Criteria for the diagnosis of chronic bronchitis. Acute bronchitis

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

Any disease has its causes and symptoms. When diagnosing, the doctor must identify why the disease developed, and the symptoms will help establish a diagnosis. Therefore, consideration should be given to 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 with their "joint activity".

infections

These include viruses, bacteria, atypical microflora. And the largest number infectious cases of acute bronchitis occurs when exposed to viruses on the human body.

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

Among the viruses that provoke acute bronchitis, like independent disease or as a continuation of other respiratory ailments, it is possible to isolate the influenza virus, parainfluenza, adenovirus, RS virus, etc.

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

Pathogens of a non-infectious nature

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

Symptoms of acute bronchitis are known to almost everyone. When the disease occurs, the patient has 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 sputum discharge, which causes pain in chest.
  With the course of the disease, the cough is gradually moistened, sputum gradually begins to separate, which greatly alleviates the patient's condition.
• Sputum. With the addition of a bacterial infection, sputum acquires a greenish or yellowish tint. If acute bronchitis was caused by allergens, then the cough is paroxysmal in nature, and it often occurs at night.
• The temperature can fluctuate between 38-40 0C. With allergic bronchitis, it remains normal.
• Headache, muscle, joint pain.
• Lethargy, fatigue, general weakness.
• Increased sweating.
• Dyspnea. Occurs if the patency of the air flow decreases sharply, i.e., there is an obstruction.

History and examination of the patient

Any visit to the doctor begins with the collection of anamnesis from the words of the patient or those close to him who know him. Initially, the doctor listens to all the patient's complaints about the state of health, and then he himself begins to conduct a survey.

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

• In what conditions the patient grew up and lived. What are the living conditions of the patient this moment- dry or humid air in the house, whether there are mold formations in it, pets, whether there are any industries near the dwelling, etc.;
• what are the conditions of his work (humidity, temperature, dustiness, 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, from what age;
• what diseases the patient suffered during his life (for sure, everyone heard the question from the doctor: what did they hurt in childhood?);
• whether the patient currently has a chronic disease;
• what serious illnesses the parents suffer from;
• when the first signs of the disease appeared;
• how exactly the symptoms manifest themselves, in particular: how often the cough occurs, whether it is dry or wet, at what time of the day it is more intense, whether sputum is coughed up, whether the temperature rises or not, whether shortness of breath occurs, etc.

Based on the history, a doctor can make an initial diagnosis of acute bronchitis. Moreover, this disease has no special difficulties in diagnosing.

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

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

Listening to the patient is performed in order to identify and determine the types of noise in respiratory system. Auscultation is carried out 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 the bronchial tubes accumulate liquid slime. Under the flow of air, it foams, and bursting bubbles create characteristic bubble sounds.
• Dry rales in acute bronchitis are heard when a viscous fluid accumulates in the bronchi. thick mucus that fills the bronchial lumen. With accumulation of mucus 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 conducts a special type of auscultation - bronchophony. When listening with a phonendoscope, the patient must whisper the words in which the sounds “p” and “h” are present. With bronchial asthma, these sounds will be clearly audible, in other cases only a quiet rustle will be heard.

Laboratory tests

Among laboratory tests prescribed for acute bronchitis, one can note a blood test, microflora culture and urinalysis.

Blood analysis

A blood test for uncomplicated forms of acute bronchitis is not necessary, because 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 taking place in the body. Blood parameters 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 content 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 control the reaction of the kidneys to inflammatory processes in the body.

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

At high temperature body in the urine is usually detected increased protein content. The doctor may prescribe a urinalysis during acute bronchitis, then at the end of treatment and a control analysis after another 1 month.

Sputum analysis

In acute bronchitis, microscopic and bacteriological analysis sputum.

• Microscopic examination of sputum reveals dead cells epithelium, significant amount neutrophils and macrophages (cells from the group of leukocytes that fight against bacterial infection). With acute obstructive bronchitis in sputum, Kurshman's spirals may appear, which are spiral casts of small bronchi.
• Bacteriological analysis of sputum allows you to determine the type of bacteria that caused inflammation in the bronchi. This information helps the doctor decide 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 are talking about recurrent or obstructive bronchitis. The doctor resorts to the help of x-rays.

With ordinary uncomplicated bronchitis, there is no particular need for x-rays, since no special changes in the lungs and bronchi will be observed in the pictures.

An x-ray doctor prescribes in the following cases:

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

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

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

With a running situation, the doctor in the picture can detect such changes:

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

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

Diagnostics with instruments

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

Pneumotachography

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

The device records air volumes in the form of a curve. With the help of a pneumotachograph, violations can be detected respiratory function in acute bronchitis at a stage when neither the doctor nor the patient is aware of this.

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

Peakflowmetry

This study in acute bronchitis allows you to determine the speed of forced exhalation.

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

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

Peak meter studies allow the doctor to choose the right therapy for the treatment of obstructive acute bronchitis.

The peak flow meter is so simple to use that it can be used to conduct research with it at home on your own.

Spirometry, or spirography

This study gives comprehensive assessment breathing states. With spirometry, you can examine the following indicators for acute bronchitis:

• indicator of calm breathing;
• expiration rate;
• maximum lung capacity;
• respiratory rates after the use of bronchodilators.

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

During the study, a special device spirometer records the volume 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 against the special mouthpiece of the device.

Then do the same, but the exhalation must be done with effort. Thus, fixed calm breathing and exhalation power.

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

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

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

Laboratory data

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

BAC: increase in blood levels of sialic acids, fibrin, seromucoid, alpha2- and gamma globulin (rarely) during exacerbation of purulent bronchitis, the appearance of PSA.

OA of sputum: mucous sputum of light color, purulent sputum yellowish-greenish color, mucopurulent plugs can be detected, with obstructive bronchitis - casts of the bronchi; microscopic examination of purulent sputum - a lot of neutrophils. In chronic obstructive bronchitis, alkaline reaction morning sputum and neutral or acidic - daily. Rheological properties of sputum: purulent sputum - increased viscosity, reduced elasticity; mucous sputum - reduced viscosity, increased elasticity. With obstructive bronchitis, Kurschmann spirals can be determined.

IS: a decrease in the number of T-lymphocytes in the blood, including T-suppressors, is possible.

Instrumental Research

Bronchoscopy: signs of inflammation of the bronchial mucosa (I degree - the mucous membrane of the bronchi 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, purple-bluish, bleeds easily, there is a purulent secret on it).

Bronchography: bronchi of the IV, V, VI, VII order are cylindrically dilated, their diameter does not decrease towards the periphery, as is normal, small lateral branches are obliterated, the distal ends of the bronchi are blindly cut off ("amputated"). In a number of patients, dilated bronchi in some areas are narrowed, their contours are changed (configuration of "beads" or "rosary"), the inner contour of the bronchi is notched, the architectonics of the bronchial tree is disturbed.

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

Spirography: changes in the spirogram depend on the severity of disturbances in the function of external respiration, VC usually decreases, an increase in MOD is possible, and a decrease in the oxygen utilization coefficient. Spirographic manifestations bronchial obstruction- decrease in forced vital capacity of the lungs and maximum ventilation of the lungs.

With pneumotachometry - a decrease in the maximum expiratory flow rate.

Survey program

OA of blood, urine.

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

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

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

Radiography of the lungs.

Bronchoscopy and bronchography.

Spirography, pneumotachometry.

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

The principles of complex treatment of chronic bronchitis include the impact 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 conduction.

Therapy chronic bronchitis should depend on the form, severity of the course and the individual characteristics of the patient (comorbidities, drug tolerance, etc.). If chronic simple bronchitis requires treatment, as a rule, during periods of exacerbations (antibacterial, mucolytic, if necessary, bronchodilator drugs), then with COB, and even more so with severe COB, constant complex therapy is necessary (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: reduction of mucociliary imbalance and bronchial obstruction, fight against nonspecific and microbial inflammation, immunomodulatory therapy, correction of respiratory failure and pulmonary hypertension.

