Chronic non-obstructive bronchitis

Chronic simple (non-obstructive) bronchitis

Chronic simple (non-obstructive) bronchitis is characterized by diffuse inflammation of the mucous membrane predominantly large and medium with bronchus accompanied by hyperplasia of bronchial glands, hypersecretion of mucus, increased sputum viscosity (discretion), and impaired purgative and protective function of the bronchi. The disease manifests itself as a cough with the separation of mucopurulent sputum.

The prevalence of chronic non-obstructive bronchitis among the adult population is quite high and reaches 7.3-21.8%. Men account for more than 2/3 of the total number of patients with chronic non-obstructive bronchitis. The most common chronic non-obstructive bronchitis reaches at the age of 50-59 years in men and 40-49 years in women.

Code for ICD-10 J41.0 Simple chronic bronchitis J41 Simple and mucopurulent chronic bronchitis J41.8 Mixed, simple and muco-purulent chronic bronchitis

Causes and pathogenesis of chronic simple bronchitis

In the emergence of chronic non-obstructive bronchitis, several factors are important, the main one of which, apparently, is the inhalation of tobacco smoke (active and passive smoking). Constant irritation of the bronchial mucosa with tobacco smoke leads to a reorganization of the secretory apparatus, hypercrinia and an increase in the viscosity of the bronchial secretion, as well as to damage to the ciliary epithelium of the mucosa, as a result of which mucociliary transport is violated, purifying and protective functions of the bronchi, which contributes to the development of chronic inflammation of the mucosa. Thus, smoking tobacco reduces the natural resistance of the mucous membrane and facilitates the pathogenic action of the viral-bacterial infection.

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Chronic non-obstructive bronchitis - Causes and pathogenesis

Symptoms of chronic non-obstructive bronchitis

The clinical course of chronic non-obstructive bronchitis in most cases is characterized by long periods persistent clinical remission and comparatively rarely occurring exacerbations of the disease (no more than 1-2 times per year).

The stage of remission is characterized by poor clinical symptoms. Most people with chronic non-obstructive bronchitis generally do not consider themselves to be sick, and periodically arising cough with phlegm is explained by the habit of smoking tobacco (smoker's cough). In this phase, cough, in fact, is the only symptom of the disease. It often occurs in the morning, after sleep and is accompanied by a mild mucous or mucopurulent sputum. Cough in these cases is a kind of protective mechanism that allows you to remove excess bronchial secretion accumulating overnight in bronchi and reflects already existing in the patient morpho-functional disorders - hyperproduction of bronchial secretion and a decrease in the efficiency of mucociliary transport. Sometimes such a periodic cough is provoked by inhalation of cold air, concentrated tobacco smoke or considerable physical exertion.

Chronic non-obstructive bronchitis - Symptoms

Where does it hurt?

Chest pain Chest pain in children Chest pain with cough Cough pain

What's bothering you?

Coughing in the lungs Shortness of breath

Diagnosis of chronic simple bronchitis

Catarrhal endobronchitis is usually not accompanied by a diagnostic change in the clinical blood test. Moderate neutrophilic leukocytosis with a shift of the leukocyte formula to the left and a slight increase in ESR, as a rule, indicate an exacerbation of purulent endobronchitis.

Diagnostic value is the determination of the content in the blood serum of acute phase proteins (alpha1 antitrypsin, alpha1-glycoprotein, a2-macroglobulin, haptoglobulin, ceruloplasmin, seromucoid, C-reactive protein), as well as total protein and protein fractions. An increase in the content of acute phase proteins, a-2 and beta-globulips, indicates the activity of the inflammatory process in the bronchi.

Chronic non-obstructive bronchitis - Diagnosis

What it is necessary to survey?

Bronchi Lungs

How to inspect?

Bronchoscopy Examination of bronchi and trachea X-ray of lungs Examination of respiratory (lung) organs Computed tomography of thorax

What tests are needed?

Sputum examination

Who to contact?

Pulmonologist Family doctor General practitioner

Treatment of chronic simple bronchitis

When prescribing treatment for patients with exacerbation of chronic non-obstructive bronchitis, a set of measures should be envisaged to ensure:

anti-inflammatory effect of treatment;
restoration of drainage function of the bronchi;
decreased intoxication;
fight against a viral infection.

Chronic non-obstructive bronchitis - Treatment

In addition to treatment

Treatment of bronchitis Physiotherapy for bronchitis Antibiotics for bronchitis Antibiotics for bronchitis in adults: when appointed, the names What to treat? Tavanik

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Chronic non-obstructive bronchitis - Symptoms

Other symptoms in the phase of persistent clinical remission are usually not found. The working capacity and physical activity in the life of patients with chronic non-obstructive bronchitis, as a rule, are fully preserved.

At an objective research of such patients in a phase of remission of visible deviations from norm, except for a rigid respiration, usually it is not revealed. Only occasionally with auscultation of the lungs can be detected single dry low-tonal rales, especially when forced exhalation. Chryps are very fickle and quickly disappear after a small cough.

The phase of exacerbation is marked by a more vivid clinical symptomatology. Exacerbations of bronchitis usually provoke ARVI, often during epidemics of a viral infection, to which the bacterial infection quickly joins. In other cases, a provocative factor may be expressed by overcooling ("cold"), excessive smoking or exposure to bronchial irritants of domestic or industrial character, as well as acute laryngitis, pharyngitis, tonsillitis or significant physical fatigue, affecting the immune system and the general resistance of the body.

Typical seasonality of exacerbations, which often occur in late autumn or early spring, during pronounced differences in weather and climate factors.

When questioning a patient with exacerbation of chronic non-obstructive bronchitis, there are mainly three clinical signs:

cough with phlegm;
fever (optional);
intoxication syndrome.

In most cases, in the clinical picture of an exacerbation, cough is much more important, much more intense and painful than during the period of remission of the disease. The cough worries the patient not only over the rams, on and during the day and especially tobacco smoke, volatile pollutants, respiratory viral infection

Chronic effects on the bronchial mucosa at night, when the patient occupies a horizontal position in the bed, which contributes sputum entering the larger bronchi and trachea, containing, as is known, a large number of cough receptors.

Cough is more often productive and is accompanied by separation of mucopurulent and purulent sputum, which becomes more viscous and poorly separated. Nevertheless, the daily amount significantly increases compared with the phase of remission.

An increase in body temperature to subfebrile digits is observed quite often, but not always. A higher fever is typical for exacerbations of chronic non-obstructive bronchitis, provoked by an acute viral infection.

As a rule, in patients with exacerbation of chronic non-obstructive bronchitis, working capacity decreases, there is pronounced sweating, weakness, headache, myalgia. Particularly expressed symptoms of intoxication against a background of significant fever. Nevertheless, it should be remembered that the deterioration of the general condition and individual symptoms of intoxication can be detected even in patients with normal body temperature.

With objective research, in most cases very meager changes are also detected on the part of the respiratory organs. The shape of the chest is usually not changed. Percutally determined clear pulmonary sound, the same over the symmetrical areas of the lungs.

The greatest diagnostic value is given by auscultation. For patients with exacerbation of chronic non-obstructive bronchitis, the most characteristic is hard breathing, which is heard over the entire surface light and due to uneven lumen and "roughness" of the inner surface of large and medium bronchi.

As a rule, scattered dry rales, more often lowtonal (bass), are also heard, which indicates the presence of large amounts of viscous sputum in large and medium bronchi. The movement of air during inhalation and exhalation causes low-frequency oscillations of the filaments and strands of viscous sputum, which leads to the appearance of long, prolonged sounds - buzzing and buzzing dry wheezes, which are usually heard in both phases of breathing. The peculiarity of bass rales is their inconstancy: they are listened to, then disappear, especially after coughing. In some cases, you can listen to wet and small bubbles or medium bubbling silent rales, which is associated with the appearance in the lumen of the bronchi more liquid secret.

It should be emphasized that in a relatively small proportion of patients with chronic non-obstructive bronchitis in the period of severe exacerbation, certain symptoms of bronchial obstructive syndrome, mainly due to the reversible component of obstruction - the presence of a large amount of viscous sputum in the bronchus and a moderate spasm of the smooth muscles of the bronchi. Often this situation occurs when exacerbation of chronic non-obstructive bronchitis is triggered by an acute respiratory viral infection - influenza, adenovirus or RS virus infection. Clinically, this is expressed by a certain difficulty in breathing, which occurs during physical exertion or at the time of an attack of unproductive cough. Often, respiratory discomfort occurs at night, when the patient takes a horizontal position in bed. At the same time auscultative, against the background of severe breathing, high-tonnous (dissentant) dry wheezes begin to be heard. They are best identified during a rapid forced exhalation. This method helps to recognize even the latent bronchial obstruction syndrome, which sometimes develops in chronic non-obstructive bronchitis patients in the phase of exacerbation of the disease. After relief of exacerbation of chronic non-obstructive bronchitis, signs of moderate bronchial obstruction completely disappear.

