Stages of treatment of bronchial asthma gina. Bronchial asthma: clinical guidelines, federal and international, in children (2016)

For those who have experienced asthma attacks, it is useful to know about GINA. So briefly called a group of specialists who since 1993 have been working on the diagnosis and treatment of this disease.

Its full name is Global Initiative for Asthma (“Global Initiative for Asthma”).

GINA explains what to do to the doctor, patient and family with bronchial asthma, and already in the new millennium introduced December 11, which reminds the whole world of this problem.

Medical science is constantly evolving. Research is being carried out that forms a new look at the causes of diseases.

From time to time, GINA publishes the document "Global treatment strategy and", for which the group members select the most relevant and most reliable materials on how bronchial asthma is diagnosed and treated.

They strive to make scientific advances accessible to medical professionals and ordinary people in all countries.

Definition of asthma according to GINA

According to GINA, asthma is a heterogeneous disease in which chronic inflammation develops in the airways.

Infection is not always the cause of inflammation. And this is just the case when a wide range of allergens and irritants can become its culprit.

The bronchi in this disease become overly sensitive. In response to irritation, they spasm, swell and become clogged with mucus. The lumen of the bronchi becomes very narrow, there are problems with breathing up to suffocation, which is fatal.

Classification of bronchial asthma according to GINA

At different people This disease manifests itself in different ways. Symptoms depend on age, lifestyle and individual characteristics of the organism.

For example, allergies play a separate role in the development of the disease. For some reason the system immune protection reacts to something that does not threaten the body.

But the allergic component is not detected in all patients. In women, asthma is not quite the same as in men.

The many faces of bronchial asthma prompted JINA specialists to classify its variants.

Classification of bronchial asthma according to GINA:

Allergic bronchial asthma manifests itself already in childhood. Boys usually get sick earlier than girls. Since allergies are associated with genetic characteristics, the child and his blood relatives may have different varieties. For example, atopic dermatitis, eczema, allergic rhinitis, allergy to food, medicines.
With no connection with allergies.
In women of mature age (in men this happens less often), bronchial asthma occurs with a late onset. With this option, allergies are usually absent.
After several years of illness, bronchial asthma may develop with a fixed violation of bronchial patency. With prolonged inflammation, irreversible changes develop in them.
Bronchial asthma on the background of obesity.

In the recommendations, special attention is paid to children. It also specifically refers to pregnant women, the elderly and obese patients, and those who smoke or have stopped smoking. A special group is made up of athletes and people who have. Onset in adulthood may indicate exposure to hazardous substances at work. There is already a serious question about changing jobs or professions.

Causes of the development of bronchial asthma and provoking factors

The mechanism of development of bronchial asthma is too complex to be triggered by only one factor. And while researchers still have many questions.

According to the GINA concept, genetic predisposition and influence play the main role in the occurrence of bronchial asthma. external environment.

Allergies, obesity, pregnancy and diseases of the respiratory system can start or exacerbate the disease.

Factors that provoke the appearance of symptoms of bronchial asthma have been identified:

physical exercise;
allergens of different nature. These can be dust mites, cockroaches, animals, plants, mold fungi, etc.;
irritation respiratory tract tobacco smoke, polluted or cold air, strong odors, industrial dust;
weather and climatic factors;
acute respiratory disease (cold, flu);
strong emotional arousal.

Verification of the diagnosis

When diagnosing, the doctor asks and examines the patient, and then prescribes an examination.

GINA has identified the characteristic symptoms of bronchial asthma. These are whistles and wheezing, a feeling of heaviness in the chest, shortness of breath, suffocation, coughing.

As a rule, there is not one, but several symptoms at once (two or more). They become stronger at night or immediately after sleep, provoked by the above factors.

They can go away on their own or under the influence of medications, and sometimes do not appear for weeks. A history of these symptoms and spirometry data help to distinguish bronchial asthma from similar diseases.

With bronchial asthma, exhalation becomes difficult and slows down. It is his strength and speed that is estimated by spirometry.

After maximum deep breath the doctor asks the patient to exhale sharply and forcefully, thus assessing the forced vital capacity (fVC) and forced expiratory volume (FEV1).

If the disease is not started, the bronchi often narrow, then expand. This is influenced by a huge number of factors, for example, the period of the course of the disease or the time of year.

Therefore, the FEV1 indicator may differ with each new examination. This should not be surprising, for asthma it is very typical.

Moreover, in order to assess the variability of this indicator, a test is carried out with a bronchodilator - a drug that dilates the bronchi.

There is also a peak expiratory flow rate (PEF), although it is less reliable. You can only compare the results of studies conducted using the same device, since the readings of different devices can vary greatly.

The advantage of this method is that with the help of a peak flowmeter, a person can independently assess the degree of narrowing of their bronchi.

Therefore, the signs most characteristic of bronchial asthma are considered to be a decrease in the ratio of FEV1 / fVC (less than 0.75 in adults and less than 0.90 in children) and FEV1 variability.

With spirometry, other tests may be performed: the exercise test and the bronchoprovocation test.

With young children, the situation is more complicated. Viral infections they also cause wheezing and coughing.

If these symptoms do not occur randomly, but are associated with laughter, crying, or physical activity, if they also occur when the child is sleeping, this is suggestive of bronchial asthma.

It is also more difficult for a child to perform spirometry, so for children, GINA provides for additional studies.

GINA Asthma Treatment

Unfortunately, it is impossible to completely cope with this disease. GINA recommendations for the treatment of bronchial asthma are aimed at prolonging life and improving its quality.

To do this, the patient must strive to control the course of bronchial asthma. The doctor not only prescribes medication, but also helps to adjust the lifestyle. He develops a plan of action for the patient in different situations.

As a result of successful treatment, a person returns to his favorite job or sport, women can give birth to a healthy child. Olympic champions, political leaders, media personalities lead an active busy life with this diagnosis.

GINA offers three types of drugs for the medical treatment of bronchial asthma:

inhaled non-hormonal agents relieve an asthma attack and prevent suffocation caused by physical exertion or other causes. They quickly expand the bronchi and allow you to restore breathing;
inhaled glucocorticosteroids - hormones that suppress inflammation. With this method of application, they are safer and do not cause serious complications;
additional drugs for severe course diseases.

Drug therapy consists of several steps. The more severe the disease, the higher the stage, the more drugs are prescribed and the higher their doses.

With a mild course, drugs are used only to eliminate an attack of suffocation; at subsequent stages, drugs from other groups are added to them.

Most medicines come in the form of aerosols. The doctor explains and shows how to properly use the medication devices. It happens that they give a weak effect precisely because of errors in application.

Without which treatment will not be effective

But the fight against the disease is not limited to medicines alone. A person needs to organize his life himself in such a way as to reduce the manifestations of the disease. The following measures will help in this:

smoking cessation, avoiding the society of smokers;
regular physical activity;
elimination of allergens and polluted air at work and at home;
caution when taking medications that can aggravate the course of bronchial asthma. Some people may have an intolerance to painkillers such as aspirin (non-steroidal anti-inflammatory drugs, or NSAIDs). The decision to take beta-blockers is made by the doctor, taking into account the situation and the individual characteristics of the patient;
breathing exercises;
healthy eating, a large number of vegetables and fruits in the diet;
body weight correction;
influenza vaccination in case of severe and moderate asthma;
bronchial thermoplasty. With a long course of the disease, the bronchial muscles hypertrophy. Bronchial thermoplasty removes part of the muscle layer, the lumen of the bronchi increases. This procedure allows you to reduce the frequency and dosage of inhaled glucocorticoids. It is held in several countries: USA, Germany, Israel;
emotional state management training;
allergen-specific immunotherapy. With allergen-specific immunotherapy, microdoses of the allergen are administered to the patient, gradually increasing the dosage. Such treatment should reduce sensitivity to this allergen in everyday life. Treatment is not suitable for everyone and should be done with caution.

It is important to evaluate symptom control. When a patient comes for a scheduled check-up, the doctor invites him to answer questions about his state of health over the past 4 weeks:

Whether there were symptoms of bronchial asthma during the day more than twice a week.
Do the manifestations of the disease bother you at night.
Are medications used to relieve an attack more than twice a week (does not include medications) emergency care before exercise).
Whether asthma limits normal activity.

The questions can be worded a little differently, but the main thing is to assess how the disease affects the person's daily life.

GINA Guidelines for Asthma Prevention

It is believed that there is a period of time during a woman's pregnancy and the first months of a child's life when environmental factors are able to trigger the mechanism for the development of the disease.

To reduce risks, GINA suggests the following asthma prevention actions:

the expectant mother needs to urgently stop smoking during pregnancy, and preferably before it, and refrain from cigarettes after childbirth;
if possible, do not resort to caesarean section;
breastfeeding is preferable;
do not use broad-spectrum antibiotics in the first year of a child's life unless absolutely necessary.

