1. Topic of the lecture:
«DIFFERENTIAL DIAGNOSIS of bronchial obstruction syndrome. URGENT CARE. TACTICS of GPs. "

2. The purpose of the lecture:
The general practitioner should know the main causes of the syndrome, should be able to assess changes in clinical, laboratory and instrumental data. GPs need to know and identify the diagnostic criteria, differential diagnosis, to be able to treat the disease.

3. OBJECTIVES The concept of the bronchobstructive syndrome
Changing laboratory data and their significance in lung pathology
Etiological factors, classification
Diagnostic criteria,
Diff. diagnosis, variants of the course
The principles of treatment. Treatment of major diseases of the lungs.
Rehabilitation.
Prevention.

4. Bronchoobstructive syndrome
BOS - Its symptomcomplex which is based on breach of the ventilation of bronchopulmonary apparatus, due to edema, deformation, mechanic narrowing, occlusion of bronchi, or lung compliance

5. Patient has a shortness of breath or choking due to bronchospasm, hypersecretion, and mucosal edema and bronchial obstruction in this case. The leading component of this syndrome is a spasm of the bronchi, and violations of respiratory function occur on obstructive type.

6. Mechanism of bronchial obstruction
Failure of macrophage system
Dystonia
Translating…
hyperplasia and metaplasia of mucosa
Obturation and deformation of bronchi
Local and systemic defects of immune cells
inflammation infiltrates
dyscrinia
hypercrinia
swallow
Hypertrophy of the muscular layer
Mechanism of bronchial obstruction

7. Reversible broncho obstruction
Bronchospasm
1.Hypersecretion of bronchi
2. Edemaq of bronchial mucosa
3. Violation of mucociliary clearance

8. stenosis of bronchi Restructure of bronchi
Irreversible airflow obstruction
stenosis of bronchi
Restructure of bronchi
Degradation of elastic light
expiratory prolapse
obstructive emphysema
Obliteration of small bronchi and bronchioles

9. Классификация Бронхообструктивного синдрома obstructive allergic
Immune
hemodynamic
Infectious-inflammatory
toxic-chemical
Irritative, neurogenic
эндокрин-гуморальный

10. Bronchial obstruction is the pathogenetic basis
asthma
chronic obstructive lung disease (chronic obstructive bronchitis, emphysema).

11. Bronchial asthma (BA) - a chronic inflammatory disease of the airways characterized by reversible airflow obstruction and bronchial hyperreactivity

12. The direct causes of bronchial obstruction in asthma are bronchospasm, inflammatory or allergic swelling of the bronchial mucosa, the presence of viscous secretions in the lumen of the bronchi. The defeat of the bronchi with the mandatory (basic) feature - attacks of breathlessness - is in bronchial asthma the primary nature of the direct cause of bronchial obstruction in asthma are bronchospasm, inflammatory or allergic swelling of the bronchial mucosa, the presence of viscous secretions in the lumen of the bronchi. The defeat of the bronchi with the mandatory (basic) feature - attacks of breathlessness - is bronchial asthma primary character

13. hyperreactivity of the bronchi
Endogenous factors BA
FLOOR
atopy
heredity
hyperreactivity of the bronchi
Asthma in children more often male, older women are more likely to have

14. TACTICS IN GP AD Early diagnosis of the underlying cause
Implementation of preventive measures and, if necessary, medical treatment together with specialists (BA)
Consulting a specialist in accordance with the characteristics of GP qualifying
(I or Category II)
Clinical supervision and rehabilitation
(IV category)

15. 1. Early diagnosis of the main reason (illness)
Objective
inspection
Anamnesis
Лабораторно-инструментальное
исследования
(III категория)

16. Laboratory and instrumental investigations
3.1. category
Tot. blood test
general urine analysis
- Blood Sugar
- Obsch.analiz sputum
ECG
  pikflyurometriya
3.2. category
-The lipid spectrum of the blood
- Coagulation (IPT etc.)
Fluoroscopy WGC and PPN
  bronchography
- Allergic tests
Immunological tests
Consultation of specialists (pulmonologist, allergist, ENT, etc.).
- Bronchoscopy for the indication

