J45.0 Asthma with a predominance of an allergic component. Asthma with a predominance of an allergic component (J45.0) Disease code j45 0

Asthma is a periodic narrowing of the airways that causes shortness of breath and wheezing. It can develop at any age, but up to half of all new cases are now diagnosed in children under 10 years of age. More often observed in men. In most cases, asthma runs in families. A risk factor for the development of the disease is smoking.

The severity and duration of attacks can vary greatly from time to time. Some asthmatics experience mild and infrequent attacks, while others suffer long-lasting and debilitating symptoms each time they occur. In most patients, the manifestations of the disease are between these two extremes, but each time it is impossible to predict the severity and duration of the attack. Some severe asthma attacks can be life-threatening if not treated promptly.

Allergic form

During attacks, the muscles of the bronchi contract, causing them to narrow. The mucous membrane of the bronchi becomes inflamed and produces a lot of mucus, which clogs the small airways. In some people, these changes in the airways are triggered by an allergic reaction.

Allergic asthma tends to begin early in life and then develop along with other allergic conditions such as eczema and hay fever. The predisposition often runs in families and may be inherited from parents. It is known that attacks of allergic asthma can be provoked by certain substances called allergens. These include: plant pollen, dander, hair and saliva of pets (mainly dogs and cats); Some asthmatics are very sensitive to aspirin, and taking it can also trigger an attack.

In the case of the disease in adults, no allergens have been found that provoke an inflammatory reaction in the respiratory tract. The first attack is usually associated with a respiratory infection. Factors that trigger an asthma attack can be cold air, physical activity, smoking, and sometimes emotional stress. Although industrial waste and exhaust fumes do not usually cause attacks, they can worsen symptoms in asthmatics and trigger the disease in susceptible people.

Professional uniform

In some cases, prolonged inhalation of a substance at work can cause illness in a healthy person. This form of the disease is called occupational asthma and is a form of occupational lung disease.

If, during working hours, attacks of shortness of breath begin and wheezing appears, but these symptoms disappear upon returning home, then the patient has occupational asthma. This disorder is very difficult to diagnose, because It takes a person weeks, months, and sometimes years of constant contact with an allergen before the first symptoms of the disease appear. Currently, more than 200 different chemicals have been identified that, when present in the air in the workplace, can cause illness.

Symptoms

They can develop gradually, so a person does not pay attention to them until the first attack. For example, exposure to an allergen or a respiratory infection may cause the following symptoms:

• wheezing;
• painless chest tightness;
• difficulty breathing;
• dry persistent cough;
• feeling of panic;
• sweating

These symptoms worsen sharply at night and in the early morning hours.

Some people experience wheezing with a cold or other respiratory tract infection, and in most cases this symptom does not indicate the onset of illness.

In severe asthma, the following symptoms develop:

• wheezing becomes inaudible because too little air passes through the airways;
• a person cannot finish a sentence due to shortness of breath;
• due to lack of oxygen, lips, tongue, fingers and toes turn blue;
• confusion and coma.

The goal of any drug treatment is to eliminate symptoms and reduce the frequency and severity of attacks. There are 2 main forms of therapy - fast-acting drugs that relieve symptoms, and control ones. These drugs are mainly produced in the form of inhalers, which spray a strictly measured dose. During acute asthma attacks, inhalers with aerosol cans or in the form of special sprays are more convenient for some patients. They create a thin suspension of medication in the air, which is inhaled through a snorkel or face mask. Spray cans are also used if it is difficult to accurately measure the dose of medication. Children should only use aerosol cans.

If asthma develops in an adult, it is necessary to prescribe fast-acting medications to relieve symptoms. Controller medications are gradually added if the patient must take quick-acting medications several times a week.

Attacks of wheezing are usually treated with quick-acting medications (bronchodilators). There are several types of bronchodilators that relax the muscles of the bronchi and thereby expand their lumen and at the same time eliminate respiratory problems. The effect usually occurs within a few minutes after inhalation, but lasts only a few hours.

If a sudden and severe asthma attack develops, you should immediately take a fast-acting remedy prescribed by your doctor. The patient should take a comfortable position and remain calm. Place your hands on your knees to support your back, do not lie down, try to slow down your breathing rate so as not to lose strength. If the medicine does not work, you need to call an ambulance.

When treated in a hospital, the patient is prescribed oxygen and corticosteroids. In addition, a high dose of a bronchodilator is administered or delivered through a nebulizer. In rare cases, when emergency drug treatment does not have an effect, the patient is connected to a ventilator, which pumps air with a high oxygen content into the lungs. Once the condition has stabilized, chest physiotherapy is prescribed (to facilitate coughing up accumulated mucus).

Control and prevention

The most important aspects of successful disease control are careful selection of drug treatment and regular monitoring of the patient's condition. When symptoms are regularly monitored, severe and life-threatening asthma attacks rarely occur.

Most medications for the control and prevention of attacks belong to the group of corticosteroids. They slow down the production of mucus, relieve inflammation of the airways, thereby reducing the likelihood of subsequent narrowing under the influence of provoking substances. In some cases, NSAIDs are used, which reduce the severity of the allergic reaction and prevent narrowing of the airways. Controller medications must be taken daily for several days to be effective. For patients with long-standing and severe asthma, low-dose controller medications are given orally (instead of inhaled).

Precautions and Diagnosis

If a patient develops a severe asthma attack or symptoms continue to worsen, an ambulance should be called immediately.

If there are breathing problems that are not present at the time of the medical appointment, the doctor must examine the patient and write down the symptoms in his words. The patient will be referred for various tests (such as spirometry) to determine the efficiency of the lungs.

If an attack develops right at the doctor’s appointment, the patient’s exhalation rate is measured using a pneumotachometer and a bronchodilator (a drug that widens the airways) is inhaled. A doctor can diagnose asthma if the rate at which you exhale increases sharply when you take a bronchodilator.

If severe shortness of breath develops, the patient should be referred to the hospital for examination, during which the level of oxygen in the blood will be measured and fluorography will be done to rule out other severe pulmonary dysfunctions (such as pneumothorax), which have symptoms similar to asthma.

Once the diagnosis is made, the patient must undergo skin testing to identify allergens that can cause attacks.

Some asthmatics do not need treatment, provided they avoid any triggers, follow doctor's advice, and take medications as prescribed.

In about half of cases, childhood asthma goes away by age 20. The prognosis for adult asthmatics who are in generally good health is also very good if they closely monitor their condition.

Exogenous bronchial asthma, allergic asthma, atopic asthma, occupational asthma, allergic bronchopulmonary aspergillosis, allergic bronchitis, allergic rhinitis with asthma, exogenous allergic asthma, hay fever with asthma.

Version: MedElement Disease Directory

Asthma with a predominant allergic component (J45.0)

general information

Short description

Based on GINA (Global Initiative for Asthma) - 2011 revision.

Bronchial asthma is a chronic inflammatory disease of the airways in which many cells and cellular elements are involved. Chronic inflammation causes bronchial hyperresponsiveness, which leads to repeated episodes of wheezing, shortness of breath, chest tightness and cough, especially at night or in the early morning. These episodes are usually associated with widespread but variable airway obstruction in the lungs, which is often reversible either spontaneously or with treatment.

J46 Asthmatic status
J44- Other chronic obstructive pulmonary disease
J60-J70 LUNG DISEASES CAUSED BY EXTERNAL AGENTS
J82 Pulmonary eosinophilia, not elsewhere classified

Classification

The classification of asthma is based on a joint assessment of clinical symptoms and pulmonary function indicators, while at the same time there is no generally accepted classification of bronchial asthma.

According to the severity of the disease according to clinical signs before treatment

Mild intermittent bronchial asthma (stage 1):

1. Symptoms less than once a week.
2. Short exacerbations.
3. Night symptoms no more than 2 times a month.
4. FEV1 or PEF>= 80% of predicted values.
5. Variability in FEV1 or PEF< 20%.

Mild persistent bronchial asthma (stage 2):

1. Symptoms occur more often than once a week, but less than once a day.
2. Night symptoms more often than 2 times a month FEV1 or PEF>= 80% of predicted values.
3. Variability of FEV1 or PEF = 20-30%.

Persistent bronchial asthma of moderate severity (stage 3):

1. Daily symptoms.
2. Exacerbations can affect physical activity and sleep.
3. Nighttime symptoms more often than once a week.
4. FEV, or PSV from 60 to 80% of the required values.
5. Variability of FEV1 or PEF >30%.

Severe persistent bronchial asthma (stage 4):

1. Daily symptoms.
2. Frequent exacerbations.
3. Frequent night symptoms.
4. Limiting physical activity.
5. FEV 1 or PEF<= 60 от должных значений.
6. Variability of FEV1 or PEF >30%.