To give up smoking

Quitting smoking is extremely important. Smoking cessation improves the prognosis of the disease, reduces the rate of fall in FEV 1 and, therefore, should take the first place in the tactics of managing patients with chronic bronchitis. In order to achieve the maximum effect, it is necessary not only to motivate the patient, but also to train 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 extremely important. Smoking cessation improves the prognosis of the disease, reduces the rate of fall in FEV, and therefore should take the first place in the tactics of managing patients with chronic bronchitis. In order to achieve the maximum effect, it is necessary not only to motivate the patient, but also to train 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 dependence, it is possible to prescribe chewing gums or skin applicators containing nicotine, which helps to 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 depends on the severity of the disease.

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

In some cases, patients with COB are indicated for bronchodilator therapy using nebulizers. Typically, this method of drug delivery is used in severe bronchial obstruction with a pronounced decrease in functional respiratory reserves, 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 into the lungs is guaranteed. Airways.

b 2 -Agonists

The action of b 2 -agonists in chronic bronchitis and COPD is multifaceted. Although we should not expect such significant bronchodilation in these diseases 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 the cilia of the epithelium, which leads to an improvement in the function of the mucociliary escalator.

The most widespread of b 2 -agonists in Russia are salbutamol and fenoterol, much less frequently used terbutaline. These drugs have the same duration of action (4-6 hours) and are available both as metered-dose inhalers and solutions for spraying through a nebulizer (Table 2).

Anticholinergic drugs

Despite the lower bronchodilating activity compared to b 2 -agonists, it is anticholinergics ( ipratropium bromide and tiotropium bromide) are recognized as first-line drugs in the treatment of chronic bronchitis and COPD.

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

Their appointment 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 the 1st and 3rd types, located in the large bronchi, eliminates the increased afferent stimulation and leads to a decrease in bronchoconstriction and the effects of tracheobronchial dyskinesia. In addition, the secretory activity of the bronchial glands decreases, which reduces the formation of sputum without violating its viscous properties.

Anticholinergics have several advantages over b 2 -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.

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

Theophylline

With the widespread use of anticholinergic drugs and b 2 -agonists, theophylline, despite its weak bronchodilating effect and a narrow therapeutic corridor, has not lost its significance in the treatment of COPD and COPD exacerbations.

In addition to the bronchodilating effect, theophylline appears to have a positive inotropic effect on the respiratory muscles, which is extremely important in COPD, when respiratory muscles poorly positioned. Theophylline also improves mucociliary clearance, stimulates the respiratory center, reducing the likelihood of hypoventilation and carbon dioxide retention. Despite the low bronchodilatory 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 risk of arrhythmic complications is high.

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

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

It should be remembered that the range of therapeutic concentration of theophylline in plasma is small and is 5-15 μg / 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

Violation of mucociliary clearance underlies the pathogenesis of chronic bronchitis and COPD, so the use of mucolytics and mucoregulators is recommended at all stages of the disease, despite conflicting results of studies of their effectiveness. Ambroxol, acetylcysteine ​​and carbocysteine ​​are currently the most preferred drugs that affect bronchial secretion, although the use of standardized phytotherapeutic agents is not excluded.

Ambroxol causes depolymerization of acid 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. Against the background of the use of ambroxol, the effectiveness of antibiotic therapy increases, since it contributes to a better penetration of antibiotics into the bronchial secretion and bronchial mucosa. Ambroxol can be administered orally, intravenously and with a nebulizer, average therapeutic dose- 30 mg 3 times a day.

At the heart of the action acetylcysteine lies its ability to destroy the 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 given in doses of 600–1200 mg/day as tablets or powders, or by nebulizer at a dose of 300–400 mg twice daily.

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

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 corticosteroids is estimated by an increase in FEV1 by more than 10% of the due values ​​or 200 ml. With a positive effect of corticosteroids, it is necessary to include them in the basic therapy in such patients.

The mandatory rule is the initial assignment inhaled corticosteroids and only if they are ineffective, transfer the patient to taking GCS tablets. You should be aware of 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 COB and COPD as an etiotropic therapy are prescribed empirically, since waiting for the results of a bacteriological study is an unacceptable waste of time. When choosing them, it is taken into account that, as a rule, pathogens in infectious exacerbation of bronchitis are Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae.

Summarizing the data of 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), etc., 2nd generation cephalosporins. When prescribing fluoroquinolones, the possibility of their insufficient anti-pneumococcal activity should be taken into account. Antibacterial therapy is recommended to be adjusted according to the results of sputum culture if empirically prescribed therapy is ineffective.

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

Therapy for respiratory failure

Respiratory failure is the inability 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 is important to divide the RP according to the rate of its development. On this basis, acute and chronic respiratory failure are distinguished. Acute respiratory failure (ARF) develops within minutes, hours, or days. Required attribute ODN are changes in the acid-base state - respiratory acidosis (pH< 7,35). hallmark chronic DN (CDN) is the inclusion of compensatory mechanisms, tk. it develops over many months and years. Due to this, the pH level is kept within the normal range or at values ​​close to normal, however, there is a change on the part of the buffer systems (primarily the bicarbonate buffer). The criterion for exacerbation of chronic renal failure (or acute respiratory failure on the background of chronic) is also a decrease in arterial blood pH.

The occurrence of respiratory failure or decompensation of chronic renal failure in patients with COPD and COPD implies mandatory hospitalization and therapy aimed at resolving or stabilizing the respiratory failure. Both the level of hypoxemia and the presence or absence of hypercapnia will be decisive in the tactics of treatment at the hospital stage (Fig. 1). Also in the hospital, it is necessary to resolve the issue of conducting long-term oxygen therapy on an outpatient basis using oxygen concentrators (duration - 16-18 hours a day, flow - from 2 to 5 liters per minute). The purpose of such therapy is to correct hypoxemia and maintain values ​​of p and O 2 at the level of 60 mm Hg. A further increase in the partial tension of oxygen will slightly affect 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 step in the treatment of patients with chronic bronchitis and COPD is outpatient treatment. Adequate basic therapy not only increases life expectancy, but also improves its quality (including working capacity). Hospitalization is necessary only in cases where the exacerbation cannot be effectively controlled on an outpatient basis, as well as in case of aggravation of manifestations of respiratory failure or decompensation cor pulmonale.

REHABILITATION AND EXPERTISEWORKABILITY

The possibilities of 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 treatment are widely used, primarily in climatic, 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 the countryside. Assessing the results of rehabilitation treatment of patients with chronic bronchitis on the basis of a specialized rehabilitation department organized under the direction of VNIIP in 1974, with a combination of drug therapy, physiotherapy, exercise therapy, we could state the achievement of clinical remission in the vast majority of patients

Regular 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 the possibilities of rehabilitation requires longer follow-up periods. As for the social rehabilitation of patients with chronic obstructive bronchitis, with steadily increasing respiratory failure, it seems to be 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 with obstructive disorders. With a forced exit volume in 1 s (FEV]) of more than 1.5 liters, the prognosis is favorable. Patients with an OOBi of about 0.5 liters die on average within 5 years. Hypoxemia and hypercapnia are other poor prognostic factors, but their effects are 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 required minimum research. The course of the disease. Pathogenetic bases of therapy.

Definition of COPD in the GOLD project is laconic: “COPD is a disease state characterized by airflow limitation that is not fully reversible. This limitation is usually progressive and is associated with an abnormal reaction of the lungs to noxious particles and gases. The authors of this formulation stipulate that until the causative 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 "morbid condition", which 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 disease progression. Moreover, in the wording, instead of chronic inflammation, the concept of “pathological reaction” to the main risk factors appears. The advantage of this formulation is its conciseness, and the main disadvantage is the absence of the concept of “chronic inflammation” in it.