When it comes to exposure to allergens, not everything is clear. Dust mite allergens definitely cause the development of allergies. Research on allergens in pets has been inconsistent.

It is important to maintain a good psychological environment in the family. It always helps to cope with any diseases.

Summing up, we can say that the prevention of development comes down to the following points:

Quit smoking as soon as possible and keep others from smoking. Tobacco smoke not only maintains chronic inflammation in the airways, but, most dangerously, provokes asthma attacks. It can cause another disease - chronic obstructive pulmonary disease (COPD). The combination of both pathologies worsens the condition, and also complicates the diagnosis and selection of treatment;
avoid contact with allergens as much as possible;
avoid smoke, exhaust gases, cold air, strong odors;
get vaccinated against influenza in the absence of contraindications, try not to catch a cold;
choose the right medicines. Taking painkillers (NSAIDs) and beta-blockers is possible only in agreement with the doctor
regular practice of permitted sports, taking into account the recommendations of a doctor (prophylactic medication may be needed to prevent an attack of suffocation);

Finally

Bronchial asthma makes it difficult to fully enjoy the taste of life. It is dangerous because the complete absence of symptoms is suddenly replaced by an asthma attack, sometimes fatal.

V different countries it occurs in 1-18% of the population, often beginning in childhood.

This article provides only general information about the view of this international organization on bronchial asthma. Only a doctor can correctly recognize and prescribe treatment for each patient.

Bronchial asthma is a chronic respiratory disease. Inflammation is the root of the disease. resulting in hyperreactivity of the respiratory system.

The manifestations of bronchial asthma include a feeling of tightness in the chest both at night and in the morning.

There are special documents of scientific societies, which in a general and concise form contain recommendations for the detection and treatment of diseases. These guidance materials are designed to assist practitioners in the treatment of various diseases, including bronchial asthma.

Organization that solves the problem of bronchial asthma at the international level - this is GINA. The disease is incurable and occurs worldwide in people of all ages.

The organization has developed general rules treatment and, which are followed by physicians around the world. In 2016, an international structure presented a new report suggesting a way to get rid of the disease based on current best practice using clinical guidelines. The GINA plan is designed to be implemented in virtually any healthcare system

Latest GINA Updates

In 2016, the following were included in the GINA document:

hacking cough;
feeling of tightness in the chest;
wheezing;
sweating;
feeling of anxiety, panic;
dyspnea.

Also in 2016, the organization was created. The disease is divided into several phenotypes that differ according to the degree of manifestation and age of the patient. There are the following types:

Allergic. This phenotype is the most common. Compared to other types, it is the easiest to both identify and treat. For treatment, ICS - corticosteroid inhalation drugs are used.
Non-allergic. ICS drugs are not able to cure this type of asthma.
Asthma with belated onset. It is found mainly in mature women.
Bronchial asthma in obese patients.
A phenotype that is characterized by a syndrome of obstruction of the respiratory tract. Occurs as a result of frequent long treatment bronchial asthma.

Treatment

The main treatment for asthma is. There are five degrees of severity of the disease, for each of which a special treatment is indicated. In this case, the severity of the disease is determined by the degree of therapy used.

Attention! The effectiveness of therapy should be evaluated every six months. If asthma symptoms persist and the risk of exacerbation increases, then it is recommended to increase therapy by moving on to the next step.

If the threat decreases, and the patient's well-being improves within 3 months, then the volume of therapy should be reduced. In this case, the number of ICS is reduced from 25% to 50% every 3 months. However, for such a step you need to make sure total absence patient's respiratory dysfunction and be sure that there is no danger to health. It is not recommended to completely exclude ICS in order to avoid the threat of exacerbations.

In accordance with the stepwise approach, GINA has developed a treatment for each step:

At the first stage, beta-2 antagonists are used. These drugs are short-acting and are indicated for patients with mild disease. Asthma symptoms in such people appear less than twice a month and subside with appropriate treatment, but research on the safety of such treatment is still underway.
At the second stage are patients with high risk of exacerbations. They are advised to take reduced doses of ICS (inhaled glucocorticosteroids) and SABAs (short-acting beta2-agonists), if necessary, supplementing them with drugs that relieve asthmatic symptoms.
The third stage therapy involves taking low doses of ICS combined with LABA (long-acting beta2-agonists) and SABA. However, during exacerbation, this strategy is not effective.
On the fourth step it is recommended to combine medium and high doses of ICS, LABA and SABA focusing on the needs of the patient.
The fifth step requires the use of the anti-IgE drug Omalizumab. Such treatment is indicated for patients who have not been helped by therapy with maximum doses of inhaled drugs.

Thus, the main method of treatment is the use of ICS, in some cases in combination with LABA. Such therapy helps to quickly reduce inflammation.

Important! Currently, there are no drugs to completely get rid of bronchial asthma. However, there are medications that relieve symptoms and destroy the allergen.

There is also a scheme for the course of treatment in several stages. This scheme includes the following recommendations:

it is necessary to teach the patient basic self-help skills to apply them during the onset of symptoms of the disease;
required treatment of comorbidities and getting rid of bad habits;
attention should also be paid to non-drug therapy, for example, physical activity.

Bronchial asthma is the most common. At the same time, it is difficult to diagnose - asthma has symptoms similar to a cold.

Helps distinguish asthma from a cold temperature measurement- with asthma, its increase is not observed. Symptoms are preceded by:

discharge of watery mucus from the nose on waking in the morning, accompanied by sneezing;
severe dry cough a few hours after waking up;
the appearance of a wet and stronger cough during the day;
the manifestation of asthma symptoms after a day or several days, by this time the cough becomes paroxysmal.

The symptoms themselves include:

paroxysmal cough after sleep;
dyspnea;
intermittent breathing;
pressure in the chest;
difficult breathing;
dry cough when inhaling through the mouth;

Designed to prevent the development of allergies. For prevention, it is desirable to give preference breastfeeding and isolate the child from exposure to tobacco smoke.

The Russian medical community has its own strategies for the treatment of bronchial asthma. The document in which main approaches to the diagnosis and treatment of pathology, are "Federal clinical guidelines for the diagnosis and treatment of bronchial asthma. Basically, these recommendations coincide with the points of the GINA strategy.

Thus, the domestic document also notes stepwise approach to the treatment of the disease. Determination of the scope of therapy depends on the severity clinical manifestations asthma. Attention is drawn to checking the correct inhalation technique, clarifying the diagnosis and eliminating concomitant diseases. All these conditions are necessary to advance to the next stage of treatment. Factors should also be controlled. environment that have a significant impact on the effectiveness of therapy.

About diagnostics

Diagnosis of pathology in adults is based on the identification of relevant symptoms. Symptoms and degree of airway obstruction requires an accurate assessment. Thus, a complete and accurate clinical picture of the disease is obtained.

Those that increase the risk of asthma include:

choking, chest congestion and morning cough, wheezing;
symptoms during physical exertion, under the influence of allergens, low temperature;
the appearance of signs of illness after taking aspirin;
atopic diseases present in history;
hereditary factor.

There are also signs that reduce the risk of having the disease:

dizziness and darkening in the eyes;
regular normal test results chest;
productive cough that is chronic;
voice change;
manifestation of symptoms as a result of a cold;
heart diseases.

Bronchial asthma is chronic illness long-term nature, in the manifestation of which a significant role is played by the hereditary factor and exposure to allergens. The main goal of therapy is to control the disease. The correct drug treatment can only be prescribed by a specialist after a thorough diagnosis. However, in addition to medical treatment, it is important to pay attention and proper nutrition, moderate physical activity and environmental conditions.

Each patient with a diagnosis of bronchial asthma is registered in the clinic, where his medical card is located, which allows you to control the treatment of asthmatic attacks and keep statistics on changes in the patient's condition. The history of bronchial asthma is described in a special diary. It starts with a person's passport data, and contains information about the initial manifestations of the diagnosis, complaints, seizure frequency and diagnosis.

All medical records are kept in the archive of the hospital for another 25 years after discharge. Therefore, each new specialist can see a report on the work done by doctors who have previously treated the patient - a therapist, an allergist, a pulmonologist. For therapeutic procedures, the type of asthma is initially determined - allergic, non-allergic or mixed, and its severity.

Forms of bronchial asthma

Allergic bronchial asthma. Asthma in this form often develops from childhood, and is caused by the course of diseases such as atopic dermatitis or allergic rhinitis. Moreover, heredity in this case plays a significant role - if close relatives had asthma, then the risk of developing the disease in a child increases. Recognizing the allergic form of asthma is the easiest. Before starting treatment, induced sputum should be examined for airway inflammation. Patients with this disease phenotype have a good response to inhaled corticosteroids.

Non-allergic bronchial asthma. This phenotype can result from exposure to medications, as is the case with aspirin asthma. Also, the development of the disease can occur against the background of hormonal changes in the body of women, for example, during the bearing of a child.