GINA 2011. Given the shortcomings, the current consensus classification of asthma severity is based on the amount of therapy required to achieve disease control. Mild asthma is asthma that can be controlled with a small amount of therapy (low-dose ICS, antileukotriene drugs or cromones). Severe asthma is asthma that requires a large volume of therapy to control (eg, GINA stage 4), or asthma that cannot be controlled despite a large volume of therapy. It is known that patients with different asthma phenotypes have different responses to traditional treatment. Once specific treatments for each phenotype become available, asthma that

Previously considered severe, it may become mild. The ambiguity of terminology associated with asthma severity is due to the fact that the term “severity” is also used to describe the severity of bronchial obstruction or symptoms. Many patients believe that severe or frequent symptoms indicate severe asthma. However, it is important to understand that these symptoms may be the result of inadequate treatment.

J45.0 Asthma with a predominance of an allergic component (if there is a connection between the disease and an identified external allergen) includes the following clinical variants:

• Allergic bronchitis.
• Allergic rhinitis with asthma.
• Atopic asthma.
• Exogenous allergic asthma.
• Hay fever with asthma.

Etiology and pathogenesis

According to GINA-2011, bronchial asthma is a chronic inflammatory disease of the airways, which involves a number of cells and inflammatory mediators, which leads to characteristic pathophysiological changes.

Atopic asthma usually begins in childhood and is provoked by household allergens: house dust, animal skin flakes and food. Allergic diseases in relatives are typical. Asthma itself is preceded by allergic rhinitis, urticaria or diffuse neurodermatitis.
Atopic bronchial asthma (AA) is a classic example of type I hypersensitivity (IgE-mediated). Allergens entering the respiratory tract provoke the synthesis of class E immunoglobulins by B cells, the activation and proliferation of mast cells and the attraction and activation of eosinophils.
Phases of the asthmatic reaction:
-The early phase is caused by contact of sensitized (IgE-coated) mast cells with the same or similar (cross-sensitivity) antigen and develops within a few minutes. As a result, mediators are released from mast cells, which themselves or with the participation of the nervous system cause bronchospasm, increase vascular permeability (causing tissue swelling), stimulate mucus production and, in the most severe cases, cause shock. Mast cells also release cytokines that attract white blood cells (especially eosinophils).
-The late phase develops under the influence of mediators secreted by leukocytes (neutrophils, eosinophils, basophils), endothelial and epithelial cells. It occurs 4-8 hours after contact with the allergen and lasts 24 hours or more.
The main mediators causing bronchospasm in AA
- Leukotrienes C4, D4, E4 cause prolonged bronchospasm, increase vascular permeability, and stimulate mucus secretion.
- Acetylcholine leads to contraction of bronchial smooth muscle
- Histamine leads to contraction of bronchial smooth muscle
- Prostaglandin D4 constricts the bronchi and dilates blood vessels,
- Platelet activating factor provokes platelet aggregation and the release of histamine and serotonin from their granules.
Morphology.
- During autopsy of patients with status asthmaticus (see J46 Asthmatic status), swollen lungs are found, although there are foci of atelectasis. The section shows blockage of the bronchi and bronchioles with thick and viscous mucus (mucus plugs).
- Microscopy in mucus plugs reveals layers of bronchial epithelial cells (the so-called Kurshman spirals), numerous eosinophils and Charcot-Leyden crystals (crystal-like formations from eosinophil proteins). The basal membrane of the bronchial epithelium is thickened, the walls of the bronchi are swollen and infiltrated with inflammatory cells, the bronchial glands are increased in size, the smooth muscles of the bronchi are hypertrophied.

Epidemiology

Around the world, bronchial asthma affects about 5% of the adult population (1-18% in different countries). In children, the incidence varies from 0 to 30% in different countries.

The onset of the disease is possible at any age. In approximately half of patients, bronchial asthma develops before 10 years of age, and in a third - before 40 years of age.
Among children with bronchial asthma, there are twice as many boys as girls, although the sex ratio levels off at age 30.

Risk factors and groups

Factors influencing the risk of developing asthma are divided into:
- factors determining the development of the disease - internal factors (primarily genetic);
- factors that provoke the occurrence of symptoms - external factors.
Some factors apply to both groups.
The mechanisms of influence of factors on the development and manifestations of AD are complex and interdependent.

Internal factors:

1. Genetic (for example, genes predisposing to atopy and genes predisposing to bronchial hyperresponsiveness).

2. Obesity.

External factors:

1. Allergens:

Indoor allergens (house dust mites, pet hair, cockroach allergens, fungi, including mold and yeast);

External allergens (pollen, fungi, including mold and yeast).

2. Infections (mainly viral).

3. Professional sensitizers.

4. Tobacco smoking (passive and active).

5. Air pollution indoors and outdoors.

6. Nutrition.

Elimination of risk factors can significantly improve the course of asthma.

In patients with allergic asthma, elimination of the allergen is of primary importance. There is evidence that in urban areas, in children with atopic asthma, individual comprehensive measures to remove allergens in the home led to a decrease in pain.

Clinical picture

Clinical diagnostic criteria

Unproductive hacking cough, - prolonged exhalation, - dry, whistling, usually treble, wheezing in the chest, more at night and in the morning, - attacks of expiratory suffocation, - congestion in the chest, - dependence of respiratory symptoms on contact with provoking agents.

Symptoms, course

Clinical diagnosis of bronchial asthma(BA) is based on the following data:

1. Detection of bronchial hyperreactivity, as well as reversibility of obstruction spontaneously or under the influence of treatment (decrease in response to appropriate therapy).
2. Non-productive hacking cough; extended exhalation; dry, whistling, usually treble-like, wheezing in the chest, occurring more at night and in the morning; expiratory shortness of breath, attacks of expiratory suffocation, congestion (stiffness) of the chest.
3. Dependence of respiratory symptoms on contact with provoking agents.

Also essential the following factors:
- the appearance of symptoms after episodes of contact with the allergen;
- seasonal variability of symptoms;
- a family history of asthma or atopy.

When diagnosing, it is necessary to clarify the following questions:
- Does the patient have episodes of wheezing, including repeated ones?

Does the patient have a cough at night?

Does the patient wheeze or cough after exercise?

Does the patient have episodes of wheezing, chest congestion, or cough after exposure to aeroallergens or pollutants?

Does the patient notice that his cold “goes down into the chest” or lasts more than 10 days?

Do symptoms improve with appropriate asthma medications?

During physical examination, symptoms of asthma may be absent due to the variability of manifestations of the disease. The presence of bronchial obstruction is confirmed by wheezing sounds detected during auscultation.
In some patients, wheezing may be absent or detected only during forced expiration, even in the presence of severe bronchial obstruction. In some cases, patients with severe exacerbations of asthma do not wheeze due to severe limitation of airflow and ventilation. In such patients, as a rule, there are other clinical signs indicating the presence and severity of an exacerbation: cyanosis, drowsiness, difficulty speaking, distended chest, participation of auxiliary muscles in the act of breathing and retraction of intercostal spaces, tachycardia. These clinical symptoms can only be observed when examining the patient during the period of pronounced clinical manifestations.

Variants of clinical manifestations of asthma

1.Cough variant of asthma. The main (sometimes the only) manifestation of the disease is cough. Cough asthma is most common in children. The severity of symptoms increases at night, and during the day, manifestations of the disease may be absent.
For such patients, testing for variability in pulmonary function tests or bronchial hyperresponsiveness, as well as determination of sputum eosinophils, are important.
The cough variant of BA is differentiated from the so-called eosinophilic bronchitis. In the latter, patients present with cough and sputum eosinophilia, but have normal pulmonary function tests on spirometry and normal bronchial responsiveness.
In addition, cough can occur due to taking ACE inhibitors, gastroesophageal reflux, postnasal drip syndrome, chronic sinusitis, and vocal cord dysfunction.

2. Bronchospasm induced by physical activity. Refers to the manifestation of non-allergic forms of asthma, when the phenomena of airway hyperreactivity dominate. In most cases, physical activity is an important or sole cause of the onset of symptoms of the disease. Bronchospasm as a result of physical activity usually develops 5-10 minutes after cessation of exercise (rarely during exercise). Patients experience typical symptoms of asthma or sometimes a prolonged cough that goes away on its own within 30-45 minutes.
Forms of exercise such as running cause asthma symptoms more often.
Bronchospasm caused by physical activity often develops when inhaling dry, cold air, and more rarely in hot and humid climates.
Evidence in favor of asthma is the rapid reduction of symptoms of post-exertional bronchospasm after inhalation of a β2-agonist, as well as the prevention of the development of symptoms due to inhalation of a β2-agonist before exercise.
In children, asthma can sometimes manifest itself only during physical activity. In this regard, in such patients or if there is doubt about the diagnosis, it is advisable to conduct an exercise test. The diagnosis is facilitated by an 8-minute running protocol.

