Criteria for the diagnosis of chronic bronchitis. Acute bronchitis

Diagnosis of acute bronchitis is necessary not only for diagnosis accurate diagnosis, as well as to determine the cause of the disease, determine how difficult the disease is.

Any disease has its own causes and symptoms. When diagnosing, the doctor must identify why the disease developed, and the symptoms will help establish a diagnosis. Therefore, it is necessary to consider what may cause acute bronchitis, and how it manifests itself.

Causes and symptoms of acute bronchitis

Acute bronchitis can begin to develop for two types of reasons or due to their “joint activity.”

Infections

These include viruses, bacteria, and atypical microflora. Moreover greatest number Infectious cases of acute bronchitis occur when viruses influence the human body.

Quite often to viral infection bacterial is also added. The virus affects inner wall bronchi, which contains and immune cells, i.e. they are created favorable conditions for the penetration and reproduction of pathogenic bacteria.

Among the viruses that provoke acute bronchitis, such as independent disease or as a continuation of other respiratory ailments, one can distinguish influenza virus, parainfluenza, adenovirus, RS virus, etc.

Bacterial pathogens include pneumococcus, Haemophilus influenzae, streptococcus, and staphylococcus.

Non-infectious pathogens

It can be physical factors(dry, damp, cold or hot air), chemical irritants (vapors of chlorine, ammonia, nitrogen oxides, etc.), allergens (house or industrial dust, pet hair, bird feathers and fluff, pollen flowering plants, medicines, food, etc.).

The symptoms of acute bronchitis are known to almost everyone. When the disease occurs, the patient experiences the following symptoms:

• Cough. This is the most main symptom bronchitis of any kind. Whatever the cause of the disease, cough is an indispensable “attribute” of the disease. In acute bronchitis viral nature The cough will initially be dry and hacking with difficult expectoration, which causes pain in the chest.
  As the disease progresses, the cough gradually moistens, sputum gradually begins to separate, which significantly alleviates the patient’s condition.
• Sputum. When a bacterial infection occurs, the sputum becomes greenish or yellowish. If acute bronchitis was caused by allergens, then the cough has a paroxysmal character, and it often occurs at night.
• The temperature can fluctuate between 38-4 0 0C. In allergic bronchitis it remains normal.
• Headache, muscle, joint pain.
• Lethargy, fatigue, general weakness.
• Increased sweating.
• Dyspnea. Occurs if air flow is sharply reduced, i.e. obstruction occurs.

History and examination of the patient

Any visit to a doctor begins with collecting an anamnesis from the words of the patient or loved ones who know him. Initially, the doctor listens to all the patient’s complaints about his state of health, and then begins to conduct a survey himself.

To make the most accurate diagnosis and the causes of acute bronchitis, already at the anamnesis stage, the doctor learns from the patient:

• Under what conditions did the patient grow up and live? What are the patient's living conditions? this moment– dry or humid air in the house, is there mold in it, pets, are there any industries near the house, etc.;
• what are the working conditions (humidity, temperature, dust, crowding, etc.), how many years the patient has been working in this profession;
• what the patient eats;
• does the patient have bad habits, in particular, whether he smokes and, if so, at what age;
• what diseases the patient suffered during his life (surely everyone has heard the question from a doctor: what did you get sick with in childhood?);
• does the patient currently have chronic diseases;
• what serious diseases do the parents suffer from?
• when did the first signs of the disease appear;
• How exactly do the symptoms manifest themselves, in particular: how often does the cough occur, is it dry or wet, at what time of day is it more intense, whether phlegm comes out when coughing, whether the temperature rises or not, whether shortness of breath occurs, etc.

Based on your medical history, your doctor can make an initial diagnosis of acute bronchitis. Moreover, this disease does not have any particular difficulties in diagnosing.

However, the doctor does not have the right to rely only on anamnesis, so an examination of the patient is also required.

When examining a patient with acute bronchitis, the doctor performs auscultation, or simply listening, using a phonendoscope.

Listening to the patient is carried out in order to identify and determine the types of noise in respiratory system. Auscultation is performed over the entire surface of the lungs in the anterior, lateral and posterior sections.

During the audition, the patient must sit or stand, while the doctor asks for deep breathing for clearer results.

In acute bronchitis, the patient may hear dry or moist rales.

• Moist rales in acute bronchitis are detected when fluid accumulates in the bronchial tubes. liquid mucus. Under the flow of air, it foams, and the bursting bubbles create characteristic bubble sounds.
• Dry wheezing in acute bronchitis is heard when viscous fluid accumulates in the bronchi. thick mucus, which fills the bronchial lumen. When mucus accumulates in large bronchi buzzing sounds will be heard, and when it is concentrated in the small bronchi and bronchioles, the sounds become whistling.
• To exclude suspicions of bronchial asthma, the doctor performs a special type of auscultation - bronchophony. When listening with a phonendoscope, the patient must whisper words containing the sounds “r” and “ch”. In case of bronchial asthma, these sounds will be clearly audible; in other cases, only a quiet rustling will be heard.

Lab tests

Among laboratory tests prescribed for acute bronchitis, a blood test, microflora culture and urine test can be noted.

Blood analysis

A blood test is not necessary for uncomplicated forms of acute bronchitis, since characteristic symptoms diseases and examination of the patient already allow the doctor to diagnose the disease.

• A general blood test simply confirms that inflammatory processes are occurring in the body. Blood counts indicate an increased content of leukocytes (10-12*10 9 /l) and a slight increase in ESR (erythrocyte sedimentation rate) - up to 100 mm/h.
• A biochemical blood test for acute bronchitis will show the appearance of C-reactive protein, which is a specific marker of inflammation in the body. The higher the level of CRP in the blood, the more severe the inflammatory process. For acute bronchitis biochemical analysis blood will reveal increased content alpha-2-globulins, which also confirm the presence inflammatory processes.

General urine analysis

This analysis is necessary in order to monitor the kidneys’ response to inflammatory processes in the body.

It is carried out to assess the course of the disease, monitor the development of complications and the effectiveness of the treatment.

At high temperature bodies in the urine usually reveals an increased protein content. The doctor may prescribe a urine test during the period of acute bronchitis, then at the end of treatment and a control test after another 1 month.

Sputum analysis

In acute bronchitis, microscopic and bacteriological analysis phlegm

• Microscopic analysis reveals in sputum dead cells epithelium, significant amount neutrophils and macrophages (cells from the group of leukocytes that fight bacterial infection). In acute obstructive bronchitis in sputum, Kurshman spirals may appear, which are spiral-shaped casts of small bronchi.
• Bacteriological analysis of sputum allows you to determine the type of bacteria that caused inflammatory processes in the bronchi. This information helps the doctor choose effective drugs for the treatment of acute bronchitis.

X-ray studies

Auscultation is used in medical practice long enough. However, this diagnostic method still has some inaccuracies, especially when we're talking about about recurrent or obstructive bronchitis. The doctor uses an x-ray.

With ordinary uncomplicated bronchitis, there is no particular need for an X-ray, since the images will not show any special changes in the lungs and bronchi.

The doctor prescribes an X-ray in the following cases:

• the patient has a high temperature for a long time;
• shortness of breath appears;
• the previously prescribed treatment did not produce any results.

X-ray examination of complicated acute bronchitis may reveal the following signs:

• the presence of liquids and other chemical elements in the lungs;
• the root of the lung is somewhat deformed, has an enlarged and blurry appearance;
• small vessels of the lungs become invisible;
• the walls of the bronchi have a somewhat thickened appearance.

In an advanced situation, the doctor may detect the following changes in the image:

• in some areas of the tissue the vessels are not visible;
• the pulmonary pattern is greatly modified;
• V lower area lungs there is an increased air content.

X-ray examination may be contraindicated in seriously ill people or pregnant women due to radiation exposure.

Diagnostics using devices

If acute bronchitis is complicated by an obstructive component, then the extent of these complications can be detected using instrumental diagnostics.

Pneumotachography

At this study The amount of air inhaled and exhaled is determined. The pneumotachograph mouthpiece is inserted into the patient's mouth and the nose is pinched.

The device records air volumes in the form of a curve. With the help of a pneumotachograph it is possible to detect abnormalities respiratory function in acute bronchitis at a stage when neither the doctor nor the patient is even aware of it.

Thanks to this, timely and correct treatment can be prescribed.

Peak flowmetry

This study for acute bronchitis allows you to determine the rate of forced expiration.

To do this, the patient exhales air from the lungs with great effort into a device - a peak flow meter, which is a tube with a scale.

Such studies help to identify the degree of narrowing of the bronchial lumens in obstructive acute bronchitis, and therefore prevent the progress of obstruction.

Peak flow meter studies allow the doctor to select the necessary therapy for the treatment of obstructive acute bronchitis.

The peak flow meter is so easy to use that you can conduct research with it at home yourself.

Spirometry, or spirography

This study provides comprehensive assessment breathing conditions. Spirometry can be used to test the following indicators for acute bronchitis:

• indicator of quiet breathing;
• increased exhalation rate;
• maximum lung capacity;
• respiratory parameters after the use of bronchodilators.

Spirometry can detect obstruction early bronchial tree and prescribe the correct treatment.

During the study, a special device, a spirometer, records the volumes of inhaled and exhaled air.

The patient is asked to dial full lungs air, hold your breath for a few seconds, and then exhale slowly, pressing your lips to the special mouthpiece of the device.

Then do the same thing, but the exhalation must be done with effort. Thus, it is fixed calm breathing and exhalation force.

An important indicator in obstructive acute bronchitis is the volume of forced expiration in the first second. All these indicators give a complete picture of the severity of the obstruction.

Thus, when diagnosing acute bronchitis, not only the diagnosis of the disease is established, but also its causes, severity, etc.

We hope that acute bronchitis will never bother you or your family. Be healthy!

Laboratory data

OAK: during exacerbation purulent bronchitis moderate increase in ESR, leukocytosis with a shift to the left.

BAK: increased blood levels of sialic acids, fibrin, seromucoid, alpha2- and gammaglobulin (rarely) with exacerbation of purulent bronchitis, the appearance of PSA.

OA of sputum: light-colored mucous sputum, purulent sputum yellowish-greenish color, mucopurulent plugs may be detected, with obstructive bronchitis - casts of the bronchi; microscopic examination of purulent sputum reveals many neutrophils. In chronic obstructive bronchitis it is noted alkaline reaction morning sputum and neutral or acidic - daily. Rheological properties of sputum: purulent sputum - increased viscosity, decreased elasticity; mucous sputum - reduced viscosity, increased elasticity. In obstructive bronchitis, Kurschmann spirals can be detected.

II: there may be a decrease in the number of T-lymphocytes in the blood, including T-suppressors.

Instrumental studies

Bronchoscopy: signs of inflammation of the bronchial mucosa (I degree - the bronchial mucosa is pale pink, covered with mucus, does not bleed, translucent vessels are visible under the thinned mucous membrane, II degree - the mucous membrane is bright red, bleeds, thickened, covered with pus, III degree - the mucous membrane of the bronchi and trachea is thickened, purplish-bluish, bleeds easily, there is a purulent secretion on it).

Bronchography: bronchi of the IV, V, VI, VII order are cylindrically expanded, their diameter does not decrease towards the periphery, as is normal, small lateral branches are obliterated, the distal ends of the bronchi are blindly broken off (“amputated”). In a number of patients, the dilated bronchi are narrowed in certain areas, their contours are changed (the configuration of “beads” or “rosaries”), the internal contour of the bronchi is jagged, and the architectonics of the bronchial tree is disrupted.

X-ray of the lungs: mesh deformation and increased pulmonary pattern, 30% of patients have pulmonary emphysema.

Spirography: changes in the spirogram depend on the severity of respiratory dysfunction, vital capacity usually decreases, MOD may increase, and the oxygen utilization rate may decrease. Spirographic manifestations bronchial obstruction- decrease in forced vital capacity and maximum ventilation of the lungs.

With pneumotachometry - a decrease in maximum expiratory flow.

Examination program

OA of blood, urine.

BAK: total protein, protein fractions, seromucoid, sialic acids, fibrin, haptoglobin.

Blood II: B- and T-lymphocytes, their subpopulations, immunoglobulins.

General analysis of sputum, its cytological composition, for Koch's bacilli and atypical cells, flora and sensitivity to antibiotics, Kurschmann spirals. Gives the most accurate results sputum examination obtained by bronchoscopy or processed using the Mulder method.

X-ray of the lungs.

Bronchoscopy and bronchography.

Spirography, pneumotachometry.

With pronounced respiratory failure- study of acid-base balance indicators, gas composition blood.

The principles of complex treatment of chronic bronchitis provide for action in four main areas:

1) elimination or maximum correction of pathogenic factors;

2) effects on infection and inflammation;

3) correction of secondary immunological deficiency;

4) improvement of bronchial conductivity.

Therapy chronic bronchitis should depend on the form, severity and individual characteristics of the patient (comorbidities, drug tolerance, etc.). If chronic simple bronchitis requires treatment, as a rule, during periods of exacerbations (antibacterial, mucolytic, and, if necessary, bronchodilator drugs), then with COB, and even more so with severe COB, constant complex therapy is required (Table 1). The main goal of treatment is to reduce the frequency of exacerbations and slow the progression of the disease. Due to the lack of etiotropic therapy, pathogenetic treatment is carried out: reducing mucociliary imbalance and bronchial obstruction, combating nonspecific and microbial inflammation, immunomodulatory therapy, correction of respiratory failure and pulmonary hypertension.

To give up smoking

Quitting smoking is an extremely important undertaking. Smoking cessation improves the prognosis of the disease, reduces the rate of decline in FEV 1 and therefore should occupy 1st place in the management of patients with chronic bronchitis. In order to achieve maximum effect, it is necessary not only to motivate the patient, but also to educate him. It should be explained to the patient that immediate cessation of smoking is more effective than a gradual reduction in the number of cigarettes smoked; When quitting smoking, constant contact with a doctor is necessary to monitor and maintain a high degree of motivation.