17. Diagnosis and management in a hovercraft or OP
2. STRATEGY GP
I category
category II
Early diagnosis and referral to a specialist or to hospital
Diagnosis and management in a hovercraft or OP
BA 1 -II stage
BA III- IV stage

18. Differential diagnosis of bronchial asthma and cardiac asthma (left ventricular failure).
criteria
Asthma attacks
The attack of cardiac asthma
Previous disease
Bronchopulmonary diseases
vasomotor rhinitis
Arterial hypertension, coronary heart disease, heart disease
The reasons for the attack
The aggravation of the inflammatory process in the respiratory tract, contact with an allergen
Physical and mental stress
The nature of suffocation
Expiratory
Inspiratory
Character cyanosis
Central
acrocyanosis
These lung auscultation
Diffuse dry wheezing, elongated exhalation
Wet sonorous rales in the lower lungs
Swelling, hepatomegaly
Missing
Often occur
The character of sputum
Thick, viscous, in a small amount is excreted in difficulty
Liquid,floamy that separates easily, sometimes pink
Pulse
Tachycardia, a rhythm right
Tachycardia, arrhythmia
ECG
Signs of an overload of the right heart
Signs of ischemia and myocardial necrosis, the overload of the left heart
The therapeutic effect of diuretics and cardiac glycosides
Absent
present
The therapeutic effect of bronchodilators

19. Differential diagnosis of asthma and lung tumors
Evidence
Bronchial asthma
lung tumor
clinical symptoms
Paroxysms of suffocation with periods of remission, cough at the end of the attack
Constant shortness of breath, often without cough, paroxysms of suffocation can be inspiratory or expiratory
Type of breathing
expiratory
Inspiratory or mixed
Auscultation changes in the lungs
Dry, wheezing in all lung fields, elongated exhalation
Often, not tapped breath sounds on site of injury (asymmetry)
Type disorders of pulmonary ventilation
obstructive
restrictive
Skin allergological tests
Positive
negative
Bronchological study
Bronchospasm, bronchial obstruction
The narrowing of the lumen of the bronchus
X-ray examination
Emphysematous swelling of the lungs, "dehiscence" mediastinum
Homogeneous intensive shade

20. Differential diagnosis of bronchial asthma and tracheobronchial dyskinesia.
clinical symptoms
Paroxysms of suffocation with periods of remission, cough at the end of the attack
Attacks bitonal painful barking cough and breathlessness provoking exercise, laugh, change in body position, possible fainting
Type of breathlessness
expiratory
Auscultation changes in the lungs
Dry, wheezing in all lung fields
Dry, wheezing in small quantities в небольшом количестве
Type disorders of pulmonary ventilation
obstructive
Obstructive, the presence of air trapping in the forced expiratory curve
Skin allergy tests
positivelyе
positively
bronchoscopy study
Bronchospasm, bronchial obstruction
Prolapse of the rear wall of the trachea and main bronchi into the lumen of the airways during forced breathing or coughing
X-ray examination
Emphysematous swelling of the lungs
The sharp decrease in the ventral-dorsal incision of the trachea and main bronchi, right
Prior to the full adhesion of the walls

21. Drug-free methods Lifestyle changes Dosage exercise
Reducing body weight
Reducing the use of table salt and 4.5 grams per day
Diet
Reducing alcohol consumption of grams of pure ethanol per day
To give up smoking
autotraining

22. Drug therapy Glucocorticosteroids B-2 agonists weeks long action
At the present stage, bronchial asthma is regarded as a chronic inflammatory disease of the bronchial tree formation in which mast cells are involved, eozinophili, T lymphocytes and others.
               Based on the concept of inflammatory asthma, are the mainstay of therapy drugs affecting the inflammatory process:
Glucocorticosteroids
B-2 agonists weeks long action
Mast cell stabilizers membranes
Leukotriene receptor antagonists
Theophylline

23. When selecting a drug must be considered:
Efficiency
Security
Acceptability
Economy

24. Leukotriene receptor antagonists
астма
Basic therapy
Leukotriene receptor antagonists
cromolyn sodium , intal, ifiral
Glucocorticosteroids (GCS)
DAI
MCMC
М-Х