Clinical picture of an asthma attack quite typical.
With an allergic etiology of asthma, before the development of suffocation, itching (in the nasopharynx, ears, in the chin area), nasal congestion or rhinorrhea, a feeling of lack of “free breathing,” and a dry cough may be observed. With the development of an attack of suffocation, expiratory shortness of breath occurs: inhalation is shortened, exhalation lengthened; the duration of the respiratory cycle increases and the respiratory rate decreases (up to 12-14 per minute).
When listening to the lungs, in most cases, against the background of prolonged exhalation, a large number of scattered dry rales, mainly whistling, are detected. As the attack of suffocation progresses, wheezing sounds on exhalation are heard at a certain distance from the patient in the form of “wheezing” or “music of the bronchi.”

With a prolonged attack of suffocation, which lasts more than 12-24 hours, the small bronchi and bronchioles become blocked with inflammatory secretions. The patient's general condition worsens significantly, and the auscultatory picture changes. Patients experience painful shortness of breath, which worsens with the slightest movements. The patient takes a forced position - sitting or half-sitting with the shoulder girdle fixed. All auxiliary muscles are involved in the act of breathing, the chest expands, and the intercostal spaces are drawn in during inhalation, cyanosis of the mucous membranes and acrocyanosis occurs and intensifies. It is difficult for the patient to speak; sentences are short and abrupt.
On auscultation, there is a decrease in the number of dry rales; in some places they are not heard at all, as is vesicular breathing; so-called silent lung zones appear. Above the surface of the lungs, a pulmonary sound with a tympanic tint is determined by percussion - a box sound. The lower edges of the lungs are lowered, their mobility is limited.
The end of an attack of suffocation is accompanied by a cough with the release of a small amount of viscous sputum, easier breathing, a decrease in shortness of breath and the number of wheezing heard. For a long time, a few dry rales may be heard while maintaining an extended exhalation. After the attack stops, the patient often falls asleep. Signs of asthenia persist for a day or more.

Exacerbation of asthma(attacks of asthma, or acute asthma) according to GINA-2011 is divided into mild, moderate, severe and such a point as “respiratory arrest is inevitable.” The severity of asthma and the severity of exacerbation of asthma are not the same thing. For example, with mild asthma, mild and moderate exacerbations may occur; with moderate and severe asthma, mild, moderate, and severe exacerbations may occur.

Infancy (2-12 months)<160 в минуту;

Younger (1-2 years)<120 в минуту;

Preschool and school age (2-8 years)<110 в минуту.
3. Normal breathing rate in children while awake:

Under 2 months< 60 в минуту;

2-12 months< 50 в минуту;

1-5 years< 40 в минуту;

6-8 years< 30 в минуту.

Diagnostics

Basics of diagnosing bronchial asthma(BA):
1. Analysis of clinical symptoms, which are dominated by periodic attacks of expiratory suffocation (for more details, see the section “Clinical picture”).
2. Determination of pulmonary ventilation indicators, most often using spirography with registration of the forced expiratory flow-volume curve, identifying signs of reversibility of bronchial obstruction.
3. Allergological research.
4. Detection of nonspecific bronchial hyperreactivity.

Study of external respiratory function indicators

1. Spirometry Spirometry - measurement of vital capacity of the lungs and other lung volumes using a spirometer
. In patients with asthma, signs of bronchial obstruction are often diagnosed: a decrease in indicators - POSV (peak expiratory volume flow), MEF 25 (maximum volume flow at the point of 25% FVC, (FEF75) and FEV1.

To assess the reversibility of bronchial obstruction, it is used pharmacological bronchodilation test with short-acting β2-agonists (most often salbutamol). Before the test, you should avoid taking short-acting bronchodilators for at least 6 hours.
First, the initial flow-volume curve of the patient's forced breathing is recorded. Then the patient takes 1-2 inhalations of one of the short-acting β2-agonists. After 15-30 minutes, the flow-volume curve is recorded. When FEV1 or POS increases by 15% or more, airway obstruction is considered reversible or bronchodilator-responsive, and the test is considered positive.

For BA, identifying significant daily variability of bronchial obstruction is diagnostically important. For this purpose, spirography is used (when the patient is in a hospital) or peak flowmetry (at home). A spread (variability) of FEV1 or POS values ​​of more than 20% during the day is considered to confirm the diagnosis of asthma.

2. Peak flowmetry. It is used to assess the effectiveness of treatment and objectify the presence and severity of bronchial obstruction.
Peak expiratory flow (PEF) is assessed - the maximum speed at which air can exit the airways during forced exhalation after a full inhalation.
The patient's PEF values ​​are compared with normal values ​​and with the best PEF values ​​observed in this patient. The level of decrease in PEF allows us to draw conclusions about the severity of bronchial obstruction.
The difference in PSV values ​​measured during the day and evening is also analyzed. A difference of more than 20% indicates an increase in bronchial reactivity.

2.1 Intermittent asthma (stage I). Daytime attacks of shortness of breath, coughing, and wheezing occur less than once a week. The duration of exacerbations ranges from several hours to several days. Night attacks - 2 or less times a month. In the period between exacerbations, lung function is normal; PEF - 80% of normal or less.

2.2 Mild course of persistent asthma (stage II). Daytime attacks occur 1 or more times a week (no more than 1 time per day). Night attacks recur more often than 2 times a month. During an exacerbation, the patient's activity and sleep may be disrupted; PEF - 80% of normal or less.

2.3 Persistent asthma of moderate severity (stage III). Daily attacks of suffocation, night attacks occur once a week. Due to exacerbations, the patient’s activity and sleep are disrupted. The patient is forced to use short-acting inhaled beta-agonists daily; PSV - 60 - 80% of the norm.

2.4 Severe persistent asthma (stage IV). Daytime and nighttime symptoms are constant, which limits the patient’s physical activity. The PEF indicator is less than 60% of the norm.

3. Allergy research. An allergy history (eczema, hay fever, family history of asthma or other allergic diseases) is analyzed. Positive skin tests with allergens and increased levels of general and specific IgE in the blood testify in favor of asthma.

4. Provocative tests with histamine, methacholine, physical activity. They are used to detect nonspecific bronchial hyperreactivity, manifested by latent bronchospasm. It is performed in patients with suspected asthma and normal spirography values.

During a histamine test, the patient inhales nebulized histamine in progressively increasing concentrations, each of which can cause bronchial obstruction.
The test is assessed as positive when the volumetric air flow rate deteriorates by 20% or more as a result of inhalation of histamine in a concentration one or several orders of magnitude less than that which causes similar changes in healthy people.
A test with methacholine is carried out and evaluated in the same way.

5. Additional research:
- radiography of the chest organs in two projections - most often they reveal signs of pulmonary emphysema (increased transparency of the pulmonary fields, depleted pulmonary pattern, low standing domes of the diaphragm), and the absence of infiltrative and focal changes in the lungs is important;
- fibrobronchoscopy;

Electrocardiography.
Additional studies are carried out in cases of atypical asthma and resistance to anti-asthma therapy.

Main diagnostic criteria for asthma:

1. The presence in the clinical picture of the disease of periodic attacks of expiratory suffocation, which have their beginning and end, passing spontaneously or under the influence of bronchodilators.
2. Development of status asthmaticus.
3. Determination of signs of bronchial obstruction (FEV1 or POS ext.< 80% от должной величины), которая является обратимой (прирост тех же показателей более 15% в фармакологической пробе с β2-агонистами короткого действия) и вариабельной (колебания показателей более 20% на протяжении суток).
4. Detection of signs of bronchial hyperreactivity (hidden bronchospasm) in patients with initial normal levels of pulmonary ventilation using one of three provocative tests.
5. The presence of a biological marker - a high level of nitric oxide in the exhaled air.

Additional diagnostic criteria:
1. The presence in the clinical picture of symptoms that may be “small equivalents” of an attack of expiratory suffocation:
- unmotivated cough, often at night and after physical activity;
- repeated sensations of chest tightness and/or episodes of wheezing;
- the fact of waking up at night from these symptoms strengthens the criterion.
2. A burdened allergic history (the patient has eczema, hay fever, hay fever) or a burdened family history (BA, atopic diseases in the patient’s family members).

3. Positive skin tests with allergens.
4. An increase in the level of general and specific IgE (reagins) in the patient’s blood.

Professional BA

Bronchial asthma caused by professional activities is often not diagnosed. Due to the gradual development of occupational asthma, it is often regarded as chronic bronchitis or COPD. This leads to incorrect treatment or lack thereof.