To start adequate treatment for a mixed form of the disease, it is necessary to study the patient's complaints, learn about the time and conditions for the onset of the first attack. It is necessary to find out what medications were used to suppress the attack, and how effective the prescribed treatment was.

The medical history of bronchial asthma, mixed form, may contain the following information:

Complaints: Abrupt attacks of suffocation, repeated several times a day. At night, there is an increase in shortness of breath. Symptoms completely disappear after taking beta-agonists. After an attack of suffocation, a short-term cough with sputum discharge begins.
Initial onset of symptoms: The first attack happened unexpectedly, during a trip in a crowded trolleybus. The patient could not fully inhale the air, shortness of breath began. After he went outside, the symptoms disappeared after 15 minutes. In the future, the symptoms began to recur 1-2 times a month under various conditions. The patient was in no hurry to consult a doctor, because he believed that the cause of such symptoms was bronchitis, and was treated on his own.
Factors provoking the onset of the disease: bad habits, place of work and the degree of harmfulness of working conditions, food addictions, previous diseases, allergic reactions, heredity.
General examination of the patient: the constitution of the patient, the condition of the nails, hair, skin, mucous membranes. The condition of the lymph nodes and tonsils is taken into account. The musculoskeletal system is being studied: joint mobility, problems with the spine. The respiratory and cardiovascular systems are most carefully studied.

An integrated approach will allow you to identify what exactly provokes breathing problems and, on this basis, make the correct diagnosis. The mixed form of asthma is characterized by frequent attacks of suffocation, shortness of breath with hoarseness. More often, the development of such a disease contributes to a hereditary factor.

Determining the severity of bronchial asthma

For the successful diagnosis of the disease, a clinical picture is compiled with the study characteristic features, symptoms and signs that are not characteristic of other diseases. The medical history of asthma therapy begins with the initial diagnosis, in which the physician assesses the degree of airway obstruction. If the likelihood of asthma is high, it is necessary to start a trial treatment immediately, and further, in the absence of the effect of therapy, appoint additional studies.

With a low to moderate likelihood of asthma, the characteristic symptoms may be due to another diagnosis.

There are 4 stages in the development of the disease:

Intermittent asthma- the safest stage of the disease. Short attacks occur rarely, no more than once a week. At night, exacerbations occur even less frequently.
Mild persistent asthma- attacks occur more often than once a week, but only once a day. At night, there are 2-3 attacks per month. Along with shortness of breath, sleep disturbance occurs, and a decrease physical activity.
Persistent asthma moderate - the disease daily makes itself felt with acute attacks. Nocturnal manifestations also become more frequent, and appear more often than once a week.
Persistent severe asthma. Attacks are repeated daily, at night it comes to several cases a week. Sleep problems - the patient is tormented by insomnia, physical activity. too difficult.

The patient, regardless of the severity of the disease, may experience mild, moderate and severe exacerbations. Even a patient with intermittent asthma can experience life-threatening attacks after a long time without any symptoms.

The severity of the condition of patients is not static, and can change over the years.

Treatment and clinical recommendations

After the patient is assigned asthmatic status, clinical recommendations for treatment are prescribed by the attending physician. Depending on the form and stage of the course of the disease, the following methods can be used:

Drug therapy aimed at maintaining the work of the bronchi, preventing inflammation, treating symptoms, stopping asthma attacks.
Isolation of the patient from conditions that cause deterioration of the condition (allergens, harmful working conditions, etc.).
A diet that excludes fatty, salty, junk food.
Measures to improve and strengthen the body.

At drug treatment asthma, you can not use only symptomatic drugs, because the body gets used to and stops responding to the active ingredients. Thus, against the background of the development of pathological processes in the bronchi, treatment stops flowing, which negatively affects the dynamics, delaying full recovery.

There are 3 main groups of drugs that are used in the treatment and relief of asthma attacks:

emergency aids - they provide quick assistance in case of suffocation;
basic drugs;
control drugs.

All treatment is aimed at reducing the frequency of attacks and minimizing possible complications.

Forms of bronchial asthma

Allergic bronchial asthma. Asthma in this form often develops from childhood, and is caused by the course of diseases such as atopic dermatitis or allergic rhinitis. Moreover, heredity in this case plays a significant role - if close relatives had asthma, then the risk of developing the disease in a child increases. Recognizing the allergic form of asthma is the easiest. Before starting treatment, induced sputum should be examined for airway inflammation. Patients with this disease phenotype have a good response to inhaled corticosteroids.

Non-allergic bronchial asthma. This phenotype can result from exposure to medications, as is the case with aspirin asthma. Also, the development of the disease can occur against the background of hormonal changes in the body of women, for example, during the bearing of a child.

Case history on the example of a mixed form of bronchial asthma

The medical history of bronchial asthma, mixed form, may contain the following information:

Complaints: Abrupt attacks of suffocation, repeated several times a day. At night, there is an increase in shortness of breath. Symptoms completely disappear after taking beta-agonists. After an attack of suffocation, a short-term cough with sputum discharge begins.
Initial onset of symptoms: The first attack happened unexpectedly, during a trip in a crowded trolleybus. The patient could not fully inhale the air, shortness of breath began. After he went outside, the symptoms disappeared after 15 minutes. In the future, the symptoms began to recur 1-2 times a month under various conditions. The patient was in no hurry to consult a doctor, because he believed that the cause of such symptoms was bronchitis, and was treated on his own.
Factors provoking the onset of the disease: bad habits, place of work and the degree of harmfulness of working conditions, food addictions, previous diseases, allergic reactions, heredity.
General examination of the patient: the constitution of the patient, the condition of the nails, hair, skin, mucous membranes. The condition of the lymph nodes and tonsils is taken into account. The musculoskeletal system is being studied: joint mobility, problems with the spine. The respiratory and cardiovascular systems are most carefully studied.

Determining the severity of bronchial asthma

For the successful diagnosis of the disease, a clinical picture is compiled with the study of characteristic features, symptoms and signs that are not characteristic of other diseases. The medical history of asthma therapy begins with the initial diagnosis, in which the physician assesses the degree of airway obstruction. If the likelihood of asthma is high, it is necessary to start a trial treatment immediately, and further, in the absence of the effect of therapy, appoint additional studies.

With a low to moderate likelihood of asthma, the characteristic symptoms may be due to another diagnosis.

The pathogenesis of bronchial asthma

There are 4 stages in the development of the disease:

Intermittent asthma- the safest stage of the disease. Short attacks occur rarely, no more than once a week. At night, exacerbations occur even less frequently.
Mild persistent asthma- attacks occur more often than once a week, but only once a day. At night, there are 2-3 attacks per month. Along with shortness of breath, there is a sleep disturbance, and a decrease in physical activity.
Persistent moderate asthma- the disease daily makes itself felt with acute attacks. Nocturnal manifestations also become more frequent, and appear more often than once a week.
Persistent severe asthma. Attacks are repeated daily, at night it comes to several cases a week. Sleep problems - the patient is tormented by insomnia, physical activity. too difficult.

The severity of the condition of patients is not static, and can change over the years.

Treatment and clinical recommendations

Drug therapy aimed at maintaining the work of the bronchi, preventing inflammation, treating symptoms, stopping asthma attacks.
Isolation of the patient from conditions that cause deterioration of the condition (allergens, harmful working conditions, etc.).
A diet that excludes fatty, salty, junk food.
Measures to improve and strengthen the body.

In the medical treatment of asthma, only symptomatic drugs should not be used, since the body gets used to and stops responding to the active ingredients. Thus, against the background of the development of pathological processes in the bronchi, treatment stops flowing, which negatively affects the dynamics, delaying full recovery.

There are 3 main groups of drugs that are used in the treatment and relief of asthma attacks:

emergency aids - they provide quick assistance in case of suffocation;
basic drugs;
control drugs.

All treatment is aimed at reducing the frequency of attacks and minimizing possible complications.

Recommendations for patients with bronchial asthma and principles of treatment

The proposed recommendations for patients with bronchial asthma are based on the latest data obtained in the course of many years of scientific work. All the advice is based on the causes of the development of bronchial asthma, which have not been fully studied. However, effective prevention development of bronchial asthma is possible already at the current stage of development of medical science. To do this, it is important to follow all the above recommendations for patients with bronchial asthma, which will restore the level of health and forget about asthma attacks forever. The material highlights the basic principles of the treatment of bronchial asthma in terms of modern science in symbiosis with various methods of non-traditional therapy, for example, the use of leeches.

Psychological and other causes of bronchial asthma

Bronchial asthma- is always present inflammatory disease airways, which is always accompanied by bronchial hyperreactivity, paroxysms of complete or partially reversible bronchial obstruction, clinically manifested by asthma attacks or respiratory discomfort in the form of paroxysmal cough and (or) wheezing and shortness of breath. Bronchial asthma is a chronic disease.

