously over time.

Chronic obstructive bronchitis

The obstructive form of the disease is initially asymptomatic. Then it manifests itself as a hacking cough, wheezing and difficulty breathing in the morning, which disappears after the sputum is discharged.

The main signs of chronic obstructive bronchitis are:

• severe unproductive cough;
• severe shortness of breath during physical exertion and irritation of the respiratory tract;
• wheezing when exhaling;
• prolongation of the expiratory phase.

According to the form of its course, bronchitis is divided into acute and chronic.

Chronic bronchitis
is a chronic inflammation of the bronchial tubes.
Chronic bronchitis is considered if the cough continues for at least three months a year for two years in a row. According to etiology
(causes of occurrence),
viral, bacterial and allergic bronchitis are distinguished.
More than 80% of bronchitis is viral, infection occurs through airborne droplets, and proceeds like a normal acute respiratory viral infection, with the difference that the viruses that cause bronchitis prefer to “settle” in the bronchial tissue.

Treatment of chronic bronchitis

This is a whole complex of events. Depending on what phase of the disease the patient is in - remission or exacerbation, the doctor chooses treatment tactics.

During exacerbations it is important:

• Eliminate the inflammatory process in the bronchi;
• Normalize mucus secretion;
• Improve lung ventilation, eliminate bronchospasm;
• Support the work of the heart.

During the period of relative attenuation of the disease it is necessary:

• Eliminate foci of nasopharyngeal infection;
• Conduct sanatorium-resort treatment;
• Do breathing exercises

Treatment regimen and drugs used for chronic bronchitis:

1. Elimination of the provoking factor. It should be remembered: no drug therapy will produce results without eliminating the cause. However, quitting smoking for 20 years or more will not bring the desired success due to the irreversibility of changes in the mucosa.
2. Antibiotics. They are used for purulent and purulent-catarrhal bronchitis; for catarrhal bronchitis, they are usually not needed! Prescribed after sputum examination. This gives the doctor information about the sensitivity of bacteria to a particular drug. In cases where it is impossible to examine sputum, antibiotics of the penicillin group are prescribed. Recently, particularly effective drugs Sumamed and Rulid have been used, since most of the microorganisms that cause chronic bronchitis are sensitive to them. A reserve group antibiotic, Gentamicin, in the absence of a positive effect, is delivered directly to the bronchi in hospital treatment.
3. Considering that for chronic bronchitis the course of treatment can be quite long, we must not forget about supporting one of the most important organs of the human body - the liver. After all, this organ is a natural filter and passes all chemical elements through itself, while the liver cells weaken and die. To restore and support the liver, you need to take herbal hepatoprotectors (karsil, darsil, milk thistle extract, hepatophyte).
4. Bronchodilators. Prescribed at the first attacks of obstruction. The attending physician chooses one of the drugs: Atrovent, Salbutamol, Berodual (combined drug) or Theophylline if the above-mentioned drugs are ineffective.
5. Expectorants. It is more advisable to take drugs that dilute sputum (ACC, Fluimucil), mucoregulators (Lazolvan, Bromhexine) and reflex agents (potassium iodide, marshmallow and plantain syrups).
6. Immune support agents. Recently, in the treatment of chronic bronchitis, drugs that specifically affect the body’s immune system have been increasingly used. This is Timalin or T-activin. The positive effect of vitamins C, A, and immunomodulators of plant origin also affects the successful treatment of chronic bronchitis.
7. If an exacerbation of chronic bronchitis is caused by influenza viruses or ARVI, then it is advisable to take antiviral drugs (groprinosin, amizon, anaferon, aflubin).
8. Inhalations. The best option for inhalation for chronic bronchitis is a nebulizer, which ensures the flow of antibacterial (Dioxidin, etc.), anti-inflammatory (Rotokan) and expectorant agents even into the small bronchi.
9. Physical methods. Massage and breathing exercises (breathing techniques according to Buteyko and Strelnikova are especially effective) significantly improve the cleansing of mucus from the bronchi. The only condition: regularity of procedures.

Why can an elderly person get bronchitis?

Bronchitis in old people can develop as a result of smoking tobacco (in particular, in elderly passive smokers - that is, those who do not even smoke themselves, but simply stand next to someone smoking), environmental problems, inhalation of toxic harmful substances, long exposure to in the cold. In addition, bronchitis can develop for more common reasons:

• if pathogenic flora enters, such as streptococci, staphylococci and pneumococci;
• due to a fungal infection;
• due to viral invasion - influenza virus, parainfluenza, adenovirus and the like;
• atypical flora - chlamydia and mycoplasma;
• due to the combined nature of the occurrence - this happens most often, with an elderly person first becoming infected with the virus, the virus makes the human body weaker and bacteria penetrate there more easily.