Occupational asthma should be suspected when symptoms of rhinitis, cough and/or wheezing appear, especially in non-smoking patients. Establishing a diagnosis requires systematic collection of information about work history and workplace environmental factors.

Criteria for diagnosing professional asthma:
- clearly established occupational exposure to known or suspected sensitizing agents;
- absence of asthma symptoms before hiring or a clear worsening of asthma after hiring.

Laboratory diagnostics

Non-invasive determination of markers of airway inflammation.
1. To assess the activity of inflammation in the airways in asthma, sputum spontaneously produced or induced by inhalation of a hypertonic solution can be examined for inflammatory cells - eosinophils or neutrophils.

2. In addition, exhaled nitric oxide (FeNO) and carbon monoxide (FeCO) levels have been proposed as noninvasive markers of inflammation in the airways of asthma. In patients with asthma, there is an increase in FeNO levels (in the absence of ICS therapy) compared to individuals without asthma, but these results are not specific for asthma. The value of FeNO for the diagnosis of AD has not been assessed in prospective studies.
3. Skin testing with allergens is the main method for assessing allergic status. They are easy to use, do not require much time and money, and are highly sensitive. However, performing samples incorrectly may result in false positive or false negative results.
4. Determination of specific IgE in blood serum is not more reliable than skin tests and is a more expensive method. The main disadvantage of methods for assessing allergic status is that positive test results do not necessarily indicate the allergic nature of the disease and the connection of the allergen with the development of asthma, since in some patients specific IgE can be detected in the absence of any symptoms and do not play any role in the development of asthma. The presence of relevant allergen exposure and its relationship with asthma symptoms should be confirmed by medical history. Measuring the level of total IgE in serum is not a method for diagnosing atopy.
Clinical tests
1. UAC. Eosinophilia is not detected in all patients and cannot serve as a diagnostic criterion. An increase in ESR and eosinophilia are determined during an exacerbation.
2. General sputum analysis. When microscopy in sputum, you can detect a large number of eosinophils, Charcot-Leyden crystals (brilliant transparent crystals formed after the destruction of eosinophils and shaped like rhombuses or octahedrons), Kurshman spirals (formed due to small spastic contractions of the bronchi and look like casts of transparent mucus in the form spirals). The release of Creole bodies during an attack was also noted - these are round formations consisting of epithelial cells.

3. A biochemical blood test is not the main diagnostic method, since the changes are of a general nature and such studies are prescribed to monitor the patient’s condition during an exacerbation.

Differential diagnosis

1. Differential diagnosis of asthma variants.

Main differential diagnostic signs of atopic and infection-dependent variants of BA(according to Fedoseev G. B., 2001)

2. Conduct differential diagnosis of BA with chronic obstructive pulmonary disease(COPD), which is characterized by more persistent bronchial obstruction. In patients with COPD, the spontaneous lability of symptoms typical of BA is not observed, there is no or significantly less daily variability in FEV1 and POS, and complete irreversibility or less reversibility of bronchial obstruction is determined in a test with β2-agonists (increase in FEV1 is less than 15%).
In COPD sputum, neutrophils and macrophages predominate rather than eosinophils. In patients with COPD, the effectiveness of bronchodilator therapy is lower; anticholinergic drugs are more effective bronchodilators rather than short-acting β2-agonists; Pulmonary hypertension and signs of chronic cor pulmonale are more common.

Some features of diagnosis and differential diagnosis (according to GINA 2011)

1.In children aged 5 years and younger Episodes of wheezing are common.

Types of wheezing in the chest:

1.1 Transient early wheezing, which children often “outgrow” in the first 3 years of life. Such wheezing is often associated with prematurity and parental smoking.

1.2 Persistent wheezing with early onset (before age 3 years). Children commonly experience recurrent episodes of wheezing associated with acute respiratory viral infections. In this case, children do not have signs of atopy and there is no family history of atopy (unlike children of the next age group with late onset of wheezing/bronchial asthma).
Episodes of wheezing typically continue into school age and are still present in a significant proportion of children aged 12 years.
The cause of episodes of wheezing in children under 2 years of age is usually a respiratory syncytial viral infection; in children 2-5 years of age - other viruses.

1.3 Late-onset wheezing/bronchial asthma. AD in these children often lasts throughout childhood and continues into adulthood. Such patients are characterized by a history of atopy (often manifesting as eczema) and respiratory tract pathology typical of asthma.

In case of repeated episodes of wheezing, it is necessary to exclude other causes of wheezing:

Chronic rhinosinusitis;

Gastroesophageal reflux;

Repeated viral infections of the lower respiratory tract;

Cystic fibrosis;

Bronchopulmonary dysplasia;

Tuberculosis;

Foreign body aspiration;
- immunodeficiency;

Primary ciliary dyskinesia syndrome;

Developmental defects that cause narrowing of the lower respiratory tract;
- Congenital heart defect.

The possibility of another disease is indicated by the appearance of symptoms in the neonatal period (in combination with insufficient weight gain); wheezing associated with vomiting, signs of focal lung damage or cardiovascular pathology.

2. Patients over 5 years of age and adults. Differential diagnosis should be carried out with the following diseases:

Hyperventilation syndrome and panic attacks;

Upper airway obstruction and foreign body aspiration;

Other obstructive pulmonary diseases, especially COPD;

Non-obstructive pulmonary diseases (for example, diffuse lesions of the lung parenchyma);

Non-respiratory diseases (for example, left ventricular failure).

3. Elderly patients. BA should be differentiated from left ventricular failure. In addition, asthma is underdiagnosed in old age.

Risk factors for underdiagnosis of asthma in elderly patients

3.2 From the doctor's side:
- misconception that asthma does not begin in old age;
- difficulties in studying pulmonary function;
- perception of asthma symptoms as signs of aging;
- accompanying illnesses;
- underestimation of shortness of breath due to decreased physical activity of the patient.

Complications

Complications of bronchial asthma are divided into pulmonary and extrapulmonary.

Pulmonary complications: chronic bronchitis, hypoventilation pneumonia, emphysema, pneumosclerosis, respiratory failure, bronchiectasis, atelectasis, pneumothorax.

Extrapulmonary complications:"pulmonary" heart, heart failure, myocardial dystrophy, arrhythmia; in patients with a hormone-dependent variant of BA, complications associated with long-term use of systemic corticosteroids may occur.

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Treatment

Objectives of treatment of bronchial asthma(BA):

Achieving and maintaining symptom control;

Maintaining a normal level of activity, including physical activity;

Maintaining lung function at normal or as close to normal levels as possible;

Prevention of exacerbations of asthma;

Preventing unwanted effects of anti-asthma drugs;

Preventing deaths from asthma.

Levels of asthma control(GINA 2006-2011)

1 Pulmonary function testing is not reliable in children 5 years of age and younger. Periodic assessment of the level of asthma control in accordance with the criteria specified in the table will allow individual selection of a pharmacotherapy regimen for the patient
2 Each exacerbation requires an immediate review of maintenance therapy and assessment of its adequacy
3 By definition, the development of any exacerbation indicates that asthma is not controlled

Drug therapy

Medicines for the treatment of asthma:

1. Drugs that control the course of the disease (maintenance therapy):
- inhaled and systemic corticosteroids;
- antileukotriene drugs;
- inhaled long-acting β2-agonists in combination with inhaled corticosteroids;
- sustained release theophylline;
- cromones and antibodies to IgE.
These drugs provide control over the clinical manifestations of asthma; they are taken daily and for a long time. The most effective for maintenance therapy are inhaled corticosteroids.

2. Emergency medications (to relieve symptoms):
- inhaled rapid-acting β2-agonists;
- anticholinergics;
- short-acting theophylline;
- oral short-acting β2-agonists.
These medications are taken to relieve symptoms as needed. They have a rapid effect, eliminate bronchospasm and relieve its symptoms.

Drugs for the treatment of asthma can be administered in different ways - inhalation, oral or injection. Advantages of the inhalation route of administration:
- delivers drugs directly to the respiratory tract;
- a locally higher concentration of the drug is achieved;
- the risk of systemic side effects is significantly reduced.

For maintenance therapy, inhaled corticosteroids are most effective.

The drugs of choice for relieving bronchospasm and for preventing exercise-induced bronchospasm in adults and children of any age are inhaled fast-acting β2-agonists.

Increasing use (especially daily use) of rescue medications indicates worsening asthma control and the need for a review of therapy.

Inhaled corticosteroids are most effective for the treatment of persistent asthma:
- reduce the severity of asthma symptoms;
- improve quality of life and lung function;
- reduce bronchial hyperreactivity;
- inhibit inflammation in the respiratory tract;
- reduce the frequency and severity of exacerbations, the frequency of deaths in asthma.