Because in medical practice 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 contingent of patients in different regions. As for the lack of knowledge of one or another pathogenetic mechanism, then these are already philosophical categories (the process of cognition is endless). The OP does not clearly define the concept of COPD, which is its disadvantage.

Today, the wording 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, it would be necessary to specify the range of diseases included in this concept, the stage of progression, when COPD turns from a collective concept into a nosological form. As for the details of pathogenetic mechanisms and biomarkers, it is premature to introduce them into the formulation today. And not only because these mechanisms and biomarkers are not yet fully understood, but also because they can only be assessed in the diagnostic process in a limited number of medical institutions.

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

Etiology and pathogenesis of COPD

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

COPD is an inflammatory disease, with macrophages and neutrophils, as well as CD8+ T-lymphocytes, taking part in the development of the inflammatory process. Of the mediators of inflammation, leukotriene B4 and interleukin 8 are characteristic of COPD. This is due to the difference between COPD and bronchial asthma, in which characteristic inflammatory cells are eosinophils and CD-4+ T-lymphocytes, and 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. COPD also releases a number of inflammatory mediators that have a systemic effect (for example, tumor necrosis factor alpha).

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

Thus, inflammatory changes lead to changes in the wall of the bronchial tree, which are caused by the pathological action 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 in the process of inflammation.

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

At the same time different patients different degrees of severity of various changes. 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 isolated, and with predominant signs of damage to the bronchial tree with the corresponding clinical manifestations - bronchial obstruction, cough, sputum - bronchitis type. These phenotypes are recommended to be included in the diagnosis. COPD is characterized by a systemic effect of the disease (unlike bronchial asthma). The action of inflammatory mediators, products of oxidative stress is not limited to lung tissue. First of all, the skeletal muscles are damaged, as a result of which the patient loses muscle mass and force, and myocytes are exposed to the expressed dystrophic changes. This leads to even more limitation physical activity in COPD patients due to low anaerobic threshold. Patients with COPD are more likely to have high risk fractures and decreased density bone tissue, which is due to the advanced age of patients, smoking and a reduced level of physical activity.

The results of a retrospective analysis of a database of patients with COPD who received inhaled glucocorticosteroids (IGCS) and/or bronchodilators suggest that the risk of fractures may be more due to the underlying respiratory disease than the use of ICS. Approximately 66% of COPD patients included in the TORCH study had osteoporosis or osteopenia prior to study entry (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 development is formed by changes in the right sections with the formation of a "cor pulmonale".

COPD classification

Stage	lung function
0 - risk of developing the disease	Normal performance
I - easy	FEV/FVC<70% от должного, ОФВ 1 >80% of due
II - medium	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 progression of the disease and the predominant level of damage to the bronchial tree. The rate of progression and severity of symptoms of COPD depends on the intensity of exposure to 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 go to the doctor are cough and shortness of breath, sometimes accompanied by wheezing with sputum. These symptoms are more pronounced in the morning.

The earliest symptom, appearing by the age of 40-50, is cough. By the same time, in the cold seasons, episodes of a respiratory infection begin to occur, which are not initially associated with one disease. Dyspnea felt on exertion occurs on average 10 years after the onset of cough. However, in some cases, the onset of the disease with shortness of breath is possible.

Sputum is allocated in a small amount (rarely more than 60 ml / day) in the morning, has a mucous character. Exacerbations of an infectious nature are manifested by the aggravation 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 frequent, is not the only cause of exacerbation. Along with this, exacerbations of the disease are possible, associated with an increased effect of exogenous damaging factors or with 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 exertion to severe respiratory failure [.

Diagnostics

Objective research

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

As the disease progresses, wheezing is added to the cough, most noticeable with accelerated exhalation. Often, auscultation reveals dry rales of different timbres. As bronchial obstruction and pulmonary emphysema progress, the anteroposterior size of the chest increases. With severe emphysema, the appearance of the patient changes, a barrel-shaped chest appears (an increase in the anteroposterior direction). In connection with the expansion of the chest and the upward displacement of the clavicles, the neck seems short and thickened, the supraclavicular fossae protrude (filled with expanded tops of the lungs). On percussion of the chest, a boxed percussion sound is noted. In cases of severe emphysema, absolute dullness of the heart may not be completely determined. The edges of the lungs are displaced downward, 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 with its normal size. The mobility of the diaphragm is limited, the auscultatory picture changes: weakened breathing appears, the severity of wheezing decreases, exhalation lengthens.

The sensitivity of objective methods to determine the severity of COPD is low. Among the classic signs are 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 a 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. Patients with moderate disease may have dry rales or slightly weakened breathing (a sign of emphysema) on examination of the respiratory organs, but it may not be possible to determine the severity of airway obstruction from these symptoms.

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

As the disease progresses, first transient, and then permanent hypoxia and hypercapnia are observed, blood viscosity often increases, which is due to secondary polycythemia. A decompensated cor pulmonale develops. For patients with severe COPD, aggravation of dyspnea, diffuse cyanosis, and weight loss are characteristic.

Allocate two clinical forms of the disease- emphysematous and bronchitis. emphysematous form(type) COPD is associated predominantly with panacinar emphysema. Such patients are figuratively called “pink puffers”, because in order to overcome the premature expiratory collapse of the bronchi, exhalation is made through lips folded into a tube and is accompanied by a kind of puffing. The clinical picture is dominated by dyspnea 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 oxygenation of the blood 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 moderately pronounced, because. the reduction of the arterial bed, caused by atrophy of the interalveolar septa, does not reach significant values. Cor pulmonale is compensated for a long time. Thus, the emphysematous type of COPD is characterized by the predominant development of respiratory failure.

Bronchitis form(type) observed in centriacinar emphysema. Constant hypersecretion causes an increase in inspiratory and expiratory resistance, which contributes to a significant violation of ventilation. In turn, a sharp decrease in ventilation leads to a significant decrease in the O 2 content in the alveoli, followed by a violation of perfusion-diffusion relationships and blood shunting. This determines the characteristic blue tint of diffuse cyanosis in patients of this category. Such patients are obese, the clinical picture is dominated by cough with copious sputum. 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 selection of two forms has prognostic value. Thus, in the later stages of the emphysematous type, decompensation of the cor pulmonale occurs in comparison with the bronchitis variant of COPD. In clinical conditions, patients with a mixed type of disease are more common.

In this way, COPD is characterized by a slow, gradual onset, the development and progression of the disease occurs under the action of risk factors. The first signs of COPD are cough and shortness of breath., other signs join later as the disease progresses.

History of smoking

A prerequisite for the diagnosis of COPD, according to WHO recommendations, is the calculation of the index of a smoking person. The calculation of the index of a smoking person is carried out as follows: the number of cigarettes smoked per day is multiplied by the number of months in a 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”.

The history of smoking is also recommended to be assessed in units of “packs/years”. Total packs/years = number of packs smoked per day x number of years smoked. At the same time, one conditional pack contains 20 cigarettes. In the event that this indicator reaches the value of 10 packs / years, then the patient is considered an “unconditional smoker”. If it exceeds 25 packs / years, then the patient can be classified as a “malicious smoker”. A patient is considered an “ex-smoker” if he has stopped smoking for 6 months or more. This must be taken into account when diagnosing COPD.

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

Physical examination data in COPD are not sufficient to establish a diagnosis of the disease, they only provide guidelines for further 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 determining the function of external respiration (RF), a blood test, a cytological examination of sputum, an X-ray examination, a blood test and an ECG.

The study of the function of external respiration plays a leading role in the diagnosis of COPD and an objective assessment of the severity of the disease.

The function of external respiration

Be sure to determine the following volume and speed indicators: vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV 1), maximum expiratory velocities at various levels of FVC (MCV 75-25). The study of these indicators forms a functional diagnosis of COPD.