Quitting smoking is an extremely important undertaking. Smoking cessation improves the prognosis of the disease, reduces the rate of decline in FEV and therefore should take first place in the management of patients with chronic bronchitis. In order to achieve maximum effect, it is necessary not only to motivate the patient, but also to educate him. It should be explained to the patient that immediate cessation of smoking is more effective than a gradual reduction in the number of cigarettes smoked; When quitting smoking, constant contact with a doctor is necessary to monitor and maintain a high degree of motivation.

In order to reduce nicotine addiction, it is possible to prescribe chewing gum or skin applicators containing nicotine, which helps reduce the craving for smoking.

Drug therapy

Bronchodilators

The main groups of bronchodilators used to treat chronic bronchitis and COPD are anticholinergics, b 2 -sympathomimetics and theophylline. The choice of drug and the amount of therapy depend on the severity of the disease.

The use of inhaled bronchodilators is mainly carried out using metered aerosols, as well as metered aerosols using volumetric nozzles (spacers) and dry powders.

In some cases, patients with COB are prescribed bronchodilator therapy using nebulizers. Typically, this method of drug delivery is used in cases of severe bronchial obstruction with a pronounced decrease in the functional reserves of breathing, when its advantages become especially valuable - no forced inspiratory maneuvers are required and there is no dependence on the coordination of the patient's inhalation with the release of the drug, and adequate delivery of the drug to the patient is guaranteed. Airways.

b 2 -Agonists

The effect of b 2 -agonists in chronic bronchitis and COPD is multifaceted. Despite the fact that in these diseases we cannot expect such significant bronchodilation as in bronchial asthma, even a slight improvement in bronchial patency can lead to a decrease in airway resistance and a decrease in the work of breathing. Moreover, due to an increase in the concentration of AMP under the influence of b2-agonists, not only relaxation of the smooth muscles of the bronchi occurs, but also an increase in the beating of epithelial cilia, which leads to an improvement in the function of the mucociliary escalator.

The most widely used b 2 -agonists in Russia are salbutamol and fenoterol, are used much less often terbutaline. These drugs have the same duration of action (4-6 hours) and are available both in the form of metered-dose inhalers and solutions for nebulization (Table 2).

Anticholinergic drugs

Despite their lower bronchodilatory activity compared to b2-agonists, it is anticholinergics ( ipratropium bromide and tiotropium bromide) are recognized as first-line drugs in the treatment of chronic bronchitis and COPD.

Despite their lower bronchodilatory activity compared to b-agonists, it is anticholinergics () that are recognized as first-line drugs in the treatment of chronic bronchitis and COPD.

Their prescription is more justified in COB, since the most reversible component of bronchoconstriction in these diseases remains increased tone vagus nerve. Blockade of M-cholinergic receptors of types 1 and 3, located in the large bronchi, eliminates increased afferent stimulation and leads to a decrease in bronchoconstriction and tracheobronchial dyskinesia. In addition, the secretory activity of the bronchial glands decreases, which reduces the formation of sputum without compromising its viscosity properties.

Anticholinergic drugs have several advantages over b2-sympathomimetics:

Wide therapeutic corridor;

Minor side effects (unlike b 2 -agonists do not cause tremor and tachycardia);

Do not lead to the development of hypoxemia and hypokalemia, and also reduce oxygen consumption;

Longer action – up to 8 hours.

Considering the different application points, it is reasonable to combined use of anticholinergics and b 2 -agonists, which also makes it possible to reduce the total dose of b 2 -agonists and thereby reduce the risk of side effects of the latter. In addition, a prolonged effect is achieved with a rapid onset of bronchodilation.

Theophylline

With the widespread use of anticholinergic drugs and b2-agonists, theophylline, despite its weak bronchodilator effect and narrow therapeutic corridor, has not lost its importance in the treatment of exacerbations of COPD and COPD.

In addition to its bronchodilation effect, theophylline appears to have a positive inotropic effect on the respiratory muscles, which is extremely important in COPD when respiratory muscles unfavorably positioned. Theophylline also helps improve mucociliary clearance, stimulates the respiratory center, reducing the likelihood of hypoventilation and carbon dioxide retention. Despite the low bronchodilation activity, when combined with b 2 -agonists, an additive effect of theophylline is noted. However, such a combination can be recommended only in extreme cases, since the danger of arrhythmic complications is high.

The use of theophylline in cor pulmonale is also of interest - the drug increases cardiac output, reduces pulmonary vascular resistance, and improves perfusion of ischemic myocardium.

The presence of prolonged oral forms of theophylline (Theotard, etc.) allows you to clearly control the symptoms of the disease, especially at night.

It should be remembered that the range of therapeutic concentrations of theophylline in plasma is small and amounts to 5-15 mcg/ml. Increasing the dose is not justified, as it leads to the development of a large number of side effects, some of which (arrhythmias) can be life-threatening.

Mucoregulatory agents

Impaired mucociliary clearance underlies the pathogenesis of chronic bronchitis and COPD, therefore the use of mucolytics and mucoregulators is recommended at all stages of the disease, despite the contradictory results of studies of their effectiveness. The most preferred drugs affecting bronchial secretions today are ambroxol, acetylcysteine ​​and carbocysteine, although the use of standardized phytotherapeutic agents is not excluded.

Ambroxol causes depolymerization of acidic mucopolysaccharides of bronchial mucus, thus improving rheological properties sputum. Moreover, it stimulates the motor activity of the cilia of the ciliated epithelium, increases the synthesis of surfactant and its resistance to adverse factors. The use of ambroxol increases the effectiveness of antibacterial therapy, as it promotes better penetration of antibiotics into bronchial secretions and the bronchial mucosa. Ambroxol can be administered orally, intravenously and via nebulizer, medium therapeutic dose– 30 mg 3 times a day.

At the heart of the action acetylcysteine lies its ability to destroy disulfide bonds of sputum mucopolysaccharides and stimulate goblet cells. However, its effects are not limited to this: by increasing the synthesis of glutathione, acetylcysteine ​​has antioxidant properties and promotes the detoxification process; Acetylcysteine ​​also inhibits the production of pro-inflammatory cytokines. The drug is usually prescribed in doses of 600–1200 mg/day in the form of tablets or powders, or by nebulizer at a dose of 300–400 mg twice daily.

Carbocisteine(daily dose 1500–2250 mg) in addition to improving the rheological properties of sputum, due to its effect on mucus synthesis, it stimulates the regeneration of the mucous membrane and reduces the number of goblet cells.

Glucocorticosteroids

Therapy with glucocorticosteroids (GCS) is used when the maximum doses of basic drugs are ineffective and with a positive result from the use of GCS in history or from a trial course of tableted corticosteroids (prednisolone at the rate of 0.4–0.6 mg/kg for 2–4 weeks). The effectiveness of a trial course of GCS is assessed by an increase in FEV1 by more than 10% of the required values ​​or 200 ml. If the effect of GCS is positive, it is necessary to include them in basic therapy in such patients.

The mandatory rule is the initial appointment inhaled corticosteroids and only if they are ineffective, transfer the patient to take tableted corticosteroids. You should remember the risk of developing severe side effects when taking systemic corticosteroids (steroid myopathy, steroid gastrointestinal ulcers, steroid diabetes, hypokalemia, osteoporosis, etc.), and therefore it is necessary to prevent possible side effects and constantly try to minimize the maintenance dose.

Antibacterial therapy

Antibacterial drugs for exacerbation of chronic simple bronchitis COPD and COPD as etiotropic therapy are prescribed empirically, since waiting for the results of a bacteriological study is an unacceptable waste of time. When choosing them, take into account that, as a rule, the pathogens during infectious exacerbation of bronchitis are Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae.

Summarizing the data from the most significant microbiological studies during exacerbation of bronchitis, we can say that H. influenzae occurs on average in 50% of cases, M. catarrhalis in 15%, and S. pneumoniae in 20–25%. As a rule, they use amoxicillin with clavulanic acid, new macrolides - clarithromycin (Fromilid) and others, 2nd generation cephalosporins. When prescribing fluoroquinolones, the possibility of their insufficient antipneumococcal activity should be taken into account. Antibacterial therapy is recommended to be adjusted based on sputum culture results if empirically prescribed therapy is ineffective.

In most cases, antibiotics should be prescribed orally, since most modern drugs are well absorbed and can accumulate in tissues in high concentrations. In case of severe exacerbations of the disease, antibiotics should be prescribed intravenously; after stabilization of the patient's condition, a transition to oral medications is possible - the so-called sequential therapy. Typically, the duration of antibiotic therapy does not exceed 7–14 days.

Treatment of respiratory failure

Respiratory failure means the failure of the respiratory system to maintain normal values ​​of oxygen (paO2 > 60 mm Hg) and carbon dioxide (paCO2< 45 мм рт.ст.) в arterial blood.

It seems important to divide the DN according to the speed of its development. On this basis, acute and chronic respiratory failure are distinguished. Acute respiratory failure (ARF) develops over minutes, hours or days. Required attribute ARF are changes in the acid-base state - respiratory acidosis (pH< 7,35). Distinctive feature chronic DN (CDN) is the inclusion of compensatory mechanisms, because it develops over many months and years. Due to this, the pH level is kept within normal limits or at values ​​close to normal, but a change is noted on the part of buffer systems (primarily the bicarbonate buffer). A criterion for exacerbation of chronic respiratory failure (or acute respiratory failure against the background of chronic) is also a decrease in arterial blood pH.

The appearance of respiratory failure or decompensation of chronic respiratory failure in patients with chronic obstructive pulmonary disease (COPD) implies mandatory hospitalization and therapy aimed at resolving or stabilizing respiratory failure. Both the level of hypoxemia and the presence or absence of hypercapnia will determine the treatment tactics at the hospital stage (Fig. 1). Also in the hospital it is necessary to resolve the issue of carrying out long-term oxygen therapy on an outpatient basis using oxygen concentrators (duration – 16-18 hours per day, flow – from 2 to 5 liters per minute). The goal of such therapy is to correct hypoxemia and maintain paO2 values ​​at 60 mmHg. A further increase in the partial tension of oxygen will have a slight effect on its total content in arterial blood, but it can lead to the accumulation of carbon dioxide, and therefore is not rational.

It should be noted that the most important stage of treatment for patients with chronic bronchitis and COPD is outpatient treatment. Adequate basic therapy not only increases life expectancy, but also improves its quality (including ability to work). Hospitalization is necessary only in cases where the exacerbation cannot be effectively controlled in an outpatient setting, as well as in cases of worsening manifestations of respiratory failure or decompensation pulmonary heart.

REHABILITATION AND EXAMINATIONWORK ABILITY

The possibilities for rehabilitation of patients with chronic bronchitis should be considered specifically depending on the form of the disease and the degree of impairment of pulmonary ventilation. For the rehabilitation treatment of patients with chronic bronchitis in our country, the possibilities of sanatorium-resort treatment are widely used, primarily in climatic conditions, both southern (Crimea, Yalta, etc.) and local (in the Urals, Siberia, Altai, the Baltic states and etc.) resorts. A relatively new form of rehabilitation treatment is the rehabilitation department in a suburban area. Assessing the results of rehabilitation treatment of patients with chronic disease on the basis of a specialized rehabilitation department, organized under the leadership of the VNIIP in 1974, with a combination of drug therapy, physiotherapy, and exercise therapy, we could state the achievement of clinical remission in the vast majority of patients

Regularly carried out rehabilitation measures, apparently, can provide medical and, to a large extent, professional rehabilitation in patients with chronic non-obstructive bronchitis and in a certain category of patients with chronic obstructive bronchitis (in particular, in the initial phase of the formation of disorders, with functionally unstable bronchitis). A more accurate assessment of rehabilitation possibilities requires longer periods of observation. As for the social rehabilitation of patients with chronic obstructive bronchitis, with steadily increasing respiratory failure, it is apparently futile, which once again emphasizes the need for early rehabilitation therapy for these patients, designed to preserve their professional performance.

FORECAST

The prognosis of chronic bronchitis worsens as the ventilation capacity of the lungs decreases due to obstructive disorders. If the forced output volume in 1 s (FEV]) is more than 1.5 liters, the prognosis is favorable. Patients with OOBi of about 0.5 l die on average within 5 years. Other poor prognostic factors include hypoxemia and hypercapnia, but their impact is difficult to quantify. An unfavorable prognostic factor is the development of cor pulmonale and cardiac arrhythmias.

Chronic obstructive pulmonary disease. Modern aspects of etiology, pathogenesis. Classification. Diagnostic criteria, the required minimum of research. Course of the disease. Pathogenetic basis of therapy.

Definition of COPD in the GOLD project is distinguished by brevity: “COPD is a painful condition characterized by incompletely reversible airflow limitation. This limitation is usually progressive and is associated with an abnormal response of the lungs to harmful particles and gases.” The authors of this formulation stipulate that until the causal mechanisms of COPD are established, a clearer definition of COPD and its relationship with other obstructive pulmonary diseases will remain controversial.

In this formulation, COPD is not classified as a specific disease, i.e. nosological form, but is called a “painful condition” that has certain features: partially reversible obstruction and progression of the disease. Moreover, this definition does not indicate that chronic inflammation- the main consequence of the influence of etiological factors and main reason progression of the disease. Moreover, in the formulation, instead of chronic inflammation, the concept of “pathological reaction” to the main risk factors appears. The advantage of this formulation is its brevity, and the main disadvantage is the absence of the concept of “chronic inflammation” in it.

Since in medical practice When the concept of COPD is used, there must be a working formulation of this concept, including the main features by which the disease or group of diseases belongs to this category. And only under this condition is it possible to compare the results of work with this cohort of patients in different regions. As for the lack of knowledge of this or that pathogenetic mechanism, then these are already philosophical categories (the process of cognition is endless). The AF does not have a clear formulation of the concept of COPD, which is its disadvantage.