Inhaled corticosteroids do not cure asthma, and when they are discontinued, some patients experience a worsening of their condition within weeks or months.
Local undesirable effects of inhaled corticosteroids: oropharyngeal candidiasis, dysphonia, and sometimes cough due to irritation of the upper respiratory tract.
Systemic side effects of long-term therapy with high doses of inhaled corticosteroids: tendency to bruise, suppression of the adrenal cortex, decreased bone mineral density.

Calculated equipotent daily doses of inhaled corticosteroids in adults(GINA 2011)

*CFC - chlorofluorocarbon (Freon) inhalers
** HFA - hydrofluoroalkane (Freon-free) inhalers

Calculated equipotent daily doses of inhaled corticosteroids for children over 5 years of age(GINA 2011)

Antileukotriene drugs: antagonists of cysteinyl leukotriene receptors of the 1st subtype (montelukast, pranlukast and zafirlukast), as well as a 5-lipoxygenase inhibitor (zileuton).
Action:
- weak and variable bronchodilator effect;
- reduce the severity of symptoms, including cough;
- improve lung function;
- reduce the activity of inflammation in the respiratory tract;
- reduce the frequency of asthma exacerbations.
Antileukotriene drugs can be used as second-line drugs for the treatment of adult patients with mild persistent asthma. Some patients with aspirin-induced asthma also respond well to therapy with these drugs.
Antileukotriene drugs are well tolerated; side effects are few or absent.

Long-acting inhaled β2-agonists: formoterol, salmeterol.
They should not be used as monotherapy for asthma, since there is no evidence that these drugs suppress inflammation in asthma.
These drugs are most effective in combination with inhaled corticosteroids. Combination therapy is preferable in the treatment of patients in whom the use of medium doses of inhaled corticosteroids does not allow them to achieve control of asthma.
With regular use of β2-agonists, it is possible to develop relative refractoriness to them (this applies to both short- and long-acting drugs).
Therapy with long-acting inhaled β2-agonists is characterized by a lower incidence of systemic adverse effects (such as cardiovascular stimulation, skeletal muscle tremor, and hypokalemia) compared with long-acting oral β2-agonists.

Long-acting oral β2-agonists: sustained-release dosage forms of salbutamol, terbutaline and bambuterol (a prodrug that is converted into terbutaline in the body).
Used in rare cases when additional bronchodilator action is required.
Undesirable effects: stimulation of the cardiovascular system (tachycardia), anxiety and skeletal muscle tremor. Adverse cardiovascular reactions may also occur when oral β2-agonists are used in combination with theophylline.

Rapid-acting inhaled β2-agonists: salbutamol, terbutaline, fenoterol, levalbuterol HFA, reproterol and pirbuterol. Due to its rapid onset of action, formoterol (a long-acting β2-agonist) can also be used to relieve asthma symptoms, but only in patients receiving regular maintenance therapy with inhaled corticosteroids.
Inhaled rapid-acting β2-agonists are emergency medications and are the drugs of choice for relieving bronchospasm during exacerbation of asthma, as well as for preventing exercise-induced bronchospasm. Should be used only as needed, with the smallest possible doses and frequency of inhalations.
Increasing, especially daily, use of these drugs indicates a loss of control over asthma and the need to review therapy. If there is no rapid and stable improvement after inhalation of a β2-agonist during an exacerbation of asthma, the patient should also be monitored further and, possibly, given a short course of therapy with oral corticosteroids.
The use of oral β2-agonists in standard doses is accompanied by more pronounced undesirable systemic effects (tremor, tachycardia) than when using inhaled forms.

Oral short-acting β2-agonists(refer to emergency medicine) can be prescribed only to a few patients who are unable to take inhaled drugs. Side effects are observed more often.

Theophylline is a bronchodilator and, when administered in low doses, has a slight anti-inflammatory effect and increases resistance.
Theophylline is available in sustained-release dosage forms that can be taken once or twice daily.
Based on available data, sustained-release theophylline has little effectiveness as a first-line agent for maintenance treatment of bronchial asthma.
The addition of theophylline may improve treatment outcomes for patients in whom monotherapy with inhaled corticosteroids does not achieve asthma control.
Theophylline has been shown to be effective as monotherapy and therapy prescribed in addition to inhaled or oral corticosteroids in children over 5 years of age.
When using theophylline (especially in high doses - 10 mg/kg body weight per day or more), significant side effects are possible (usually decrease or disappear with long-term use).
Undesirable effects of theophylline:
- nausea and vomiting are the most common side effects at the beginning of use;
- disorders of the gastrointestinal tract;
- loose stools;
- heart rhythm disturbances;
- convulsions;
- death.

Sodium cromoglycate and nedocromil sodium(cromones) have limited value in long-term therapy of asthma in adults. There are known examples of the beneficial effect of these drugs in mild persistent asthma and bronchospasm caused by physical activity.
Cromones have a weak anti-inflammatory effect and are less effective compared to low doses of inhaled corticosteroids. Side effects (cough after inhalation and sore throat) are rare.

Anti-IgE(omalizumab) are used in patients with elevated serum IgE levels. Indicated for severe allergic asthma, control of which is not achieved with inhaled corticosteroids.
In a small number of patients, the emergence of an underlying disease (Churg-Strauss syndrome) was observed when GCS was discontinued due to anti-IgE treatment.

System GCS for severe uncontrolled asthma, they are indicated in the form of long-term therapy with oral medications (recommended use for a longer period than with the usual two-week course of intensive therapy with systemic corticosteroids - standard 40 to 50 mg of prednisolone per day).
The duration of use of systemic corticosteroids is limited by the risk of developing serious undesirable effects (osteoporosis, arterial hypertension, suppression of the hypothalamic-pituitary-adrenal axis, obesity, diabetes mellitus, cataracts, glaucoma, muscle weakness, stretch marks and a tendency to bruise due to thinning of the skin). Patients taking any form of systemic corticosteroids for a long time require medications to prevent osteoporosis.

Oral antiallergic drugs(tranilast, repirinast, tazanolast, pemirolast, ozagrel, celatrodust, amlexanox and ibudilast) - are offered for the treatment of mild to moderate allergic asthma in some countries.

Anticholinergic drugs - ipratropium bromide and oxitropium bromide.
Inhaled ipratropium bromide is less effective than inhaled rapid-acting β2-agonists.
Inhaled anticholinergics are not recommended for long-term treatment of asthma in children.

Comprehensive treatment program BA (according to GINA) includes:

Patient education;
- clinical and functional monitoring;
- elimination of causative factors;
- development of a long-term therapy plan;
- prevention of exacerbations and drawing up a plan for their treatment;
- dynamic observation.

Drug Therapy Options

Treatment for asthma is usually lifelong. It should be borne in mind that drug therapy does not replace measures to prevent the patient’s contact with allergens and irritants. The approach to treating a patient is determined by his condition and the goal currently facing the doctor.

In practice, it is necessary to distinguish between the following treatment options:

1. Relief of an attack is carried out with the help of bronchodilators, which can be used situationally by the patient himself (for example, for mild respiratory disorders - salbutamol in the form of a metered-dose aerosol device) or by medical personnel through a nebulizer (for severe respiratory disorders).

Basic anti-relapse therapy: maintenance dose of anti-inflammatory drugs (the most effective are inhaled glucocorticoids).

3. Basic anti-relapse therapy.

4. Treatment of status asthmaticus - is carried out using high doses of systemic intravenous glucocorticoids (SGC) and bronchodilators with the correction of acid-base metabolism and blood gas composition using medications and non-drug agents.

Long-term maintenance therapy for asthma:

1. Assessment of the level of control over asthma.
2. Treatment aimed at achieving control.
3. Monitoring to maintain control.

Treatment aimed at achieving control is carried out according to step therapy, where each step includes treatment options that can serve as alternatives when choosing maintenance therapy for asthma. The effectiveness of therapy increases from step 1 to step 5.

Stage 1
Includes use of emergency medications as needed.
Intended only for patients who have not received maintenance therapy and who occasionally experience short-term (up to several hours) asthma symptoms during the day. For more frequent symptoms or episodic deterioration, patients should receive regular maintenance therapy (see step 2 or higher) in addition to rescue medications as needed.

Recommended rescue medications in step 1: rapid-acting inhaled β2-agonists.
Alternative drugs: inhaled anticholinergics, short-acting oral β2-agonists, or short-acting theophylline.

Stage 2
Emergency drug + one disease control drug.
Drugs recommended as initial maintenance therapy for asthma in patients of any age at stage 2: low-dose inhaled corticosteroids.
Alternative agents for asthma control: antileukotriene drugs.

Stage 3

3.1. Rescue drug + one or two disease control drugs.
At stage 3, children, adolescents and adults are recommended: a combination of a low dose of inhaled corticosteroids with a long-acting inhaled β2-agonist. Administration is carried out using one inhaler with a fixed combination or using different inhalers.
If control of asthma has not been achieved after 3-4 months of therapy, an increase in the dose of inhaled corticosteroids is indicated.