In the period from 1950, asthma was considered a psychosomatic disease, and it responded well to treatment by methods of psychocorrection. The psychological causes of bronchial asthma were closely examined, and often the treatment was based on psychoanalysis. Psychoanalysts interpreted wheezing as a child's suppressed crying, so they believed that treating internal depression was especially important for patients with asthma.

Others believed that asthma develops in those who have difficult living conditions or are faced with a problem that they cannot solve, but cannot accept. In a literal sense, the patient "suffocates in the conditions of his reality." It can be either an adult or a child. On the physical plane, stress does not directly cause asthma symptoms. Be sure to include the correction methods from the article on the psychosomatics of diseases - they work well. Other causes of asthma are also considered, such as the effect of allergens on the immune system.

Mechanism and risk factors for the development of bronchial asthma

External and internal risk factors for the development of bronchial asthma lead to the fact that there is an increase in the protective response of the immune system. A peculiar mechanism for the development of bronchial asthma is triggered, which consists in provoking the release of a large amount of mucous secretion by the membranes of the bronchial tree. With a protective purpose, the mechanism of reflex narrowing of the lumen of the large bronchi and trachea is also launched.

Triggers, factors provoking attacks of exacerbation of the disease are allergic reactions of our body. The use of leeches as a prophylactic significantly increases immunity and resistance to allergies. Theoretically, there may be an allergy to hirudin, but it occurs in one in several hundred thousand, and so far no one has died (there are no such facts), therefore hirudotherapy is successfully used in the treatment various kinds allergies in both adults and children.

The studies allowed to give recommendations for the prevention of bronchial asthma, aimed at actively reducing the content of aeroallergens in the home where the child is. But these guidelines for bronchial asthma led to different data.

For example, the complete elimination of house dust mite allergens reduces the risk of allergic sensitization and slightly reduces the risk of developing asthma until the child is 8 years old. However, research has also shown that exposure to allergens from pets (cats and dogs) has the opposite effect. Exposure to these allergens in the very first year of a child's life reduces the risk of allergic sensitization and asthma later in life.

These are absolutely natural preparations, they give a pronounced effect when taken for at least a month, and preferably three, and even get rid of Giardia in gallbladder and liver. Immunity increases, asthma weakens.

Clinical guidelines for nutrition in the treatment of bronchial asthma

The patient's diet, in accordance with the recommendations for the treatment of bronchial asthma, should contain a limited amount of carbohydrates, proteins, fats, i.e., the so-called "acidic" food, and an unlimited amount of "alkaline" food - fresh fruits, vegetables, sprouted grains and seeds.

Observing clinical recommendations for the treatment of bronchial asthma, the patient should avoid food that provokes the formation of sputum: rice, sugar, cottage cheese, cream, milk. He should also avoid fried and other indigestible foods, strong tea, coffee, condiments, pickles, sauces, and all refined and refined foods.

The use of warm alkaline mineral drinks (Borjomi, etc.) is shown, which help to free the bronchi from sputum. Food should be hypoallergenic.

Basic therapy of bronchial asthma with herbs

In this disease, basic therapy of bronchial asthma with herbs that have expectorant and anti-inflammatory effects is indicated. There are herbs that are able to act on the two main factors of bronchial asthma - inflammation and allergies. And they must have the following properties: bronchodilator, anti-inflammatory, anti-allergic, expectorant, sputum thinning, sedative, immunomodulatory. But their use can be an alternative only with a mild degree of bronchial asthma.

In severe cases, they are used as part of the complex therapy of bronchial asthma, gradually improving the situation. The following herbs have such properties: marshmallow root, violet grass, watch leaves, chamomile flowers, rosehip fruit, cumin fruit, anise fruit, birch leaves, viburnum flowers, plantain leaves, St. fennel, coltsfoot leaves, pine buds, rosemary shoots, violet, primrose, cyanosis, celandine, birch leaves, oregano herb, succession, yasnotka, St. John's wort, valerian, angelica, wild rosemary, etc.

From this list, you can choose 3-5 items to collect and drink for three months, then replace it with another.

Features of the asthma treatment strategy

The proposed features of the treatment of bronchial asthma are primarily in the gradual, but complete rejection of various medications that worsen the already shaky health. The main strategy for the treatment of bronchial asthma today is to remove toxins from the body, poisons and toxins.

Folk recipes with aspirin are contraindicated in bronchial asthma, including lotions. To thin viscous sputum during an attack, take soda on the tip of a knife. You can breathe in the evening over the steam with a cup hot water, in which a little soda is dissolved - you will sleep peacefully, without seizures.

Avoid excitement and great physical stress, do not smoke, do not drink alcohol. You can also take 15-20 drops of valerian. Physical activity, regular therapeutic exercises, tempering procedures are shown. Gives good results spa treatment in pine forests and coastal areas.

Hirudotherapy as a modern method of treating bronchial asthma

Hirudotherapy as a method of treating bronchial asthma has anti-inflammatory, anti-allergic, as well as a tonic effect. As a result, the patient feels better, asthma attacks occur less often, their strength and duration decrease. With hirudotherapy, the concentration of oxygen in the blood increases, the stressful state gradually disappears, calmness and balance appear, which are so necessary for this disease.

Modern treatment of bronchial asthma works like this: normalization of the liver and endocrine system is achieved, which has a beneficial effect on the immune system, which is also very important. Quantity and frequency: at least three courses for 3 months, it is possible for 4. Sessions - 1-2 times a week. Breaks between courses - 2-3 months. Next, feel free. With a certain persistence, an integrated approach and the simultaneous inclusion of phytotherapy on an ongoing basis - without interruptions.

Treatment of bronchial asthma with leeches is not unusual. Bronchial asthma can be cured with leeches in several courses with an integrated approach to the problem, not forgetting the psychosomatic factor. If the reason leading to constant stress is obvious, it is necessary to work with it. Treatment of asthma with leeches is carried out until the patient is fully recovered. Chronic asthma is also not an incurable disease.

Zones of attachment of leeches - these settings are alternated with settings of the general course or carried out after the general course. If there are nodules in the thyroid gland, put on the zone thyroid gland and liver at least 2-3 times for each course.

If the liver is enlarged, give it extra attention both with leeches and a change in diet and water - it is responsible for almost all processes in the body. Restoring the liver by placing it on the right hypochondrium, place one leech on the top of the xiphoid process - the solar plexus area (the bone above the solar plexus) - from it and draw a line.

Pass the interscapular zone on the back (starting from the 3rd, 4th thoracic vertebrae and in different directions), then the level of the 9th, 10th thoracic vertebrae and in different directions for two transverse fingers), sacrum, coccyx, at the level navel and leech next to the navel in different directions - two transverse fingers to the side). Remember about the lung zone both in front and from the back. These performances can be alternated and repeated.

Respiratory disease is very common today. The reason for this situation is the presence of a large number of viruses, bacteria, air pollution, reduced immunity in people. Often there is bronchial asthma among other diseases, so there are certain clinical recommendations for combating the disease.

Bronchial asthma is a chronic inflammatory process that is localized in the respiratory organs and manifests itself with severe symptoms. The patient experiences shortness of breath, discomfort in the lungs (congestion), wheezing during breathing, and during an exacerbation, airway obstruction occurs.

The main factors influencing the development of bronchial asthma

Internal factors. Here we can distinguish obesity and a genetic tendency to allergic manifestations, bronchial hyperreactivity. Also, the age category (in childhood, bronchial asthma is more common in boys, and in older people, i.e. adolescents and adults, the female sex is exposed to the disease).
environmental factors. This category includes allergens (dust and dust mites, pets, cockroaches, fungi, plant pollen), air pollutants (ozone, exhaust gases Vehicle, sulfur and nitrogen dioxide, tobacco smoke). Also very influential professional activity, the presence of viruses and malnutrition (for example, the consumption of overly processed vegetables and fruits).

Diagnosis of bronchial asthma according to clinical guidelines

According to clinical guidelines, the diagnosis of bronchial asthma is made according to the patient's complaints, a detailed history, tests and examinations. Differential diagnostics is also carried out, which excludes the presence of another respiratory disease, similar in symptoms to bronchial asthma.

The probabilistic indicators of the manifestation of bronchial asthma increase with such clinical signs:

There are also indicators that can refute the presence of the above diagnosis. So, the following clinical signs reduce the likelihood of having bronchial asthma:

the presence of severe dizziness and darkening in the eyes;
the presence of a chronic cough, in which there is a copious discharge of sputum (without whistling and wheezing);
voice change;
heart disease;
excessive smoking;
indicators within the normal range in the study of the chest and respiratory function.

If the doctor determines a high probability of having bronchial asthma, then according to clinical recommendations, he can start a trial treatment. However, in the opposite case, the doctor must conduct additional studies and tests, as well as exclude the presence of an ailment with similar symptoms.