Functional disorders in COPD are manifested not only by a violation of bronchial patency, but also by a change in the structure of static volumes, a violation of the elastic properties, diffusion capacity of the lungs, and a decrease in physical performance. The definition of these types of disorders is optional.

Criteria for bronchial obstruction

Most important for the diagnosis of COPD is the determination of 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 for determining chronic airflow limitation, or chronic obstruction, is drop in FEV 1 up to a level of less than 80% of due values. Possessing a high degree of reproducibility with the correct performance of the respiratory maneuver, this parameter makes it possible to document the presence of obstruction in a patient and subsequently monitor the state of bronchial patency and its variability. Bronchial obstruction is considered chronic if it is recorded during repeated spirometry studies at least 3 times within one year, despite ongoing therapy.

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

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

Obstruction reversibility

To study the reversibility of obstruction are used tests with inhaled bronchodilators, and evaluate their impact on the performance of the flow-volume curve, mainly on the FEV 1 . Parameters MCV 75-25, indicating the level of forced expiratory flows at different levels of FVC, cannot be compared, because the FVC itself, in relation to which these flows are calculated, changes during 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 bronchodilatory response, it is recommended to use the FEV 1 parameter.

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

When examining a particular patient with COPD, it must be remembered that the reversibility of obstruction is a variable value and in the same patient it may be different during periods of exacerbation and remission.

Bronchodilation tests: choice of prescribed drug and dose

As bronchodilator drugs when testing in adults, it is recommended to prescribe:

b 2 -short-acting agonists(starting 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 bronchodilatory response after 15 minutes;

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

It is possible to conduct bronchodilatory tests with the appointment 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 allowable 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 micrograms of ipratropium bromide.

In order to avoid distorting the results and for the correct performance of the bronchodilation test, it is necessary to cancel the ongoing therapy in accordance with the pharmacokinetic properties of the drug being taken (short-acting b 2 -agonists - 6 hours before the start of the test, long-acting b 2 -agonists - 12 hours before, prolonged theophyllines - for 24 hours).

FEV increase 1 more than 15% of baseline is conditionally characterized as reversible obstruction. It should be emphasized that the normalization of FEV 1 in the 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 .

Bronchodilation response calculation method

Determining the reversibility of airflow obstruction is not technically difficult, but the interpretation of the results of this study remains a matter of debate. The simplest way is to measure the bronchodilatory response by the absolute increase in FEV 1 in ml:

FEV 1 abs (ml) \u003d FEV 1 dilat (ml) - FEV 1 ref (ml)

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

DEFV 1 due \u003d ((FEV 1 dilat. (ml) - FEV 1 outgoing (ml)) / FEV 1 due (ml)) x 100%,

and as a percentage of the maximum possible reversibility:

DOFE 1 possible \u003d ((FEV 1 dilat. (ml) - FEV 1 out. (ml)) / (FEV 1 due (ml) - FEV 1 out. (ml))) x 100%,

where FEV 1 ref. - initial parameter, FEV 1 dilat. - indicator after bronchodilator 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 investigated, 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 ways to calculate the bronchodilatory response, which quantifies the reversibility of obstruction, most official documents on this issue recommend a method for calculating the increase in relation to the proper FEV 1 values.

A reliable bronchodilatory response in its value should exceed the spontaneous variability, as well as the response to bronchodilators noted in healthy individuals. Therefore, the magnitude of the increase in FEV 1, equal to or greater than 15% of the due value, is recognized as a marker of a positive bronchodilatory response. Upon receipt of such an increase, bronchial obstruction is documented as reversible.

FEV monitoring 1

An important method to confirm the diagnosis of COPD is the monitoring of FEV 1 - a 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 carried out in different countries have shown that COPD patients are characterized by an annual decrease in FEV 1 more than 50 ml per year .

At home, to monitor the severity of obstruction, it is convenient to use the indicator peak expiratory flow (PEV) determined using an individual peak flowmeter. For COPD, peak flow is of relative importance. Nevertheless, the method allows to determine the daily variability in the severity of bronchial obstruction, which usually does not exceed 15% in COPD. The most valuable is the measurement of PSV indicators for the differentiation of COB and BA. In classical uncomplicated forms of AD, the diurnal variability of PSV usually exceeds 15%. Along with this, regular measurement of PSV is an easily accessible method for objectively assessing the effectiveness of bronchodilatory therapy with 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 lung hyperair. In order to detect changes in the ratios of static volumes that make up the structure of the total lung capacity in hyperair and emphysema, the use of two main methods is generally accepted: body plethysmography and measurement of lung volumes by dilution of inert gases (ECCS guidelines, 1993).

The main manifestation of hyperair lung is increase in total lung capacity determined by a body plethysmographic study or by the method of diluting gases.

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

Impaired diffusion capacity of the lungs

Measurement of lung diffusion capacity is performed at the second stage of lung function assessment after forced spirometry or pneumotachometry and determination of the structure of static volumes. The diffusion study is used to detect damage to the lung parenchyma due to emphysema.

With emphysema, the diffusion capacity of the lungs - DLCO and its relationship 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 lung capacity. Diffusion capacity is usually reduced in the presence of COPD symptoms, which means the attachment of emphysema.

Blood gases

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

The relationship between FEV 1 and blood gases is negligible. It is recommended to determine the gas composition of the blood in moderate and severe COPD. This is necessary to assess pulmonary gas exchange, clarify the nature of the progression of the disease and the severity of respiratory failure.

In some patients with COPD, hypoxemia and hypercapnia are exacerbated during sleep. These patients also have more pronounced pulmonary hypertension in the pulmonary artery. When COPD is combined with obstructive sleep apnea (prerecrest 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), however, it makes it possible to record only the level of oxygenation and does not allow monitoring changes in PaCO 2. If SaO 2 is less than 94%, then blood gas testing .

With the progression of COPD, an increase in pressure in the pulmonary artery is often observed. The severity of pulmonary hypertension has prognostic value. Among non-invasive methods for the control of pulmonary hypertension, the best results are obtained using Doppler echocardiography. In the normal practice of managing patients with COPD, the use of direct methods for measuring pressure in the pulmonary artery is not recommended.

Pulmonary function testing in COPD is done 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 for a timely study of respiratory function.

Due to its good reproducibility and ease of measurement, FEV 1 is now the accepted indicator for assessing the degree of obstruction in COPD. Based on this indicator, the severity of COPD is also determined. Mild severity - FEV 1 > 70% of due values, medium - 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 in assessing severity. In some cases, patients with COB require a functional study of the respiratory muscles. This is especially important in patients with weight loss, suspected steroid myopathy and hypercapnia, not proportional to FEV 1.

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 exertion. 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. There are various methods for objectifying and documenting the degree of reduction 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 traveled by the patient in a certain time (step test) is used as a criterion for physical tolerance.

When conducting six minute walk test the patient is tasked to walk as far as possible in 6 minutes, after which the distance traveled is recorded. If possible, oxygen saturation should be monitored during the test using pulse oximetry. There is data on the correlation of the distance traveled with indicators of pulmonary diffusion. Typically, a COPD patient with an FEV1 of about 1 liter or 40% of predicted walks about 400 m in 6 minutes. 6-minute test scores are very variable and depend largely on emotional state and motivation. This method is the simplest means for individual observation and monitoring of the course of the disease.

An exercise stress test 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 after the wording of the concept in GOLD is the 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 single out stage 0 - the risk stage, since this group can include not only patients with obstructive bronchitis. The second, highly controversial position is the expansion of the boundaries of moderate COPD to FEV 1 - 30% of the proper values. Thus, patients with FEV 1 equal to 79% and 30% fall into one category according to severity. I think that today we cannot accept this division according to the degree of severity. The classification in the FP corresponds to the classification proposed by the ERO, has been successfully implemented in our country and is convenient for use. Another thing is that it is quite convenient to place the classification according to the degree of severity immediately after 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 research sputum is advisable to carry out with uncontrolled progression of the infectious process and the selection of rational antibiotic therapy. It is an additional method of examination.