25. Bronchodilators 1. β2-agonists - (DAI) 2. Anticholinergics
Selective (short-acting)
salbutamol, fenoterol, terbutaline,
Selective long d-I
      salmeterol, formoterol
      alupent, astmopent.
2. Anticholinergics
Atrovent (ipratropium bromide), (tiotropium bromide), oxitropium bromide.
I - 12 hours generation
  II - generation of action 24 hours.
Pervoe- teopec, teodur, durofillin, retafil, teobilong, teotard
      second -unifil, teodur-24 eufilong.
3. Methylxanthines or theophylline - 2nd generation

26. Agonists short-acting β2-
Salbutamol (Ventolin, salben, salamol), terbutaline (brikanil), fenoterol hydrobromide (berotek H)
Agonists short-acting β2-
Daily dose of 1-2 and operates more than 12 hours. They are not used as monotherapy, because Do not replace the IGCS.

27. β2-agonists long-acting
Salmeterol (salmeterol Serevent)
formoterol fumarate

28. Inhaled anticholinergics M
M-anticholinergics
2. Flomax
1. Ipratropium bromide
(Atrovent)

29. theophylline, aminophylline lats (aminophylline).
TREATMENT OF ASTHMA
methylxanthines:
Short e-I
Methylxanthines: long e-I
Methylxanthines
(Theophylline)
teopec, unifem, teodur-24 eufillin
theophylline, aminophylline lats (aminophylline).

30. Chronic obstructive bronchitis Severe bronchial asthma (BA)
COPD Causes
COPD
Emphysema
Chronic obstructive bronchitis
(COPD)
Severe bronchial asthma (BA)

31. Clinical manifestations of COPD
symptoms
cough
sputum expectoration
shortness of breath under load
Exacerbations as the disease progresses
Deterioration of health (quality of life)
Typically, patients present with a chronic and productive cough, varying degrees of breathlessness on exertion and a significant and progressive reduction in expiratory airflow, interspersed with exacerbations
This leads to a decline in the patients health related quality of life
GOLD, updated 2011

32. Action risk factors Age> 35 years later appearance and slow steady increase in respiratory symptoms (cough, dyspnea, sputum production)
Reduced FEV1 and FEV1 / FVC The increase in FEV1 <15% of the sample with a beta-2-agonists
Early diagnosis ( 1 phase) is possible only with the active detection of patients at risk populations.

33. Classification of COPD
Классификация ХОБЛ
Classification of COPD
Стадия
Характеристика
I. Easy
FEV1 / FVC <70%
  FEV1 ≥ 80% of predicted values
  Chronic cough and sputum production is usually, but not always
II. Moderate
  50% ≤ FEV1 <80% of predicted values
  Chronic cough and sputum production often but not
    always
III. Severe
  30% ≤ FEV1 <50% of predicted values
IV. Extremely
      severe
30% ≤ FEV1 <50% of predicted values
Chronic cough and sputum production often but not
always

34. The diagnostic criteria for COPD:
mucous expectoration
character
It stands out in the morning
  in a small
amount (rarely more
60 ml) quantities.
Productive
cough and shortness
of breath
In the anamnesis
  frequent
  episodes of respiratory
  infection.
Whistling rale indicate
airway constriction.
However, these signs do not reflect the
the severity of the disease
Increasing the amount of phlegm and
the emergence in its composition purulent
elements testify
exacerbation of the disease.

35. Exogenous factors COPD Socio-economic low level Adenovirus
Environmental pollution
 environment and
occupational factors
Adenovirus
infection
Alcoholism and
addiction
Smoking

36. hyperreactivity of the bronchi
Lack of weight
Male
Older than 40 years
Elevated levels of Ige
Reduced levels (IgG)
hyperreactivity of the bronchi
A (II) blood group
Nasli moyillik
prematurity
Trypsin deficiency L1
hereditary factor
COPD
Endogenous factors