3.2. Another treatment option for adults and children (the only one recommended for the management of children) is to increase the doses of inhaled corticosteroids to medium doses.

3.3. Treatment option at step 3: combination of low-dose inhaled corticosteroids with an antileukotriene drug. A low dose of sustained-release theophylline may be prescribed instead of an anti-leukotriene drug (these options have not been fully studied in children 5 years of age and younger).

Stage 4
Rescue drug + two or more disease control drugs.
The choice of drugs in step 4 depends on previous prescriptions in steps 2 and 3.
The preferred option: a combination of inhaled corticosteroids in a medium or high dose with a long-acting inhaled β2-agonist.

If asthma control is not achieved with a combination of moderate-dose inhaled corticosteroids and a β2-agonist and/or a third maintenance drug (eg, an anti-leukotriene drug or sustained-release theophylline), the use of high-dose inhaled corticosteroids is recommended, but only as a trial therapy lasting 3-6 months.
With long-term use of high doses of inhaled corticosteroids, the risk of side effects increases.

When using medium or high doses of inhaled corticosteroids, the drugs should be prescribed 2 times a day (for most drugs). Budesonide is more effective when the frequency of administration is increased to 4 times a day.

The treatment effect is increased by the addition of a long-acting β2-agonist to medium and low doses of inhaled corticosteroids, as well as the addition of antileukotriene drugs (less compared to a long-acting β2-agonist).
The addition of low doses of sustained-release theophylline to inhaled corticosteroids in medium and low doses and a long-acting β2-agonist may also increase the effectiveness of therapy.

Level 5
Emergency drug + additional options for using drugs to control the course of the disease.
The addition of oral corticosteroids to other maintenance therapy drugs can increase the effect of treatment, but is accompanied by severe adverse events. In this regard, this option is considered only in patients with severe uncontrolled asthma on the background of therapy corresponding to step 4, if the patient has daily symptoms that limit activity and frequent exacerbations.

Prescribing anti-IgE in addition to other maintenance therapy drugs improves control of allergic asthma if it is not achieved during treatment with combinations of other maintenance therapy drugs, which include high doses of inhaled or oral corticosteroids.

Well antibacterial therapy indicated in the presence of purulent sputum, high leukocytosis, accelerated ESR. Taking into account the antibiograms, the following is prescribed:
- spiramycin 3,000,000 units x 2 times, 5-7 days;
- amoxicillin + clavulanic acid 625 mg x 2 times, 7 days;
- clarithromycin 250 mg x 2 times, 5-7 days;
- ceftriaxone 1.0 x 1 time, 5 days;
- metronidazole 100 ml intravenously.

Forecast

The prognosis is favorable with regular follow-up (at least 2 times a year) and rationally selected treatment.
Death may be associated with severe infectious complications, progressive pulmonary heart failure in patients with cor pulmonale, untimely and irrational therapy.

The following points should be kept in mind:
- in the presence of bronchial asthma (BA) of any severity, the progression of dysfunction of the bronchopulmonary system occurs faster than in healthy people;

With a mild course of the disease and adequate therapy, the prognosis is quite favorable;
- in the absence of timely treatment, the disease can develop into a more severe form;

In severe and moderate severity of asthma, the prognosis depends on the adequacy of treatment and the presence of complications;
- concomitant pathology can worsen the prognosis of the disease.

X The nature of the disease and long-term prognosis depend on the age of the patient at the time of the onset of the disease.

In case of asthma that began in childhood, about The long-term prognosis is favorable. As a rule, by puberty, children “outgrow” asthma, but they still have impaired pulmonary function, bronchial hyperreactivity, and abnormalities in the immune status.
With asthma that begins in adolescence, an unfavorable course of the disease is possible.
In asthma that begins in adulthood and old age, the nature of development and prognosis of the disease are more predictable.
The severity of the course depends on the form of the disease:
- allergic asthma is milder and has a more favorable prognosis;
- “pollen” asthma, as a rule, has a milder course compared to “dust” asthma;
- in elderly patients, a primarily severe course is observed, especially in patients with aspirin-induced asthma.

Asthma is a chronic, slowly progressive disease. With adequate therapy, asthma symptoms can be eliminated, but treatment does not affect the cause of their occurrence. Periods of remission may last for several years.

Hospitalization

Indications for hospitalization:
- severe attack of bronchial asthma;

There is no rapid response to bronchodilators and the effect lasts less than 3 hours;
- no improvement within 2-6 hours after starting oral corticosteroid therapy;
- further deterioration is observed - an increase in respiratory and pulmonary-cardiac failure, a “silent lung”.

Patients at high risk of death:
- having a history of conditions close to lethal;
- requiring intubation and artificial ventilation, which leads to an increased risk of intubation during subsequent exacerbations;
- who have already been hospitalized or sought emergency care due to bronchial asthma over the past year;
- taking or recently stopped taking oral medicationsglucocorticosteroids;
- using inhaled rapid-acting β2-agonists in excess quantities, especially more than one package of salbutamol (or equivalent) per month;
- with mental illness, a history of psychological problems, including abuse of sedatives;
- poor compliance with the treatment plan for bronchial asthma.

Prevention

Preventive measures for bronchial asthma (BA) depend on the patient's condition. If necessary, it is possible to increase or decrease the activity of treatment.

Asthma control should begin with a thorough study of the causes of the disease, since the simplest measures can often have a significant impact on the course of the disease (it is possible to save a patient from the clinical manifestations of atopic asthma by identifying the causative factor and eliminating contact with it in the future).

Patients should be taught proper administration of medications and the correct use of drug administration devices and peak flow meters to monitor peak expiratory flow (PEF).

The patient must be able to:
- control PSV;
- understand the difference between drugs of basic and symptomatic therapy;
- avoid asthma triggers;
- identify signs of worsening of the disease and independently stop attacks, as well as promptly seek medical help to stop severe attacks.
Control of asthma over a long period requires a written treatment plan (patient action algorithm).

List of preventive measures:

Stopping contact with cause-related allergens;
- termination of contact with nonspecific irritating environmental factors (tobacco smoke, exhaust gases, etc.);
- exclusion of occupational hazards;
- in the aspirin form of BA - refusal to use aspirin and other NSAIDs, as well as compliance with a specific diet and other restrictions;
- refusal to take beta-blockers, regardless of the form of asthma;
- adequate use of any medications;
- timely treatment of foci of infection, neuroendocrine disorders and other concomitant diseases;
- timely and adequate therapy of asthma and other allergic diseases;
- timely vaccination against influenza, prevention of respiratory viral infections;
- carrying out therapeutic and diagnostic measures using allergens only in specialized hospitals and offices under the supervision of an allergist;
- premedication before invasive examination methods and surgical interventions - parenteral administration of drugs: corticosteroids (dexamethosone, prednisolone), methylxanthines (aminophylline) 20-30 minutes before the procedure. The dose should be determined taking into account age, body weight, severity of asthma and volume of intervention. Before carrying out such an intervention, a consultation with an allergist is indicated.

Information

Sources and literature

1. Damianov I. Secrets of pathology / translation from English. edited by Kogan E. A., M.: 2006

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The purpose of the lecture is Based on the acquired knowledge, diagnose bronchial asthma, formulate a diagnosis, carry out a differential diagnosis with a syndrome-like pathology, prescribe personalized treatment for a particular patient, determine preventive measures and prognosis for this disease.

Lecture outline

Clinical case

Definition of asthma

Epidemiology of asthma

Etiology of asthma

Pathogenesis, pathomorphology, pathophysiology of asthma

BA Clinic

Diagnostic criteria for asthma

Differential diagnosis of asthma

Classification of asthma

Treatment of asthma

Prognosis, prevention of asthma

Patient A, 52 years old, economist by profession.

She was taken to the clinic with an attack of suffocation. Due to significant difficulty breathing, she could answer questions in abrupt phrases. She complained of suffocation that was not relieved by salbutomol and a nonproductive cough.

History of the disease. Since childhood, I was prone to colds, which manifested themselves as cough, difficulty in nasal breathing, and runny nose. Over the past 5 years, episodes of ARVI have become frequent, accompanied by a prolonged cough and difficult “wheezing” breathing, especially at night. She began to react to tobacco smoke, cold air, and physical activity—difficulty breathing and coughing. I went to see a doctor and was diagnosed with chronic bronchitis. On the doctor’s recommendation, I began using salbutamol, which relieved the cough and shortness of breath. The condition deteriorated for about a week and is associated with a “cold.” There was a cough with viscous sputum, shortness of breath with difficulty exhaling, constant wheezing and a feeling of heaviness in the chest, nasal congestion, and the temperature increased to 37.5 degrees. S. I didn’t see a doctor, I took paracetamol and inhaled salbutamol every 2-3 hours. A severe attack of suffocation that was not relieved by salbutamol, and the cessation of coughing up sputum forced an ambulance to be called.