Blood test

Clinical Analysis: with a stable course of COPD, there are no significant changes in the content of peripheral blood leukocytes. During exacerbation, neutrophilic leukocytosis with a stab 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, a polycythemic syndrome is formed, which is characterized by a change 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 detect signs of immune deficiency.

X-ray methods of research

X-ray examination of the chest organs is a mandatory method of examination. X-ray of the lungs in direct and lateral projections in COPD reveals an increase in the transparency of the lung tissue, low standing of the dome of the diaphragm, limitation of its mobility, and an increase in the retrosternal space, which is typical for emphysema.

In mild COPD, significant x-ray changes may not be detected. In patients with moderate and severe COPD, one can detect: low standing of the dome of the diaphragm, flattening and limitation of its mobility; hyperair lung fields, bullae and an increase in 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.

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

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

Electrocardiography

Electrocardiography can detect in some patients signs of right heart hypertrophy, however, her ECG criteria change dramatically due to emphysema. ECG data in most cases allow us to exclude the cardiac genesis of respiratory symptoms.

Paradoxical pulse

Paradoxical pulse is defined as a decrease in the amplitude of the pulse wave on the radial artery during a shallow breath. If changes in amplitude are mild, a sphygmomanometer cuff should be used. Systolic pressure during inspiration decreases by more than 10 mm Hg. 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:

Inspection of the bronchial mucosa

Cultural examination of bronchial contents

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

Biopsy of the bronchial mucosa.

The quality of life

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

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 associated with his socio-economic status (at work and at home). To determine the quality of life, special questionnaires are used. The most famous for patients with COPD is the questionnaire of St. George's Hospital.

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 dyspnea, impaired bronchial patency during the study of respiratory function (decrease in FEV 1). An important component of the diagnosis is an indication of the progression of the disease. A prerequisite for diagnosis is the exclusion of other diseases that can lead to the appearance of similar symptoms.

Differential Diagnosis

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

Clinical examination reveals paroxysmal asthma symptoms, often in combination with extrapulmonary signs of allergy (rhinitis, conjunctivitis, skin manifestations, food allergy). Patients with COB are characterized by constant, little-changing symptoms. An important element of differential diagnosis is a decrease in FEV1 by 50 ml or more per year in patients with COB, which is not observed in BA. COB is characterized by low diurnal 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 in AD, an increase in the content of IgE is more common.

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 - COB and the approach of the final phase of the disease - COPD. The main differential diagnostic signs of BA and COB are shown in Table 4.

Formulation of the diagnosis

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

Chronic obstructive bronchitis. remission phase. Medium severity. Emphysema of the lungs. DN I.

Chronic obstructive bronchitis. Exacerbation phase. Medium severity. Emphysema of the lungs. DN II. Chronic cor pulmonale in the stage of compensation. HK I.

If it is impossible to clearly define the nosological affiliation of the disease (the predominance of irreversible obstruction), the diagnosis should be started with the term "chronic obstructive pulmonary disease" (COPD) with a further indication of the diseases that led to its development. Similar situations are more often observed in 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 the heading J.44.8. identified chronic obstructive bronchitis without further specification, which is part of the specified chronic obstructive pulmonary disease. Section J.44.9. identifies chronic obstructive pulmonary disease, unspecified, which is considered as the terminal phase of the disease, in which all the individual characteristics of individual diseases that led to COPD are already erased.

The objectives of COPD therapy are to prevent the progression of the disease, 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 COPD treatment are to reduce the impact of adverse environmental factors (including smoking cessation), patient education, the use of drugs 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- non-specific inflammation of the lower respiratory tract, occurring with damage to the bronchi of various calibers. Bronchitis in children is manifested by cough (dry or with sputum of a different nature), fever, chest pain, bronchial obstruction, wheezing. Bronchitis in children is diagnosed on the basis of an auscultatory picture, X-ray data of the lungs, complete blood count, sputum examination, respiratory function, bronchoscopy, bronchography. Pharmacotherapy of bronchitis in children is carried out with antibacterial drugs, mucolytics, antitussives; physiotherapy treatment includes inhalations, ultraviolet radiation, 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 1,000 children, there are 100-200 cases of bronchitis every year. Acute bronchitis accounts for 50% of all respiratory tract infections in young children. Especially often the disease develops in children of the first 3 years of life; 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 after a viral illness - influenza, parainfluenza, rhinovirus, adenovirus, respiratory syncytial infection. Somewhat less often, 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 the course of measles, diphtheria, whooping cough.

Bronchitis of allergic etiology occurs in children sensitized by inhaled 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.

Predisposition to bronchitis is present in children with a burdened perinatal background (birth trauma, prematurity, malnutrition, etc.), anomalies of the constitution (lymphatic-hypoplastic and exudative-catarrhal diathesis), congenital malformations 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 most important are the cold season (mainly the autumn-winter period), seasonal outbreaks of SARS and influenza, the stay of children in children's groups, and unfavorable social and living conditions.

The pathogenesis of bronchitis in children

The specificity of the development of bronchitis in children is inextricably linked with the anatomical and physiological characteristics of the respiratory tract in childhood: abundant blood supply to the mucosa, looseness of the submucosal structures. These features contribute to the rapid spread of the exudative-proliferative reaction from the upper respiratory tract to the depth of the respiratory tract.

Viral and bacterial toxins inhibit the motor activity of the ciliated epithelium. As a result of infiltration and edema of the mucosa, 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-purification of the bronchi. This leads to a sharp decrease in the drainage function of the bronchi and difficulty in the outflow of sputum from the lower respiratory tract. Against this background, conditions are created for further reproduction and spread of infection, obturation with a secret of bronchi of a smaller caliber.

Thus, the features of bronchitis in children are the significant length and depth of the lesion of the bronchial wall, the severity of the inflammatory reaction.

Classification of bronchitis in children

By origin, primary and secondary bronchitis in children are 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 isolated.

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 the lesions of the respiratory tract is occupied by bronchiolitis in children (including obliterating) - bilateral inflammation of the terminal sections of the bronchial tree.

According to etiology, viral, bacterial, viral-bacterial, fungal, irritant and allergic bronchitis in children are distinguished. By the presence of an obstructive component, non-obstructive and obstructive bronchitis in children are 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. Soon there is a cough: 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 acute bronchitis, a child has 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 in an average of 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, pronounced signs of respiratory failure (tachypnea, expiratory dyspnea, cyanosis of the nasolabial triangle, acrocyanosis). Complications of bronchiolitis in children can be apnea and asphyxia.

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

allergic bronchitis in children it usually has a relapsing course. During periods of exacerbation, sweating, weakness, cough with mucus sputum are noted. Body temperature remains normal. Allergic bronchitis in children is often combined with allergic conjunctivitis, rhinitis, atopic dermatitis and can turn 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 intermittent fever. Chronic purulent-inflammatory process in the bronchi may be accompanied by the development of deforming bronchitis and bronchiectasis in children.

Diagnosis of bronchitis in children

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

The auscultatory picture in bronchitis in children is characterized by scattered dry (with bronchial obstruction - whistling) and wet various rales,

In the general analysis of blood at the height of the severity of the inflammatory process, neutrophilic leukocytosis, lymphocytosis, and an increase in ESR are detected. Eosinophilia is characteristic of allergic bronchitis in children. The study of the gas composition of the blood 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 analysis, PCR analysis. If it is impossible for the child to independently cough up bronchial secretions, bronchoscopy with sputum sampling is performed.