The most characteristic clinical symptoms of exacerbation of chronic non-obstructive bronchitis are:
- cough with mucous membrane or mucopurulent sputum;
- increase in body temperature to low-grade figures;
- Intense intoxication;
- dry scattered low-tone wheezing in the lungs against the background of hard breathing.
Only a part of patients with chronic non-obstructive bronchitis in the phase of acute exacerbation can be detected moderate signs of bronchial obstructive syndrome (shortness of breath, high treble rales, seizures of low-productivity cough), caused by a reversible component of bronchial obstruction - the presence of viscous sputum and bronchospasm.
In the phase of remission of chronic non-obstructive bronchitis, cough with sputum is detected in patients, while dyspnea and other signs of bronchial obstructive syndrome are completely absent.

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Chronic non-obstructive bronchitis - Treatment

When prescribing treatment for patients with exacerbation of chronic non-obstructive bronchitis, a set of measures should be envisaged to ensure:

anti-inflammatory effect of treatment;
restoration of drainage function of the bronchi;
decreased intoxication;
fight against a viral infection.

The course and prognosis of chronic simple (non-obstructive) bronchitis

In patients with chronic non-obstructive bronchitis, the disease lasts for many years, almost all of life, although in most cases it does not significantly affect the quality of life and performance. Nevertheless, it should be borne in mind that patients with chronic non-obstructive bronchitis are particularly vulnerable to adverse weather and occupational factors have an increased risk of acute respiratory viral infections, bacterial and viral-bacterial pneumonia.

Strict implementation of a number of preventive measures, first of all, cessation of smoking, can significantly improve the current diseases, reduce the frequency of exacerbations of chronic non-obstructive bronchitis, the emergence of bronchopneumonia, and the like.

Particular attention should be paid to patients with a functionally unstable course of chronic obstructive bronchitis, which are observed relatively frequent and protracted exacerbations of bronchitis, accompanied by transient phenomena of moderate bronchial obstructive syndrome. It is these patients who have the highest risk of transforming chronic non-obstructive bronchitis into chronic obstructive bronchitis, leading to the development of emphysema, pneumosclerosis, progressive respiratory failure, pulmonary hypertension and the formation of pulmonary heart.

Chronic non-obstructive bronchitis in most cases is characterized by a relatively favorable course. Nevertheless, patients with simple non-obstructive bronchitis, in comparison with healthy individuals, are more likely to be affected by adverse weather and climate conditions, occupational and household factors, acute respiratory viral infections and the emergence of bronchopneumonia.

In some cases, in patients with a functionally unstable course of chronic non-obstructive bronchitis, especially in patients with purulent endobronchitis, the transformation of the disease is possible over time in chronic obstructive bronchitis with the progression of bronchial obstructive syndrome, respiratory failure, the development of pulmonary arterial hypertension and pulmonary heart.

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Chronic non-obstructive bronchitis - Diagnosis

Laboratory and instrumental diagnostics

Blood test

Sputum examination

With a low activity of inflammation in the sputum of a mucous character, the eliminated cells of the bronchial epithelium predominate (about 40-50%). The number of neutrophils and alveolar macrophages is relatively small (from 25% to 30%).

With a moderate activity of inflammation in the contents of the bronchi, in addition to the cells of the bronchial epithelium, there is a large number of neutrophils (up to 75%) and alveolar macrophages. Sputum, as a rule, has a mucus-purulent character.

Finally, pronounced inflammation is characterized by the presence in the bronchial content of a large number of neutrophils (about 85-95%), single alveolar macrophages and dystrophically altered cells of the bronchial epithelium. The sputum becomes purulent.

Retgenology research

The significance of X-ray examination of patients with chronic non-obstructive bronchitis is mainly due to the possibility To exclude the presence of other diseases similar in clinical manifestations (pneumonia, lung cancer, tuberculosis, etc.). Any specific changes, characteristic of chronic non-obstructive bronchitis, can not be detected on radiographs. Pulmonary pattern is usually little changed, pulmonary fields are transparent, without focal shadows.

External respiration function

The function of external respiration in patients with chronic non-obstructive bronchitis in most cases remains normal both in the phase of remission and in the phase of exacerbation. An exception is a small category of patients with chronic non-obstructive bronchitis who, during the expressed exacerbation of the disease can reveal a slight decrease in FEV1 and other indicators compared with the proper values. These pulmonary ventilation disorders are transient and are caused by the presence of viscous sputum in the airway lumen, as well as hyperreactivity bronchial tubes and a tendency to moderate bronchospasm, which are completely eliminated after the activity of the inflammatory process in the bronchi subsides.

According to L.P. Kokosova et al. (2002) and H.A. Savinova (1995), such patients with a functionally unstable bronchitis should be included in the group risk, because over time they are more likely to develop obstructive pulmonary ventilation. It is not excluded that at the heart of the described hyperreactivity of the bronchi and their functional destabilization during the period of exacerbation bronchitis is a persistent viral infection (influenza, PC-viral or adenovirus infection).

Bronchoscopy

The need for endoscopic examination in patients with chronic non-obstructive bronchitis can occur during a period of severe exacerbation of the disease. The main indication for reduced bronchoscopy in patients with chronic non-obstructive bronchitis is suspected for the presence of purulent endobronchitis. In these cases, the state of the bronchial mucosa is assessed, the nature and prevalence of the inflammatory process, the presence of bronchial mucopurulent or purulent contents in the luminaire, etc.

Bronchoscopy is also indicated in patients with a painful paroxysmal pertussis-like cough caused by hypotonic tracheobronchial dyskinesia II-III degree, accompanied by an expiratory collapse of the trachea and large bronchi, which contributes to the development of a small proportion of patients chronic obstructive bronchitis obstructive ventilation disorders and maintains purulent inflammation of the bronchi.

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Chronic obstructive bronchitis - Treatment

With such a disease as chronic obstructive bronchitis treatment is meant long-term and symptomatic. Due to the fact that chronic obstruction of the lungs is inherent in smokers with many years of experience, as well as people engaged in harmful production with a high content of dust in the inspired air, the main task of treatment is to stop the negative impact on the lungs.

Chronic obstructive bronchitis: treatment with modern means

Treatment of chronic obstructive bronchitis in most cases is an extremely difficult task. First of all, this is explained by the main regularity of the development of the disease - the steady progression of bronchial obstruction and respiratory failure due to inflammatory process and hyperreactivity of the bronchi and the development of persistent irreversible violations of bronchial patency, caused by the formation of obstructive pulmonary emphysema. In addition, the low effectiveness of treatment of chronic obstructive bronchitis is due to their late treatment to the doctor, when there are already signs of respiratory failure and irreversible changes in the lungs.

Nevertheless, modern adequate complex treatment of chronic obstructive bronchitis in many cases allows to achieve a decrease in the rate of progression of the disease leading to increase of bronchial obstruction and respiratory failure to reduce the frequency and duration of exacerbations, increase work capacity and tolerance to physical activity.

Treatment of chronic obstructive bronchitis includes:

non-pharmacological treatment of chronic obstructive bronchitis;
use of bronchodilators;
the appointment of mukoregulatory therapy;
correction of respiratory failure;
anti-infective therapy (with exacerbations of the disease);
anti-inflammatory therapy.

Most patients with COPD should be treated on an outpatient basis, according to an individual program developed by the attending physician.

Indications for hospitalization are:

Exacerbation of COPD, not controlled on an outpatient basis, despite the course (preservation of fever, cough, separation of purulent sputum, signs of intoxication, increasing respiratory insufficiency, etc.).
Acute respiratory failure.
Increased arterial hypoxemia and hypercapnia in patients with chronic respiratory failure.
The development of pneumonia in COPD.
The appearance or progression of signs of heart failure in patients with chronic pulmonary heart disease.
The need for relatively complex diagnostic manipulations (for example, bronchoscopy).
The need for surgical interventions with the use of anesthesia.

The main role in recovery belongs undoubtedly to the patient himself. First and foremost, it is necessary to abandon the pernicious habit of cigarettes. The irritating effect that nicotine exerts on the lung tissue will nullify all attempts to "unlock" the work of the bronchi, improve the blood supply in the respiratory organs and their tissues, remove the coughing attacks and bring the breath into a normal state.