Today, the formulation of COPD could look like this: “Chronic obstructive pulmonary disease (COPD) is a collective concept that combines chronic environmentally mediated inflammatory diseases of the respiratory system with a predominant lesion of the distal respiratory tract with partially reversible bronchial obstruction, which are characterized by progression and increasing chronic respiratory insufficiency." Further, in the comments, one should specify the range of diseases included in this concept, the stage of progression when COPD from a collective concept turns into a nosological form. As for the details of pathogenetic mechanisms and biomarkers, today it is premature to introduce them into the formulation. This is not only because these mechanisms and biomarkers are not yet fully understood, but also because they can only be assessed during the diagnostic process in a limited number of institutions.

This group includes chronic obstructive bronchitis (COB), pulmonary emphysema (PE), some forms bronchial asthma (BA) with an increase in irreversible bronchial obstruction (usually non-atopic BA).

Etiology and pathogenesis of COPD

Risk factors for the development of COPD are recurrent respiratory tract infection, airway hyperresponsiveness, impaired growth and development of the lungs, genetic predisposition, occupational inhalation hazards, air pollution, low socio-economic level. But smoking plays the most important role in the development and progression of the disease.

COPD is an inflammatory disease, and mainly macrophages and neutrophils, as well as CD8+ T-lymphocytes, take part in the development of the inflammatory process. Among the inflammatory mediators characteristic of COPD are leukotriene B4 and interleukin 8. This determines the difference between COPD and bronchial asthma, in which the characteristic inflammatory cells are eosinophils and CD-4+ T-lymphocytes, and the inflammatory mediators are leukotriene D4, interleukins 4 and 5. In COPD, the characteristic morphological consequences of inflammation are epithelial metaplasia and the development of sclerotic changes in the bronchial wall, and in bronchial asthma – desquamation of the epithelium and thickening of the basement membrane. Also, COPD releases a number of inflammatory mediators that have systemic effects (for example, tumor necrosis factor alpha).

It is important to emphasize that oxidative stress plays vital role in the formation of destructive processes in lung tissue, participating not only in the pathogenesis of the disease, but also having a systemic effect.

Thus, changes in the wall of the bronchial tree are caused by inflammatory changes, which are caused by the pathological effect of inhalation damaging factors and disrupt mucociliary clearance, change the elastic properties of the bronchi in the lung parenchyma, which leads to emphysema, as well as in the pulmonary vessels affected during inflammation.

Inflammation in respiratory system from a pathophysiological point of view, it leads to reversible (bronchospasm, edema of the bronchial wall, quantitative and qualitative disturbance of bronchial secretions, dynamic hyperinflation during physical activity) and irreversible changes (hardening of the bronchial wall, expiratory collapse of small bronchi on exhalation, emphysema).

At the same time different patients the degree of severity of various changes differs. In this regard, when emphysema and debilitating shortness of breath come to the fore in the clinical picture, the predominantly emphysematous type of COPD is distinguished, and when there are predominant signs of damage to the bronchial tree with corresponding clinical manifestations - bronchial obstruction, cough, sputum - the bronchitis type. It is recommended to include these phenotypes in the diagnosis. COPD is characterized by a systemic effect of the disease (unlike bronchial asthma). The action of inflammatory mediators and oxidative stress products is not limited to lung tissue. First of all, damage to the skeletal muscles occurs, as a result of which the patient loses muscle mass and strength, and myocytes undergo pronounced dystrophic changes. This leads to even greater limitation physical activity in patients with COPD due to a low anaerobic threshold. Patients with COPD typically have more high risk fractures and decreased density bone tissue, which is due to the elderly age of patients, smoking and a reduced level of physical activity.

The results of a retrospective analysis of a database of patients with COPD treated with inhaled glucocorticosteroids (ICS) and/or bronchodilators suggest that the risk of fractures may be more determined by the underlying respiratory disease than by the use of ICS. About 66% of patients with COPD included in the TORCH study had osteoporosis or osteopenia before enrollment (according to WHO criteria). In patients with COPD great importance have changes in the cardiovascular system. Of course, COPD is a risk factor for the development of various diseases of the cardiovascular system. At the same time the most important factor development of COPD - smoking is also a risk factor for the development of atherosclerotic damage to blood vessels and the heart. The development of respiratory failure in severe stages of COPD is formed by changes in the right parts with the formation of a “pulmonary heart”.

Classification of COPD

Stage	Lung function
0 – risk of developing the disease	Normal indicators
I – light	FEV/FVC<70% от должного, ОФВ 1 >80% of due
II – average	FEV/FVC<70% от должного, 50%<ОФВ1<80% от должного
III – heavy	FEV/FVC<70% от должного, 30%<ОФВ 1 <50% от должного
IV – extremely severe	FEV/FVC<70% от должного,ОФВ 1 <30% от должного или ОФВ 1 <50% от должного в сочетании с хронической дыхательной недостаточностью

Clinical picture

The clinical picture of COPD is characterized by the same type of clinical manifestations - cough and shortness of breath, despite the heterogeneity of the diseases that make it up. The degree of their severity depends on the stage of the disease, the rate of disease progression and the predominant level of damage to the bronchial tree. The rate of progression and severity of COPD symptoms depends on the intensity of the impact of etiological factors and their summation. Thus, the standards of the American Thoracic Society emphasize that the appearance of the first clinical symptoms in patients with COPD is usually preceded by smoking at least 20 cigarettes per day for 20 years or more.

The first signs with which patients usually consult a doctor are cough and shortness of breath, sometimes accompanied by wheezing with sputum production. These symptoms are more pronounced in the morning.

The earliest symptom, appearing by the age of 40-50, is cough. By this time, during cold seasons, episodes of respiratory infection begin to occur, which at first are not associated with one disease. Shortness of breath felt during physical activity occurs on average 10 years after the onset of cough. However, in some cases the disease may begin with shortness of breath.

Sputum secreted in small quantities (rarely more than 60 ml/day) in the morning, has a mucous character. Exacerbations of an infectious nature are manifested by a worsening of all signs of the disease, the appearance of purulent sputum and an increase in its quantity.

It should be emphasized that bronchopulmonary infection, although common, is not the only cause of exacerbation. Along with this, exacerbations of the disease are possible due to increased exposure to exogenous damaging factors or inadequate physical activity. In these cases, signs of infection of the respiratory system are minimal. As COPD progresses, the intervals between exacerbations become shorter.

Dyspnea can vary over a very wide range: from a feeling of lack of air during normal physical activity to severe respiratory failure[.

Diagnostics

Objective research

The results of an objective study of patients with COPD depend on the severity of bronchial obstruction and emphysema.

As the disease progresses, the cough is accompanied by wheezing, which is most noticeable with rapid exhalation. Auscultation often reveals dry rales of different timbres. As bronchial obstruction and emphysema progress, the anteroposterior size of the chest increases. With severe emphysema, the patient’s appearance changes, a barrel-shaped chest appears (enlargement in the anteroposterior direction). Due to the expansion of the chest and upward displacement of the clavicles, the neck appears short and thick, the supraclavicular fossae are protruded (filled with expanded apices of the lungs). When percussing the chest, a boxy percussion sound is noted. In cases of severe emphysema, the absolute dullness of the heart may not be completely determined. The edges of the lungs are shifted downwards, their mobility during breathing is limited. As a result, a soft, painless edge of the liver may protrude from under the edge of the costal arch, although its size is normal. The mobility of the diaphragm is limited, the auscultatory picture changes: weakened breathing appears, the severity of wheezing decreases, and exhalation lengthens.

The sensitivity of objective methods for determining the severity of COPD is low. Classic signs include wheezing and prolonged expiratory time (more than 5 seconds), which indicate bronchial obstruction.

However, the results of an objective examination do not fully reflect the severity of the disease, and the absence of clinical symptoms does not exclude the presence of COPD in the patient. Other signs, such as incoordination of respiratory movements, central cyanosis, also do not characterize the degree of airway obstruction.

In mild COPD, respiratory pathology is usually not detected. In patients with moderate disease, when examining the respiratory system, dry rales or slightly weakened breathing may be heard (a sign of emphysema), but these symptoms may not be able to determine the severity of airway obstruction.

With the loss of the reversible component of obstruction, persistent signs of respiratory failure dominate, pulmonary hypertension increases, and chronic cor pulmonale forms. It is difficult to identify signs of compensated cor pulmonale during physical examination.

As the disease progresses, first transient and then permanent hypoxia and hypercapnia are observed, and blood viscosity often increases, which is caused by secondary polycythemia. A decompensated cor pulmonale develops. Patients with severe COPD are characterized by worsening shortness of breath, diffuse cyanosis, and loss of body weight.

Highlight two clinical forms of the disease- emphysematous and bronchitis. Emphysematous form(type) COPD is associated primarily with panacinar emphysema. Such patients are figuratively called “pink puffers”, since in order to overcome the premature expiratory collapse of the bronchi, exhalation is made through pursed lips and is accompanied by a kind of puffing. The clinical picture is dominated by shortness of breath at rest due to a decrease in the diffusion surface of the lungs. Such patients are usually thin, their cough is often dry or with a small amount of thick and viscous sputum. The complexion is pink, because... Sufficient blood oxygenation is maintained by increasing ventilation as much as possible. The limit of ventilation is reached at rest, and patients tolerate physical activity very poorly. Pulmonary hypertension is moderate, because the reduction of the arterial bed caused by atrophy of the interalveolar septa does not reach significant values. Cor pulmonale has been compensated for a long time. Thus, the emphysematous type of COPD is characterized by the predominant development of respiratory failure.

Bronchitic form(type) observed in centriacinar emphysema. Constant hypersecretion causes an increase in resistance during inhalation and exhalation, which contributes to a significant impairment of ventilation. In turn, a sharp decrease in ventilation leads to a significant decrease in the O 2 content in the alveoli, subsequent disruption of perfusion-diffusion relationships and blood shunting. This causes the characteristic blue tint of diffuse cyanosis in patients in this category. Such patients are obese, and the clinical picture is dominated by cough with copious sputum production. Diffuse pneumosclerosis and obliteration of blood vessels lead to the rapid development of cor pulmonale and its decompensation. This is facilitated by persistent pulmonary hypertension, significant hypoxemia, erythrocytosis and constant intoxication due to a pronounced inflammatory process in the bronchi.

The identification of two forms has prognostic significance. Thus, with the emphysematous type, decompensation of the cor pulmonale occurs in later stages compared to the bronchitis variant of COPD. In clinical settings, patients with a mixed type of disease are more common.

Thus, COPD is characterized by a slow, gradual onset, the development and progression of the disease occurs under the influence of risk factors. The first signs of COPD are cough and shortness of breath, other signs appear later as the disease progresses.

Smoking history

A necessary condition for diagnosing COPD, according to WHO recommendations, is calculating the smoking index. The smoking index is calculated as follows: the number of cigarettes smoked per day is multiplied by the number of months in the year, i.e. at 12; if this value exceeds 160, then smoking in this patient poses a risk for the development of COPD; if the index is more than 200, then the patient should be classified as a “heavy smoker.”

Smoking history is also recommended to be assessed in pack/year units. Total packs/years = number of packs smoked per day x number of years of smoking. In this case, one conventional pack contains 20 cigarettes. If this indicator reaches a value of 10 packs/years, then the patient is considered an “absolute smoker.” If it exceeds 25 packs/years, then the patient can be classified as a “heavy smoker.” A patient is considered a “former smoker” if he has stopped smoking for 6 months or more. This must be taken into account when diagnosing COPD.

Establishing a diagnosis of COPD is based on identifying the main clinical signs of the disease, taking into account the effect of risk factors and excluding lung diseases with similar symptoms. Most patients are heavy smokers with a history of frequent respiratory diseases, mainly in the cold season.

Physical examination data for COPD are insufficient to establish a diagnosis of the disease; they only provide guidelines for further direction of diagnostic research using instrumental and laboratory methods.

Diagnostic methods can be roughly divided into mandatory minimum, used in all patients, and additional methods, used for special indications. Mandatory methods, in addition to physical ones, include determination of pulmonary function (PRF), blood test, cytological examination of sputum, X-ray examination, blood test and ECG.

The study of external respiratory function is of leading importance in the diagnosis of COPD and objective assessment of the severity of the disease.

External respiration function

The following volume and velocity indicators must be determined: vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV 1), maximum expiratory velocities at various levels of FVC (MSV 75-25). The study of these indicators forms the functional diagnosis of COPD.

Functional disorders in COPD are manifested not only by impaired bronchial obstruction, but also by changes in the structure of static volumes, impaired elastic properties, diffusion capacity of the lungs, and decreased physical performance. The definition of these types of disorders is optional.

Criteria for bronchial obstruction

The most important thing for diagnosing COPD is to determine chronic airflow limitation, i.e. bronchial obstruction. The generally accepted methods for recording bronchial obstruction are spirometry and pneumotachometry performed during a forced expiratory maneuver. The main criterion defining chronic airflow limitation, or chronic obstruction, is fall in FEV 1 up to a level of less than 80% of the required values. Having a high degree of reproducibility when the respiratory maneuver is performed correctly, this parameter allows you to document the presence of obstruction in the patient and subsequently monitor the state of bronchial patency and its variability. Bronchial obstruction is considered chronic if it is recorded during repeated spirometric studies at least 3 times within one year, despite the therapy.

For early diagnosis of COPD, partial flow-volume curve testing is more effective.

For more accurate diagnosis and choice of treatment, it is necessary to determine the presence and severity of reversible and irreversible components of bronchial obstruction.

Reversibility of obstruction

To study the reversibility of obstruction, tests with inhaled bronchodilators, and their influence on the flow-volume curve parameters, mainly on FEV 1, is assessed. The parameters MSV 75-25, indicating the level of forced expiratory flows at different levels of FVC, cannot be compared, because FVC itself, in relation to which these flows are calculated, changes with repeated tests. Other indicators of the flow-volume curve (with the exception of FEV 1) are also mainly derived and calculated from FVC. To calculate the bronchodilation response, it is recommended to use the FEV 1 parameter.