37. Differential-diagnostic criteria for COPD and asthma
Indicators
COPD
Asthma
Orthopnoe
not characterized
Characteristic
Cough
Standing, different intensity
paroxysmal
Dyspnea
Permanent, without sharp fluctuations
Attacks expiratory dyspnea
Daily change in FEV1
Менее 10% от должного
More than 10% of predicted
Bronchial obstruction
Irreversible
Reversible
Eosinophilia of blood, sputum
characterized by

38. GOLD (updated 2011): The goals of treatment of COPD
Prevention of disease progression
Reduction of symptoms
Increased exercise tolerance
Improving quality of life
Prevention and treatment of complications
Preventing and treating exacerbations
Reducing mortality
GOLD, updated 2011

39. Four basic components work with patients with COPD
Diagnosis and systematic monitoring of COPD
Reducing risk factors action
Treatment of COPD exacerbations

40. MAIN TRENDS IN THE TREATMENT OF STABLE COPD
Educational programs
Drug therapy
Medication

41. Educational programs for patients with COPD
Formation of vital self-help skills, the ability to carry disease, improve health
The fight against smoking - the most effective method for reducing the risk of action.
Improving the efficiency of the treatment in the final phase of the patient's life

42. Классификация БА Stage I Stage II Stage III Stage IV
The scheme of treatment with bronchodilators at different stages of COPD exacerbations
Stage I
Stage II
Stage III
Stage IV
Регулярный прием М-холинолитиков короткого действия
или
2. Регулярный прием М-холинолитиков длительного действия
3. Регулярный прием ингаляционных ДДБА
4. Регулярный прием М-холинолитиков короткого или длительного действия + КДБА или ДДБА
5. Регулярный прием М-холинолитиков длительного действия +
теофиллины длительного действия
6. ДДБА + теофиллины длительного действия
Или

43. Treatment of COPD exacerbations
The degree of severity
Antibacterial agents
Bronchodilators
Corticosteroids
hemodilution
Mucoregulator
oxygen therapy
Light
If there are signs of infection
M-anticholinergics (increase dose) + β2-agonists
Not required
is appointed
Moderate
M-anticholinergics (increase dose) + β2-agonists (nebulizer), methylxanthines (possibly intravenously)
With the ineffectiveness of maximal doses of oral or intravenous bronchodilators
An increase in Hb of more than 150 g / l erythrocytophoresis
At decrease in PaO 2 below 65 mm. Hg. Art., malopotochnaya through a mask or nasal catheter
Severe
M-anticholinergics (increase dose) + β2-agonists (nebulizer or intravenously), methylxanthines (possibly intravenously)
Erytrocytoforesis, desagregants
Through a mask or nasal catheter

44. Apply 3rd groups of bronchodilators:
1. Anticholinergic drugs - ipratropium bromide, tiotropium bromide affect the reversible component bronhoconstruction.
    Metered aerosol 20 mcg. in one inhalation dose inhalation times a day.

45. Extension
.2. Selective B2-agonists, short and long-term actions: short-term - salbutamol (albuterol) - in a single inhaled dose of1mg, when nebulized inhalation mg; metoproterenol (alupent) - in a single inhaled dose of 65 mg, with the inhalation nebulizer mg; terbutaline (brikanil) mg and 0.25 mg of Fenaterol (berotek) mg and 2.1 mg. long - (12-24 hours). Serevent (salmeterol) - 50 or 100 mg 2 times a day

46. extension
3. Methylxanthines. Apply with inefficiency B2 agonists and anticholinergics: Theophylline 10 mg / kg per day; teopek 100,300 mg per day (two doses); dilatran 200, 350, 400 mg daily (once); aminophylline (theophylline ethylene diamine +), 100, 200 mg 3 times a day;

47. Corticosteroids in COPD: influence not only on symptoms but also on the course of the disease
Structural
changes
Inflammation
Increased number / activity:
- Neutrophils
- Macrophages
- CD8 + lymphocytes Increased IL-8, TNFa, LTB4?
The imbalance of the protease system,
  antiproteases
Swelling of the mucous
Alveolar destruction
epithelial hyperplasia
Hyperplasia glands
Goblet cell hyperplasia
collagen Production
Fibrosis airway  
ICSs address the multi-component nature of COPD:
Inhibition of structural changes (e.g. glandular hypertrophy and goblet cell hyperplasia)
Reduction of airway inflammation (e.g. decrease in macrophage and T-cell numbers, release of pro-inflammatory mediators)      