Modern medicine suggests combining two treatment options - basic and symptomatic. The basis of the basic treatment of chronic obstructive bronchitis are such drugs that relieve irritation and stagnation in the lungs, facilitate the departure of sputum, expand the lumen of the bronchi and improve blood circulation in them. This includes xanthine series preparations, corticosteroids.

At the stage of symptomatic treatment, mucolytics are used, as the main means for fighting cough and antibiotics, in order to exclude the attachment of secondary infection and the development of complications.

Periodic physiotherapy and therapeutic exercises for the chest area are shown, which greatly facilitates the outflow of viscous sputum and ventilation of the lungs.

Chronic obstructive bronchitis - treatment with non-pharmacological methods

The complex of non-medicinal treatment measures in patients with COPD includes unconditional cessation of smoking and, if possible, elimination of other external causes of the disease (including the effects of domestic and industrial pollutants, repeated respiratory viral infections, etc.). Of great importance are sanation of foci of infection, primarily in the oral cavity, and the restoration of nasal breathing, etc. In most cases, a few months after stopping smoking the clinical manifestations of chronic obstructive bronchitis (cough, sputum and dyspnea) decrease and the rate of decrease in FEV1 and other parameters of the function of external respiration slows down.

The diet of patients with chronic bronchitis should be balanced and contain a sufficient amount of protein, vitamins and minerals. Particular importance is attached to the additional intake of antioxidants, for example tocopherol (vitamin E) and ascorbic acid (vitamin C).

Nutrition in patients with chronic obstructive bronchitis should also include an increased amount of polyunsaturated fatty acids (eicosapentaenoic and docosahexaenoic), contained in marine products and have a kind of anti-inflammatory effect, caused by a decrease in the metabolism of arachidonic acid.

With respiratory failure and violations of the acid-base state, a hypocaloric diet and a restriction of the intake of simple carbohydrates, increasing due to their accelerated metabolism, the formation of carbon dioxide, and, accordingly, reducing the sensitivity of the respiratory center. According to some data, the use of a hypocaloric diet in severe COPD patients with signs of respiratory failure and chronic Hypercapnia is comparable in effectiveness to the results of long-term low-flow oxygen therapy in these patients.

Medication for chronic obstructive bronchitis

Bronchodilators

The tone of the smooth musculature of the bronchi is regulated by several neurohumoral mechanisms. In particular, the dilatation of the bronchi develops with stimulation:

beta2-adrenoceptors with epinephrine and
VIP receptors of the NASH (non-adrenergic, noncholinergic nervous system) vasoactive intestinal polypeptide (VIP).

Conversely, the narrowing of the lumen of the bronchi arises with stimulation:

M-cholinergic receptors with acetylcholine,
receptors to P-substance (NANH-system)
alpha-adrenergic receptors.

In addition, numerous biologically active substances, including inflammatory mediators (histamine, bradykinin, leukotrienes, prostaglandins, platelet activating factor - FAT, serotonin, adenosine, etc.) also have a pronounced effect on the tone of the smooth muscles of the bronchi, contributing, mainly, to reducing the clearance of the bronchi.

Thus, the bronchodilation effect can be achieved in several ways, at which time the blockade of M-cholinergic receptors and the stimulation of bronchi beta2-adrenergic receptors are most widely used. In accordance with this, M-holinolytics and beta2-agonists (sympathomimetics) are used in the treatment of chronic obstructive bronchitis. The third group of bronchodilator drugs that are used in patients with COPD include methylxanthine derivatives, the mechanism of their action on the smooth muscles of the bronchi is more complicated

According to modern ideas, the systematic use of bronchodilators is the basis of basic therapy in patients with chronic obstructive bronchitis and COPD. Such treatment of chronic obstructive bronchitis is the more effective the more. the reversible component of bronchial obstruction is expressed. True, the use of bronchodilators in patients with COPD for obvious reasons has a significantly lower positive effect than in patients with bronchial asthma, since the most important pathogenetic mechanism of COPD is the progressive irreversible airway obstruction caused by the formation of emphysema in them. At the same time, it should be borne in mind that some of the modern bronchodilator preparations have a fairly wide range of action. They contribute to reducing the edema of the bronchial mucosa, the normalization of mucociliary transport, reducing the production of bronchial secretions and inflammatory mediators.

It should be emphasized that often in patients with COPD described above functional tests with bronchodilators are negative, since the increase in FEV1 after a single application of M-holinolitikov and even beta2-sympathomimetics is less than 15% of the proper value. However, this does not mean that it is necessary to refuse from the treatment of chronic obstructive bronchitis with bronchodilators, since The positive effect of their systematic use usually comes not earlier than 2-3 months after the start of treatment.

Inhalation of bronchodilators

It is preferable to use inhalation forms of bronchodilators, since this way of administration of the drugs promotes faster penetration drugs in the mucous membrane of the respiratory tract and long-term preservation of a sufficiently high local concentration of drugs. The latter effect is provided, in particular, by the repeated entry into the lungs of drugs that are absorbed through the mucosa bronchus in the blood and falling on the bronchial veins and lymphatic vessels in the right heart, and from there again into the lungs

An important advantage of the inhalation route of bronchodilator administration is the selective effect on the bronchi and a significant limitation of the risk of developing side effects of the system.

Inhalational administration of bronchodilators is provided by the use of powder inhalers, spacers, nebulizers, etc. When using a metered-dose inhaler, the patient needs certain skills in order to ensure a more complete ingestion of the drug into the airways. To do this, after a smooth calm exhalation mouthpiece inhaler tightly wrapped lips and begin to slowly and deeply inhale, once press the can and continue to take a deep breath. After that they hold their breath for 10 seconds. If two doses (inhalations) of the inhaler are prescribed, you should wait at least 30-60 seconds, then repeat the procedure.

In patients of senile age who find it difficult to master fully the habits of using a dosed inhaler, it is convenient to use the so-called spacers in which a drug in the form of an aerosol by pressing the can is sprayed in a special plastic flask just before inhaling. In this case, the patient takes a deep breath, holds his breath, exhales into the mouthpiece of the spacer, then again takes a deep breath, no longer pressing the can.

The most effective is the use of compressor and ultrasonic nebulizers (from lat.: nebula - fog), in which spraying is provided liquid medicinal substances in the form of finely dispersed aerosols, in which the drug is contained in the form of particles with a size of 1 to 5 microns. This allows you to significantly reduce the loss of medicinal aerosol that does not enter the respiratory tract, and also provide a significant penetration depth of the aerosol in the lungs, including middle and even small bronchi, whereas with traditional inhalers such penetration is limited to proximal bronchi and trachea.

The advantages of inhalation of drugs through nebulizers are:

the penetration depth of the medicinal fine aerosol into the respiratory tract, including medium and even small bronchi;
simplicity and convenience of inhalation;
lack of coordination of inspiration with inhalation;
the possibility of introducing high doses of medicines, which makes it possible to use nebulizers for relief of the most severe clinical symptoms (pronounced dyspnea, attack of suffocation, etc.);
the possibility of incorporating nebulizers into the ventilator circuit and oxygen therapy systems.

In this regard, the introduction of drugs through nebulizers is used primarily in patients with severe obstructive syndrome, progressive respiratory failure, in persons of elderly and senile age and so-called. Through nebulizers, it is possible to inject into the respiratory tract not only bronchodilators, but also mucolytic agents.

Anticholinergic drugs (M-cholinolytics)

Currently, M-holinolitiki are regarded as the first choice drugs in COPD patients, since the leading pathogenetic the mechanism of the reversible component of bronchial obstruction in this disease is the cholinergic bronchoconstriction. It is shown that in patients with COPD holinolitiki on the strength of bronchodilator action are not inferior to beta2-adrenomimetics and exceed theophylline.

The effect of these bronchodilators is associated with competitive inhibition of acetylcholine on the receptors of postsynaptic membranes of the smooth muscles of the bronchi, mucous glands and mast cells. As you know, excessive stimulation of cholinergic receptors leads not only to an increase in the tone of smooth muscles and an increase in the secretion of bronchial mucus, but also to degranulation mast cells leading to the release of a large number of mediators of inflammation, which ultimately enhances the inflammatory process and the hyperreactivity of the bronchi. Thus, cholinolytics inhibit the reflex response of smooth muscles and mucous glands, caused by activation of the vagus nerve. Therefore, their effect manifests itself both with the use of the drug before the onset of the action of the irritating factors and with the already developed process.

It should also be remembered that the positive effect of cholinolytics is primarily manifested at the level of the trachea and large bronchi, since it is here that there is a maximum density of cholinergic receptors.