The bronchodilator response depends on the pharmacological group of the bronchodilator, the route of administration and the inhalation technique. Factors influencing the bronchodilation response also include the dose administered; time elapsed after inhalation; bronchial lability during the study; baseline pulmonary function; reproducibility of compared indicators; research errors.

When examining a particular patient with COPD, it is necessary to remember that the reversibility of obstruction is a variable value and may differ in the same patient during periods of exacerbation and remission.

Bronchodilation tests: choice of prescribed drug and dose

It is recommended to prescribe the following as bronchodilator drugs when conducting tests in adults:

b 2 -short acting agonists(from the minimum dose to the maximum allowable: fenoterol - from 100 to 800 mcg; salbutamol - from 200 to 800 mcg, terbutaline - from 250 to 1000 mcg) with measurement of the bronchodilator response after 15 minutes;

anticholinergic drugs: it is recommended to use ipratropium bromide as a standard drug (starting from the minimum dose - 40 mcg, up to the maximum possible - 80 mcg) with measurement of the bronchodilation response after 30-45 minutes.

It is possible to conduct bronchodilation tests with the prescription of higher doses of drugs that are inhaled through nebulizers. Repeated studies of FEV 1 in this case should be carried out after inhalation of the maximum permissible doses: 15 minutes after inhalation of 0.5-1.5 mg of fenoterol (or 2.5-5 mg of salbutamol or 5-10 mg of terbutaline) or 30 minutes after inhalation of 500 mcg ipratropium bromide.

To avoid distortion of the results and to correctly perform the bronchodilator test, it is necessary to cancel the therapy in accordance with the pharmacokinetic properties of the drug taken (short-acting b2-agonists - 6 hours before the test, long-acting b2-agonists - 12 hours before, long-acting theophyllines - within 24 hours).

Increase in FEV 1 more than 15% of the initial indicators are conventionally characterized as reversible obstruction. It should be emphasized that normalization of FEV 1 in a test with bronchodilators in patients with COPD almost never occurs. At the same time, negative results in the test with bronchodilators (increase< 15%) не исключают увеличения ОФВ 1 на большую величину в процессе длительного адекватного лечения. После однократного теста с b 2 -агонистами примерно у 1/3 пациентов ХОБЛ происходит существенное увеличение ОФВ 1 , у остальных обычно это наблюдается после серии тестов .

Method for calculating bronchodilation response

Determining the reversibility of bronchial obstruction is technically straightforward, but the interpretation of the results of this study remains a matter of debate. The simplest way is to measure the bronchodilation response by the absolute increase in FEV 1 in ml:

FEV 1 abs (ml) = FEV 1 dilate (ml)-FEV 1 ref (ml)

However, this method does not allow one to judge the degree of relative improvement in bronchial conductivity, since the values ​​of neither the initial nor the achieved indicator in relation to the expected value are taken into account. A very common method for measuring reversibility is the ratio of the absolute increase in FEV 1 expressed as a percentage of the expected value [(DOFEV 1 expected (%)]:

DOEF 1 must. = ((FEV 1 dilat. (ml) – FEV 1 initial (ml))/FEV 1 proper (ml)) x 100%,

and as a percentage of the maximum possible reversibility:

DOEF 1 possible = ((FEV 1 dilat. (ml) - FEV 1 original (ml)) / (FEV 1 dilat. (ml) - FEV 1 original (ml))) x 100%,

where FEV 1 ref. - initial parameter, FEV 1 dilate. - indicator after bronchodilation test, FEV 1 should. - proper parameter.

The choice of the reversibility index used should depend on the clinical situation and the specific reason for which reversibility is being studied, but the use of a reversibility index that is less dependent on the initial parameters allows for a more correct comparative analysis of data from different researchers.

Despite the variety of methods for calculating the bronchodilation response, which quantitatively reflects the reversibility of obstruction, most official documents on this issue recommend a method for calculating the increase in relation to the proper values ​​of FEV 1 .

A reliable bronchodilator response must exceed spontaneous variability in magnitude, as well as the response to bronchodilators observed in healthy individuals. Therefore, the magnitude of the increase in FEV 1, equal to or exceeding 15% of the expected value, is recognized as a marker of a positive bronchodilation response. When such an increase is obtained, bronchial obstruction is documented as reversible.

FEV monitoring 1

An important method to confirm the diagnosis of COPD is monitoring of FEV 1 - long-term repeated measurement of this spirometric indicator. In adulthood, there is normally an annual decrease in FEV 1 within 30 ml per year. Large epidemiological studies conducted in different countries have established that Patients with COPD are characterized by an annual decrease in FEV 1 more than 50 ml per year .

At home, it is convenient to use the indicator to monitor the severity of obstruction peak expiratory flow (PEF), determined using an individual peak flow meter. For COPD, peak flowmetry is of relative importance. Nevertheless, the method makes it possible to determine the daily variability of the severity of bronchial obstruction, which in COPD usually does not exceed 15%. The most valuable is the measurement of PEF indicators for differentiating COB and BA. In classical uncomplicated forms of asthma, daily variability of PEF usually exceeds 15%. Along with this, regular measurement of PEF serves as an easily accessible method for objectively assessing the effectiveness of bronchodilator therapy during daily self-monitoring both in outpatient and inpatient settings.

Changes in the structure of static volumes and elastic properties of the lungs

Bronchial obstruction can lead to a change in the structure of static volumes towards hyperairiness of the lungs. In order to identify changes in the ratios of static volumes that make up the structure of the total lung capacity in hyperairiness and emphysema, it is generally accepted to use two main methods: body plethysmography and measurement of lung volumes by the method of diluting inert gases (ECCS guidelines, 1993).

The main manifestation of hyperairy lungs is increase in total lung capacity determined by body plethysmography or gas dilution method.

Anatomical changes in the lung parenchyma during emphysema (expansion of air spaces, destructive changes in the alveolar walls) are functionally manifested by changes in the elastic properties of the lung tissue - increased static extensibility. There is a change in the shape and angle of the pressure-volume loop.

Impaired diffusion capacity of the lungs

Measurement of the diffusion capacity of the lungs is performed at the second stage of assessing pulmonary function after performing forced spirometry or pneumotachometry and determining the structure of static volumes. Diffusion studies are used to detect damage to the lung parenchyma due to emphysema.

In emphysema, the indicators of the diffusion capacity of the lungs - DLCO and its ratio to the alveolar volume DLCO/Va are reduced, mainly due to the destruction of the alveolar-capillary membrane, which reduces the effective area of ​​gas exchange. However, a decrease in the diffusion capacity of the lungs per unit volume (i.e., the area of ​​the alveolar-capillary membrane) can be compensated by an increase in the total capacity of the lungs. Diffusion capacity is usually reduced in the presence of COPD symptoms, which means the addition of emphysema.

Blood gases

COPD is accompanied by disturbances in ventilation-perfusion ratios, which can lead to arterial hypoxemia- increasing oxygen tension in arterial blood (PaO 2). In addition, ventilation respiratory failure leads to hypercapnia- increased carbon dioxide tension in arterial blood (PaCO 2). In COPD patients with chronic respiratory failure, the onset of acidosis is metabolically compensated by increased production of bicarbonate, which allows maintaining a relatively normal pH level.

The relationship between FEV 1 and blood gas composition is insignificant. Determining blood gas composition is recommended for moderate and severe forms of COPD. This is necessary to assess pulmonary gas exchange, clarify the nature of disease progression and the severity of respiratory failure.

In some patients with COPD, hypoxemia and hypercapnia are worsened during sleep. In these patients, pulmonary hypertension in the pulmonary artery is more pronounced. When COPD is combined with obstructive sleep disordered breathing (pre-cross syndrome), a special somnological study and correction of this disorder are indicated.

Pulse oximetry is used to measure and monitor blood oxygen saturation (SaO 2), but it only allows you to record the level of oxygenation and does not allow you to monitor changes in PaCO 2. If SaO 2 is less than 94%, then it is indicated blood gas test .

As COPD progresses, an increase in pressure in the pulmonary artery is often observed. The severity of pulmonary hypertension has prognostic significance. Among non-invasive methods for controlling pulmonary hypertension, the best results are obtained using Doppler echocardiography. In routine practice for the management of patients with COPD, the use of direct methods for measuring pulmonary artery pressure is not recommended.

Pulmonary function testing in COPD is performed to determine the severity of the disease, its progression and prognosis. The main reason for the late diagnosis of COPD is the lack of opportunity to conduct a timely study of respiratory function.

Due to its good reproducibility and ease of measurement, FEV 1 is now a generally accepted indicator for assessing the degree of obstruction in COPD. Based on this indicator, the severity of COPD is determined. Mild severity - FEV 1 > 70% of the required values, moderate - 50-69%; severe degree -<50%. Эта градация рекомендована Европейским Респираторным Обществом и принята за рабочую в России.

The American Thoracic Society also uses FEV 1 when assessing severity. In some cases, patients with COB require a functional study of the respiratory muscles. This is especially important when patients are losing weight, suspected steroid myopathy, and with hypercapnia that is not proportional to FEV 1 values.

Exercise studies

In the initial stages of the disease, disturbances in the diffusion capacity and gas composition of the blood at rest may be absent, and appear only during physical activity. In patients of a more severe category, the decision on the advisability of prescribing oxygen therapy may also depend on the degree of limitation of physical performance. Various methods exist to objectify and document the degree of decline in exercise tolerance.

Tests with physical activity can be carried out using various devices for dosing the load (bicycle ergometers, treadmills) or without them, when the distance covered by the patient in a certain time (step test) is used as a criterion of physical tolerance.

When conducting six-minute step test The patient is given the task of walking as far as possible in 6 minutes, after which the distance traveled is recorded. If possible, blood oxygen saturation should be monitored using pulse oximetry during the test. There is evidence of a correlation between the distance traveled and pulmonary diffusion parameters. Typically, a COPD patient with an FEV 1 of about 1 liter or 40% of predicted walks about 400 m in 6 minutes. The performance of the 6-minute test is very variable and depends largely on the emotional state and motivation. This method is the simplest means for individual observation and monitoring of the course of the disease.

Exercise testing is used in cases where the severity of shortness of breath does not correspond to a decrease in FEV 1 . It is used to select patients for rehabilitation programs.

Immediately following the formulation of the concept in GOLD is a classification according to the severity of COPD.

The advantage of this classification is the introduction of the concept of “stages” of the disease, which is a consequence of the progression of COPD. On the other hand, it is very difficult to distinguish stage 0 - the risk stage, since this group can include not only patients with obstructive bronchitis. The second, very controversial position is the expansion of the boundaries of moderate COPD to FEV 1 - 30% of the required values. Thus, patients with FEV 1 equal to 79% and 30% fall into the same category according to severity. I think that today we cannot accept this division according to severity. The classification in the FP corresponds to the classification proposed by the EPO, has been successfully implemented in our country and is convenient to use. Another thing is that it is quite convenient to place the classification according to severity immediately following the formulation of the concept.

Laboratory research methods

Sputum examination

Cytological examination of sputum provides information about the nature of the inflammatory process and its severity and is a mandatory method.

Cultural microbiological examination It is advisable to carry out sputum testing in case of uncontrolled progression of the infectious process and the selection of rational antibiotic therapy. It is an additional examination method.

Blood test

Clinical analysis: with a stable course of COPD, significant changes in the content of peripheral blood leukocytes do not occur. During an exacerbation, neutrophilic leukocytosis with a band shift and an increase in ESR are most often observed. However, these changes are not always observed. With the development of hypoxemia in patients with COPD, polycythaemic syndrome is formed, which is characterized by changes in hematocrit (hematocrit > 47% in women and > 52% in men), an increase in the number of red blood cells, a high level of hemoglobin, low ESR and increased blood viscosity.

Immunological study blood is additional and is carried out with the steady progression of the infectious inflammatory process to identify signs of immune deficiency.

X-ray research methods

X-ray examination of the chest organs is a mandatory examination method. X-rays of the lungs in frontal and lateral projections in COPD reveal an increase in the transparency of the lung tissue, a low position of the dome of the diaphragm, limited mobility, and an increase in the retrosternal space, which is characteristic of emphysema.

With mild COPD, significant radiographic changes may not be detected. In patients with moderate and severe COPD, one can find: low standing of the dome of the diaphragm, flattening and limitation of its mobility; hyperairy pulmonary fields, bullae and enlarged retrosternal space; narrowing and elongation of the heart shadow; against the background of depletion of vascular shadows, a high density of the walls of the bronchi is determined, infiltration along their course, i.e. a number of signs are revealed that characterize the inflammatory process in the bronchial tree and the presence of emphysema.

During the initial X-ray examination, it is important to exclude other lung diseases, in particular, neoplastic processes and tuberculosis. During exacerbation of COPD, chest x-ray can exclude pneumonia, spontaneous pneumothorax and other complications.

CT scan lungs is an additional method and is performed according to special indications. It allows you to quantitatively determine morphological changes in the lungs, primarily emphysema, and more clearly identify bullae, their location and size.

Electrocardiography

Electrocardiography makes it possible to identify signs of right heart hypertrophy, however, her ECG criteria change dramatically due to emphysema. ECG data in most cases allows us to exclude the cardiac origin of respiratory symptoms.

Paradoxical pulse

Paradoxical pulse is defined as a decrease in the amplitude of the pulse wave at the radial artery during shallow inspiration. If changes in amplitude are mild, it is necessary to use a sphygmomanometer cuff. Systolic pressure during inspiration decreases by more than 10 mmHg. Art.