48. IGCS– mechanisms of action
The stimulation of mucociliary clearance, decrease mucosal damage
Reduction in fibrosis and fibroblast proliferation
Inflammation
mukotsiliary disfunktstion
mucociliary dysfunction
Shortness of air movement
Relaxed muscles of the bronchi
Reduction of cells and inflammatory mediators
Reducing the number of neutrophils and monocytes
systematic
component

49. ICS - the main group of drugs for the treatment of asthma and COPD
Non-halogenated
Budesonide (Pulmicort, benacort)
Ciclesonide (Alvesko)
Chlorinated beclomethasone dipropionate (Beclason Eco Beclason ECO Easy Breathe)
Mometasone furoate (Asmoneks)
Fluorinated flunisolide (Ingakort)
Triamtsenolonaacetonide
Fluticasone propionate (Flixotide)

50. Marked increase in intensity of symptoms
Global strategy for the diagnosis, treatment and prevention of COPD? The criteria for acute / Indications for hospitalization
Marked increase in intensity of symptoms
Severe manifestations of COPD with ARF
The emergence of new physical signs
Lack of effect of drug therapy
Furthermore, indications for hospitalization are:
Increased exacerbations
Severe manifestation of concomitant diseases
Elderly age
Inability to achieve at home improvement

51. Treatment of patients with acute exacerbation of COPD? Inpatient
The main indications for hospitalization is a severe hypoxemia and hypercapnia.
Bronchodilators: B2-agonists, short-acting and / or IB and / or a combination of short-acting B2-agonists and IB using 2-4 doses of the spacer and / or 2 ml nebulizer. on demand.
oxygen inhalation, if the blood oxygen saturation (SatO2) less than 90%.
Corticosteroids (prednisolone) mg per day orally for days;
-with impossibility oral assigned equivalent dose corticosteroids in / up to days.
-perhaps the appointment of ICS via metered dose inhaler or a nebulizer.
Antibiotics. They can be used when a purulent sputum and / or increasing its amount. Used amoxicillin, ampicillin, cephalosporins 2 nd generation (cefuroxime axetil), doxycycline, macrolides (azithromycin, clarithromycin).

52. TACTICS of GPs in COPD and asthma? Action program on 6 fields :
Establish and maintain control of symptoms;
Prevention of acute illness;
The maximum possible recovery of respiratory function;
Maintaining normal zhiznideyatelnosti, including physical activities;
Avoiding side effects in drug therapy;
Preventing the formation of irreversible disorders of respiratory function;
Prevention of mortality of the disease.

53. PREVENTION of BA
Activities aimed at raising the educational level of the population, building people install on a healthy lifestyle and to create conditions for its implementation.
Rejection of bad habits
Balanced diet
Compliance with rest mode
Prevention of inactivity
Preventing stress
Prevention of obesity and its treatment
Correction dislipidemia
Primary prevention

54. Establish and maintain control of symptoms;
Prevention of acute illness;
The maximum possible recovery of respiratory function;
Maintaining normal zhiznideyatelnosti, including physical activities;
Avoiding side effects in drug therapy;
Preventing the formation of irreversible disorders of respiratory function;
Prevention of mortality of the disease.
Secondary prevention

55. - Prevention of complications
- Psychological support
Tertiary prevention

56. X-ray examination of chest organ
Clinical examination
Seeing the GP and pulmonologist
General sputum analysis
GBA
Peak Flow Meter
X-ray examination of chest organ
ECG

57. Planning and procedure of prescribing;
Principles of conduct and of follow-up of patients
  Asthma and COPD in a hovercraft or a family clinic
Education and training of patients in order to establish partnerships in the course of treatment;
Determinity and the establishment of control by an objective assessment of the functioning of the respiratory system;
Accounting and preventing the causes of disease; bmbvmbm
Planning and procedure of prescribing;
A plan of action in cases of exacerbation;
Ensuring the regularity and consistency of treatment.