Department faculty and hospital therapy of medical faculty and department internal diseases of medical prophylactic faculty. BRONCHIAL ASTHMA

Bronchial asthma (BA) A chronic inflammatory disorder of the airways hyper-reactivity is accompanied by bronchial cough, wheezing and asthma, caused by the violation of bronchial patency varying degrees and duration.

EPIDEMIOLOGY From 4 to 10% of the world's population suffer from bronchial asthma, in children the prevalence of 10-15%. Predominant sex: children under 10 years old - male, adult - female

AETIOLOGY Risk Factors Heredity Contact with the allergens

TRIGGERS (provocateurs) Respiratory tract infections (especially viral respiratory infections),  -blockers reception, air pollutants (SO2, NO2, etc.), cold air, exercise, aspirin and other NSAIDs in patients with "aspirin" of bronchial asthma, psychological, environmental and occupational factors, the sharp smell, smoking (active and passive), concomitant diseases (gastro- esophageal reflux, sinusitis, hyperthyroidism, etc.)

PATHOGENESIS The pathogenesis of asthma is a chronic inflammation of. For asthma is characterized by a particular form of inflammation of the bronchi, leading to the formation of hyperreactivity (increased sensitivity to various nonspecific stimuli compared to normal), a leading role in inflammation owned by eosinophils, mast cells and lymphocytes. Inflamed bronchial hyperreactivity to respond to the impact of triggers spasm of airway smooth muscle, mucus hypersecretion, edema and inflammatory cell infiltration of the mucous lining of the airways leading to the development of an obstructive syndrome, clinically manifested in the form of an attack of wheezing or breathlessness.

PATHOMORPHOLOGY In the bronchi reveal inflammation, mucus plugs, mucosal edema, smooth muscle hyperplasia, thickening of the basement membrane, the signs of disorganization. When endobronchial biopsies in patients with asthma reveal desquamation of bronchial epithelium, eosinophilic infiltration of the mucosa. In the washing liquid exhibit a high content of epithelial, mast cells, eosinophils and high levels of lymphocytes.

CLINIC COMPLAINTS AND HISTORY Episodic attacks of expiratory dyspnea and / or cough The appearance of distant wheeze Feeling of heaviness in the chest OBJECTIVELY Expiratory dyspnea Swelling of the nose wings during inspiration Excitement, interrupted speech Participation of the auxiliary muscles in the act of breathing Forced attitude For percussion: the development of emphysema box note Auscultation: listen to the whistling and whirring dry wheezes and lengthening the exhalation phase

Diagnosis of BA Ask the patient or the parents are there: Repeated episodes of wheezing Painful cough or wheeze at night or early morning Cough or wheeze after exercise Coughing, wheezing or feeling of heaviness in the chest after exposure to allergens or pollutants Colds, which "falls in the chest" or lasts for more than 10 days Are asthma medications and if so, how often Examine, if possible, lung function, peak flow or spirometry conducted.

Determining the severity of BA StepsThe clinical picture before treatment Necessary medical treatment Step 4. Severe persistent asthma Persistent symptoms frequent exacerbations Frequent nocturnal symptoms Physical activity is limited by manifestations of asthma PEF or FEV1  60% of normal fluctuations> 30% Long-term preventive treatment: high doses of inhaled steroids-traditional, long- acting bronchodilators drugs and long-term course of oral glucocorticosteroids Step 3. Moderate persistent asthma Daily symptoms Exacerbations violate activity and sleep Night asthma symptoms occur more than 1 time per week Daily intake of  2- agonists short- acting PEF or FEV1 60 to 80% of normal fluctuations> 30% Daily preventive therapy: Inhaled corticosteroids and long acting bronchodilators (especially at night symptoms)

Determining the severity of BA (continuation) StepsThe clinical picture before treatment Necessary medical treatment Step 2. Mild persistent asthma Symptoms of a once a week or more, but less than 1 time per day Exacerbation of disease activity and can disrupt sleep Nocturnal symptoms of asthma occur more than 2 times per month PEF or FEV1  80% of normal vibration % Any anti-inflammatory drug. Consider adding long-acting bronchodilators (especially at night symptoms) Step 1. intermittent asthma Symptoms of less than 1 time per week Short acute disease of (from several hours to several days) Nocturnal symptoms 2 times a month or less. No symptoms and normal lung function between exacerbations PEF or FEV1  80% of normal fluctuations <20% Preparation for emergency relief, imposed only when necessary: inhaled  2 - agonists, short-acting. Intensity of treatment depends on the severity of exacerbation: Is it possible the use of corticosteroids in pill form

CLASSIFICATION OF MAJOR PATHOGENETIC VARIANTS BA (according to the classification, supplemented BG Fedoseyev) 1. Infection-dependent 2. Atopic 3. Autoimmune 4. Dyshormonal 5. Dysovarial 6. Neuropsychiatric 7. Adrenergic imbalance 8. Cholinergic 9. Asthma of physical effort 10.Aspirin asthma (Triad)

The severity of bronchial asthma 1. Easy 2. During moderate ? 3. Severe

Phase of bronchial asthma 1. Exacerbation 2. Unstable remission 3. Sustained remission (more than 2 years)

Complications Pulmonary: atelectasis, pneumo thorax, pulmonary insufficiency, etc. Extra pulmonary: pulmonary heart, congestive heart failure.

Differential diagnosis 1) COPD 2) Emphysema 3) Cardiac asthma

Treatment Steps Preventive control of long-acting drugs Drugs that attack stoped Step 4. Severe persistent asthma Daily: · Inhaled corticosteroids, mg or more; · Long-acting bronchodilator: inhaled  2 - agonists or theophylline, and / or  2 - agonist tablets or syrup; corticosteroids orally for a long time If necessary: ​​ a short-acting bronchodilators - inhaled  2 - agonists Step 3. Moderate persistent asthma Daily: · Inhaled corticosteroids mg; bronchodilators Prolong-centered actions, especially when nighttime symptoms: inhaled  2 - agonists or theophylline, or  2 - agonist tablets or syrup If necessary (but not more than 3-4 times a day): a short-acting bronchodilators - inhaled  2 - agonists

Treatment (continued) Name (in parentheses other possible names) Generic nameThe mechanism of action Corticosteroids (adrenoco- corticoids, glucocorticoids) Inhaled: beclomethasone budesonide flunizolid fluticasone triamcinolone Anti-inflammatory drugs Prevent or inhibit the activation and migration of inflammatory cells, reduce the swelling of the bronchial wall, mucus production and increased microvascular permeability, increases the sensitivity of the  2 - receptor of bronchial smooth muscle Sodium cromoglycate (cromolyn, cromolyn sodium, cromones) Anti-inflammatory drug

Treatment (continued) Name (in parentheses other possible names) Generic nameThe mechanism of action Nedocromil (Cromones, nedocromil sodium) Anti-inflammatory drug Inhibits the activation of inflammatory cells and release of these mediators  2 -agonists long-acting (  - adrenergic drugs long) Inhaled salmeterol formoterol Tablets salbutamol terbutaline Bronchodilators Relax bronchial smooth muscle, enhance mucociliary clearance and reduces vascular permeability

FORECAST Prognosis depends on the timeliness of detection, patient education and its ability to self-control. Crucial to the elimination of precipitating factors and timely treatment for a qualified Medical Assistance.