Table of differential diagnosis of BA

Diagnosis of bronchial asthma in children

Clinical guidelines make it possible to determine the presence of bronchial asthma in children of different age categories. It is the presence of allergic diseases in relatives, especially on the maternal side, that may be suspected as asthma in children under two years of age. Also, the baby often reacts to allergic reactions after taking certain foods and medicines. Suffers from allergic skin diseases. During initial stage ARVI in a child manifests broncho-obstructive syndrome.

If, in general, children under five years of age are considered, then bronchial asthma can be suspected by the features of the following manifestations:

IMPORTANT! The presence of frequent allergic manifestations in the form of rhinitis and dermatitis in a patient or his blood relatives significantly increases the likelihood of diagnosing asthma. Bronchial asthma in relatives also increases the risk of this disease in a child.

Periods of exacerbation of the disease

During an exacerbation of bronchial asthma, the patient experiences severe increasing shortness of breath, congestion in the chest. During breathing, whistles are clearly heard, and a strong cough is tormented without sputum discharge. According to clinical guidelines, attention should be paid to the fact that an exacerbation can occur, both in a patient with an existing diagnosis of varying severity, and be the first manifestation of the disease.

An exacerbation in speed can develop both over several minutes or hours, and over two weeks. The recommendations state that the patient should immediately seek medical care at the onset of an exacerbation of the disease.

Treatment of bronchial asthma

An individual approach to therapy is applied to each patient according to his medical history and individual characteristics. Clinical guidelines for treatment also offer step therapy, which consists in a gradual increase in the volume of therapy (if there is no control, and there are risk factors for exacerbation) or a decrease in the volume of therapy (with stable control and the absence of risk factors).

Disease prevention

Each person is not immune from the appearance of a particular disease, but everything necessary should be done to increase the body's immunity. If there are symptoms that indicate the possible presence of bronchial asthma, clinical recommendations will help to understand the exact diagnosis, determine the severity of the disease, and also draw up a treatment regimen.

Mixed asthma (J45.8)

Pulmonology, Pulmonology for children

general information

Short description

Russian Respiratory Society

DEFINITION

Bronchial asthma (BA)- a chronic inflammatory disease of the respiratory tract, in which many cells and cellular elements take part. chronic inflammation causes the development of bronchial hyperreactivity, which leads to recurring episodes of wheezing, shortness of breath, a feeling of congestion in the chest and cough, especially at night or in the early morning. These episodes are associated with widespread variable airway obstruction in the lungs, which is often reversible spontaneously or with treatment.

At the same time, it should be emphasized that the diagnosis of AD is primarily established on the basis of clinical picture. An important feature is the lack of standardized characteristics of symptoms or laboratory or instrumental studies that would help to accurately establish the diagnosis of bronchial asthma. In this regard, it is impossible to develop evidence-based recommendations for the diagnosis of AD.

Classification

Determining the severity of bronchial asthma

Classification of bronchial asthma according to severity based on the clinical picture before the start of therapy (Table 6)

STAGE 1: Intermittent asthma

Symptoms less than once a week
short exacerbations
Nocturnal symptoms no more than twice a month

Scatter PSV or FEV1< 20%

STEP 2: Mild persistent asthma

Symptoms more than once a week but less than once a day
Exacerbations can reduce physical activity and disturb sleep
Nocturnal symptoms more than twice a month
FEV1 or PEF ≥ 80% predicted
Spread PSV or FEV1 20-30%

STAGE 3: Moderate persistent asthma

Daily symptoms
Exacerbations can lead to limited physical activity and disturbed sleep
Nocturnal symptoms more than once a week
Daily use of short-acting inhaled β2-agonists
FEV1 or PSV 60-80% of the due
Spread PSV or FEV1 > 30%

STEP 4: Severe persistent asthma

Daily symptoms
Frequent exacerbations
Frequent nocturnal symptoms
Restriction of physical activity
FEV1 or PEF ≤ 60% predicted
Spread PSV or FEV1 > 30%

Classification of asthma severity in treated patients is based on the smallest amount of therapy required to maintain disease control. Mild asthma is asthma that can be controlled with a small amount of therapy (low-dose ICS, anti-leukotriene drugs, or cromones). Severe asthma is asthma that requires a large amount of therapy to control (eg, step 4 or 5, (Figure 2)), or asthma that cannot be controlled despite a large amount of therapy.

2 When determining the degree of severity, the presence of one of the signs of severity is sufficient: the patient should be assigned to the most severe degree in which any sign occurs. The characteristics noted in this table are general and may overlap, since the course of asthma is highly variable, moreover, over time, the severity of a particular patient may change.

3 Patients with any severity of asthma may have mild, moderate or severe exacerbations. A number of patients with intermittent asthma experience severe and life-threatening exacerbations against the background of long asymptomatic periods with normal lung function.

Diagnostics

PRINCIPLES OF DIAGNOSTICS IN ADULTS AND CHILDREN

Diagnostics:
The diagnosis of asthma is purely clinical and is established on the basis of complaints and anamnestic data of the patient, clinical and functional examination with an assessment of the reversibility of bronchial obstruction, a specific allergological examination (skin tests with allergens and / or specific IgE in the blood serum) and the exclusion of other diseases (GPP).
The most important diagnostic factor is a thorough history taking, which will indicate the causes, duration and resolution of symptoms, the presence of allergic reactions in the patient and his blood relatives, causal features of the occurrence of signs of the disease and its exacerbations.

Factors influencing the development and manifestations of AD (Table 3)

Factors	Description
1. Internal factors	1. Genetic predisposition to atopy 2. Genetic predisposition to BHR (bronchial hyperreactivity) 3. Gender (in childhood, BA is more common in boys; in adolescence and adulthood, in women) 4. Obesity
2. environmental factors	1. Allergens 1.1. Indoors: house dust mites, pet hair and skin, cockroach allergens, fungal allergens. 1.2. Outdoors: plant pollen, fungal allergens. 2. Infectious agents (mainly viral) 3. Professional factors 4. Aeropollutants 4.1. External: ozone, sulfur and nitrogen dioxide, combustion products of diesel fuel, etc. 4.2. Inside the dwelling: tobacco smoke (active and passive smoking). 5. Diet (increased consumption of highly processed foods, increased intake of omega-6 polyunsaturated fatty acids and reduced intake of antioxidants (in the form of fruits and vegetables) and omega-3 polyunsaturated fatty acids (as part of fatty fish).

DIAGNOSTICS OF BA IN CHILDREN

The diagnosis of bronchial asthma in children is clinical. It is based on observation of the patient and assessment of symptoms while excluding other causes of bronchial obstruction.

Diagnosis at different age periods

Clinically during an exacerbation bronchial asthma in children is determined by an obsessive dry or unproductive cough (sometimes to vomiting), expiratory dyspnea, diffuse dry wheezing in the chest against the background of uneven weakened breathing, bloating of the chest, a boxy shade of percussion sound. Noisy wheezing can be heard in the distance. Symptoms may worsen at night or in the early hours of the morning. The clinical symptoms of bronchial asthma change during the day. The entire set of symptoms over the past 3-4 months should be discussed, with particular attention to those that have bothered you during the previous 2 weeks. Wheezing should be confirmed by a doctor, as parents may misinterpret the sounds their child makes when breathing.

Additional diagnostic methods

Examination of the function of external respiration:
. Peakflowmetry (determination of peak expiratory flow, PSV) - a method for diagnosing and monitoring the course of BA in patients older than 5 years. Measured morning and evening indicators of PSV, daily variability of PSV. The daily variability of PSV is defined as the amplitude of PSV between the maximum and minimum values during the day, expressed as a percentage of the average daily PSV and averaged over 2 weeks.

. Spirometry. Assessment of the function of external respiration under conditions of forced exhalation can be carried out in children over the age of 5-6 years. A 6-minute jogging protocol is used to detect post-exercise bronchospasm (high sensitivity but low specificity). Bronchoconstrictor tests are of diagnostic value in some doubtful cases during adolescence.

. In the period of remission of bronchial asthma (i.e. in children with a controlled course of the disease), lung function indicators may be slightly reduced or correspond to normal parameters.

Allergological examination

. Skin tests(prick tests) can be performed on children of any age. Since skin tests in young children are less sensitive, the role of a carefully collected anamnesis is great.
. Determination of allergen-specific IgE useful when skin testing is not possible (severe atopic dermatitis/eczema, or cannot be discontinued) antihistamines, or there is a real threat of developing an anaphylactic reaction to the introduction of an allergen).
. Inhalation challenge tests withallergens are practically not used in children.