Bronchological examination

Bronchological examination is optional for patients with COPD. It is carried out to assess the condition of the bronchial mucosa and differential diagnosis with other lung diseases. In some cases, diseases that cause chronic bronchial obstruction can be identified. Research may include:

Examination of the bronchial mucosa

Cultural examination of bronchial contents

Bronchoalveolar lavage with determination of cellular composition to clarify the nature of inflammation

Biopsy of the bronchial mucosa.

The quality of life

In the last decade, quality of life has been determined to assess the nature of the disease and the patient’s adaptation to COPD.

Quality of life is an integral indicator that determines the patient’s adaptation to the presence of the disease and the ability to perform the patient’s usual functions related to his socio-economic status (at work and at home). To determine the quality of life, special questionnaires are used. The most well-known questionnaire for COPD patients is the St. George's Hospital questionnaire.

Diagnosis of COPD is carried out by summing up the following data- the presence of risk factors, clinical signs, the main of which are cough and expiratory shortness of breath, impaired bronchial obstruction during the study of respiratory function (decrease in FEV 1). An important component of diagnosis is an indication of the progression of the disease. A prerequisite for diagnosis is the exclusion of other diseases that can lead to similar symptoms.

Differential diagnosis

In the early stages of COPD development, it is necessary to distinguish between COPD and asthma, because At this time, fundamentally different approaches to the treatment of each of these diseases are required. The most difficult differential diagnosis is BA and COB.

Clinical examination reveals paroxysmal symptoms in asthma, often in combination with extrapulmonary signs of allergy (rhinitis, conjunctivitis, skin manifestations, food allergies). Patients with COB are characterized by constant, little changing symptoms. An important element of differential diagnosis is a decrease in FEV 1 by 50 ml or more per year in patients with COB, which is not observed in BA. COB is characterized by low daily variability of peak flow measurements (< 15%). При БА разность между утренними и вечерними показателями пикфлоуметрии увеличивается и превышает 20%. При БА чаще наблюдается бронхиальная гиперреактивность.

Of the laboratory signs of asthma, the most common is an increase in IgE content.

When an irreversible component of bronchial obstruction appears in patients with asthma, the differential diagnosis between these diseases loses its meaning, because we can state the addition of a second disease - COPD and the approach of the final phase of the disease - COPD. The main differential diagnostic signs of BA and COB are given in Table 4.

Formulating a diagnosis

When formulating a diagnosis in situations where the nosological affiliation of the disease can be clearly identified, the term COPD should be omitted and limited to indicating the nosology, severity, phase of the disease and the presence of complications. Such situations are typical for COPD of mild to moderate severity. For example:

Chronic obstructive bronchitis. Remission phase. Moderate severity. Emphysema. DN I.

Chronic obstructive bronchitis. Exacerbation phase. Moderate severity. Emphysema. DN II. Chronic pulmonary heart disease in the compensation stage. H.K.I.

If it is impossible to clearly determine the nosological affiliation of the disease (the predominance of irreversible obstruction), the diagnosis should begin with the term “chronic obstructive pulmonary disease” (COPD) with a further indication of the diseases that led to its development. Such situations are more often observed with moderate and severe degrees of severity. For example:

1. COPD: bronchial asthma, chronic obstructive bronchitis, pulmonary emphysema, exacerbation phase, severe course, DN II, chronic cor pulmonale, HK I.

2. COPD: chronic obstructive bronchitis, obstructive pulmonary emphysema, severe course, stable course (remission), DN II, polycythemia, chronic cor pulmonale, HK I.

According to the International Classification of Diseases, X Revision, under heading J.44.8. chronic obstructive bronchitis without additional specifications is identified, which is part of the specified chronic obstructive pulmonary disease. Section J.44.9. identifies unspecified chronic obstructive pulmonary disease, which is considered as the terminal phase of the disease, in which all the individual characteristics of the individual diseases that led to COPD are already erased.

The goals of COPD therapy are to prevent disease progression, reduce the severity of clinical symptoms, achieve better exercise tolerance and improve the quality of life of patients, prevent complications and exacerbations, and reduce mortality.

The main directions of treatment for COPD are reducing the impact of adverse environmental factors (including smoking cessation), patient education, the use of medications and non-drug therapy (oxygen therapy, rehabilitation, etc.). Various combinations of these methods are used in patients with COPD in remission and exacerbation.

Bronchitis in children– nonspecific inflammation of the lower respiratory tract, occurring with damage to bronchi of various sizes. Bronchitis in children is manifested by a cough (dry or with sputum of various types), increased body temperature, chest pain, bronchial obstruction, and wheezing. Bronchitis in children is diagnosed on the basis of auscultation, chest radiography, general blood test, sputum examination, respiratory function, bronchoscopy, bronchography. Pharmacotherapy of bronchitis in children is carried out with antibacterial drugs, mucolytics, and antitussives; physiotherapeutic treatment includes inhalations, ultraviolet irradiation, electrophoresis, cupping and vibration massage, exercise therapy.

Bronchitis in children

Bronchitis in children is an inflammation of the mucous membrane of the bronchial tree of various etiologies. For every 1000 children, there are 100-200 cases of bronchitis annually. Acute bronchitis accounts for 50% of all respiratory tract lesions in young children. The disease develops especially often in children in the first 3 years of life; It is most severe in infants. Due to the variety of causally significant factors, bronchitis in children is the subject of study in pediatrics, pediatric pulmonology and allergology-immunology.

Causes of bronchitis in children

In most cases, bronchitis in a child develops following viral diseases - influenza, parainfluenza, rhinovirus, adenovirus, respiratory syncytial infection. Somewhat less frequently, bronchitis in children is caused by bacterial pathogens (streptococcus, pneumococcus, Haemophilus influenzae, Moraxella, Pseudomonas aeruginosa and Escherichia coli, Klebsiella), fungi of the genus Aspergillus and Candida, intracellular infection (chlamydia, mycoplasma, cytomegalovirus). Bronchitis in children often accompanies measles, diphtheria, and whooping cough.

Bronchitis of allergic etiology occurs in children sensitized by inhalation allergens entering the bronchial tree with inhaled air: house dust, household chemicals, plant pollen, etc. In some cases, bronchitis in children is associated with irritation of the bronchial mucosa by chemical or physical factors: polluted air, tobacco smoke, gasoline vapors, etc.

There is a predisposition to bronchitis in children with a burdened perinatal background (birth injuries, prematurity, malnutrition, etc.), constitutional anomalies (lymphatic-hypoplastic and exudative-catarrhal diathesis), congenital defects of the respiratory system, frequent respiratory diseases (rhinitis, laryngitis, pharyngitis, tracheitis), impaired nasal breathing (adenoids, deviated nasal septum), chronic purulent infection (sinusitis, chronic tonsillitis).

In epidemiological terms, the cold season (mainly the autumn-winter period), seasonal outbreaks of acute respiratory viral infections and influenza, the presence of children in children's groups, and unfavorable social and living conditions are of greatest importance.

Pathogenesis of bronchitis in children

The specifics of the development of bronchitis in children are inextricably linked with the anatomical and physiological characteristics of the respiratory tract in childhood: abundant blood supply to the mucous membrane, looseness of the submucosal structures. These features contribute to the rapid spread of the exudative-proliferative reaction from the upper respiratory tract into the depths of the respiratory tract.

Viral and bacterial toxins suppress the motor activity of the ciliated epithelium. As a result of infiltration and swelling of the mucous membrane, as well as increased secretion of viscous mucus, the “flickering” of the cilia slows down even more - thereby turning off the main mechanism of self-cleaning of the bronchi. This leads to a sharp decrease in the drainage function of the bronchi and difficulty in the outflow of mucus from the lower parts of the respiratory tract. Against this background, conditions are created for further reproduction and spread of infection, obstruction of smaller caliber bronchi with secretions.

Thus, the characteristics of bronchitis in children are the significant extent and depth of damage to the bronchial wall and the severity of the inflammatory reaction.

Classification of bronchitis in children

Based on their origin, primary and secondary bronchitis in children is distinguished. Primary bronchitis initially begins in the bronchi and affects only the bronchial tree. Secondary bronchitis in children is a continuation or complication of another pathology of the respiratory tract.

The course of bronchitis in children can be acute, chronic and recurrent. Taking into account the extent of inflammation, limited bronchitis (inflammation of the bronchi within one segment or lobe of the lung), widespread bronchitis (inflammation of the bronchi of two or more lobes) and diffuse bronchitis in children (bilateral inflammation of the bronchi) are distinguished.

Depending on the nature of the inflammatory reaction, bronchitis in children can be catarrhal, purulent, fibrinous, hemorrhagic, ulcerative, necrotic and mixed. In children, catarrhal, catarrhal-purulent and purulent bronchitis is more common. A special place among respiratory tract lesions is occupied by bronchiolitis in children (including obliterative) - bilateral inflammation of the terminal parts of the bronchial tree.

According to etiology, viral, bacterial, viral-bacterial, fungal, irritative and allergic bronchitis in children are distinguished. Based on the presence of obstructive components, non-obstructive and obstructive bronchitis in children is distinguished.

Symptoms of bronchitis in children

Development acute bronchitis In children, in most cases, signs of a viral infection precede: sore throat, coughing, hoarseness, runny nose, conjunctivitis. A cough soon appears: obsessive and dry at the beginning of the disease, by 5-7 days it becomes softer, moist and productive with the separation of mucous or mucopurulent sputum. In case of acute bronchitis, a child experiences an increase in body temperature up to 38-38.5 ° C (lasting from 2-3 to 8-10 days depending on the etiology), sweating, malaise, chest pain when coughing, in young children - shortness of breath. The course of acute bronchitis in children is usually favorable; the disease ends with recovery on average after 10-14 days. In some cases, acute bronchitis in children can be complicated by bronchopneumonia. With recurrent bronchitis in children, exacerbations occur 3-4 times a year.

Acute bronchiolitis develops mainly in children of the first year of life. The course of bronchiolitis is characterized by fever, severe general condition of the child, intoxication, severe signs of respiratory failure (tachypnea, expiratory shortness of breath, cyanosis of the nasolabial triangle, acrocyanosis). Complications of bronchiolitis in children may include apnea and asphyxia.

Obstructive bronchitis in children it usually manifests itself in the 2-3rd year of life. The leading sign of the disease is bronchial obstruction, which is expressed by paroxysmal cough, noisy wheezing, prolonged exhalation, and distant wheezing. Body temperature may be normal or low-grade. The general condition of children usually remains satisfactory. Tachypnea, shortness of breath, and participation of auxiliary muscles in breathing are less pronounced than with bronchiolitis. Severe obstructive bronchitis in children can lead to respiratory failure and the development of acute cor pulmonale.

Allergic bronchitis in children it usually has a recurrent course. During periods of exacerbation, sweating, weakness, and cough with mucous sputum are noted. Body temperature remains normal. Allergic bronchitis in children is often combined with allergic conjunctivitis, rhinitis, atopic dermatitis and can develop into asthmatic bronchitis or bronchial asthma.

Chronical bronchitis in children it is characterized by exacerbations of the inflammatory process 2-3 times a year, occurring sequentially for at least two years in a row. Cough is the most constant sign of chronic bronchitis in children: during remission it is dry, during exacerbations it is wet. Sputum is coughed up with difficulty and in small quantities; has a mucopurulent or purulent character. There is a low and variable fever. A chronic purulent-inflammatory process in the bronchi can be accompanied by the development of deforming bronchitis and bronchiectasis in children.

Diagnosis of bronchitis in children

The primary diagnosis of bronchitis in children is carried out by a pediatrician, and further diagnosis is carried out by a pediatric pulmonologist and a pediatric allergist-immunologist. When establishing the form of bronchitis in children, clinical data (nature of cough and sputum, frequency and duration of exacerbations, course characteristics, etc.), auscultatory data, results of laboratory and instrumental studies are taken into account.

The auscultatory picture of bronchitis in children is characterized by scattered dry (wheezing in case of bronchial obstruction) and moist wheezing of various sizes,

In a general blood test, at the height of the severity of the inflammatory process, neutrophilic leukocytosis, lymphocytosis, and an increase in ESR are detected. Allergic bronchitis in children is characterized by eosinophilia. A blood gas study is indicated for bronchiolitis to determine the degree of hypoxemia. Of particular importance in the diagnosis of bronchitis in children is sputum analysis: microscopic examination, sputum culture, AFB examination, PCR analysis. If the child is unable to independently cough up bronchial secretions, bronchoscopy with sputum collection is performed.

X-ray of the lungs with bronchitis in children reveals an increase in the pulmonary pattern, especially in the hilar zones. When performing an FVD, a child may experience moderate obstructive disorders. During the period of exacerbation of chronic bronchitis in children, bronchoscopy reveals symptoms of widespread catarrhal or catarrhal-purulent endobronchitis. To exclude bronchiectasis, bronchography is performed.

Differential diagnosis of bronchitis in children should also be carried out with pneumonia, bronchial foreign bodies, bronchial asthma, chronic aspiration of food, tuberculosis infection, cystic fibrosis, etc.

Treatment of bronchitis in children

In the acute period, children with bronchitis are prescribed bed rest, rest, plenty of fluids, and a nutritious diet.

Specific therapy is prescribed taking into account the etiology of bronchitis in children: it may include antiviral drugs (umifenovir hydrochloride, rimantadine, etc.), antibiotics (penicillins, cephalosporins, macrolides), and antifungals. An obligatory component of the treatment of bronchitis in children are mucolytics and expectorants that enhance the dilution of sputum and stimulate the activity of the ciliated epithelium of the bronchi (ambroxol, bromhexine, mucaltin, chest preparations). For a dry, hacking cough that debilitates a child, antitussive drugs (oxeladine, prenoxdiazine) are prescribed; for bronchial obstruction - aerosol bronchodilators. Antihistamines are indicated for children with allergic bronchitis; for bronchiolitis, inhalation of bronchodilators and corticosteroid drugs is performed.