Remember:

Cholinolytics serve as first-choice drugs in the treatment of chronic obstructive bronchitis, since parasympathetic tone in this disease is the only reversible component of bronchial obstruction.
The positive effect of M-cholinolytics is:
1. in reducing the tone of the smooth muscles of the bronchi,
2. decrease the secretion of bronchial mucus and
3. reducing the degranulation of mast cells and limiting the release of inflammatory mediators.
The positive effect of anticholinergics is primarily manifested at the level of the trachea and large bronchi

In COPD patients, inhalation forms of anticholinergics are usually used - so-called quaternary ammonium compounds, which poorly penetrate the mucous membrane of the respiratory tract and practically do not cause systemic side effects. The most common of these are ipratropium bromide (atrovent), oxytropium bromide, ipratropium iodide, tiotropium bromide, which is used primarily in metered aerosols.

The bronchodilating effect begins 5-10 minutes after inhalation, reaching a maximum in about 1-2 hours. The duration of the action of ipratropium iodide is 5-6 h, ipratropium bromide (atrovent) 6-8 h, oxytropium bromide 8-10 h and tiotropium bromide 10-12 h.

Side effects

Among the undesirable side effects of M-holinoblokatorov include dry mouth, sore throat, cough. Systemic side effects of blockade of M-cholinergic receptors, including cardiotoxic effects on the cardiovascular system, are practically absent.

Ipratropium bromide (atrovent) is available in the form of a dosed aerosol. Assign 2 inhalations (40 mcg) 3-4 times a day. Inhalation of atrovent even by short courses significantly improves bronchial patency. Especially effective in COPD is the long-term use of atrovent, which reliably reduces the number of exacerbations of chronic bronchitis, significantly improves oxygen saturation (SaO2) in the arterial blood, normalizes sleep in patients with COPD.

In COPD of mild severity, it is permissible to prescribe the course of inhalation of atrovent or other M-holinolitikon, usually during periods of exacerbation of the disease, the duration of the course should not be less than 3 weeks. With COPD of moderate to severe severity, anticholinergics are used continuously. It is important that with prolonged therapy, the patient does not experience tolerance to taking the drug and tachyphylaxis.

Contraindications

M-holinoblokatory are contraindicated in glaucoma. Care should be taken when they are prescribed for patients with prostate adenoma

Selective beta2-adrenomimetics

Beta-2 adrenomimetics are rightfully considered to be the most effective bronchodilators, which are now widely used for the treatment of chronic obstructive bronchitis. We are talking about selective sympathomimetics, which selectively exert a stimulating effect on the beta2-adrenoreceptors of the bronchi and almost do not act on beta1-adrenergic receptors and alpha-receptors, only in a small amount present in the bronchi.

Alpha-adrenergic receptors are mainly determined in the smooth muscles of blood vessels, in the myocardium, CNS, spleen, platelets, liver and adipose tissue. In the lungs, a comparatively small number of them is located mainly in the distal parts of the respiratory tract. Stimulation of alpha-adrenergic receptors, in addition to pronounced reactions from the cardiovascular system, CNS and platelets, leads to an increase in the tone of the smooth muscles of the bronchi, an increase in the secretion of mucus in the bronchi and the release of histamine mast cells.

Beta1-adrenergic receptors are widely represented in the myocardium of the atria and ventricles of the heart, in the conducting system heart, liver, muscle and adipose tissue, in the blood vessels and almost absent in the bronchi. Stimulation of these receptors leads to a pronounced reaction from the cardiovascular system in the form of a positive inotropic, chronotropic and dromotropic effects in the absence of any local response from the respiratory tract.

Finally, beta2-adrenergic receptors are found in the smooth muscles of blood vessels, uterus, adipose tissue, as well as in the trachea and bronchi. It should be emphasized that the density of beta2-adrenergic receptors in the bronchial tree significantly exceeds the density of all distal adrenoreceptors. Stimulation of beta2-adrenergic receptors with catecholamines is accompanied by:

relaxation of the smooth muscles of the bronchi;
a decrease in histamine release by mast cells;
activation of mucociliary transport;
stimulation of epithelial cell production of bronchial relaxation factors.

Depending on the ability to stimulate alpha, beta1 or beta2-adrenergic receptors, all sympathomimetics are divided into:

universal sympathomimetics, affecting both alpha- and beta-adrenoreceptors: epinephrine, ephedrine;
nonselective sympathomimetics, stimulating both beta1 and beta2-adrenergic receptors: isoprenaline (Novorin, isadrin), orciprenaline (alupeptin, astomopent) hexaprenaline (ipradol);
selective sympathomimetics, selectively acting on beta2-adrenoreceptors: salbutamol (ventolin), fenoterol (berotek), terbutaline (bricanil), and some prolonged forms.

At present, for the treatment of chronic obstructive bronchitis, universal and nonselective sympathomimetics are practically not are used because of a large number of side effects and complications due to their pronounced alpha and / or beta1 activity

The currently widely used selective beta2-adrenomimetics hardly cause serious complications from the cardiovascular system and the central nervous system (tremor, headache, tachycardia, rhythm disturbances, arterial hypertension, etc.), characteristic of nonselective and all the more universal sympathomimals Nevertheless, it should be borne in mind that the selectivity of various beta2-adrenomimetics is relative and does not completely exclude beta1-activity.

All selective beta2-adrenomimetics are divided into short and long-acting drugs.

Short-acting medicines include salbutamol (ventolin, fenoterol (berotek), terbutaline (bricanil), etc. Preparations of this group are administered by inhalation and are considered a means of choice mainly for relief of attacks of acutely occurring bronchial obstruction (for example, in patients with bronchial asthma) and the treatment of chronic obstructive bronchitis. Their action begins 5-10 minutes after inhalation (in some cases before), the maximum effect is manifested in 20-40 minutes, the duration of the action is 4-6 hours.

The most common drug of this group is salbutamol (ventolin), which is considered one of the safest beta-adrenomimetics. Drugs are more often used by inhalation, for example, using a spinner, in a dose of 200 mm no more than 4 times a day. Despite its selectivity, even with the inhalation application of salbutamol, some patients (about 30%) experience undesirable systemic reactions in the form of tremors, palpitations, headaches, and the like. This is because most of the drug is deposited in the upper parts respiratory tract, is swallowed by the patient and absorbed into the blood in the gastrointestinal tract, causing the described systemic reactions. The latter, in turn, are related to the presence of minimal reactivity in the preparation.

Fenoterol (berotek) has a somewhat greater activity compared with salbutamol and a longer half-life. However, its selectivity is about 10 times lower than salbutamol, which explains the poor tolerability of this drug. Fenoterol is administered in the form of metered-dose inhalations of 200-400 μg (1-2 breaths) 2-3 times a day.

Side effects are observed with prolonged use of beta2-adrenomimetics. These include tachycardia, extrasystole, increased episodes of angina in patients with IHD, elevation of systemic arterial pressure, and others caused by incomplete selectivity of drugs. Long-term use of these drugs leads to a decrease in the sensitivity of beta2-adrenergic receptors and the development of their functional blockade, which can lead to an exacerbation of the disease and a sharp decrease in the effectiveness of previously conducted treatment of chronic obstructive bronchitis. Therefore, COPD patients are recommended, if possible, only sporadic (non-regular) use of drugs of this group.

Long-acting beta2-adrenomimetics include formoterol, salmeterol (sulfur), saltos (salbutamol with sustained release), and others. The prolonged effect of these drugs (up to 12 hours after inhalation or oral administration) is due to their accumulation in the lungs.

In contrast to the short-acting beta2-agonists, the listed long-acting drugs appear to be slow, so they are used primarily for long-term (or course) bronchodilator therapy for the prevention of progression of bronchial obstruction and exacerbation of the disease. According to some researchers, beta2-adrenomimetics of prolonged action also have an anti-inflammatory effect, since they reduce vascular permeability, prevent activation of neutrophils, lymphocytes, macrophage inhibiting the release of histamine, leukotrienes and prostaglandins from mast cells and eosinophils. A combination of long-acting beta2-adrenomimetics with inhaled glucocorticoids or other anti-inflammatory drugs is recommended.

Formoterol has a significant duration of bronchodilator action (up to 8-10 hours), including with inhalation. The drug is administered by inhalation in a dose of 12-24 μg 2 times a day or in tableted form at 20, 40 and 80 μg.

Volmax (salbutamol SR) is a prolonged preparation of salbutamol intended for reception per os. The drug is prescribed 1 tablet (8 mg) 3 times a day. The duration of action after a single dose of 9 hours.