Often, symptoms of chronic bronchitis in the elderly begin to appear in winter or autumn, when the protective functions of the human body are significantly weakened because there are not enough vitamins. While this is, again, easier for the young to bear, the old suffer seriously.

Breathing exercises

Breathing exercises are the main physiotherapeutic procedure shown to help permanently cure chronic bronchitis. It can consist not only of passive breathing exercises, but also involve the whole body.

One of the most famous breathing exercises complexes was developed in the USSR by A.N. Strelnikova and bears her name. For example, it involves the use of arms, legs, tension in the shoulder and abdominal girdle. Due to complex physical activity, tissue respiration is enhanced, the respiratory organs are toned, and a cascade of reactions is launched that stimulate the immune system and improve mood.

In general, for bronchitis in the chronic stage, any moderate physical activity is useful: walking, climbing stairs, exercise, swimming.

Sources

1. Chronic non-obstructive bronchitis / T.A. Mukhtarov, A.V. Tumarenko, V.V. Skvortsov // Nurse. — 2015 — No. 8.
2. Tatochenko V.K. Respiratory diseases: a practical guide. - M.: Pediatrician. — 2012.
3. Jefferson T., Jones MA, Doshi P., et al. Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children // Cochrane Database Syst Rev. - 2012; 1.
4. Pharmacotherapy of acute bronchitis/ Benz T.M. — 2021.
5. Patrusheva Yu. S., Bakradze M.D., Kulichenko T.V. Diagnosis and treatment of acute bronchiolitis in children: Diagnostic issues in pediatrics. - 2011. - T.Z, No. 1.
6. Maznev, N. Asthma, bronchitis and other respiratory diseases / N. Maznev. — M.: House. XXI century, Ripol Classic, 2011.

Inhalations

This is one of the most effective physiotherapeutic procedures for bronchitis. Inhalations can be steam and finely dispersed. Such procedures can be carried out both in a hospital and at home. For steam inhalations, vapors of herbs, essential oils, and sodium bicarbonate are used. For finely dispersed inhalations using a nebulizer, herbal infusions, Borjomi-type mineral water, and phlegm-thinning medications (ACC, mucolvan, hypertonic potassium solution or sodium iodide) are used.

A lytic mixture administered using an inhaler will help relieve bronchospasm:

• atropine 0.1% solution – 2 ml,
• adrenaline 0.1% solution – 2 ml,
• diphenhydramine 0.1% solution – 2 ml.

All ingredients are mixed, poured into the inhaler reservoir and administered by fine spraying into the respiratory organs. The advantage of this method is that inhalations can be used for quite a long time - up to 2-3 months.

FEATURES OF TREATMENT OF NPD INFECTIONS IN ELDERLY PEOPLE

In older people, the frequency of PD infections increases, which is associated with such predisposing factors as partial atrophy (especially in smokers) and low activity of the ciliated epithelium of PD, decreased general immunity, and the presence of concomitant diseases. Therefore, antibiotic therapy should be based on the possible influence of these unfavorable factors.

Due to age-related changes in kidney function, it may be necessary to adjust the AMP dosage regimen. This primarily concerns aminoglycosides and co-trimoxazole.

With existing pathology of the liver and gallbladder, it is possible to change the kinetics of a number of AMPs that are metabolized in the liver or excreted in the bile (lincosamides, metronidazole, macrolides). In patients with gallbladder pathology, ceftriaxone should be used with caution due to the increased risk of developing pseudocholelithiasis.

Table 7. Doses of antibiotics for the treatment of urinary tract infections in adults

Table 8. Typical errors in antibiotic therapy for NPD infections

Features of nutrition and lifestyle with bronchitis

Against the background of exacerbation of bronchitis, drinking plenty of fluids is traditionally recommended. For an adult, the daily volume of fluid consumed should be at least 3 – 3.5 liters. Alkaline fruit drink, hot milk and Borjomi in a 1:1 ratio are usually well tolerated.

The daily diet should contain a sufficient amount of proteins and vitamins. Against the background of high temperature and general intoxication, you can fast a little (if the body requires it, of course), but in general, any restrictive diets are contraindicated for such patients.