Among the methods of physiotherapy for the treatment of bronchitis in children, medicinal, oil and alkaline inhalations, nebulizer therapy, ultraviolet irradiation, UHF and electrophoresis on the chest, microwave therapy and other procedures are used. Mustard plasters, cupping, and cupping massage are useful as a distraction therapy. If there are difficulties in sputum discharge, chest massage, vibration massage, postural drainage, sanitary bronchoscopy, and exercise therapy are prescribed.

Prevention of bronchitis in children

Prevention of bronchitis in children includes preventing viral infections, early use of antiviral drugs, avoiding contact with allergic factors, protecting the child from hypothermia, and hardening. Timely preventive vaccination of children against influenza and pneumococcal infection plays an important role.

Children with recurrent and chronic bronchitis need observation by a pediatrician and pediatric pulmonologist until exacerbations cease permanently within 2 years, and anti-relapse treatment in the autumn-winter period. Vaccine prophylaxis is contraindicated in children with allergic bronchitis; in other forms it is carried out a month after recovery.

Diagnosis of bronchitis in children

The diagnosis of bronchitis is established on the basis of its clinical picture (for example, the presence of obstructive syndrome) and in the absence of signs of damage to the lung tissue (no infiltrative or focal shadows on the radiograph). Often bronchitis is combined with pneumonia, in which case it is included in the diagnosis if it significantly complements the clinical picture of the disease. Unlike pneumonia, bronchitis with ARVI is always diffuse in nature and usually evenly affects the bronchi of both lungs. When local bronchitis changes predominate in any part of the lung, the appropriate definitions are used: basal bronchitis, unilateral bronchitis, bronchitis of the afferent bronchus, etc.

Acute bronchitis (simple). The main symptom is cough. At the beginning of the disease, the cough is dry, after 1-2 days it becomes wet and persists for 2 weeks. A longer cough is observed after previous tracheitis. If coughing attacks (especially in schoolchildren) continue for 4-6 weeks in the absence of other symptoms, you should think about another possible cause, for example, whooping cough, a foreign body in the bronchus, etc.

The sputum at the beginning of the disease is mucous in nature. At the 2nd week of illness, sputum may acquire a greenish color, due to the admixture of fibrin dehydration products, and not the addition of a secondary bacterial infection, and does not require the prescription of antibiotics.

In children of the first year of life, moderate shortness of breath may be observed (respiratory rate (RR) up to 50 per minute). Percussion sometimes reveals a boxy tone of the pulmonary sound, or there are no changes. On auscultation, diffuse dry and moist large- and medium-bubble rales are heard in the lungs, which can vary in quantity and character, but do not disappear with coughing. Some children experience wheezing when exhaling during sleep. Asymmetry of auscultatory changes should be alarming in terms of pneumonia.

Acute obstructive bronchitis. Bronchial obstruction syndrome is characterized by shortness of breath (respiratory rate up to 60-70 per minute), increased obsessive dry cough, the appearance of dry wheezing against the background of prolonged exhalation, not only during auscultation, but also audible at a distance. In half of the patients, moist, small, fine bubbling rales are also heard. The chest is distended. Temperature is moderate or absent. The child is noted to be restless.

Acute bronchiolitis usually develops as the first obstructive episode on the 3-4th day of acute respiratory viral infection, most often of PC-viral etiology. Bronchial obstruction is associated more with swelling of the mucous membrane, rather than with bronchoconstriction. Body temperature is usually normal or low-grade. Bronchiolitis is characterized by shortness of breath with retraction of the compliant areas of the chest (jugular fossa and intercostal spaces), flaring of the wings of the nose in small children, with respiratory rate up to 70-90 per minute, prolongation of exhalation (may be absent with tachypnea). The cough is dry, sometimes with a high-pitched, spasmodic sound. Perioral cyanosis is noted.

Acute obliterating bronchiolitis (post-infectious obliterating bronchiolitis). The disease is characterized by an extremely severe course and a vivid clinical picture. In the acute period, severe respiratory distress is observed against the background of persistent febrile temperature and cyanosis. There is noisy wheezing breathing. On auscultation, against the background of prolonged exhalation, an abundance of crepitating and fine-bubbly moist rales are heard. usually asymmetrical.

Mycoplasma bronchitis most often develops in school-age children. A distinctive feature of mycoplasma bronchitis is a high temperature reaction from the first days of the disease, conjunctivitis, usually without effusion, an obsessive cough, severe obstructive syndrome (exhalation prolongation, wheezing) in the absence of toxicosis and disturbances in general well-being. Catarrhal phenomena are slightly expressed.

With mycoplasma infection, small bronchi are affected, therefore, upon auscultation, crepitating rales and a mass of fine moist bubbles are heard, which are localized asymmetrically, which indicates uneven damage to the bronchi.

Mycoplasma bronchitis can occur atypically: without obstructive syndrome and shortness of breath. This etiology of bronchitis can be suspected by the presence of asymmetric wheezing and conjunctivitis.

Chlamydial bronchitis in children in the first months of life is caused by Chlamydia trachomatis. Infection occurs during childbirth from a mother who has a chlamydial infection of the genitals. Against the background of good health and normal temperature at the age of 2-4 months, a picture of bronchitis appears. A cough appears, which intensifies in the 2-4th week. In some cases, it becomes paroxysmal, as with whooping cough, but unlike the latter, it proceeds without recurrence. The symptoms of obstruction and toxicosis are mild, shortness of breath is moderate. Against the background of harsh breathing, fine- and medium-bubble moist rales are heard.

A characteristic medical history and the presence of conjunctivitis in the first month of life help in diagnosing chlamydial bronchitis.

In school-age children and adolescents, bronchitis is caused by Chlamydia pheumonia and is characterized by a violation of the general condition, high temperature, hoarseness of voice due to concomitant pharyngitis, and a sore throat may be observed. Obstructive syndrome often develops, which can contribute to the development of “late-onset bronchial asthma.”

In these cases, it is necessary to exclude pneumonia, which is confirmed by the absence of focal or infiltrative changes in the lungs on an x-ray.

Recurrent bronchitis. The main symptoms of recurrent bronchitis are a moderate increase in temperature for 2-3 days followed by the appearance of a cough, often wet, but unproductive. Then the cough becomes productive with the release of mucopurulent sputum. On auscultation, moist, varied rales of a widespread nature are heard. The disease can last from 1 to 4 weeks.

Recurrent obstructive bronchitis. In the first days of ARVI (2-4 days), bronchial obstruction syndrome occurs as acute obstructive bronchitis, but obstruction syndrome can persist for a long time with shortness of breath, first dry and then wet cough with the release of mucopurulent sputum. During auscultation, dry whistling and moist rales of various sizes are heard against the background of prolonged exhalation; wheezing can be heard at a distance.

Acute bronchitis (simple). Changes in clinical blood tests are often caused by a viral infection; moderate leukocytosis may be observed.

Acute obstructive bronchitis. The hemogram shows characteristic signs of a viral infection.

Acute bronchiolitis. The hemogram shows hypoxemia (pa O 2 decreases to 55-60 mm Hg) and hyperventilation (pa O 2 decreases).

Acute obliterating bronchiolitis (post-infectious obliterating bronchiolitis). A clinical blood test reveals moderate leukocytosis, neutrophil shift, and increased ESR. Hypoxemia and hypercapnia are also characteristic.

Mycoplasma bronchitis. There are usually no changes in the clinical blood test; sometimes the ESR increases with a normal leukocyte count. There are no reliable express methods for diagnostics. Specific IgM appears much later. An increase in antibody titer allows only a retrospective diagnosis to be made.

Chlamydial bronchitis. The hemogram shows leukocytosis, eosinophilia, and increased ESR. Chlamydial antibodies of the IgM class are detected in a titer of 1:8 or more, of the IgG class in a titer of 1:64 or higher, provided that they are lower in the mother than in the child.

Acute bronchitis (simple). X-ray changes in the lungs are usually presented in the form of an increase in the pulmonary pattern, more often in the hilar and inferomedial zones; sometimes there is an increase in the airiness of the lung tissue. There are no focal or infiltrative changes in the lungs.

Acute obstructive bronchitis. The X-ray shows swelling of the lung tissue.

Acute bronchiolitis. Radiographs reveal signs of swelling of the lung tissue, increased bronchovascular pattern, and, less commonly, small atelectasis, linear and focal shadows.

Acute bronchiolitis obliterans (post-infectious bronchiolitis obliterans). Radiographs reveal soft-shadowed merging lesions, often one-sided, without clear contours - “cotton lung” with an air bronchogram pattern. Respiratory failure increases during the first two weeks.

Mycoplasma bronchitis. The radiograph shows an increase in the pulmonary pattern, which coincides in localization with the localization of the maximum number of wheezes. Sometimes the shadow is so pronounced that it must be differentiated from an area of ​​inhomogeneous infiltration, typical of mycoplasma pneumonia.

Chlamydial bronchitis. On the radiograph in the case of chlamydial pneumonia, small focal changes are noted, and the clinical picture is dominated by severe shortness of breath.

Recurrent bronchitis. X-ray shows an increase in the bronchovascular pattern; in 10% of children there is increased transparency of the lung tissue.

Recurrent obstructive bronchitis. Radiographs reveal some swelling of the lung tissue, increased bronchovascular pattern, and the absence of foci of infiltration of the lung tissue (unlike pneumonia). Chronic lung diseases that also occur with obstruction should be excluded: cystic fibrosis, bronchiobliterans obliterans, congenital lung malformations, chronic aspiration of food, etc.

Acute bronchitis (simple). With repeated episodes of obstructive bronchitis, bronchial asthma should be excluded.

Acute obstructive bronchitis. In the case of a persistent course of obstructive bronchitis that is resistant to therapy, it is necessary to think about other possible causes, for example, malformations of the bronchi, a foreign body in the bronchi, habitual aspiration of food, a persistent inflammatory focus, etc.

Diagnostic criteria for chronic bronchitis

1) Persistent cough with sputum production for at least 3 months for 2 consecutive years or more (WHO criterion)

2) A typical auscultatory picture is rough, hard vesicular breathing with prolonged exhalation, scattered dry and moist rales.

3) Inflammatory changes in the bronchi according to bronchoscopy.

4) Exclusion of other diseases manifested by long-term productive cough (bronchiectasis, chronic lung abscess, tuberculosis, etc.)

5) Detection of airway obstruction (reversible and irreversible components) for the diagnosis of chronic obstructive bronchitis.

Diagnosis of exacerbation of chronic disease.

The following signs indicate an active inflammatory process in the bronchi:

Increased general weakness, the appearance of malaise, decreased overall performance

The appearance of severe sweating, especially at night (symptom of “wet pillow or sheet”)

Increased amount and purulence of sputum

Tachycardia at normal temperature

The appearance of biochemical signs of inflammation

A shift in the leukocyte formula to the left and an increase in ESR to moderate numbers

Differential diagnosis

CB should be differentiated from:

Acute and prolonged recurrent bronchitis

Expiratory collapse of the trachea and large bronchi

A protracted course of acute bronchitis is characterized by the existence of symptoms for more than 2 weeks; recurrent acute bronchitis is characterized by repeated but short-lived episodes of the disease 3 times a year or more. Thus, both variants of bronchitis do not meet the temporary criteria for chronic bronchitis.

Bronchiectasis is characterized by the appearance of a cough from early childhood, the discharge of a large amount of purulent sputum (“mouth full”), the connection of sputum production with a certain position of the body, thickening of the terminal phalanges in the form of “drumsticks” and nails in the form of “watch glasses”, local purulent endobronchitis with fiberoptic bronchoscopy, detection of bronchial dilations with bronchography.

Bronchial tuberculosis: characterized by tuberculosis intoxication - night sweats, anorexia, weakness, low-grade fever, in addition to hemoptysis, absence of purulence in sputum, the presence of Koch's bacilli in sputum and bronchial lavage water, tuberculosis family history, positive tuberculin tests, local endobronchitis with scars and fistulas with fibrobronchoscopy, positive effect of treatment with tuberculostatic drugs.

Bronchial cancer is more common in men who smoke and is characterized by a hacking cough mixed with blood, atypical cells in the sputum, and in advanced stages, chest pain, emaciation, and hemorrhagic exudative pleurisy. Bronchoscopy and biopsy play a decisive role in diagnosis.

Expiratory collapse of the trachea and large bronchi (tracheobronchial dyskinesia) is manifested by expiratory stenosis due to prolapse of the membranous part. The basis of clinical diagnosis is the analysis of cough: dry, paroxysmal, “trumpety,” “barking,” “rattling,” rarely bitonal, provoked by sudden bending, turning the head, forced breathing, laughter, cold, straining, physical activity, accompanied by dizziness, sometimes fainting, urinary incontinence, feeling of suffocation. During forced exhalation, a characteristic “notch” is visible on the spirogram. The diagnosis is confirmed by fiberoptic bronchoscopy. There are three degrees of stenosis: 1st degree - narrowing of the lumen of the trachea or large bronchi by 50%, 2nd degree - up to 75%, 3rd degree - more than 75% or complete closure of the lumen of the trachea.

Examples of formulation of the diagnosis of CB

Chronic catarrhal bronchitis with rare exacerbations, remission phase, DN-0

Chronic purulent bronchitis with frequent exacerbations, exacerbation phase, DN-1

· Chronic obstructive bronchitis, exacerbation phase, DN-2

Complications of chronic disease

All complications of chronic disease can be divided into two groups:

1- Directly caused by infection

d. Asthmatic (allergic) components

2- Caused by the evolution of bronchitis

b. Emphysema

c. Diffuse pneumosclerosis

d. Pulmonary failure

e. Pulmonary heart

The prognosis for complete recovery is unfavorable in chronic disease. The prognosis for obstructive bronchitis is worse, since pulmonary insufficiency quickly develops, and then cor pulmonale.

Treatment of chronic disease

Therapeutic measures for CB are determined by its clinical form, the characteristics of its course and should be aimed at reducing the rate of progression, reducing the frequency of exacerbations, increasing tolerance to physical activity, and improving the quality of life.