Salmeterol (sulfur) also refers to relatively new prolonged beta2-sympathomimetics with a duration of 12 hours. The strength of bronchodilating effect exceeds the effects of salbutamol and fenoterol. The distinctive features of the preparation are very high selectivity, which is more than 60 times greater such as salbutamol, which provides a minimal risk of adverse systemic effects.

Salmeterol is prescribed in a dose of 50 mcg 2 times a day. In severe bronchial obstructive syndrome, the dose can be increased 2-fold. There is evidence that prolonged therapy with salmeterol leads to a significant decrease in the occurrence of exacerbations of COPD.

Tactics of the use of selective beta2-adrenomimetics in patients with COPD

Considering the expediency of the use of selective beta2-adrenomimetics for the treatment of chronic obstructive bronchitis, several important circumstances should be emphasized. Despite the fact that the bronchodilators of this group are now widely prescribed in the treatment of COPD patients and are regarded as drugs of basic therapy, patients should be noted that in actual clinical practice, their use encounters significant, sometimes insurmountable, difficulties, associated, first of all, with the presence of most of them expressed side effects. In addition to cardiovascular disorders (tachycardia, arrhythmias, a tendency to elevation of systemic arterial pressure, tremor, headaches, etc.), these drugs with prolonged use can aggravate arterial hypoxemia, as they contribute to improving the perfusion of poorly ventilated areas of the lungs and further impair ventilation-perfusion relationships. Long-term use of beta2-adrenomimetics is also accompanied by hypocapnia due to redistribution potassium inside and outside the cell, which is accompanied by an increase in the weakness of the respiratory muscles and deterioration of ventilation.

However, the main disadvantage of prolonged use of beta2-addressymmetrics in patients with bronchial obstructive syndrome is the regular formation of tachyphylaxis - a decrease in strength and duration bronchodilator effect, which over time can lead to ricochet bronchoconstriction and a significant decrease in the functional parameters characterizing the patency of the airways. In addition, beta2-adrenomimetics increase the hyperactivity of the bronchial tubes to histamine and methacholine (acetylcholine), thus causing an exacerbation of parasympathetic bronchoconstrictor influences.

From what has been said, several important conclusions in practical terms follow.

Given the high efficiency of beta2-adrenomimetics in the relief of acute episodes of bronchial obstruction, their use in patients with COPD is shown, especially at the time of exacerbation of the disease.
It is advisable to use modern, prolonged highly selective sympathomimetics, for example salmeterol (sulfur), although this does not exclude the possibility of sporadic (non-regular) administration of short-acting beta2-adrenomimetics (such as salbutamol).
Prolonged regular use of beta2-agonists as monotherapy in patients with COPD, especially elderly and senile, can not be recommended as a permanent basic therapy.
If patients with COPD continue to need to reduce the reversible component of bronchial obstruction, and monotherapy with traditional M-anticholinergics is not completely effective, it is advisable to switch to the use of modern combined bronchodilators, including M-cholinergic inhibitors in combination with beta2-adrenomimetics.

Combined bronchodilators

In recent years, combined bronchodilators have become increasingly used in clinical practice, including long-term therapy for COPD patients. The bronchodilator effect of these drugs is provided by stimulation of beta2-adrenergic receptors peripheral bronchi and inhibition of cholinergic receptors of large and medium bronchi.

Berodual is the most common combined aerosol preparation containing anticholinergic ipratropium bromide (atrovent) and beta2-adrenostimulator fenoterol (berotek). Each dose of berodual contains 50 μg of fenoterol and 20 μg of atrovent. This combination allows you to get a bronchodilator effect with a minimal dose of fenoterol. The drug is used both for relief of acute attacks of suffocation, and for the treatment of chronic obstructive bronchitis. The usual dose is 1-2 doses of aerosol 3 times a day. The beginning of the drug - after 30 seconds, the maximum effect - after 2 hours, the duration of the action does not exceed 6 hours.

Combinent is the second combined aerosol preparation containing 20 μg. cholinolytics of ipratropium bromide (atrovent) and 100 μg of salbutamol. Combine used for 1-2 doses of the drug 3 times a day.

In recent years, the positive experience of combined use of anticholinergics with beta2-agonists of prolonged action (for example, atrovent with salmeterol) began to accumulate.

This combination of bronchodilators of the two described groups is very common, because combined drugs have a more potent and persistent bronchodilator effect than both components alone.

Combined preparations containing M-cholinergic inhibitors in combination with beta2-adrenomimetics, are characterized by a minimal risk of side effects due to a relatively small dose of sympathomimetic. These advantages of combined drugs allow us to recommend them for long-term basic bronchodilator therapy of COPD patients with insufficient effectiveness of monotherapy with atrovent.

Derivatives of methylxanthines

If the reception of holiolytic or combined bronchodilators is not effective, to treatment of chronic Obstructive bronchitis can be supplemented with methylxanthine-type drugs (theophylline, etc.). These drugs have been used successfully for many decades as effective medicines for the treatment of patients with bronchial obstructive syndrome. Theophylline derivatives have a very wide spectrum of action, which goes far beyond the bronchodilator effect alone.

Theophylline inhibits phosphodiesterase, resulting in the accumulation of cAMP in smooth muscle cells of the bronchi. This facilitates the transport of calcium ions from myofibrils to the sarcoplasmic reticulum, which is accompanied by relaxation of smooth muscles. Theophylline also blocks the purine receptors of the bronchi, eliminating the bronchoconstrictive effect of adenosine.

In addition, theophylline inhibits the degranulation of mast cells and the isolation of inflammatory mediators from them. It also improves renal and cerebral blood flow, increases diuresis, increases the strength and frequency of contractions heart, lowers pressure in a small circle of blood circulation, improves the function of the respiratory muscles and diaphragm.

Short-acting drugs from the theophylline group have a pronounced bronchodilator effect, they are used to arrest acute episodes of bronchial obstruction, for example, in patients with bronchial asthma, as well as for prolonged therapy of patients with chronic bronchial obstructive syndrome.

Euphyllin (compound theophyllip and ethylenediamine) is released in ampoules of 10 ml of a 2.4% solution. Euphyllin is administered intravenously in 10-20 ml of isotonic sodium chloride solution for 5 minutes. With rapid administration, it is possible to drop blood pressure, dizziness, nausea, tinnitus, palpitations, redness of the face and a feeling of heat. Introduced intravenously, euphyllin acts for about 4 hours. With intravenous drip introduction, a longer duration of action (6-8 hours) can be achieved.

The theophyllines of prolonged action in recent years are widely used for the treatment of chronic obstructive bronchitis and bronchial asthma. They have significant advantages over short-range theophyllines:

decreases the frequency of medication;
the accuracy of dosing of drugs increases;
provides a more stable therapeutic effect;
prevention of asthma attacks in response to physical stress;
drugs can be successfully used to prevent night and morning attacks of suffocation.

Prolonged theophyllines have a bronchodilator and anti-inflammatory effect. They largely suppress both the early and late phases of the asthmatic reaction that occur after the inhalation of the allergen, and also have an anti-inflammatory effect. Long-term treatment of chronic obstructive bronchitis with prolonged theophyllines effectively controls the symptoms of bronchial obstruction and improves lung function. Since the drug is released gradually, it has a longer duration of action, which is important for the treatment of night symptoms of the disease that persist, despite the treatment of chronic obstructive bronchitis with anti-inflammatory drugs.

Prolonged theophylline preparations are divided into 2 groups:

Preparations of the 1st generation are active for 12 hours; they are prescribed 2 times a day. These include: theodore, theotard, theopek, durofillin, ventax, theogard, teobid, slobid, euphyllin SR, and others.
Preparations of the second generation last about 24 hours; they are prescribed once a day. These include: theodur-24, uniphil, dilatran, euphylong, phylocontin, and others.

Unfortunately, theophyllines act in a very narrow range of therapeutic concentrations of 15 μg / ml. With increasing doses, a large number of side effects occur, especially in elderly patients:

gastrointestinal disorders (nausea, vomiting, anorexia, diarrhea, etc.);
cardiovascular disorders (tachycardia, rhythm disturbances, up to ventricular fibrillation);
disorders of the central nervous system (tremor of hands, insomnia, agitation, convulsions, etc.);
metabolic disorders (hyperglycemia, hypokalemia, metabolic acidosis, etc.).

Therefore, when using methylxanthines (short and prolonged action), it is recommended to determine the level of theophylline in the blood at the beginning of the treatment of chronic obstructive bronchitis, every 6-12 months and after changing doses and preparations.