Anamnesis of life. Professional activity is not associated with harmful factors, living conditions are good. The gynecological history is not burdensome, menopause is about a year. Two pregnancies and births. I do not smoke.

Allergological history. Since childhood, there were signs of food intolerance - urticaria when eating seafood. During the flowering season of wormwood and ragweed, nasal congestion, sneezing and watery eyes appeared, for which she took antihistamines. Recently he has been reacting to contact with house dust. Heredity is aggravated: the maternal grandmother had bronchial asthma, the mother had hay fever.

Objective status. The patient's condition is serious due to a severe attack of suffocation. Forced sitting position with fixation of the shoulder girdle. The skin is pale with mild diffuse cyanosis, respiratory rate is 15 per minute, exhalation is prolonged, there is no apnea phase. The chest is in a state of deep inspiration, the muscles of the neck and shoulder girdle are actively involved in breathing, the supraclavicular spaces bulge. On palpation, vocal tremor occurs evenly in all parts of the lungs; with percussion over the upper parts of the lungs, there is a box-like tint of sound. Auscultation reveals uneven ventilation, alternating areas of weakened and hard breathing, prolonged exhalation, and an abundance of whistling dry rales, which intensify with forced exhalation. The pulse is rhythmic, 105 beats/min. Heart sounds are rhythmic, muffled due to the abundance of wheezing. Blood pressure 140/85 mm Hg. Art. The abdominal organs are unremarkable. Peak flowmetry revealed signs of bronchial obstruction: a decrease in PEF to 47% of the expected values, an increase in the post-bronchodilation test was less than 10%, followed by a deterioration in the indicator within an hour. Pulse oximetry revealed hypoxemia - oxygen saturation -SaO92%. Laboratory data without deviations from the norm. The ECG shows signs of overload of the right ventricle of the heart. A chest x-ray revealed increased airiness mainly in the upper parts of both lungs.

So, the severity of the patient’s condition is determined by the following syndromes: asthma - asthma, bronchial obstruction and respiratory failure.

"Asthma" translated from Greek means “choking” - this is paroxysmal shortness of breath . Asthma in the classical sense is bronchial asthma. However, there is paroxysmal suffocation of a different nature. Consequently, the main diagnostic task of the doctor at the preliminary diagnosis stage is to establish the origin of suffocation, to establish what factors underlie bronchial obstruction. To carry out the diagnostic process, it is necessary to consider the basic provisions of asthma that determine its nosological independence.

Definition

The modern concept of bronchial asthma considers asthma as

chronic inflammatory disease respiratory tract, in which many cells and cellular elements take part. Chronic inflammation causes bronchial hyperresponsiveness, which leads to repeated episodes of wheezing, shortness of breath, chest tightness and cough, especially at night or in the early morning. These episodes are usually associated with widespread but variable airway obstruction in the lungs, which is often reversible either spontaneously or with treatment.

Epidemiology

AD is currently one of the most common human diseases in all age groups. There are about 300 million patients with asthma in the world. The incidence of asthma is about 5%, the mortality rate is 0.4-0.8 per 100,000. The prevalence of asthma varies and depends on many factors: climatic and geographical zone, lifestyle, genetic characteristics, environmental factors, socio-economic factors. The highest prevalence of symptoms is recorded in Australia, New Zealand, and Great Britain, the lowest in Indonesia, Turkey, Taiwan, and Albania. A sharp increase in the incidence of asthma, 7-10 times higher than the incidence in previous decades, occurred from the 30s to the 80s of the 20th century and has continued in the last 20 years, both among children and adults. IN Russia Before 1900, asthma was a relatively rare disease. Russian medical journals of that time described isolated cases of the disease in adults and children. In the modern period, according to official statistics, the total number of patients with asthma in the Russian Federation is about 1 million, however, according to expert opinions, the estimated number of patients with asthma is about 7 million. BA is the cause of death of 250 thousand deaths per year (GINA.2011).

Modern features of the course of asthma:

BA became much easier;

There are more patients with asthma;

AD is common among both adults and children;

AD is characterized by significant heterogeneity and variability of symptoms;

There is an underdiagnosis of asthma, which is associated with an underestimation of mild and rare episodes of the disease.

• Etiology of asthma

The nosological affiliation of asthma is based on the specific etiology, pathomorphology, mechanisms of the disease, clinical manifestations and methods of treatment, prevention and educational programs. In the concept of disease there are predisposing, etiological and resolving factors. Throughout the entire period of formation of the doctrine of the mechanisms of asthma development, the role of resolving factors causing the development of the first attack or exacerbation of the disease in a previously sensitized organism has been considered.

Factors influencing the risk of occurrence and manifestation of asthma, are divided into factors that determine the development of the disease (internal) and factors that provoke the appearance of symptoms (external). External factors can be considered as:

A) causal (initiating) - inducers of inflammation, cause the onset of the disease and its exacerbation;

B) aggravating - triggers, increase the possibility of occurrence and exacerbation of asthma. Some factors apply to both groups.

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Bronchial asthma, allergic rhinitis

1.Etiology and epidemiology

2. Clinical classification

3. Pathogenesis of development

4. Clinical manifestations

5.Diagnostics, treatment, prevention

Class

Bronchial asthma (BA). ICD 10 code: BA - J 45.0-J 45.9, J 46 - status asthmaticus

Definition: a chronic inflammatory disease of the airways in which many cells and cellular elements are involved. Chronic inflammation causes bronchial hyperresponsiveness, which leads to recurrent episodes of wheezing, shortness of breath, chest tightness and coughing, especially at night or in the early morning. These episodes are associated with widespread, variable airway obstruction in the lungs, which is often reversible spontaneously or with treatment.

Prevalence in the population: According to WHO, bronchial asthma (BA) affects up to 235 million people worldwide and the annual mortality from asthma, according to world experts, is 250 thousand people. The main international document regulating asthma is GINA (Global Strategy for the Management and Prevention of Asthma). According to GINA experts, the incidence of asthma in different countries of the world ranges from 1-18%. In Russia, the prevalence of asthma among adults is 5-7%, among children – 5-12%. Gender prevalence: boys under 14 years of age are more likely to get sick; in adulthood, women predominate. The incidence of asthma is steadily increasing in all age groups. The incidence of asthma is traditionally higher in developed countries, and mortality is higher in third world countries. The main causes of mortality are the lack of adequate anti-inflammatory therapy and failure to provide emergency care during an attack. In our country, mortality rates are low (less than 1:100,000), although in recent years there has been an increase in these rates in large cities.

Risk factors AD is a hereditary burden, a history of atopic diseases, contact with aeroallergens, occupational allergization (latex for medical workers, flour, pollen, mold, etc.), tobacco smoke, obesity, low social status, diet.

BA is a heterogeneous disease, the key factor of which is chronic inflammation, manifested in the cooperation of macrophages, dendritic cells, T-lymphocytes, eosinophils, neutrophils, and plasma cells. In 70% of cases this is an allergic IgE-dependent process, in other cases it is eosinophilic inflammation not associated with IgE or neutrophilic inflammation.

After the initial entry of the antigen into the body, primary sensitization occurs, with the participation of Th2 - helpers, activation of B - lymphocytes, the formation of memory cells and the formation of specific IgE antibodies. Specific IgE interacts with a receptor on the surface of mast cells. When AG is re-injected, histamine, IL5, IL9, IL13 are released, which leads to activation of effector cells in the bronchial wall: hyperproduction of mucus, bronchoconstriction, activation of fibroblasts and wall remodeling as a result of the process.

Diagnostics: The diagnosis of BA is established on the basis of complaints and anamnestic data of the patient, a clinical and functional examination with an assessment of the reversibility of bronchial obstruction, a specific allergological examination (skin tests with allergens and/or specific IgE in the blood serum) and the exclusion of other diseases.

It should be noted that atopic asthma makes up about 75% of the total number of patients, that is, every fourth patient with asthma does not have an increase in blood IgE levels and positive skin allergy tests.

Pulmonary function tests are helpful in making a diagnosis. In practical healthcare, examination methods aimed at studying respiratory function by measuring physical parameters: volumes, flow speed, mechanical vibration of the chest, and studying the gas composition of exhaled air have become widespread.

Mild asthma, which accounts for up to 60% of the patient population, usually occurs with minimal changes in respiratory function during remission, which does not mean the absence of asthma and, consequently, morphological and immunochemical changes in the respiratory tract.