The main direction of treatment and prevention of the progression of chronic disease is the elimination of exposure to harmful impurities in the inhaled air (smoking, passive smoking is prohibited, rational employment is necessary). Treatment of CB consists of a set of measures that differ slightly in the period of exacerbation and remission. The period of exacerbation should be treated in a hospital, preferably in a specialized one (pulmonology). There is a treatment program for patients with chronic disease:

1- Bed rest is prescribed for high temperatures, the development of complications in the form of respiratory failure, the formation of cor pulmonale, etc.

2- Therapeutic nutrition - you need a balanced diet with a sufficient amount of vitamins and easily digestible proteins. Most often this is diet number 10

3- Drug treatment consists of 2 main directions: etiotropic and pathogenetic

Etiotropic treatment is aimed at eliminating the inflammatory process in the bronchi and includes antibiotic therapy. Antibacterial therapy is carried out during the period of exacerbation of purulent bronchitis for 7-10 days (if severe, up to 14 days). Criteria for the effectiveness of therapy during an exacerbation:

1- Positive clinical dynamics

2- Mucous nature of sputum

3- Reduction and disappearance of indicators of the active inflammatory process (normalization of ESR, leukocyte count, biochemical indicators of inflammation)

For CB, the following groups of antibacterial drugs can be used: antibiotics, nitrofurans, trichopolum, antiseptics (dioxidine), phytoncides. They can be administered in the form of aerosols, parenterally, endotracheally and endobronchially. The last two methods are the most effective, as they allow the drug to penetrate directly into the site of inflammation.

Antibiotics. They are prescribed taking into account the sensitivity of the flora sown from sputum or bronchial contents. If sensitivity cannot be determined, then treatment should be started with penicillin antibiotics (penicillin, ampicillin). In case of intolerance, antibiotics of the cephalosporin group (cephamezin, ceporin) are administered. In recent years, macrolides (summamed, rultd) have been prescribed. The main causative agents of exacerbation of catarrhal or purulent bronchitis are sensitive to them. The most preferred method of administration is intratracheal (filling with a laryngeal syringe or through a bronchoscope). With pronounced activity of the inflammatory process in the bronchi and its purulent nature, local (intratracheal) administration of antibiotics should be combined with parenteral administration. For simple (catarrhal) chronic disease, the main, and in most cases, the only method of treatment is the use of expectorants aimed at normalizing mucociliary clearance and preventing the addition of purulent inflammation.

Pathogenetic treatment is aimed at improving pulmonary ventilation, restoring bronchial patency, combating pulmonary hypertension and right ventricular failure.

Improvement of impaired pulmonary ventilation is achieved by eliminating the inflammatory process in the bronchi, as well as oxygen therapy and exercise therapy.

The main thing in CB therapy is the restoration of bronchial patency, which is achieved by improving their drainage and eliminating bronchospasm. To improve bronchial drainage, expectorants (hot, alkaline drinks, herbal decoctions, mucaltin, etc.), mucolytic drugs - acetylcysteine, bromhexine, ambroxol (lasolvan, lasolvan) are prescribed. Therapeutic bronchoscopy has been successfully used. To eliminate bronchospasm, bronchodilators are used. This type of therapy is the main (basic) one for obstructive CB. Anticholinergic drugs are used (ipratropium bromide-antrovent, domestic drug-troventol), a combination of atrovent and fenoterol (berodual) and methylxanthines (aminophylline and its derivatives). The most preferable and safest route for administering drugs is inhalation. Long-acting aminophylline preparations (teoprek, theodur, etc.) are effective, which are prescribed orally 2 times a day. If there is no effect of such therapy, small doses of corticosteroids are administered orally (10-15 mg of prednisolone per day) or inhalation of Ingacort 500 mg 2 times a day.

To combat pulmonary hypertension, long-term (several hours) oxygen inhalations are used; according to indications, calcium channel blockers (veropamil) and long-acting nitrates (nitrone) are used.

For prolonged exacerbations, immunocorrective drugs are used: T-activin or thymalin (100 mg subcutaneously for 3 days), orally immunocorrective drugs: ribomunil, bronchomunal, bronchovacone.

Physiotherapeutic procedures are prescribed: diathermy, electrophoresis, chest massage, breathing exercises.

Outside of an exacerbation of mild CB, foci of infection are eliminated, the body is hardened, and exercise therapy (breathing exercises) is performed. With moderate and severe CB, patients are forced to constantly receive supportive drug treatment. The same drugs are prescribed as during an exacerbation, only in smaller doses.

77. Recurrent bronchitis. Diagnostic criteria. Treatment tactics.

Recurrent bronchitis is bronchitis without pronounced clinical signs of bronchospasm that recurs at least 3-4 times a year for 2 years.

With recurrent bronchitis, unlike chronic pneumonia, there are no irreversible morphological changes in the lung tissue.

The prevalence of recurrent bronchitis is up to 7% per 1000 children.

Etiology: viral and viral-bacterial infection. “Critical period 4-7 years.” Viremia up to 2-3 months (!) plays a significant role in the etiopathogenesis of recurrent bronchitis. Thus, the persistence of the virus plays an important role in the etiopathogenesis of bronchitis.

In addition, genetic factors (blood type A(2)) and other factors of hereditary predisposition play an important role. The presence of constitutional anomalies - diathesis, concomitant pathology of the ENT organs, environmental factors, living conditions.

The clinical picture of recurrent bronchitis during the period of remission is almost similar to acute simple bronchitis. However, the course of the disease is protracted, sometimes up to 2-3 months.

A “reactive hemogram” is characteristic.

X-ray changes are nonspecific.

An endoscopic examination reveals signs of mild endobronchitis in 75%.

Bronchoscopy does not reveal any pathological changes in most children.

Cystic fibrosis and other hereditary pathologies.

Basic principles of treatment of recurrent bronchitis

During an exacerbation, it is treated as acute bronchitis.

Much attention is paid to the additional use of immunotropic drugs, antiviral agents, and aerosol therapy.

For bronchospasm, mucolytics, bronchodilators, and local corticosteroids (beclomet, becotide, etc.) are prescribed.

In the remission phase - dispensary observation and recovery in the clinic - local and climatic sanatoriums (stage 2).

Dispensary observation is stopped if there have been no exacerbations for 2 years.

78. Chronic bronchitis in children. Definition, etiology, pathogenesis, clinical picture, treatment.

Chronic bronchitis is a chronic common inflammatory disease of the bronchi, characterized by repeated exacerbations with restructuring of the secretory apparatus of the mucous membrane, the development of sclerotic changes in the deep layers of the bronchial tree of the bronchial tree.

Chronic bronchitis in childhood is divided into primary and secondary.

Primary chronic bronchitis, the definition of which is presented above, is rarely detected, because the main causes of primary chronic bronchitis, such as smoking, occupational hazards, are not as important in childhood as in adults. The most common diagnosis is secondary chronic bronchitis.

Secondary chronic bronchitis accompanies many chronic lung diseases. It is an integral part of many malformations of the lungs and bronchi, ciliary dyskinesia syndrome, chronic food aspiration syndrome, chronic bronchiolitis (with obliteration), and is detected in local pneumosclerosis (chronic pneumonia), as well as in cystic fibrosis and immunodeficiency states. Chronic bronchitis often develops in connection with a long-term tracheostomy, after lung surgery, as well as in newborn premature babies who have been on mechanical ventilation for a long time (bronchopulmonary dysplasia). Moreover, it is chronic bronchitis that is responsible for the main symptoms of the bronchopulmonary process in these diseases. Below are the diseases with which it is necessary to carry out a differential diagnosis of chronic bronchitis.

Differential diagnosis of chronic bronchitis:

Aspiration syndrome (bronchial foreign bodies, gastroesophageal reflux, swallowing disorders);

Chronic sinusitis, tonsillitis, rhinopharyngitis;

Congenital malformations of the trachea, bronchi, lungs;

Chronic pneumonia (local pneumosclerosis);

Tumors of the lungs, bronchi and mediastinum;

Ciliary dyskinesia syndrome;

Congenital anomalies of the aorta, pulmonary artery, congenital heart defects.

The clinical manifestations of chronic bronchitis depend on the underlying disease, which is the cause for the development of bronchitis. General symptoms: chronic cough with mucous or purulent sputum, constant wheezing of various sizes in the lungs. Bronchoscopic examination reveals chronic endobronchitis (local or widespread). Impaired respiratory function and x-ray changes also reflect changes in the lungs and depend on the underlying disease. It should be emphasized that the diagnosis of “chronic bronchitis” in childhood should serve as a reason for an in-depth examination of the patient in a specialized pulmonology hospital.

The principles of therapy depend on the cause of the disease. What is common is the use of antibacterial, mucolytic agents and the use of methods that improve the evacuation of sputum from the tracheobronchial tree.

Antibiotics are prescribed during an exacerbation of the disease, taking into account the pathogenic microflora isolated from sputum or bronchial aspirate. Most often it is created by Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis. The choice of drug depends on the sensitivity of the flora to antibiotics and the presence of signs of drug allergies in the patient. It is advisable to use semi-synthetic penicillins, cephalosporins of the II-III generation, macrolides. In children over 12 years of age - fluoroquinolones. Outside of an exacerbation, antibiotics are not prescribed.

For hypersecretion of mucus, antihistamines are indicated for courses of up to 2 weeks. For broncho-obstructive syndrome, salbutamol, ipratropium bromide/fenoterol, formoterol are prescribed through a nebulizer or in the form of a metered aerosol. It is possible to use theophylline preparations.

As mucolytic agents, salt-alkaline mixtures, saline solution, and also drugs such as carbocisteine ​​and ambroxol are used in inhalations. The course of inhalations is usually no more than 2 weeks, after which treatment continues with oral mucolytic therapy. After each inhalation, postural drainage and vibration massage of the chest should be performed. Acetylcysteine ​​and dornase alpha are effective for purulent endobronchitis.

Dornase alfa (PULMOZYM) is used in inhalation through a compressor inhaler at 1.25-2.5 mg 1-3 times a day. The drug can be prescribed to young children. The course of treatment is 2-3 weeks. For purulent endobronchitis with a persistent course, long-term use of the drug for several months or years is possible, for example in cystic fibrosis.

Therapeutic bronchoscopy with bronchial lavage with saline and mucolytic solutions (acetylcysteine, dornase alfa) is indicated when aerosol inhalations and postural drainage are ineffective. Therapeutic exercise and kinesitherapy are important components of the treatment of chronic bronchitis, aimed at stimulating sputum production, improving the respiratory function of the lungs, the state of the cardiovascular system, strengthening the respiratory and skeletal muscles, increasing the physical performance and emotional status of the child. Both classical methods of exercise therapy (positional drainage, vibration massage of the chest, breathing exercises, etc.) and special exercises (autogenic drainage, active breathing cycle, exercises using breathing equipment) are used.

Chronic bronchitis and its treatment in children

Chronical bronchitis- damage to the bronchial tree with restructuring of the secretory apparatus of the mucous membrane, the development of the inflammatory process and sclerotic changes in the deep layers of the bronchial wall, the manifestations of which are a productive cough, constant wheezing of various sizes in the lungs (at least 3 months) and the presence of exacerbations at least 2 times a year in for 2 years.

Chronic bronchitis in childhood is often secondary and develops with other chronic lung diseases: cystic fibrosis, bronchopulmonary dysplasia, congenital malformations of the bronchi and lungs. As an independent disease, primary chronic bronchitis is diagnosed more often in older children and adolescents.

Criteria for diagnosing chronic bronchitis:

history of long-term (for 2-3 months) exacerbations of bronchitis at least 2 times a year over the last 2 years; complaints of a constant (for 9-10 months) wet cough; data on active or passive smoking; family history of bronchopulmonary diseases; living in environmentally unfavorable areas.

Clinical:

Respiratory syndrome: productive cough with the release of mucous or mucopurulent sputum during an exacerbation; cough persists even with stable clinical well-being, and is easily provoked by changes in the physicochemical properties of air, psycho-emotional factors, physical activity, and infections;

Bronchopulmonary syndrome: persistent moist rales of various sizes in the lungs (usually diffuse) against the background of hard breathing;

Symptoms of chronic intoxication of varying degrees, with a periodic increase in body temperature to febrile levels during exacerbation and to subfebrile levels during remission.

Paraclinical:

X-ray of the chest organs: increased bronchovascular pattern and persistent deformation of a local or diffuse nature;

Bronchoscopy: a picture of catarrhal, catarrhal-purulent endobronchitis during remission and purulent during exacerbation of the process;

Bronchography: changes in the course of the bronchi, their lumen with expansion of varying degrees in the distal sections;

Complete blood count: slight leukocytosis with signs of inflammation or no changes during remission, neutrophilic leukocytosis and increased ESR during exacerbation;

Sputum examination: increased number of segmented neutrophils and eosinophils, decreased number of macrophages, decreased level of secretory IgA;

Biochemical blood test: dysproteinemia, hypogammaglobulinemia, positive C-reactive protein;

Broncho-alveolar lavage: increased content of alpha-1 antiproteases, decreased surfactant properties of surfactant, increased number of neutrophils, eosinophils, decreased number of alveolar macrophages, lysozyme, positive results of bacteriological examination with the isolation of predominantly gram-positive microflora;

External respiration function: mixed nature of disorders with a predominance of obstructive changes in pulmonary ventilation;

Differential diagnosis is carried out with bronchial asthma, pulmonary tuberculosis, between primary and secondary forms of chronic bronchitis.

Example of diagnosis: Cystic fibrosis, pulmonary form, chronic purulent bronchitis, cylindrical bronchiectasis in the lower right part, DN II, exacerbation period.

Treatment of chronic bronchitis.