Other research methods
. In children under 5 years of age - computer bronchography

. Chest x-ray (to rule out an alternative diagnosis)
. Trial treatment (response to anti-asthma therapy)
. There are no characteristic changes in blood tests in AD. Eosinophilia is often detected, but it cannot be considered a pathognomonic symptom.
. In the sputum of children with bronchial asthma, eosinophils, Kurshman's spirals can be detected.
. V differential diagnosis using the following methods: bronchoscopy, computed tomography. The patient is referred for specialist consultations (otorhinolaryngologist, gastroenterologist, dermatologist)

Algorithm for diagnosing bronchial asthma in children
When asthma is suspected in children, emphasis is placed on the presence of key information in the anamnesis and symptoms on examination, with careful exclusion of alternative diagnoses.

High chance of asthma

Refer to specialist consultation (pulmonologist, allergist)
Start anti-asthma treatment
Evaluate response to treatment
Investigate further patients who do not respond to treatment

Low chance of asthma

Conduct a more detailed examination

Intermediate likelihood of asthma and proven airway obstruction

Perform spirometry
Perform a bronchodilator trial (FEV1 or PEF) and/or assess response to trial treatment over a specified period:
· If there is significant reversibility or treatment is effective, the diagnosis of asthma is likely. It is necessary to continue to treat asthma, but strive for the minimum effective dose of drugs. Subsequent tactics are aimed at reducing or canceling treatment.
· If there is no significant reversibility and trial treatment fails, consider testing to rule out alternative causes.

Intermediate likelihood of asthma without evidence of airway obstruction

Children who can have spirometry and do not have airway obstruction:
Schedule an allergy test
Order a reversibility test with a bronchodilator and, if available, tests for bronchial hyperresponsiveness with methacholine, exercise, or mannitol
Refer for expert advice

DIAGNOSTICS OF ADULTS

Primary examination:
Diagnosis of asthma is based on the detection of characteristic features, symptoms and signs in the absence of an alternative explanation for their occurrence. The main thing is to obtain an accurate clinical picture (history).
The initial diagnosis should be based on a careful assessment of symptoms and the degree of airway obstruction.
In patients with a high risk of asthma, start trial treatment immediately. Provide additional studies in case of insufficient effect.
· In patients with low risk of asthma, whose symptoms are suspected to be the result of another diagnosis, evaluate and treat appropriately. Reconsider the diagnosis in those patients whose treatment fails.
· The preferred approach for patients with an average likelihood of asthma is to continue the investigation while administering a trial treatment for a certain period of time until the diagnosis is confirmed and maintenance treatment is determined.

Clinical signs that increase the likelihood of having asthma:
Presence of more than one of the following symptoms: wheezing, choking, chest tightness and coughing, especially in cases of:
- worsening of symptoms at night and early in the morning;
- the onset of symptoms during exercise, exposure to allergens and cold air;
- the onset of symptoms after taking aspirin or beta-blockers.
The presence of atopic diseases in history;
The presence of asthma and / or atopic diseases in relatives;
Widespread dry wheezing when listening (auscultation) of the chest;
· Low performance peak expiratory flow or forced expiratory volume in 1 second (retrospectively or in a series of studies) that is not explained by other reasons;
Eosinophilia of peripheral blood, unexplained by other causes.

Clinical signs that reduce the likelihood of having asthma:
Severe dizziness, darkening in the eyes, paresthesia;
· Chronic productive cough in the absence of wheezing or choking;
Persistently normal chest examination findings in the presence of symptoms;
Change of voice;
Occurrence of symptoms exclusively on the background of colds;
Having a significant history of smoking (more than 20 packs/years);
heart disease;
Normal peak expiratory flow or spirometry when symptomatic (clinical).

SPIROMETRY AND REVERSIBILITY TESTS

The spirometry method allows confirming the diagnosis when airway obstruction is detected. but normal performance Spirometry (or peak flowmetry) does not exclude the diagnosis of AD.
In patients with normal lung function, an extrapulmonary cause of symptoms is possible, but a bronchodilatory test may reveal latent reversible airflow obstruction.
· Tests for bronchial hyperreactivity (BHR) as well as markers of allergic inflammation may help in establishing the diagnosis.
In adults and children, tests for obstruction, bronchial hyperresponsiveness, and airway inflammation may confirm the diagnosis of asthma. However, normal values, especially at the time when symptoms are absent, do not exclude the diagnosis of asthma.

Patients with bronchial obstruction
Peak expiratory flow rate variability, lung volumes, gas diffusion, bronchial hyperresponsiveness, and airway inflammation tests have limited opportunities in the differential diagnosis of patients with bronchial obstruction in asthma and other lung diseases. Patients may have other diseases that cause obstruction, which complicates the interpretation of tests. Asthma and COPD can be especially common.

Patients with bronchial obstruction and an average likelihood of asthma should have a reversibility test and / or trial therapy for a certain period:
· At positive test reversibility or if a positive effect is achieved during the therapeutic test, the patient should be treated as a patient with asthma in the future
In case of negative reversibility and the absence of a positive response during a trial course of therapy, further examination should be continued to clarify the diagnosis

Algorithm for examining a patient with suspected AD (Fig. 1).

Therapeutic trials and reversibility tests:

The use of FEV1 or PEF as the primary means of assessing reversibility or response to therapy is increasingly used in patients with initial airflow obstruction.

Patients without bronchial obstruction:
In patients with normal spirometry, additional testing should be performed to detect bronchial hyperreactivity and/or airway inflammation. These tests are quite sensitive, so normal results obtained during their conduct may confirm the absence of asthma.
Patients without signs of bronchial obstruction and with an average likelihood of asthma should be ordered additional studies before prescribing therapy

Bronchial hyperreactivity study:
Bronchial hyperresponsiveness (BHR) tests are not widely used in clinical practice. Typically, the detection of BHR is based on measuring the FEV1 response to inhaled increasing concentrations of methacholine. Response is calculated as the concentration (or dose) of the provocative agent causing a 20% drop in FEV1 (PC20 or PD20) using linear interpolation of the log concentration of the dose-response curve.
· The distribution of BHR indicators in the population is normal, 90-95% of the healthy population has PK20 values > 8 mg / ml (equivalent PD20 > 4 micromoles). This level has a sensitivity index in the range of 60-100% for detecting clinically diagnosed asthma.
· In patients with normal lung function, the BHR study has an advantage over other tests in identifying patients with asthma (Table 4). In contrast, GHR tests play a minor role in patients with established bronchial obstruction, as the specificity of the test is low.
Other used bronchoconstrictor tests - with indirect provocative agents (mannitol, exercise test). A positive response to these stimuli (i.e., a fall in FEV1 of more than 15%) is a specific indicator of AD. However, these tests are less specific than those with methacholine and histamine, especially in patients receiving anti-asthma therapy.

Methods for assessing airway inflammation (Table 4)

Test	Norm	Validity
Test	Norm	sensitivity	specificity
Methacholine PK20	>8 mg/ml	high	Medium
Indirect provocation *	Varies	Medium#	high
FENO	<25 ppb	High#	Medium
Eosinophils in sputum	<2%	High#	Medium
PSV variability (% of max)	<8 <20%*	Low	Medium

PC20 = provocative concentration of methacholine causing a 20% drop in FEV1; FENO = exhaled nitric oxide concentration
*those. provocation by physical activity, inhalation of mannitol;# in untreated patients ; **when measured twice a day; ***for more than four measurements

PSV monitoring:
The best indicator is recorded after 3 attempts to perform a forced maneuver with a pause not exceeding 2 seconds after inspiration. The maneuver is performed sitting or standing. More measurements are taken if the difference between the two maximum PSV values exceeds 40 l/min.
· PEF is used to estimate airflow variability across multiple measurements taken over at least 2 weeks. Increased variability can be recorded with double measurements during the day. More frequent measurements improve the estimate. An increase in measurement accuracy in this case is achieved in particular in patients with reduced compliance.
· PSV variability is best calculated as the difference between the maximum and minimum values as a percentage of the average or maximum daily PSV.
· The upper limit of normal values for variability in % of the maximum value is about 20% when using 4 or more measurements during the day. However, it may be lower when using double measurements. Epidemiological studies have shown sensitivity between 19% and 33% for the identification of clinically diagnosed asthma.
PSV variability may be increased in diseases that are most often differentially diagnosed with asthma. Therefore, in clinical practice, there is a lower level of specificity for increased variability in PSV than in population studies.
· Frequent recording of PEFs at and outside of work is important when a patient is suspected of having occupational asthma. Currently, there are computer programs for the analysis of PEF measurements in the workplace and outside it, to automatically calculate the effects of occupational exposure.
· PEF values should be interpreted with caution, taking into account the clinical situation. The PEF study is more useful for monitoring patients already diagnosed with asthma than for the initial diagnosis.

Occupational asthma is a disease characterized by the presence of reversible airway obstruction and/or hyperresponsiveness due to inflammation caused solely by occupational factors and unrelated to irritants outside the workplace.