X-ray of the lungs with bronchitis in children reveals an increase in the pulmonary pattern, especially in the root zones. During the FVD, the child may have moderate obstructive disorders. During the period of exacerbation of chronic bronchitis in children, bronchoscopy reveals the phenomena of widespread catarrhal or catarrhal-purulent endobronchitis. Bronchography is performed to rule out bronchiectasis.

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

Treatment of bronchitis in children

In the acute period, children with bronchitis are shown bed rest, rest, plenty of fluids, and a full fortified 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), antifungal agents. An obligatory component of the treatment of bronchitis in children are mucolytics and expectorant drugs that enhance sputum thinning and stimulate the activity of the ciliated epithelium of the bronchi (ambroxol, bromhexine, mukaltin, breast fees). With a dry cough that exhausts the child, antitussive drugs (oxeladin, prenoxdiazine) are prescribed; with bronchial obstruction - aerosol bronchodilators. Children with allergic bronchitis are shown antihistamines; with bronchiolitis, inhaled bronchodilators and corticosteroid drugs are performed.

Of the methods of physiotherapy for the treatment of bronchitis in children, medicinal, oil and alkaline inhalations, nebulizer therapy, UVI, UHF and electrophoresis on the chest, microwave therapy and other procedures are used. As a distraction therapy, the setting of mustard plasters and cans, cupping massage are useful. In case of difficulties in sputum discharge, chest massage, vibration massage, postural drainage, rehabilitation bronchoscopy, exercise therapy are prescribed.

Prevention of bronchitis in children

Prevention of bronchitis in children includes the prevention of viral infections, the early use of antiviral drugs, the exclusion of contact with allergic factors, the protection of the child from hypothermia, hardening. An important role is played by timely preventive vaccination of children against influenza and pneumococcal infection.

Children with recurrent and chronic bronchitis need to be observed by a pediatrician and a pediatric pulmonologist until a stable cessation of exacerbations for 2 years, anti-relapse treatment in the autumn-winter period. Vaccination 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 an 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 diagnosed with a significant addition to the clinical picture of the disease. Unlike pneumonia, bronchitis in ARVI is always diffuse in nature and usually evenly affects the bronchi of both lungs. With the predominance of local bronchitis changes 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, persists for 2 weeks. A longer cough is observed after a previous tracheitis. If coughing attacks (especially in schoolchildren) continue for 4-6 weeks in the absence of other symptoms, one should think about another possible cause, for example, whooping cough, a foreign body in the bronchi, etc.

Sputum at the beginning of the disease has a mucous character. 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 antibiotics.

In children of the first year of life, moderate shortness of breath can be observed (respiratory frequency (RR) up to 50 per minute). Percussion sometimes determines the box shade of the lung sound, or there are no changes. During auscultation in the lungs, diffuse dry and moist coarse and medium bubbling rales are heard, which can vary in number and character, but do not disappear with coughing. Some children develop wheezing when they sleep. The asymmetry of auscultatory changes should be alarming in terms of pneumonia.

Acute obstructive bronchitis. The syndrome of bronchial obstruction 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, non-abundant fine bubbling rales are also heard. The chest is swollen. The temperature is moderate or absent. The child's anxiety is noted.

Acute bronchiolitis usually develops as the first obstructive episode on the 3rd-4th day of ARVI, more often of PC-viral etiology. Bronchial obstruction is associated more with mucosal edema rather than bronchoconstriction. Body temperature is usually normal or subfebrile. Bronchiolitis is characterized by shortness of breath with retraction of compliant parts of the chest (jugular fossa and intercostal spaces), inflation of the wings of the nose in young children, with a respiratory rate of up to 70-90 per minute, lengthening of expiration (may be absent with tachypnea). The cough is dry, sometimes with a "high" spasmodic sound. There is perioral cyanosis.

Acute bronchiolitis obliterans (post-infectious bronchiolitis obliterans). The disease is characterized by an extremely severe course and a vivid clinical picture. In the acute period, severe respiratory disorders are observed against the background of persistent febrile temperature and cyanosis. Noisy "whistling" breathing is noted. During auscultation, against the background of an elongated exhalation, an abundance of crepitating and finely bubbling wet rales is heard. usually asymmetrical.

Mycoplasmal bronchitis often develops in children of school age. A distinctive feature of mycoplasmal bronchitis is a high temperature reaction from the first days of the disease, conjunctivitis, usually without effusion, an obsessive cough, a pronounced obstructive syndrome (expiratory lengthening, wheezing) in the absence of toxicosis and a violation of general well-being. The catarrhal phenomena are expressed slightly.

With mycoplasma infection, small bronchi are affected, therefore, during auscultation, crepitant rales and a mass of finely bubbling moist rales are heard, which are localized asymmetrically, which indicates an uneven lesion of the bronchi.

Mycoplasmal bronchitis can proceed atypically: without obstructive syndrome and shortness of breath. Suspect this etiology of bronchitis allows the presence of asymmetric wheezing and conjunctivitis.

Chlamydial bronchitis in children of 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 on the 2-4th week. In some cases, it becomes paroxysmal, as with whooping cough, but unlike the latter, it proceeds without reprisals. The phenomena of obstruction and toxicosis are little expressed, shortness of breath is moderate. Against the background of hard breathing, small and medium bubbling wet rales are heard.

In the diagnosis of chlamydial bronchitis, a characteristic history, the presence of conjunctivitis in the first month of life, helps.

In school-age children and adolescents, bronchitis is caused by Chlamydia pheumonia and is characterized by a violation of the general condition, high fever, hoarseness due to concomitant pharyngitis, sore throat may be observed. An obstructive syndrome often develops, which can contribute to the development of "late-onset 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 the radiograph.

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 rales of various sizes are heard. The disease can last from 1 to 4 weeks.

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

Acute bronchitis (simple). Changes in the clinical analysis of blood are more 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. In the hemogram - hypoxemia (ra O 2 decreases to 55-60 mm Hg. Art.) and hyperventilation (ra O 2 decreases).

Acute bronchiolitis obliterans (post-infectious bronchiolitis obliterans). In the clinical analysis of blood, moderate leukocytosis, a neutrophilic shift, and an increase in ESR are noted. Hypoxemia and hypercapnia are also characteristic.

Mycoplasmal bronchitis. In the clinical analysis of blood, there are usually no changes, sometimes the ESR increases with a normal content of leukocytes. In the diagnosis of reliable express methods do not exist. Specific IgM appears much later. An increase in antibody titer allows only a retrospective diagnosis.

Chlamydial bronchitis. The hemogram shows leukocytosis, eosinophilia, increased ESR. Chlamydia 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 and above, provided that they are lower in the mother than in the child.

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

Acute obstructive bronchitis. An x-ray shows swelling of the lung tissue.

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

Acute bronchiolitis obliterans (post-infectious bronchiolitis obliterans). On radiographs, soft-shadow merging foci are revealed, more often unilateral, without clear contours - a "cotton lung" with a picture of an air bronchogram. Respiratory failure increases the first two weeks.

Mycoplasmal bronchitis. On the radiograph, there is an increase in the pulmonary pattern, which coincides in localization with the localization of the maximum number of wheezing. Sometimes the shadow is so pronounced that it must be differentiated from the site of inhomogeneous infiltration typical of mycoplasmal pneumonia.

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

Recurrent bronchitis. Radiographically, there is an increase in the bronchovascular pattern, in 10% of children - increased transparency of the lung tissue.

Recurrent obstructive bronchitis. On radiographs, some swelling of the lung tissue, an increase in the bronchovascular pattern, and the absence of foci of infiltration of the lung tissue (unlike pneumonia) are revealed. Chronic lung diseases that also occur with obstruction should be excluded: cystic fibrosis, bronchiolitis obliterans, congenital malformations of the lungs, chronic food aspiration, 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 coarse 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) Identification of airway obstruction (reversible and irreversible components) for the diagnosis of chronic obstructive bronchitis.

Diagnosis of exacerbation of HB.