The use of inhalation using a nebulizer shows high efficiency. As a solution for inhalation, you can use mineral water, Ringer's solution or regular saline solution. Procedures are carried out 2-3 times a day for 5-10 days. These manipulations promote the discharge of phlegm, facilitate drainage of the bronchial tree, and reduce inflammation.

Lifestyle correction is necessary to eliminate risk factors for the development of infectious diseases of the upper respiratory tract. First of all, this concerns smoking and various types of occupational hazards (dusty production, working with paints and varnishes, frequent hypothermia, etc.). The use of breathing exercises, for example, according to the Strelnikova method, has an excellent effect on chronic lung diseases. This also applies to chronic bronchitis.

Outside of exacerbation of bronchitis, hardening measures can be carried out.

Expert opinion

Bronchitis is one of the most common diseases.
According to some data, more than 5% of the world's population suffers from acute bronchitis at least once a year. Chronic bronchitis lasts noticeably longer and produces more complications. In Russia, chronic bronchitis occurs in 10-20% of the country's population.

In order to reduce the risk of developing complications of both acute and chronic bronchitis, you need to consult a doctor at the first symptoms of the disease. When treating bronchitis, pulmonologists at SM-Clinic are guided by the clinical recommendations of the Russian Respiratory Society, approved by the Ministry of Health of the Russian Federation and use modern effective techniques and drugs.

Alexey Mikhailovich Bankov, pulmonologist at SM-Clinic in Ryazan

Prognosis and prevention

The remission period is characterized by a decrease in dry cough, which is not accompanied by shortness of breath. There is an improvement in bronchial patency. At this time, you should not forget about secondary prevention, which will prevent a relapse from happening. The most important condition for forgetting about bronchitis forever is a healthy lifestyle and quitting smoking. The air in the room where a person is located must have normal humidity, so if it is too dry, it is necessary to use humidifiers or at least place containers with water.

Clothes should always be appropriate for the weather conditions and should not be cold. Since a patient with bronchitis is subject to excessive sweating, it should not provoke overheating of the body. When working with harmful substances, it is necessary to take unprecedented protective measures, and ideally, to completely change the field of activity. Walking in the fresh air and hardening will not be amiss.

Do folk remedies help?

Often, older people use folk remedies in treatment because they believe that they can help. Therapy for bronchitis allows the use of herbs, fruits, oils - they can really cleanse the bronchi and help restore health. Antibiotics for the treatment of chronic bronchitis in older people, unfortunately, often soften the aggressive effects, and herbal medicine softens such aggression, improves immunity and promotes better functioning of internal organs during exacerbation of the disease. To prepare extracts, decoctions, and tinctures, you need independently collected plants or herbs purchased from a pharmacy chain. The raw materials are well cleaned from dust. To soften, it is soaked in water and then cooked in a water bath.

The following components have worked well:

• linden color;
• onions and milk;
• honey with radish;
• carrot juice and so on.

If older people find it difficult to cough up phlegm, you can try using essential oil herbs; eucalyptus and calamus have received good reviews in therapy. In addition, you can try less exotic plants - anise, thyme, sage, which are not too difficult to prepare. Medicinal tea with oregano and lemon balm has proven to work well as a medicinal product. It is both tasty and healthy: the cough calms down, bronchial secretion is normalized, and the nervous system becomes calmer. In herbal medicine, either one type of plant or several components can be used at once to achieve a better effect. Aromatherapy is often used to treat bronchitis; sanitizing the air in the room makes it possible to reduce the content of pathogenic bacteria by half or three times, and prevents re-infection and illness for those who live in the same house with the elderly, but are still healthy. The best option for treating upper respiratory tract disease without further problems is inhalation, which delivers medications directly to the site of the infection or virus. Inhalation treatment is carried out with special equipment - a nebulizer or inhaler. Or with improvised means using the well-known old-fashioned method.

How to diagnose the disease

Before treating chronic bronchitis, it is necessary to establish a correct diagnosis. For this purpose, the doctor (usually a pulmonologist) taps and listens to the chest. To exclude more serious diseases, the patient must undergo a comprehensive examination (instrumental and laboratory).

Instrumental methods include:

• radiography and fluoroscopy of the lungs,
• bronchoscopy and bronchography,
• determination of blood gas composition.

Laboratory tests include:

• general and biochemical blood test,
• sputum analysis,
• immunological analysis.