The most rational sequence of bronchodilators in COPD patients is as follows:

Sequence and volume of bronchodilator treatment of chronic obstructive bronchitis

With slightly expressed and inconsistent symptoms of bronchial obstruction syndrome:
- inhalation M-holinolitiki (atrovent), mainly in the phase of exacerbation of the disease;
- if necessary, inhaled selective beta2-adrenomimetics (sporadically - during exacerbations).
With more consistent symptoms (mild and moderate severity):
- inhalation M-holinolitiki (atrovent) constantly;
- with insufficient effectiveness - combined bronchodilators (fermented, combinent) constantly;
- with insufficient effectiveness - addition of methylxanthine.
At low efficiency of treatment and progression of bronchial obstruction:
- to consider the replacement of berodual or a combination with the use of a highly selective beta2-adrenomimetic of prolonged action (salmeterol) and combination with M-cholinolytics;
- Modify the methods of drug delivery (spencers, nebulayers),
- continue taking methylxanthines, theophylline parenterally.

Mucolytic and mucoregulatory agents

Improvement of bronchial drainage is the most important task of treating chronic obstructive bronchitis. To this end, any possible effects on the body, including non-drug treatments, should be considered.

A plentiful warm drink helps to reduce the viscosity of sputum and increase the sol-layer of bronchial mucus, which facilitates the functioning of the ciliated epithelium.
Vibratory massage of the chest 2 times a day.
Positional drainage of bronchi.
Expectorants with an emetic-reflex action mechanism (herb of thermopsis, terpinhydrate, root Ipecacuanas, etc.), stimulate the bronchial glands and increase the amount of bronchial secretion.
Bronchodilators, improving the drainage of bronchi.
Acetylcysteine (flumucin), viscosity of sputum due to rupture of disulfide bonds of mucopolysaccharides of sputum. It has antioxidant properties. Increases the synthesis of glutathione, which takes part in detoxification processes.
Ambroxol (lazolvan) stimulates the formation of a tracheobronchial secretion of reduced viscosity due to depolymerization acid mucopolysaccharides of bronchial mucus and the production of neutral mucopolysaccharides by goblet cells. It increases the synthesis and secretion of the surfactant and blocks the disintegration of the latter under the influence of unfavorable factors. Strengthens the penetration of antibiotics into the bronchial secretion and bronchial mucosa, increasing the effectiveness of antibiotic therapy and shortening its duration.
Carbocysteine normalizes the quantitative ratio of acidic and neutral sialomucines to bronchial secretions, reducing the viscosity of sputum. Promotes regeneration of the mucous membrane, reducing the number of goblet cells, especially in terminal bronchi.
Bromhexine is a mucolytic and a mucoregulant. Stimulates the production of surfactant.

Anti-inflammatory treatment of chronic obstructive bronchitis

Since the formation and progression of chronic bronchitis is based on the local inflammatory response of the bronchi, the success of the treatment of patients, including patients with COPD, is primarily determined by the possibility of inhibition of the inflammatory process in the airways.

Unfortunately, traditional non-steroidal anti-inflammatory drugs (NSAIDs) are not effective in patients with COPD and can not stop the progression of clinical manifestations of the disease and a steady decline in FEV1. It is suggested that this is due to the very limited, one-sided effect of NSAIDs on the metabolism of arachidonic acid, which is the source of the most important mediators of inflammation - prostaglandins and leukotrienes. As is known, all NSAIDs, by inhibiting cyclooxygenase, reduce the synthesis of prostaglandins and thromboxanes. At the same time, activation of the cyclooxygenase pathway of arachidonic acid metabolism increases the synthesis of leukotrienes, which is probably the most important cause of ineffectiveness of NSAIDs in COPD.

Another mechanism is the anti-inflammatory effect of glucocorticoids, which stimulate the synthesis of protein that inhibits the activity of phospholipase A2. This leads to a restriction of the production of the source of prostaglandins and leukotrienes, arachidonic acid, which explains the high anti-inflammatory activity of glucocorticoids in various inflammatory processes in the body, including COPD.

Currently, glucocorticoids are recommended for the treatment of chronic obstructive bronchitis, in which the use of other methods of treatment has proved ineffective. Nevertheless, only 20-30% of patients with COPD manage to improve bronchial patency with these drugs. More often we have to abandon the systematic use of glucocorticoids due to their numerous side effects.

To solve the question of the advisability of prolonged continuous use of corticosteroids in patients with COPD, it is suggested to perform a trial therapy: 20-30 mg / day. at the rate of 0.4-0.6 mg / kg (according to prednisolone) for 3 weeks (taking oral corticosteroids). The criterion for the positive effect of corticosteroids on bronchial patency is the increase in the response to bronchodilators in the bronchodilation test at 10% of the proper values of OPB1 or an increase in FEV1 of at least 200 ml. These indicators can be the basis for long-term use of these drugs. At the same time, it should be emphasized that at present there is no generally accepted point of view on the tactics of using systemic and inhaled corticosteroids in COPD.

In recent years, for the treatment of chronic obstructive bronchitis and certain inflammatory diseases of the upper and lower respiratory tract with The new anti-inflammatory drug fenspiride (erespal), which effectively acts on the mucous membrane of the respiratory tract, is used successfully. The drug has the ability to suppress the release of histamine from mast cells, reduce leukocyte infiltration, reduce exudation and release of thromboxanes, as well as permeability of blood vessels. Like glucocorticoids, fepspiride inhibits the activity of phospholipase A2 by blocking the transport of calcium ions necessary for the activation of this enzyme.

Thus, fepspiride reduces the production of many mediators of inflammation (prostaglandins, leukotrienes, thromboxanes, cytokines, etc.), having a pronounced anti-inflammatory effect.

Fenspiride is recommended for both acute exacerbations and for long-term chronic treatment of chronic obstructive bronchitis, being a safe and very well tolerated drug. When the disease worsens, the drug is prescribed in a dose of 80 mg twice a day for 2-3 weeks. With a stable course of COPD (the stage of relative remission), the drug is prescribed in the same dosage for 3-6 months. There are reports of good tolerability and high efficacy of fenspiride for continuous treatment for at least 1 year.

Correction of respiratory failure

Correction of respiratory failure is achieved through the use of oxygen therapy and training of the respiratory musculature.

Indications for long-term (up to 15-18 hours per day) low-flux (2-5 liters per minute) of oxygen therapy both in hospital and at home are:

decrease in PaO2 arterial blood <55 mm Hg. p.
reduction of SaO2 <88% at rest or <85% with a standard sample with 6-minute walking;
a decrease in PaO2 to 56-60 mm Hg. Art. in the presence of additional conditions (edema due to right ventricular failure, signs of the pulmonary heart, the presence of P-pulmonale on the ECG or erythrocytosis with a hematocrit above 56%)

For the purpose of training respiratory muscles in COPD patients, various schemes of individually selected respiratory gymnastics are prescribed.

Intubation and ventilation is indicated in patients with severe progressive respiratory failure, increasing arterial hypoxemia, respiratory acidosis, or signs of hypoxic brain damage.

Antibacterial treatment of chronic obstructive bronchitis

In the period of stable course of COPD antibiotic therapy is not indicated. Antibiotics are prescribed only during the exacerbation of chronic bronchitis in the presence of clinical and laboratory signs of purulent endobronchitis, accompanied by an increase in body temperature, leukocytosis, symptoms of intoxication, an increase in sputum and the appearance of purulent elements in it. In other cases, even the period of exacerbation of the disease and exacerbation of bronchial obstructive syndrome, the use of antibiotics in patients with chronic bronchitis has not been proven.

It has already been mentioned above that the most frequent exacerbations of chronic bronchitis are caused by Streptococcus pneumonia, Haemophilus influenzae, Moraxella catanalis, or the association of Pseudomonas aeruginosa with morocell (in smokers). In elderly, weakened patients with a severe course of COPD, staphylococci, Pseudomonas aeruginosa and Klebsiella may predominate in bronchial contents. On the contrary, in patients of a younger age, intracellular (atypical) pathogens: chlamydia, legionella, or mycoplasma, often become the causative agent of the inflammatory process in the bronchi.

Treatment of chronic obstructive bronchitis usually begins with the empirical administration of antibiotics, taking into account the spectrum of the most frequent pathogens of exacerbations of bronchitis. Selection of an antibiotic based on the sensitivity of flora in vitro is carried out only if the empirical antibiotic therapy is ineffective.

For first-line drugs with exacerbation of chronic bronchitis include aminopenicillins (ampicillin, amoxicillin), active against hemophilic rods, pneumococci and mora seksely. It is advisable to combine these antibiotics with inhibitors of ß-lactamases, (for example, with clavulonic acid or sulbactam) which provides a high activity of these drugs to lactamase-producing strains of hemophilic rod and moraxella. Recall that aminopenicillins are not effective against intracellular pathogens (chlamydia, mycoplasmas and rickettsia).