Classification of occupational asthma:
1) immunoglobulin (Ig) E-conditioned;
2) irritant asthma, including the syndrome of reactive respiratory tract dysfunction, which developed as a result of contact with extremely high concentrations of toxic substances (vapors, gases, smoke);
3) asthma caused by unknown pathogenic mechanisms.

According to the Guidelines ERS (2012), work-related or work-related asthma has the following phenotypes:

Fig.1. Clinical variants of bronchial asthma caused by working conditions
• There are several hundred substances that can cause occupational asthma.
· When inhaled at high doses, some immunologically active sensitizers behave as irritants.
For anhydrides, acrylates, cimetidine, rosin, enzymes, green coffee and castor bean dust, bakery allergens, pollen, seafood, isocyanates, laboratory animal allergens, piperazine, platinum salts, cedar tree dust, a dose-effect relationship has been proven between the incidence of occupational asthma and the concentration of these substances in the workplace.

Rice

Sensitivity and specificity of diagnostic tests:

Questionnaires for diagnosing occupational asthma have high sensitivity but low specificity.	1++
Peak expiratory flow (PEF) monitoring has a high degree of sensitivity and specificity for diagnosing occupational asthma if it is performed at least 4 times during a work shift for 3-4 working weeks, followed by comparison of indicators on weekends and / or holiday period	1+++
The methacholine test for detection of NGRH is performed during periods of exposure and elimination of industrial agents and, as a rule, correlates with the dose of inhaled substances and the worsening of asthma in the workplace.	1+++
The absence of NGRH does not exclude the diagnosis of occupational asthma.	1+++
Occupational hypertension skin prick tests and specific IgE levels are highly sensitive for detecting sensitization caused by most HMM agents.	1+++
The specific bronchial provocation test (SPTT) is the "gold standard" for determining the causative factors (inducers and triggers) of occupational asthma. It is carried out only in specialized centers using exposure chambers when it is impossible to confirm the diagnosis of PA by other methods.	1+++
If there is other compelling evidence, a negative SBT result is not sufficient to rule out occupational asthma	1++
An increase in the level of eosinophils in induced sputum by more than 1%, with a decrease in FEV1 by more than 20% after SPBT (or returning to the workplace after a day off) may confirm the diagnosis of occupational asthma	1+
The level of exhaled nitric oxide fraction correlates with the degree of airway inflammation and the dose of inhaled pollutants at the workplace.	1++

Prognosis and risk factors (endo- and exogenous) for an unfavorable outcome:

Risk factors for poor outcome in occupational asthma at the time of diagnosis: low lung volumes, high degree of NGR, or status asthmaticus during SPBT	1++
Further continuation of work in contact with an agent-inducer of PA can lead to an unfavorable outcome of the disease (loss of professional and general disability)	1++
Smoking cessation is favorable for the prognosis of PA	1++
The outcome of occupational asthma does not depend on sex differences	1+++
The presence of concomitant COPD significantly worsens the prognosis of PA	1+++

The role of medical examinations:

Preliminary (when hiring) and periodic medical examinations within the framework of Order No. 302-N dated April 12, 2011 of the Ministry of Health and Social Development are a key link in preventing the development of occupational asthma, its timely detection and prevention of disability in patients.	1+++
The use of specialized questionnaires makes it possible to separate workers with a low level of occupational risk from those who need additional research and organizational measures.	1+
Workers with a previously established diagnosis of bronchial asthma have an increased risk of worsening the course of the disease upon contact with industrial aerosols (asthma aggravated by working conditions) up to loss of ability to work, which should be warned upon employment.	1+++
A history of atopy does not predict the development of future sensitization to occupational allergens, occupational allergies or asthma	1+++
The combination of various research methods (questionnaire screening, clinical and functional diagnostics, immunological tests, etc.) increases the diagnostic value of a preventive examination	1+++

Step-by-step algorithm for diagnosing occupational asthma:

Figure 2. Algorithm for diagnosing occupational asthma.

· When taking an anamnesis from a worker with asthma, it is necessary to find out if he has contact with adverse factors in the workplace.
The relationship of symptoms of allergic asthma with work can be assumed in cases where at least one of the following criteria is present:
Increased symptoms of the disease or their manifestation only at work;
Relief of symptoms on weekends or holidays
regular manifestation of asthmatic reactions after a work shift;
increase in symptoms by the end of the working week;
Improvement in well-being, up to the complete disappearance of symptoms, with a change in the nature of the work performed (cessation of contact with causative agents).
For the irritant form of occupational asthma, it is mandatory to indicate in the anamnesis the first developed asthma-like symptoms within 24 hours after inhalation of irritating gases, vapors, smoke, aerosols in high concentrations with the persistence of symptoms from several days to 3 months.
· Methods for diagnosing occupational asthma are similar to those for non-occupational asthma.

Management tactics and prevention of occupational asthma:

Drug treatment of PA is not able to prevent its progression in cases of continued work in contact with the causative factor.	1+
Timely transfer to work outside of contact with the causative factor provides relief of PA symptoms.	1+++
A decrease in the concentration of agents in the air of the working area can lead to a decrease or relief of PA symptoms. However, this approach is less effective than the complete cessation of contact with the causative agent of asthma.	1++
The use of personal protective equipment for respiratory organs from exposure to industrial aerosols can lead to an improvement in the course of asthma, but not to the complete disappearance of respiratory symptoms and airway obstruction	1++

- The definition, classification, basic concepts and answers to key questions regarding recommendations for diagnosing occupational asthma given in this section are formulated by the working group based on existing recommendations from the British Occupational Research Foundation (british Occupational Health Research Foundation) , a review of the American College of Lung Physicians (American College of Chest Physicians), manualsAAgency for Health and Quality Research (Agency for healthcare Research and Quality). When describing the etiological factors, a meta-analysis of 556 publications on occupational asthma was used.X. Baur (2013).

Prevention

Prevention and rehabilitation of patients with asthma

In a significant proportion of patients, there is a perception that numerous environmental, dietary and other factors can be triggers of asthma and avoidance of these factors can improve the course of the disease and reduce the amount of drug therapy. Evidence that non-pharmacological methods can influence the course of bronchial asthma is insufficient and large-scale clinical trials are required.

Key provisions:
1. Medical treatment of patients with confirmed asthma is a highly effective method for controlling symptoms and improving quality of life. However, whenever possible, measures should be taken to prevent the development of asthma, symptoms of asthma, or exacerbation of asthma by reducing or eliminating exposure to risk factors.
2. Currently, there are only a small number of measures that can be recommended for the prevention of AD, since complex and not fully elucidated mechanisms are involved in the development of this disease.
3. Exacerbation of asthma can be caused by many risk factors, sometimes called triggers; these include allergens, viral infections, pollutants and drugs.
4. Reducing the exposure of patients to certain categories of risk factors can improve asthma control and reduce the need for drugs.
5. Early detection of occupational sensitizers and prevention of any subsequent exposure to sensitized patients are important components of the treatment of occupational AD.

Prospects for primary prevention of bronchial asthma (Table 10)

	Research results	Recommendations
Allergen Elimination	Data on the effectiveness of the impact of measures to ensure a hypoallergenic regime inside housing on the likelihood of developing BA are contradictory.	There is not enough evidence to recommend. 1+
Lactation	There is evidence of a protective effect on the early development of AD	Breastfeeding should be encouraged because of its many benefits. It may play a role in preventing early development of AD in children.
Milk formulas	There are no studies of sufficient duration on the effect of the use of milk formulas on the early development of AD	In the absence of proven benefits of formula milk, there is no reason to recommend its use as a strategy to prevent AD in children. 1+
Nutritional supplements	There is very limited research on the potential protective effect of fish oil, selenium and vitamin E taken during pregnancy.	There is insufficient evidence to recommend any dietary supplement during pregnancy as a means of preventing AD. 1+
Immunotherapy (specific immunotherapy)	More studies are needed to confirm the role of immunotherapy in the prevention of AD	There is currently no reason to recommend
Microorganisms	Key area for long-term follow-up studies to establish efficacy for AD prevention	There is insufficient evidence that the use of probiotics by the mother during pregnancy reduces the risk of asthma in the child.
To give up smoking	Research finds association between maternal smoking and increased risk of disease in child	Parents and mothers-to-be should be advised about the adverse effects of smoking on the child, including the risk of developing asthma. (Evidence level C) 2+

	Research results	Recommendations
Foods and supplements	Sulfites (preservatives often found in medicines and foods such as potato chips, shrimp, dried fruits, beer, and wine) are often implicated in severe asthma exacerbations.	In the case of a proven allergy to a food or food supplement, avoiding that food may lead to a reduction in the frequency of asthma exacerbations. (Evidence levelD)
Obesity	Research Shows Relationship Between Weight Gain and AD Symptoms	For overweight patients, weight loss is recommended to improve the health status and course of asthma. (Evidence levelB)