The most characteristic clinical signs of asthma for adults:

· Anamnesis: onset in childhood and adolescence, previous atopic dermatitis, presence of allergic rhinitis, especially year-round (the risk of developing asthma with year-round rhinitis is 4-5 times higher than with seasonal rhinitis), family history of atopic diseases (BP, AR, BA), no association with long-term smoking, recurring, inconsistent symptoms.

· Clinical signs : “wheezing” - distant dry wheezing, unproductive cough, with increased symptoms after physical activity, cold air, contact with aerollergens (less often with food allergens), NSAIDs, beta blockers. Shortness of breath, cough with night symptoms (2-4 a.m. with awakenings, suffocation), good effect of bronchodilators (salbutamol), hormones. Characteristic phenomena during auscultation: hard breathing, prolongation of exhalation, tachypnea with inspiratory dyspnea, dry wheezing during forced exhalation.

· Instrumental tests , studying the function of external respiration and proving bronchial hyperreactivity. The most important are spirography, peak flowmetry, body plethysmography, pneumotachometry, and study of the level of nitric oxide in exhaled air are less common.

Spirography– a method of graphically displaying changes in lung volumes in a time interval during the performance of certain breathing maneuvers. Main indicators: vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in the first second (FVC 1), peak expiratory flow (PEF). The curve obtained in a healthy person resembles a triangle, while in a patient with asthma there is a sagging of the graph due to a decrease in a number of indicators. There are low rates FVC, FVC 1, PEF, reversibility of bronchial obstruction is more 12% after a test with a bronchodilator.

Rad indices are also calculated. Tiffno index– this is the ratio of the volume of forced expiration in 1 second. to the vital capacity of the lungs, expressed as a percentage and calculated by the formula: FEV1/VC × 100. Gensler index – the ratio of FEV1 to forced vital capacity, expressed as a percentage: FEV1/FVC × 100. With normal pulmonary function, provocative tests with metachline, mannitol, and allergens are used to identify hidden obstruction in large centers.

Peak flowmetry- study of peak expiratory flow using a mechanical portable device - a peak flow meter, carried out by the patient at home. The doctor is provided with the results recorded in the diary. The variability of PEF during the day and during the week is calculated.

Laboratory diagnostics– eosinophilia in blood, sputum, and nasal swabs; increased total and specific IgE in the blood, positive prick test (skin tests).

Differential diagnosis: chronic cough syndrome (hyperventilation syndrome, vocal cord dysfunction syndrome, GERD, rhinitis, heart disease, pulmonary fibrosis). The presence of bronchial obstruction (COPD, bronchiectasis, foreign body, bronchiolitis obliterans, stenosis of large airways, lung cancer, sarcoidosis.

Of particular interest is the combination of asthma and COPD, the so-called. ACOS - overlap - syndrome. Often patients with asthma smoke for a long time and they may develop chronic mixed (eosinophilic + neutrophilic) inflammation and, conversely, a patient with COPD may have a history of sensitization to aeroallergens. The effectiveness of therapy in such patients will depend on the predominant type of inflammation. The appearance of eosinophilia in the peripheral blood of more than 3%, in the sputum of more than 3% indicates the need to add inhaled corticosteroids to the therapy of a patient with COPD. In this group of patients they show sufficient effectiveness.

Comparison chart between asthma and COPD.

Classification. The International Classification of Diseases (ICD 10) distinguishes 3 forms of asthma, regardless of age: with a predominance of the allergic component, non-allergic, mixed and unspecified.

Despite the recommendations of GINA in Russia there is classification by severity. It is preserved mainly for administrative purposes; in accordance with this classification, preferential categories of patients are determined.

There are 4 degrees of severity of the disease: intermittent and persistent (mild, moderate, severe).

Mild intermittent– attacks of the disease occur rarely (less than once a week), short exacerbations. Nocturnal attacks of the disease occur rarely (no more than twice a month), FEV1 or PEF is more than 80% of normal, the range of PEF is less than 20%.

Mild persistent– symptoms of the disease occur more often than once a week, but less than once a day. Exacerbations can disrupt the patient's sleep and inhibit physical activity. Nocturnal attacks of the disease occur at least 2 times a month, FEV1 or PEF is more than 80% of normal, PEF range is 20-30%.

Moderate persistent– Asthma attacks occur almost daily. Exacerbations disrupt the patient's sleep and reduce physical activity. Night attacks of the disease occur very often (more than once a week). FEV1 or PEF decreases to 60% to 80% of normal values. The spread of PSV is more than 30%.

Severe persistent– attacks of the disease occur daily. Nighttime asthma attacks are very common. Limiting physical activity. FEV1 or PEF is about 60% of normal. The spread of PSV is more than 30%.

Control over BA. Currently, the concept of disease management based on the level of control has been adopted. The course of bronchial asthma is always accompanied by patient complaints and there is a direct correlation between the number of complaints with mortality and disability. In the late 90s, the concept of “control/non-control” over symptoms appeared. The meaning of the concept is an assessment by the doctor and the patient of their symptoms and correction of the amount of therapy, lifestyle and everyday life (known as asthma management) based on this assessment.

Since 2014, GINA has identified 4 questions that the patient must answer:

ü Do you have daytime asthma symptoms more than twice a week?

ü Are there night awakenings due to asthma?

ü Did you use drugs to relieve an attack more than 2 times a week?

ü Have you experienced any limitation in physical activity due to asthma?

Asthma is controlled if 4 negative answers are received. With 1–2 positive answers – partially controlled, with 3-4 – uncontrolled. To assess asthma, the AST 25, AST children's, and ACQ5 questionnaires are also used, which also correlate well with the level of control.

In addition, since 2014, the concept of risk factors has been introduced; the presence of at least one risk factor in the anamnesis dictates the need to prescribe basic therapy to the patient. Such factors include hospitalization for exacerbation of asthma, requiring intubation or ICU, use of salbutamol more than 200 doses/month (1 bottle), low FEV1 - less than 60%, eosinophilia of blood or sputum, incorrect inhalation technique, contact with triggers, smoking, social and economic factors, obesity, pregnancy.

BA therapy. At the moment, asthma is an incurable chronic disease. The goal of therapy is to achieve complete disappearance of symptoms, i.e. control of chronic bronchial inflammation. The main drugs must effectively block the leading links in pathogenesis.

Currently, inhaled glucocorticosteroids (ICS) are the most effective anti-inflammatory drugs for the treatment of persistent BA. They have been shown to effectively reduce the severity of asthma symptoms, improve quality of life and lung function, reduce bronchial hyperresponsiveness, inhibit inflammation in the airways, and reduce mortality, frequency and severity of exacerbations.

There are 5 stages of asthma therapy. (drugs are written in order of preference)

1. Lack of constant basic therapy, use of short-acting bronchodilators (SABA) as needed -(if more than 2-3 times a week, basic therapy is required).

2. Application low doses of inhaled corticosteroids, an alternative is leukotriene receptor antagonists, low doses of extended-release theophyllines (use is difficult due to the need to monitor the drug in the blood, the absence of a drug with stable pharmacodynamics in the Russian Federation). Cromones have not been recommended by GINA in recent years due to extremely low efficiency and low compliance.

3. Increasing the dose of ICS by 2 times, adding other drugs to ICS.

There are 3 possible combinations – ICS + long-acting bronchodilator (LABA), iGCS + leukotriene receptor antagonist, iGCS + sustained-release theophylline. The combination of inhaled corticosteroids + LABA is preferable

4. Medium/high doses of ICS+LABA(long-acting bronchodilators), high-dose inhaled corticosteroids + leukotriene receptor antagonist or sustained-release theophylline.

5. The last stage of therapy includes high doses drugs 4 steps + oral steroids and consideration of the possibility of using monoclonal antibodies to the most important inflammatory cytokines in AD. 1 drug is registered in the Russian Federation - monoclonal antibodies to IgE - omalizumab.

At all stages of therapy, symptoms are relieved by inhalation of short-acting bronchodilators as needed; from stage 3, an alternative to SABA is formoterol + inhaled corticosteroids in one inhaler.

Prescribing systemic corticosteroids as basic therapy in patients who can be controlled with safer drugs in steps 1–4 is unacceptable!

Therapy is prescribed for a long time; therapy should be reviewed every 3–6 months. If complete control is achieved, then it is possible to move up a step by reducing the dose of inhaled corticosteroids by 25-50%.

The main criterion for dose adequacy is the physician's judgment of the patient's response to therapy. The physician should evaluate the response to therapy over time based on the level of control of clinical manifestations and, if necessary, adjust the dose of the drug. In order to reduce the risk of side effects, after achieving control of asthma, the dose of the drug should be carefully reduced to the minimum that can maintain control.

Table of correspondence between drugs and doses of inhaled glucocorticosteroids

Related information.