Cephalosporins of II-III generation belong to broad-spectrum antibiotics. They are active against not only gram-positive, but also gram-negative bacteria, including haemophilic rod strains producing ß-lactamase. In most cases, the drug is administered parenterally, although with mild to moderate severity of exacerbation, oral cephalosporins of the second generation (for example, cefuroxime) may be used.

Macrolides. High efficacy for respiratory infections in patients with chronic bronchitis have new macrolides, in particular azithromycin, which can be taken only once a day. Assign a three-day course of azithromycin at a dose of 500 mg per day. New macrolides act on pneumococci, haemophilus rod, moraxella, and intracellular pathogens.

Fluoroquinolones are highly effective against gram-negative and gram-positive microorganisms, especially "respiratory" fluoroquinolones (levofloxacin, digitaloxacin, etc.) - drugs with increased activity against pneumococci, chlamydia, mycoplasmas.

Tactics of treatment of chronic obstructive bronchitis

According to the recommendations of the National Federal Program Chronic Obstructive Lung Disease, two regimens treatment of chronic obstructive bronchitis: treatment of exacerbation (maintenance therapy) and treatment of exacerbation of COPD.

In the stage of remission (without exacerbation of COPD), bronchodilator therapy is of particular importance, emphasizing the need for an individual choice of bronchodilators. In this case, in the first stage of COPD (mild severity), the systematic use of bronchodilators is not foreseen, and only high-speed M-anticholinergics or beta2-agonists are recommended as needed. Systematic use of bronchodilators is recommended starting with the second stage of the disease, with preference given to long-acting drugs. Annual anti-influenza vaccination is recommended at all stages of the disease, the effectiveness of which is high enough (80-90%). Attitude to expectorants outside the exacerbation - restrained.

Currently, there is no medication that can affect but the main significant feature of COPD: the gradual loss of pulmonary functions. Medications in COPD (in particular, bronchodilators) only alleviate the symptoms and / or reduce the incidence of complications. In severe cases, a special role is played by rehabilitation measures and prolonged low-intensity oxygen therapy, while long-term use systemic glucocorticosteroids should be avoided, if possible, by replacing them with inhaled glucocorticoids or by taking fenspiride

With exacerbation of COPD, regardless of its cause, the significance of various pathogenetic mechanisms in the formation of the symptom-complex of the disease increases infectious factors, which often determines the need for antibacterial agents, increases respiratory insufficiency, possible decompensation of the pulmonary heart. The main principles of treatment for exacerbation of COPD are the intensification of bronchodilating therapy and the appointment of antibacterial drugs according to indications. Intensification of bronchodilating therapy is achieved by both increasing doses, and by modifying the methods of drug delivery, using spacers, nebulizers, and with severe obstruction - intravenous administration of drugs. Expanded indications for the appointment of corticosteroids, it becomes preferable to their systemic appointment (oral or intravenous) in short courses. In severe and moderate exacerbations, it is often necessary to use methods for correcting high blood viscosity - hemodilution. Treatment of decompressed pulmonary heart is performed.

Chronic obstructive bronchitis - treatment with folk methods

It helps to relieve chronic obstructive bronchitis treatment with some folk remedies. Thyme, the most effective herb for fighting bronchopulmonary diseases. It can be used in the form of tea, decoction or infusion. To prepare medicinal herbs can be at home, growing it on the beds of your garden or, in order to save time, buy a finished product in the pharmacy. How to brew, insist or boil the thyme - indicated on the chemist's packaging.

Tea from thyme

If there is no such instruction, then you can use the simplest recipe - to make tea from thyme. To do this, take 1 tablespoon chopped herb thyme, put in a porcelain teapot and pour boiling water. Drink 100 ml of this tea 3 times a day, after a meal.

Decoction of pine buds

Perfectly removes stagnation in the bronchi, reduces the number of wheezing in the lungs by the fifth day of use. Prepare such a decoction is not difficult. Pine kidneys do not need to be collected by themselves, they are available in any pharmacy.

It is better to give preference to the manufacturer who took care to indicate on the packaging the recipe of preparation, and also all the positive and negative actions that can occur in people taking a decoction of pine buds. Pay attention that pine buds should not be taken to people with blood diseases.

Magical root of licorice

Medicinal potions can be presented in the form of an elixir or breast-feeding. Both are purchased in ready-made form in the pharmacy. Elixir is taken by drops, 20-40 per hour before meals 3-4 times a day.

Breast collection is prepared in the form of infusion and is taken half a glass 2-3 times a day. Take infusion should be before eating, so that the medicinal action of the herbs could enter into force and have time to "get" to the problem organs with the blood flow.

Will allow to defeat chronic obstructive bronchitis treatment with drugs and modern and traditional medicine in the compartment with perseverance and belief in complete recovery. In addition, you should not write off a healthy lifestyle, alternation of work and rest, as well as the intake of vitamin complexes and high-calorie food.

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Chronic obstructive bronchitis and COPD

Chronic obstructive bronchitis is a diffuse inflammatory disease of the bronchi characterized by an early lesion of respiratory structures of the lung and leading to the formation of bronchial obstructive syndrome, diffuse lung emphysema and progressive pulmonary ventilation disorder and gas exchange, which are manifested by coughing, shortness of breath and sputum discharge, not associated with other diseases of the lungs, heart, blood system, etc.

Thus, unlike chronic non-obstructive bronchitis, the key mechanisms that determine the characteristics of the course of chronic non-obstructive bronchitis are:

Involvement in the inflammatory process is not only large and medium, but also small bronchi, as well as alveolar tissue.
The development as a result of this bronchoobstructive syndrome, consisting of irreversible and reversible components.
Formation of secondary diffuse emphysema of the lungs.
Progressive violation of ventilation and gas exchange, leading to hypoxemia and hypercapnia.
Formation of pulmonary arterial hypertension and chronic pulmonary heart (CHS).

If at the initial stage of the formation of chronic obstructive bronchitis the mechanisms of damage to bronchial mucosa resemble those in chronic non-obstructive bronchitis (violation of mucociliary transport, hypersecretion of mucus, seeding of mucous pathogenic microorganisms and initiation of humoral and cellular factors of inflammation), then the further development of the pathological process with chronic obstructive bronchitis and chronic non-obstructive bronchitis is fundamentally different from each other. The central link in the formation of progressive respiratory and pulmonary heart failure, characteristic of chronic obstructive bronchitis, is a centroacinar pulmonary emphysema that occurs as a result of an early lesion of respiratory parts of the lungs and an increase in bronchial obstruction.

Recently, to denote such a pathogenetically conditioned combination of chronic obstructive bronchitis and emphysema of the lung with progressive The term "chronic obstructive pulmonary disease (COPD)" is recommended for respiratory failure, which, according to the latest version of the international classification of diseases (ICD-X), it is recommended to use in clinical practice instead of the term "chronic obstructive bronchitis". According to many researchers, this term largely reflects the essence of the pathological process in the lungs with chronic obstructive bronchitis in the late stages of the disease.

Chronic obstructive pulmonary disease (COPD) is a collective concept that combines chronic inflammatory diseases of the respiratory system with a predominant lesion of the distal divisions respiratory tract with irreversible or partially reversible bronchial obstruction, which are characterized by constant progression and increasing chronic respiratory failure.. The most common causes of COPD include chronic obstructive bronchitis (in 90% of cases), bronchial asthma severe (about 10%), pulmonary emphysema, which is due to a deficiency of alpha1-antitrypsin (about 1%).

The main sign on which the COPD group is formed is the steady progression of the disease with the loss of the reversible component of bronchial obstruction and the growing phenomena of respiratory failure, the formation of centroacinar pulmonary emphysema, pulmonary arterial hypertension and pulmonary heart. At this stage of COPD development, the nosological affiliation of the disease is indeed leveled.

In the United States and Great Britain, the term "Chronic obstructive pulmonary disease" (COPD - chronic obstructive pulmonary disease; in the Russian transcription of COPD) also includes cystic fibrosis, obliterans bronchiolitis and bronchiectasis. Thus, at present, there is a clear inconsistency in the definition of COPD in the world literature.

Nevertheless, despite the similarity of the clinical picture of these diseases at the final stage of the disease development, at the early stages of the formation of these diseases it is advisable to preserve their nosological independence, since the treatment of these diseases has its own specific characteristics (especially cystic fibrosis, bronchial asthma, bronchiolitis, etc.).