I. Period of exacerbation of bronchitis:

1. For toxicosis of the 1st degree - general regimen, for toxicosis of the 2nd degree - bed rest.

2. Diet - high-protein food, fresh vegetables, fruits, juices. Limit carbohydrates and salt to half of your needs.

3. Antibacterial therapy depending on the isolated flora and its sensitivity.

4. Physiotherapy; UHF, microwave therapy, electrophoresis with solutions of platyphylline, copper sulfate, nicotinic acid, calcium chloride. Aerosol therapy: for catarrhal endobronchitis - ultrasonic inhalation of sodium chloride, sodium bicarbonate, potassium iodide. For purulent endobronchitis - trypsin, chymotrpsin, acetylcysteine, inhalation of antiseptics, antibiotics.

5. Bronchoscopic sanitation (for purulent endobronchitis) with solutions of furatsilin, polymyxin, acetyl cysteine.

6. Mucolytics and expectorants: bromhexine, ficimucin, lazolvan, 3% potassium iodide solution.

7. Elimination of broncho-obstructive syndrome: theophylline and teopec.

8. Vibration massage and postural drainage.

9. Therapeutic physical exercise, breathing exercises according to a gentle scheme.

11. Symptomatic therapy.

II. Remission period of chronic bronchitis

1. If there is a cough, use mucolytics and expectorants: bromhexine, mucaltin, terpinhydrate, pertussin.

2. Herbal medicine: collection for Chistyakova (elecampane root, calendula flowers - 30 g each, plantain leaf, thyme herb, coltsfoot leaf - 50 g each) - 1 tablespoon per 200 ml of water, take 50 ml 5 - b once a day for 4-6 weeks; chest collection No. 1, No. 2, No. 3.

3. Postural drainage and vibration massage.

4. Physical therapy (recovery period complex, then training complex).

5. Breathing exercises (according to Tokarev, according to Strelnikova), respiratory-sound gymnastics.

7. Physiotherapy: ultraviolet irradiation of the chest, inductothermy of the adrenal glands, electrophoresis with lidase.

9. Nonspecific immunomodulation: eleutherococcus extract, Chinese lemongrass tincture, aralia tincture, ginseng tincture, apilak.

10. Specific immunostimulation: ribomunil, IRS-19, imudon, bronchomunal, prodigiosan, bronchovacone.

11. Sanatorium treatment (climatotherapy).

12. Sanitation of chronic foci of infection of the ENT organs, treatment of intestinal dysbiosis.

13. Clinical examination: examination by a pediatrician - 2-4 times a year; otolaryngologist, dentist - 2 times a year; pediatric surgeon, pulmonologist - 2 times a year.

14. Surgical treatment is indicated for children with unilateral bronchiectasis who are resistant to conservative therapy.

Chronic obliterating bronchiolitis

Chronic obliterating bronchiolitis- a chronic inflammatory disease of the bronchi of viral or immunopathological origin, resulting from obliteration of bronchioles and arterioles of one or more parts of the lungs and leads to impaired pulmonary circulation and the development of emphysema.

Classification of chronic obliterating bronchiolitis:

1. Phases of the pathological process: exacerbation, remission.

2. Forms of bronchiolitis obliterans: total unilateral, focal unilateral, focal bilateral, partial.

Anamnestic: severe respiratory viral infections with obstructive syndrome.

Clinical: persistent small moist rales against the background of weakened breathing; recurrent broncho-obstructive syndrome. Paraclinical:

X-ray of the chest organs: unilateral weakening of the pulmonary pattern, reduction in the size of the pulmonary field;

Bronchography: non-filling of the bronchi with contrast at the generation level of the 5-6th order and below, a pronounced decrease in pulmonary perfusion in areas of the pathological process.

Treatment principles:

1. Correction of respiratory failure.

2. Antibacterial therapy.

3. Glucocorticoids in aerosols and parenterally (at the rate of 1-8 mg per 1 kg of body weight) according to indications.

b. Symptomatic therapy.

7. Postural drainage and gymnastics.

8. Bronchoscopic instillation according to indications.

Bronchitis is the most common disease of the human respiratory system. The morphopathological basis of bronchitis is inflammation of the walls of the bronchi.

The term chronic bronchitis is currently considered incomplete and is increasingly being replaced by another term that is more complete in the clinical sense - chronic obstructive bronchopneumopathy (COBP). This term defines the entire complex of pathological changes occurring in the lungs in the case of chronic inflammation of the bronchi.

The term bronchiolitis defines acute inflammation of the small caliber bronchi and bronchioles. Most often, bronchiolitis occurs in childhood and old age when the infectious process spreads from the bronchi to the bronchioles.

Methods for diagnosing acute bronchitis

In clinical and diagnostic terms, acute bronchitis is the mildest disease. Diagnosis of acute bronchitis does not require complex research methods and can be carried out on the basis of the patient’s complaints and objective data obtained during examination and clinical examination of the patient.

The clinical picture of acute bronchitis consists of a short prodromal period with a deterioration in the patient’s well-being, a sore throat, and discomfort in the chest. Next, a painful cough appears. In the first days of illness, the cough is dry. In the following days, the cough becomes productive (the release of mucous and purulent sputum is noted). Body temperature can rise to 38 o C. If small-caliber bronchi are involved in the process, the patient complains of difficulty breathing.

Clinical diagnosis of the patient reveals wheezing during auscultation. As a rule, acute bronchitis is preceded by an episode of hypothermia or fatigue.

The evolution of COPD is represented by alternating periods of exacerbation and remission. An exacerbation of the disease is observed in the cold season. This period is characterized by increased cough, increased body temperature, and deterioration of the patient’s general condition.

The development of the asthmatic form of COPD is characterized by the appearance of mild attacks of breathlessness.

During a clinical examination of the patient, attention is paid to the condition of the skin (cyanosis), fingers (fingers in the form of drumsticks - a sign of chronic lack of oxygen), and the shape of the chest (barrel-shaped chest with emphysema).

Disturbances of the pulmonary circulation can be expressed by the appearance of edema and enlarged liver. The appearance of these signs indicates an extremely unfavorable development of the disease.

Additional research methods for chronic obstructive bronchopneumopathy
Additional research methods used in the diagnosis of chronic obstructive bronchopneumopathy are aimed at clarifying the degree of dysfunction of the respiratory and cardiovascular systems that occur in this disease.

Determination of blood gas composition. In the initial stages of COPD, blood gas parameters (carbon dioxide and oxygen concentrations) remain within normal limits. There is only a decrease in the gradient of alveolo-arterial oxygen diffusion. At later stages of the disease, the gas composition of the blood undergoes significant changes: there is an increase in the concentration of carbon dioxide (hypercapnia) and a decrease in the concentration of oxygen (hypoxemia).

Spirometry– disturbances in the functioning of the respiratory system are observed in the later stages of COPD development. Thus, in particular, a decrease in FEV1 (forced expiratory volume in 1 second) and the ratio of FEV to vital lung volume are determined. Also characteristic is an increase in total lung capacity in parallel with an increase in residual volume (the volume of air remaining in the lungs after forced exhalation), which indicates air retention in the lungs characteristic of pulmonary emphysema.

Radiological diagnostics– reveals morphological changes in the lung tissue: emphysema (increased transparency of the lung fields), severity of the lung pattern in pneumosclerosis, expansion of the roots of the lungs. With the onset of pulmonary hypertension, dilation of the pulmonary artery and right ventricle is noted.

Electrocardiogram (ECG)– allows you to identify characteristic changes in the functioning of the heart - arrhythmias, deviation of the electrical axis of the heart to the right.

Bronchoscopy– is one of the most informative methods for diagnosing chronic bronchitis and chronic obstructive bronchopneumopathy. Bronchoscopy consists of introducing a fiber-optic imaging system into the bronchi, which allows one to examine the inner surface of the bronchi and collect materials for microbiological and histological examination. Bronchoscopy determines deformation of the walls of the bronchi, the presence of signs of chronic inflammation, the presence of purulent discharge in the lumen of the bronchi, bronchiectasis, etc.

Chronic bronchitis and the initial stages of chronic obstructive bronchopneumopathy should be differentiated from tuberculosis, lung tumors, chronic pneumonia, and bronchial asthma.

Bibliography:

• Ivanov E.M. Current issues of chronic bronchitis, Vladivostok, 2005
• Kovalenko V.L. Chronic bronchitis: Pathogenesis, diagnosis, clinical and anatomical characteristics, Novosibirsk, 1998
• Tsvetkova O.A. Acute and chronic bronchitis, pneumonia, M.: Russian doctor, 2002

Acute bronchitis (AB) is a disease that most often occurs acutely or subacutely and is associated with the introduction of a viral agent into the human body. The leading symptom of acute bronchitis is a cough that lasts no more than 2-3 weeks, and it is also accompanied by symptoms of the upper respiratory tract.

Diagnostic criteria for acute bronchitis

1. Acute cough that lasts up to 14 days;
2. Sputum production due to cough;
3. wheezing;
4. Shortness of breath and chest discomfort.

Pathogenetic moments

The pathogenesis of acute bronchitis is divided into several stages:

1. Acute stage. During the development of this stage, the pathogen actively invades the epithelial cells and mucous membrane of the respiratory tract. In this case, inflammation and nutrients that contribute to this activation are activated. At this stage, the disease occurs: fever, muscle pain, weakness, malaise;
2. Protracted stage. At this stage, hypersensitivity of the epithelium of the bronchial tree is formed. However, there are other ideas about the processes taking place at this time. They talk about disruption of the interaction between the adrenergic and cholinergic systems. Increased sensitivity of the respiratory tract lasts about 1-3 weeks and is manifested by a cough with dry wheezing.

The development of acute bronchitis is caused by the following pathophysiological reactions and mechanisms:

• Changing the ability to filter air when inhaling;
• Violation of physical protection factors;
• Changes in thermoregulation and air humidification mechanisms for the worse;
• Disturbances in the transport of sputum through the ciliated epithelium of the respiratory tract.

These changes lead to a violation of the viscosity of sputum and a decrease in the content of sulfates and lysozyme.

In addition to everything described above, the inflammatory process in the bronchi is significantly affected by vascular dysfunction, since it is through the vessels that pathogenic microorganisms enter the human body.

For example, the influenza virus has a tropism for the mucous membrane of the bronchial tree. He damages it in the process of his life. There are catarrhal, edematous and purulent forms of damage to the mucous membrane.

Epidemiological aspects

Most often, acute bronchitis develops during an increase in the incidence of the influenza virus, and is also hidden under the guise of some other acute respiratory disease. Peaks of incidence mainly occur at the end of December - beginning of March.

Predisposing and risk factors

These factors include the following:

• Allergic diseases;
• Immunodeficiency conditions and old age;
• Hypertrophy of the palatine and pharyngeal tonsils;
• Smoking and hypothermia;
• Childhood and exposure to air pollutants;
• Foci of chronic infection.

Causes of OB

The majority of all cases of bronchitis are viral. The main culprits of the disease are influenza A and B viruses, RS virus, parainfluenza, adenovirus, coronavirus, and rhinoviruses. Among the bacteria, it is worth highlighting Mycoplasma, Moraxella, Streptococcus, Hemophilus.
Classification

According to the etiology of OB, a distinction is made between viral and bacterial, toxic and burn.

Symptoms of acute bronchitis

Symptoms of OB are nonspecific, that is, the same clinical signs may occur in other diseases. The onset of OB begins with a slight sore throat, which is accompanied by chest discomfort and a dry cough. In this case, the body temperature rises to subfebrile or febrile levels. After a few days, the cough turns from dry to wet, that is, sputum begins to come out.

Diagnostics

First of all, it is necessary to exclude more severe diseases. An empirical or preliminary diagnosis is made based on the exclusion of other pathological conditions.

It is indicated when an acute cough occurs that lasts no more than three weeks. In this case, the patient should not have chronic diseases of the lungs and respiratory tract in general. Therefore, most often acute bronchitis is a diagnosis of exclusion.

Laboratory diagnostics

First, a general blood test is performed - no specific changes are observed in the results. There is leukocytosis with a shift of the formula to the left. In case of bacterial etiology, bacteriological and bacterioscopic examinations of sputum are carried out.

Instrumental and additional research methods

X-ray of the lungs is performed only if pneumonia or more severe forms of pulmonary pathology are suspected. If there is no need, other studies are not carried out.

Under what conditions can a cough occur?

It often appears when mucus from the nasopharynx flows down the back wall of the throat. In addition, a dry hacking cough appears when using medications from certain groups. The occurrence of a cough may indicate a constant reflux of gastric contents into the respiratory tract, and this is gastroesophageal reflux disease (GERD). Bronchial asthma is accompanied by a cough.

It is necessary to differentiate acute bronchitis from:

• sinusitis;
• bronchial asthma;
• GERD.

Causes of prolonged cough

Undoubtedly, these are diseases of the respiratory system, which we have already touched upon. However, there are other reasons:

1. Diseases of the heart and blood vessels - heart failure, taking certain medications (ACE inhibitors, beta blockers);
2. Connective tissue diseases – effects of medications, fibrosing alveolitis;
3. Smoking;
4. Occupational diseases – asbestosis, “farmer’s lung”, occupational bronchial asthma;
5. Allergic diseases - bronchial asthma, in which shortness of breath occurs and sputum production increases. If the sputum is purulent, it is necessary to carry out a differential diagnosis with vasculitis, eosinophilic pneumonia.

When should you consult a specialist?

If persisted during etiotropic treatment, it is necessary to consult with:

• a pulmonologist to rule out pneumonia;
• a gastroenterologist so as not to miss GERD;
• To exclude pathology of the ENT organs, you should contact an otolaryngologist.

Early differential diagnosis of acute bronchitis and pneumonia

This question is quite fundamental, since the prognosis and treatment of these diseases are fundamentally different from each other. For example, for pneumonia, treatment is usually antibacterial, and for OB, it is antiviral. Timely diagnosis will lead to successful treatment much faster than late diagnosis.

When purulent sputum appears, 1 out of 10 patients is diagnosed with pneumonia.