Asthma Secondary Prevention Outlook (Table 12)

	Research results	Recommendations
Pollutants	Studies show a relationship between air pollution (increased concentrations of ozone, nitrogen oxides, acid aerosols and particulate matter) and worsening asthma.	In patients with controlled asthma, there is usually no need to avoid adverse environmental conditions. Patients with poorly controlled asthma are advised to refrain from intense physical activity in cold weather, with low atmospheric humidity, and high levels of air pollution.
house dust mites	Measures to reduce the concentration of house dust mites help to reduce the number of mites, but there is no evidence of a change in the severity of asthma with a decrease in their concentration	Comprehensive measures to reduce house dust mite concentrations may be useful in active families
Pets	There are no controlled studies looking at a reduction in the severity of asthma after the removal of pets. However, if there is an asthma patient in the family, it is not worth getting a pet.	No reason to make recommendations
Smoking	Active and passive smoking has a negative impact on quality of life, lung function, need for rescue drugs, and long-term control with inhaled steroids	Patients and their family members should be explained the dangers of smoking for asthma patients and be assisted in quitting smoking. (Evidence level C) 2+
Allergen-specific immunotherapy	Conducting specific immunotherapy has a positive effect on the course of AD.	Immunotherapy should be considered in patients with asthma when exposure to a clinically significant allergen cannot be avoided. The patient should be informed about the possibility of serious allergic reactions to immunotherapy. (Evidence level B) 1++

Non-traditional and alternative medicine (Table 13)

	Research results	Recommendations
Acupuncture, Chinese medicine, homeopathy, hypnosis, relaxation techniques, use of air ionizers.	There is no evidence of a positive clinical effect on the course of asthma and improvement in lung function	Insufficient evidence to recommend. Air ionizers are not recommended for the treatment of asthma (Evidence level A)	1++
Breathing according to the Buteyko method	Breathing technique to control hyperventilation. Studies have shown the possibility of some reduction in symptoms and inhaled bronchodilators, but without an effect on lung function and inflammation.	May be considered as an adjunct to symptom reduction (Evidence level B)

Education and training of patients with AD (Table 14)

	Research results	Recommendations
Patient education	The basis of training is the presentation of the necessary information about the disease, the preparation of an individual treatment plan for the patient, and teaching the technique of guided self-management.	It is necessary to teach asthma patients the basic techniques for monitoring their condition, follow an individual action plan, and conduct regular assessment of the condition by a doctor. At each stage of treatment (hospitalization, repeated consultations), a revision of the patient's managed self-management plan is carried out. (Evidence level A) 1+
Physical rehabilitation	Physical rehabilitation improves cardiopulmonary function. As a result of training during exercise, the maximum oxygen consumption increases and the maximum ventilation of the lungs increases.	There is no sufficient evidence base. According to the available observations, the use of training with aerobic exercise, swimming, training of the inspiratory muscles with a threshold dosed load improves the course of BA

Information

Sources and literature

Clinical recommendations of the Russian Respiratory Society

Information

Chuchalin Alexander Grigorievich	Director of the Research Institute of Pulmonology of the FMBA, Chairman of the Board of the Russian Respiratory Society, Chief Freelance Specialist Therapist-Pulmonologist of the Ministry of Health of the Russian Federation, Academician of the Russian Academy of Medical Sciences, Professor, Doctor of Medical Sciences
Aisanov Zaurbek Ramazanovich	Head of the Department of Clinical Physiology and Clinical Research, Research Institute of Pulmonology, FMBA, Professor, MD
Belevsky Andrey Stanislavovich	Professor of the Department of Pulmonology of the Russian National Research Medical University named after N.I. Pirogov, Chief Freelance Pulmonologist of the Moscow Health Department, Professor, MD
Bushmanov Andrey Yurievich	Doctor of Medical Sciences, Professor, Chief Freelance Specialist Occupational Pathologist of the Ministry of Health of Russia, Head of the Department of Hygiene and Occupational Pathology of the Institute of Postgraduate Vocational Education, Federal State Budgetary Institution State Research Center of the Federal Medical and Biological Center named after. A.I. Burnazyan FMBA of Russia
Vasilyeva Olga Sergeevna	Doctor of Medical Sciences, Head of the Laboratory of Ecologically Dependent and Occupational Pulmonary Diseases, Research Institute of Pulmonology, Federal Medical and Biological Agency of Russia
Volkov Igor Konstantinovich	Professor of the Department of Children's Diseases of the Medical Faculty of the 1st Moscow State Medical University. I.M. Sechenova, professor, d.m.s.
Geppe Natalia Anatolievna	Head of the Department of Children's Diseases of the Medical Faculty of the 1st Moscow State Medical University. I.M. Sechenova, professor, d.m.s.
Princely Nadezhda Pavlovna	Associate Professor of the Department of Pulmonology of the Russian National Research Medical University named after A.I. N.I. Pirogova, Associate Professor, Ph.D.
Mazitova Nailya Nailevna	Doctor of Medical Sciences, Professor of the Department of Occupational Medicine, Hygiene and Occupational Pathology, Institute of Postgraduate Vocational Education A.I. Burnazyan FMBA of Russia
Meshcheryakova Natalia Nikolaevna	Leading Researcher, Laboratory of Rehabilitation, Research Institute of Pulmonology, FMBA, Ph.D.
Nenasheva Natalia Mikhailovna	Professor of the Department of Clinical Allergology of the Russian Medical Academy of Postgraduate Education, Professor, MD
Revyakina Vera Afanasievna	Head of the Allergology Department of the Research Institute of Nutrition of the Russian Academy of Medical Sciences, Professor, MD
Shubin Igor Vladimirovich	Chief Therapist of the Military Medical Directorate of the High Command of the Internal Troops of the Ministry of Internal Affairs of Russia, Ph.D.

METHODOLOGY

Methods used to collect/select evidence:
search in electronic databases.

Description of the methods used to collect/select evidence:
The evidence base for the recommendations is the publications included in the Cochrane Library, the EMBASE and MEDLINE databases. The search depth was 5 years.

Methods used to assess the quality and strength of evidence:
· Consensus of experts;
· Evaluation of significance in accordance with the rating scheme (the scheme is attached).

Levels of Evidence	Description
1++	High quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias
1+	Well-conducted meta-analyses, systematic, or RCTs with low risk of bias
1-	Meta-analyses, systematic, or RCTs with a high risk of bias
2++	High-quality systematic reviews of case-control or cohort studies. High-quality reviews of case-control or cohort studies with very low risk of confounding effects or bias and moderate likelihood of causation
2+	Well-conducted case-control or cohort studies with moderate risk of confounding effects or bias and moderate likelihood of causation
2-	Case-control or cohort studies with a high risk of confounding effects or biases and an average likelihood of causation
3	Non-analytic studies (eg: case reports, case series)
4	Expert opinion

Methods used to analyze the evidence:
· Reviews of published meta-analyses;
· Systematic reviews with tables of evidence.

Description of the methods used to analyze the evidence:
When selecting publications as potential sources of evidence, the methodology used in each study is reviewed to ensure its validity. The outcome of the study influences the level of evidence assigned to the publication, which in turn affects the strength of the recommendations that follow from it.
The evaluation process, of course, can be affected by the subjective factor. To minimize potential errors, each study was evaluated independently, ie. at least two independent members of the working group. Any differences in assessments were already discussed by the entire group. If it was impossible to reach a consensus, an independent expert was involved.

Evidence tables:
Evidence tables were filled in by members of the working group.

Methods used to formulate recommendations:
Expert consensus.

Power	Description
A	At least one meta-analysis, systematic review, or RCT rated 1++ that is directly applicable to the target population and demonstrates robustness or a body of evidence that includes results from studies rated as 1+ that are directly applicable to the target population and demonstrate overall consistency of results
V	A body of evidence that includes results from studies rated as 2++ that are directly applicable to the target population and demonstrate overall consistency of results or extrapolated evidence from studies rated 1++ or 1+
WITH	A body of evidence that includes results from studies rated as 2+ that are directly applicable to the target population and demonstrate overall consistency of results; or extrapolated evidence from studies rated 2++
D	Level 3 or 4 evidence; or extrapolated evidence from studies rated 2+

Good practice indicators (Good practice points - GPPs):
The recommended good practice is based on the clinical experience of the members of the Guideline Development Working Group.

Economic analysis:
Cost analysis was not performed and publications on pharmacoeconomics were not analyzed.

Description of the recommendation validation method:
These draft guidelines have been peer-reviewed by independent experts who have been asked to comment primarily on the extent to which the interpretation of the evidence underlying the recommendations is understandable.
Comments were received from primary care physicians and district therapists regarding the intelligibility of the presentation of recommendations and their assessment of the importance of recommendations as a working tool in everyday practice.
The draft was also sent to a non-medical reviewer for comments from a patient perspective.