There are still no reliable and accurate epidemiological data on the prevalence of this disease and the mortality of COPD patients. This is mainly due to the uncertainty of the term "COPD" that existed for many years. It is known that at present in the United States the prevalence of COPD among people over 55 is almost 10%. From 1982 to 1995 the number of COPD patients increased by 41.5%. In 1992, the mortality rate from COPD in the United States was 18.6 per 10, 00 population and was the fourth leading cause of death in that country. In European countries, COPD mortality ranges from 2.3 (Greece) to 41.4 (Hungary) per 100 000 population. In the UK, approximately 6% of men's deaths and 4% of women's deaths are due to COPD. In France, 1, 00 deaths per year are also associated with COPD, representing 2.3% of all deaths in this country.

In Russia, the prevalence of COPD in 1990-1998, according to official statistics, reached an average of 16 per 1000 population. Mortality from COPD in the same years was from 11.0 to 20.1 per 100 000 population. According to some data, COPD reduces the natural life expectancy by an average of 8 years. COPD leads to a relatively early loss of work capacity of patients, and most of them disability occurs approximately 10 years after the diagnosis of COPD.

ICD-10 code J44.8 Other specified chronic obstructive pulmonary disease J44.9 Chronic obstructive pulmonary disease, unspecified

Risk factors for chronic obstructive bronchitis

The main risk factor for COPD in 80-90% of cases is tobacco smoking. Among "smokers" chronic obstructive pulmonary disease develops 3-9 times more often than in non-smokers. The mortality from COPD determines the age at which smoking was started, the number of cigarettes smoked and the duration of smoking. It should be noted that the problem of smoking is especially relevant for Ukraine, where the prevalence of this harmful habit is 60-70% among men and 17-25% among women.

Chronic obstructive bronchitis - Causes and pathogenesis

Symptoms of chronic obstructive bronchitis

The clinical picture of COPD consists of a different combination of several interrelated pathological syndromes.

For COPD, a slow progressive progression of the disease is characteristic, which is why most patients turn to the doctor late, at the age of 40-50 years, when there are already quite pronounced clinical signs of chronic inflammation of bronchi and bronchial obstructive syndrome in the form of cough, shortness of breath and reduced tolerance for daily exercise.

Chronic obstructive bronchitis - Symptoms

What's bothering you?

Coughing in the lungs Shortness of breath

Diagnosis of chronic obstructive bronchitis

At the initial stages of the development of the disease, careful examination of the patient, evaluation of anamnestic data and possible factors Risk During this period, the results of objective clinical research, as well as data from laboratory and instrumental methods, are of little informative value. Over time, when the first signs of bronchial obstructive syndrome and respiratory failure appear, objective Clinico-laboratory and instrumental data are becoming increasingly diagnostic. Moreover, an objective assessment of the stage of the development of the disease, the severity of the course of COPD, the effectiveness of the therapy is possible only with the use of modern research methods.

Chronic obstructive bronchitis - Diagnosis

What it is necessary to survey?

Bronchi Lungs

How to inspect?

Bronchoscopy Examination of bronchi and trachea X-ray of lungs Examination of respiratory (lung) organs Computed tomography of thorax

What tests are needed?

Sputum examination

Who to contact?

Pulmonologist

Treatment of chronic obstructive bronchitis

Treatment of COPD patients in most cases is an extremely difficult task. First of all, this is explained by the main regularity of the development of the disease - the steady progression of bronchial obstruction and respiratory failure due to inflammatory process and hyperreactivity of the bronchi and the development of persistent irreversible violations of bronchial patency, caused by the formation of obstructive pulmonary emphysema. In addition, the low efficiency of treatment for many COPD patients is due to their late referral to the doctor, when there are already signs of respiratory failure and irreversible changes in the lungs.

Nevertheless, modern adequate complex treatment of patients with COPD in many cases allows to reduce the rate of progression of the disease leading to an increase bronchial obstruction and respiratory failure to reduce the frequency and duration of exacerbations, improve performance and tolerance to physical exertion.

Chronic obstructive bronchitis - Treatment

In addition to treatment

Treatment of bronchitis Physiotherapy with bronchitis Obstructive bronchitis: treatment with folk remedies Treatment of obstructive bronchitis at adults Antibiotics at a bronchitis Antibiotics at a bronchitis at adults: when appoint or nominate, names Than to treat? Tavanik Daksas

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Chronic non-obstructive bronchitis - Causes and pathogenesis

Among patients with chronic non-obstructive bronchitis, approximately 80-90% are active smokers. And the number of cigarettes smoked per day and the total duration of smoking matter. It is believed that the most irritating effect on the mucous membrane is smoking cigarettes, and to a lesser extent - tubes or cigars.

The second most important risk factor for chronic non-obstructive bronchitis is a prolonged effect on the bronchial mucosa of volatile substances (pollutants) related to industrial and domestic air pollutants (silicon, cadmium, NO2, SO2, etc.). The implementation of these harmful factors also depends on the duration of the pathogenic effect on the mucosa, i.e. from the length of service or the length of residence in unfavorable conditions.

The third factor contributing to the emergence and maintenance of chronic inflammation of the bronchial mucosa is viral-bacterial airway infection: repeated acute tracheobronchitis, acute respiratory viral infection, pneumonia and other bronchopulmonary infections.

The most common disease is caused by:

respiratory viruses (respiratory syncytial virus, influenza viruses, adenoviruses, etc.);
Pneumococcus;
haemophilus influenzae;
moraxella;
mycoplasma;
chlamydia, and others.

For smokers, the most common association is the hemophilic rod and morocell.

Of particular importance is the viral infection. Repeated exposure of respiratory viruses to the epithelium of the bronchial mucosa results in focal dystrophy and death of ciliated cells. As a result, the sections that do not contain ciliated epithelium (the so-called "bald spots") are formed on the bronchial mucosa. It is in these places that the movement of the bronchial secretion in the direction of the oropharynx is interrupted, the bronchial secret accumulates and there is the possibility adhesion of conditionally pathogenic microorganisms (pneumococci, hemophilic rod, moraxella, etc.) to the damaged areas of the mucosa. Thus, a viral infection almost always promotes bacterial superinfection.

Infestation of the bronchial mucosa by microorganisms generally having a relatively low virulence leads, however, to the formation of a cascade of humoral and cellular factors that initiate and maintain chronic inflammation of the mucosa.

As a result, a diffuse inflammatory process (endobronchitis) is formed in the mucosa of large and medium bronchi. In this case, the thickness of the walls of the bronchi becomes uneven: areas of mucosal hypertrophy alternate with areas of its atrophy. Mucous bronchus is edematous, a moderate amount of mucous, mucopurulent or purulent sputum accumulates in the lumen of the bronchi. In most cases, there is an increase in tracheobronchial and bronchopulmonary lymph nodes. Peribronchial tissue is densified, and in some cases loses airiness.

Changes in the bronchi with simple (non-obstructive) bronchitis differ in the following features:

primary lesion of large and medium bronchi;
in most cases, relatively low activity of the inflammatory process in the bronchial mucosa;
absence of significant bronchial obstruction.

In addition to the listed main exogenous risk factors leading to the formation of chronic endobronchitis (smoking, exposure to volatile pollutants and viral-bacterial infection), in the emergence of chronic non-obstructive bronchitis are important so-called endogenous factors, which include:

male;
age over 40 years;
diseases of the nasopharynx with a violation of breathing through the nose;
changes in hemodynamics of the small circle of blood circulation, mainly in the microcirculation system (for example, in chronic heart failure);
insufficiency of the T-system of immunity and synthesis of IgA;
hyperreactivity of bronchial mucosa;
family propensity to bronchopulmonary diseases;
disturbance of functional activity of alveolar macrophages and neutrophils

The listed "endogenous" risk factors, and possibly some other "biological defects", do not belong to the number of obligatory (obligate) mechanisms of occurrence of endobronchitis, appear as important predisposing factors facilitating the pathogenic effect on the bronchial mucosa of tobacco smoke, volatile pollutants and viral-bacterial infection.

The main links of the pathogenesis of chronic non-obstructive bronchitis are:

Irritant and damaging effects on the mucosa of bronchial tubes of tobacco smoke, volatile pollutants of domestic or industrial nature, as well as repeated viral-bacterial infections.
Hyperplasia of goblet cells of bronchial glands, hyperproduction of bronchial secretion (hypercrinia) and deterioration of the rheological properties of mucus (discrinia).
Violation of mucociliary clearance, protective and purifying function of bronchial mucosa.
Focal dystrophy and death of ciliated cells with the formation of "bald spots".
Colonization of the damaged mucous membrane of the bronchi by microorganisms and initiation of a cascade of cellular and humoral factors of mucosal inflammation.
Inflammatory edema and the formation of areas of hypertrophy and atrophy of the mucosa.

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