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

Strengthening of general weakness, the appearance of malaise, a decrease in overall performance

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

Increase in the amount and "purulence" of sputum

Tachycardia at normal temperature

The appearance of biochemical signs of inflammation

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

Differential Diagnosis

HB 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 episodes of the disease 3 times a year or more. Thus, both variants of bronchitis do not meet the interim criteria for chronic bronchitis.

Bronchectasis is characterized by the appearance of a cough from early childhood, the discharge of a large amount of purulent sputum (“full mouth”), the connection of sputum secretion 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 fibrobronchoscopy, detection of bronchial dilatations during bronchography.

Tuberculosis of the bronchi: tuberculosis intoxication is characteristic - night sweats, anorexia, weakness, subfebrile condition, in addition to hemoptysis, absence of purulence in the sputum, the presence of Koch's bacilli in the sputum and bronchial washings, a family history of tuberculosis, positive tuberculin tests, local endobronchitis with scars and fistulas fibrobronchoscopy, the 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, in advanced stages - chest pain, emaciation, hemorrhagic exudative pleurisy. A decisive role in the diagnosis is played by bronchoscopy and biopsy.

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, "trumpet", "barking", "rattling", rarely bitonic, provoked by sharp inclinations, turning the head, forced breathing, laughter, cold, straining, physical activity, accompanied by dizziness, sometimes fainting, urinary incontinence, feeling of suffocation. With forced exhalation, a characteristic “notch” is visible on the spirogram. The diagnosis is specified by fibrobronchoscopy. Three degrees of stenosis are distinguished: degree 1 - narrowing of the lumen of the trachea or large bronchi by 50%, degree 2 - up to 75%, degree 3 - more than 75% or complete overlap of the lumen of the trachea.

Examples of the 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 HB

All complications of HB can be divided into two groups:

1- Directly due to infection

d. Asthmatic (allergic) components

2- Evolutionary bronchitis

b. Emphysema

c. Diffuse pneumosclerosis

d. Pulmonary insufficiency

e. Pulmonary heart

The prognosis for complete recovery is poor in CB. The prognosis is worse for obstructive bronchitis, as pulmonary insufficiency quickly joins, and then cor pulmonale.

HB treatment

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 exercise tolerance, and improving the quality of life.

The main direction of treatment and prevention of progression of chronic bronchitis is to eliminate the effects of harmful impurities in the inhaled air (smoking is prohibited, passive smoking, rational employment is necessary). Treatment of CB consists of a set of measures that differ somewhat 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 CB:

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

2- Therapeutic nutrition - a balanced diet with enough vitamins, easily digestible proteins is necessary. Most often, this is diet number 10

3- Drug treatment consists of 2 main areas: 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 (with severe - up to 14 days). Criteria for the effectiveness of therapy during an exacerbation:

1- Positive clinical dynamics

2- Mucous character of sputum

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

With chronic bronchitis, the following groups of antibacterial drugs can be used: antibiotics, nitrofurans, trichopolum, antiseptics (dioxidin), 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 focus 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 with penicillin antibiotics (penicillin, ampicillin) should be started. In case of their intolerance, antibiotics of the cephalosporin group (cefamesin, tseporin) 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 route of administration is intratracheal (filling with a laryngeal syringe or through a bronchoscope). With a pronounced activity of the inflammatory process in the bronchi and its purulent nature, local (intratracheal) administration of antibiotics should be combined with parenteral administration. With simple (catarrhal) HB, the main, and in most cases the only method of treatment is the use of expectorant drugs 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.

Improving 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 the treatment of chronic bronchitis is the restoration of bronchial patency, which is achieved by improving their drainage and eliminating bronchospasm. To improve bronchial drainage, expectorants are prescribed (hot, alkaline drink, herbal decoctions, mukaltin, etc.), mucolytic drugs - acetylcysteine, bromhexine, ambroxol (lasolvan, lasolvan). Therapeutic bronchoscopy has been successfully used. In order to eliminate bronchospasm, bronchodilator drugs are used. This type of therapy is the main (basic) for obstructive CB. Anticholinergic drugs are used (ipratropium bromide-antrovent, domestic drug troventol), a combination of atrovent and fenoterol (berodual) and methylxanthines (eufillin and its derivatives). The most preferred and safest route of administration of medicinal substances. Effective preparations of prolonged aminophylline (teoprek, teodur, etc.), which are administered orally 2 r / day. In the absence of the 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 r / day.

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

With prolonged exacerbations, immunocorrective drugs are used: T-activin or thymalin (100 mg s / c for 3 days), orally immunocorrectors: ribomunil, bronchomunal, bronchovacson.

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

Outside of exacerbation in mild HB, the foci of infection are eliminated, the body is hardened, exercise therapy (respiratory gymnastics) is performed. With moderate and severe chronic bronchitis, patients are forced to constantly receive supportive drug treatment. The same drugs are prescribed as in the period of 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. "The critical period of 4-7 years". A significant role in the etiopathogenesis of recurrent bronchitis is played by viremia up to 2-3 months (!). Thus, the persistence of the virus plays an important role in the etiopathogenesis of r. bronchitis.

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

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

"Areactive hemogram" is characteristic.

X-ray changes are nonspecific.

Endoscopic examination reveals signs of mildly expressed endobronchitis in 75% of cases.

Bronchoscopy does not reveal any pathological changes in most children.

Cystic fibrosis and other hereditary pathology.

Basic principles of treatment of recurrent bronchitis

In the period of exacerbation, they are treated like acute bronchitis.

Much attention is paid to the additional use of immunotropic drugs, anti-oviral drugs, aerosol therapy.

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

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

Dispensary observation is stopped if there were no exacerbations within 2 years.

78. Chronic bronchitis in children. Definition, etiology, pathogenesis, clinic, treatment.

Chronic bronchitis is a chronic widespread inflammatory disease of the bronchi of the bronchi, characterized by repeated exacerbations with the 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 they are in adults. The most frequently detected 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), is detected in local pneumosclerosis (chronic pneumonia), as well as in cystic fibrosis and immunodeficiency states. Chronic bronchitis often develop in connection with a long-term tracheostomy, after operations on the lungs, as well as in newborn premature babies who have been on mechanical ventilation for a long time (bronchopulmonary dysplasia). At the same time, 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 differential diagnosis of chronic bronchitis.

Differential diagnosis of chronic bronchitis:

Aspiration syndrome (foreign bodies of the bronchi, gastroesophageal reflux, swallowing disorder);

Chronic sinusitis, tonsillitis, nasopharyngitis;

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 various rales in the lungs. Bronchoscopy reveals chronic endobronchitis (local or widespread). Pulmonary dysfunction and radiological 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 study of the patient in a specialized pulmonology hospital.

The principles of therapy depend on the cause of the disease. 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 secreted 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 allergy in the patient. It is advisable to use semi-synthetic penicillins, II-III generation cephalosporins, macrolides. In children over 12 years of age - fluoroquinolones. Outside of an exacerbation, antibiotics are not prescribed.

With hypersecretion of mucus, antihistamines are indicated in courses of up to 2 weeks. With broncho-obstructive syndrome, salbutamol, ipratropium bromide / fenoterol, formoterol are prescribed through a nebulizer or in the form of a metered aerosol. Perhaps the use of drugs theophylline.

Salt-alkaline mixtures, saline, as well as drugs such as carbocysteine, ambroxol are used as mucolytic agents in inhalations. The course of inhalation is usually no more than 2 weeks, after which the treatment is continued by taking the mucolytic inside. After each inhalation, postural drainage and vibromassage of the chest should be performed. With purulent endobronchitis, acetylcysteine ​​and dornase alfa are effective.

Dornase alfa (Pulmozyme) is used by inhalation through a compressor inhaler at a dose of 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. With purulent endobronchitis with a persistent course, prolonged use of the drug for several months or years is possible, for example, with cystic fibrosis.

Therapeutic bronchoscopy with bronchial lavage with saline and solutions of mucolytics (acetylcysteine, dornase alfa) is indicated for the ineffectiveness of aerosol inhalations and postural drainage. Physical therapy and kinesitherapy are important components of the treatment of chronic bronchitis, aimed at stimulating sputum discharge, 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, vibromassage of the chest, breathing exercises, etc.) and special exercises (autogenic drainage, active breathing cycle, exercises with the help of respiratory 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 an inflammatory process and sclerotic changes in the deep layers of the bronchial wall, the manifestations of which are a productive cough, constant various rales in the lungs (at least 3 months) and the presence of exacerbations at least 2 times a year in within 2 years.

Chronic bronchitis in childhood is more 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 the diagnosis of chronic bronchitis:

History of prolonged (within 2-3 months) exacerbations of bronchitis at least 2 times a year for the last 2 years; complaints of persistent (within 9-10 months) wet cough; data on active or passive smoking; burdened heredity for bronchopulmonary diseases; living in ecologically unfavorable areas.

Clinical:

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

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

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

Paraclinical:

X-ray of the chest organs: increased broncho-vascular pattern and persistent deformity 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 an 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 an increase in ESR during exacerbation;

Sputum examination: an increase in the number of segmented neutrophils and eosinophils, a decrease in the number of macrophages, a decrease in the level of secretory IgA;

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

Broncho-alveolar lavage: an increase in the content of alpha-1 antiproteases, a decrease in the surface-active properties of a surfactant, an increase in the number of neutrophils, eosinophils, a decrease in the number of alveolar macrophages, lysozyme, positive results of a bacteriological study with the isolation of predominantly gram-positive microflora;

The function of external respiration: a 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.

Diagnosis example: 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. With toxicosis of the 1st degree - a general regimen, with toxicosis of the 2nd degree - bed rest.

2. Diet - high-protein nutrition, fresh vegetables, fruits, juices. Limit carbs and salt to half of what you need.

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

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

5. Bronchoscopic sanitation (with purulent endobronchitis) with solutions of furacilin, 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 education, breathing exercises according to a sparing scheme.

11. Symptomatic therapy.

II. The period of remission of chronic bronchitis

1. In the presence of a cough - mucolytics and expectorants: bromhexine, mukaltin, terpinhydrate, pertussin.

2. Phytotherapy: collection for Chistyakova (elecampane root, calendula flowers - 30 g each, plantain leaf, thyme grass, 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. Therapeutic physical education (a complex of the recovery period, then a training complex).

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

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

9. Non-specific immunomodulation: Eleutherococcus extract, Schisandra chinensis tincture, Aralia tincture, ginseng tincture, apilac.

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

11. Sanatorium treatment (climatotherapy).

12. Sanitation of chronic foci of infection of the upper respiratory tract, treatment of intestinal dysbacteriosis.

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 with resistance to conservative therapy.,

Chronic obliterating bronchiolitis

Chronic obliterating bronchiolitis- a chronic inflammatory disease of the bronchi of viral or immunopathological origin, resulting from the obliteration of bronchioles and arterioles of one or more areas 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 obliterating bronchiolitis: total unilateral, focal unilateral, focal bilateral, partial.

History: 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: unilateral weakening of the lung pattern, a decrease in the size of the lung field;

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

Principles of treatment:

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 bronchial walls.

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

The term bronchiolitis defines an 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 patient 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, sore throat, discomfort behind the sternum. Further, the appearance of a painful cough is noted. In the first days of the illness, the cough is dry. In the following days, the cough becomes productive (there is a release of mucous and purulent sputum). The body temperature can rise to 38 o C. When the bronchi of small caliber are involved in the process, the patient complains of difficulty in breathing.

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

The evolution of COPD is represented by alternating periods of exacerbation and remission. Exacerbation of the disease is observed in the cold season. This period is characterized by increased cough, fever, worsening of the general condition of the patient.

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

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), the shape of the chest (barrel-shaped chest with emphysema).

Violations of the pulmonary circulation can be expressed by the appearance of edema, enlargement of the 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 occurring in this disease.

Determination of the gas composition of the blood. In the initial stages of COPD, blood gas parameters (carbon dioxide and oxygen concentrations) remain within the normal range. Only a decrease in the gradient of alveolo-arterial diffusion of oxygen is noted. In the later stages of the development 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- violation of the parameters of the functioning of the respiratory system is observed in the later stages of the development of COPD. So, in particular, a decrease in FEV1 (forced expiratory volume in 1 second) and the ratio of FEV to the vital volume of the lungs are determined. Also characteristic is an increase in total lung capacity in parallel with an increase in residual volume (the amount of air remaining in the lungs after a forced exhalation), which indicates air retention in the lungs characteristic of emphysema.

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

Electrocardiogram (ECG)- allows you to identify characteristic changes in the work 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 in the introduction of a fiber-optic imaging system into the bronchi, which allows you to examine the inner surface of the bronchi, to collect materials for microbiological and histological examination. When bronchoscopy is determined by the 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, bronchial asthma.

Bibliography:

• Ivanov E.M. Topical 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, while it is accompanied by symptoms of the upper respiratory tract.

Diagnostic criteria for acute bronchitis

1. Acute cough that lasts up to 14 days;
2. Separation of sputum on the background of coughing;
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 is actively introduced into the epithelial cells and the mucous membrane of the respiratory tract. In this case, the activation of inflammation and biogenic substances that contribute to this activation occurs. 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 a violation of the interaction between the adrenergic and cholinergic systems. Hypersensitivity of the respiratory tract lasts about 1-3 weeks and is manifested by a cough with dry wheezing.

The development of acute bronchitis is due to the following pathophysiological reactions and mechanisms:

• Change in the possibility of air filtration during inhalation;
• Violation of physical factors of protection;
• Change for the worse in thermoregulation and air humidification mechanisms;
• Violations of sputum transport with the help of 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 course of his life. Allocate catarrhal, edematous and purulent form of damage to the mucous membrane.

Epidemiological aspects

Most often, acute bronchitis develops during the rise in the incidence of the influenza virus, and also hides 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

Among these factors are the following:

• Allergic diseases;
• Immunodeficiency states 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

Most of all cases of bronchitis are viral. The main culprits of the disease are influenza A and B viruses, RS virus, parainfluenza, adenovirus, coronavirus, rhinoviruses. From the bacterium, it is worth highlighting mycoplasma, moraxella, streptococcus, hemophilus.
Classification

According to the etiology of OB, viral and bacterial, toxic and burns are distinguished.

Symptoms of acute bronchitis

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

Diagnostics

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

Exhibited when an acute cough occurs, which 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 in the results are observed. Here 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-rays of the lungs are performed only if pneumonia or more severe forms of pulmonary disease are suspected. If there is no need, other studies are not carried out.

Under what conditions can a cough occur?

Often appears when mucus from the nasopharynx drains down the back of the pharynx. In addition, a dry, hacking cough appears with the use of certain groups of drugs. The occurrence of a cough may indicate a constant reflux of gastric contents into the respiratory tract, and this is already gastroesophageal reflux disease (GERD). Bronchial asthma is accompanied by cough.

It is necessary to differentiate acute bronchitis from:

• sinusitis;
• bronchial asthma;
• GERD.

Causes of a long 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 - the influence of drugs, 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, sputum secretion increases. If the sputum is purulent, it is necessary to conduct a differential diagnosis with vasculitis, eosinophilic pneumonia.

When should you consult a specialist?

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

• pulmonologist to rule out pneumonia;
• gastroenterologist not to miss GERD;
• to exclude the pathology of the ENT organs, it is worth contacting an otorhinolaryngologist.

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 usually antiviral. A timely diagnosis of a particular diagnosis will lead to successful treatment much faster than a late diagnosis.

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