Methods of treatment and prevention of bronchial asthma in children and adults: stepwise therapy of bronchial asthma. Standards for the treatment of bronchial asthma by steps Folk remedies for bronchial asthma

Basic therapy of bronchial asthma in modern medicine is based on the autogenesis (origin) of the disease and taking into account its stages. This approach allows specialists to choose an adequate treatment, based on the complexity of the course of the pathology, to provide the patient with relief from the general condition.

It is necessary to identify the severity in order to rationally organize the stepwise therapy of bronchial asthma. The stage is determined by the clinical picture, etiology and severity of symptoms, the following indicators are taken into account:

the number of daytime and nighttime symptoms per week (both values are calculated separately);
peak expiratory flow (PSV) and its fluctuations.

After determining these indicators, it will not be difficult to determine the stage of the disease, which can be mild, moderate or severe.

Stages of the disease

Standards for the treatment of bronchial asthma are determined depending on the stages, each of which is characterized by a set of features.

Symptoms at the first stage

This is a mild form of the disease. The main manifestations - shortness of breath, cough reflex, wheezing in the lungs - are observed less than once a week. Night attacks occur at most twice a month. In the period between attacks, there are no pronounced symptoms, lung function is normal, PSV is more than 80% of the norm, fluctuations are not more than 20%.

Symptoms in the second stage

The second stage is also a mild form of the disease. The main symptoms appear more often than once a week, but not every day. Nocturnal disturbances occur more than once every 2 weeks. In connection with exacerbations, sleep may be disturbed and professional activity. Bronchial reactivity becomes increasing, daily fluctuations in PSV reach 30%.

Symptoms in the third stage

This stage of bronchial asthma is characterized by the middle stage of the disease, which involves the daily manifestation of the main symptoms during the day and weekly attacks at night. Due to constant exacerbations, there is a noticeable deterioration in the quality of life of the patient. Fluctuations in PSV exceed 30%. Patients require constant medication and medical supervision.

Symptoms in the fourth stage

This includes a severe form of bronchial asthma, in which symptoms appear constantly throughout the day. Often there are exacerbations at night. Due to uncontrolled attacks of suffocation and shortness of breath, the patient has difficulty with physical activity. The PSV indicator is deviated from the norm even outside the attack.
It is possible to identify the severity of the given indicators only before the start of treatment.
What studies are carried out at all stages of bronchial asthma

Diagnosis of the first and second stage

In this case, surrender general analyzes urine, blood and sputum, a study of the functions of external respiration (RF) is carried out, skin tests are taken, an x-ray is taken in the chest area. As additional measures, provocative tests with allergens or physical activity are carried out in specialized medical institutions.

Diagnosis of the third and fourth stage

Diagnosis of asthma includes the same activities as in the first, second stage, they are supplemented by sputum analysis, blood gas analysis, carried out in specialized medical institutions.

Stepwise therapy for bronchial asthma

The basic treatment of the disease in steps allows you to constantly monitor the patient's condition and monitor the results. Since bronchial asthma is a chronic phenomenon, one can only count on an improvement in the general condition, but not on a complete cure.

Treatment at the first stage

The therapy is intended for the mildest form of the disease. There are no drugs as such, if necessary, bronchodilators can be prescribed (for more than once a day). If the patient's state of health becomes worse, the medical complex is shifted, i.e., the treatment of the second stage of the disease is carried out.

Therapy at the second stage

In this case, the patient takes drugs daily, these include inhalations with agonists-2, which have a short-term effect, a special inhaled composition of glucocorticoids is used to prevent relapses.

The third stage of the disease and its treatment

The ongoing therapy is aimed at eliminating the signs of the middle stage of the disease, in the presence of such a pathology, it is necessary to take anti-inflammatory drugs, glucocorticoids daily. If there is an urgent need, the specialist prescribes 2-adrenergic receptor agonists, which may have a long or short-term effect. As necessary (with the progression or subsidence of the disease), the doctor can make adjustments to the dosage.

Fourth step

The treatment of stage 4 asthma includes measures aimed at suppressing the symptoms of the severe stage. It involves the daily intake of high doses of inhaled glucocorticoids in combination with bronchodilators. As additional means, the combinations of several drugs used can be used - theophylline, ipatropium bromide. All funds are prescribed and accepted under the strict supervision of a specialist.

Fifth step

Seizures cannot be relieved by conventional means, so systemic glucocorticoids and inhalations containing bronchodilators are often used at this stage. Prednisolone is also used. Means are prescribed in large dosages, their intake must be monitored by a specialist.

How is the disease treated in children?

Therapy of bronchial asthma in children includes two stages - the use of controlling agents and the elimination of attacks. The same groups are used in the complex medicines, as for the treatment of the disease in adult patients:

antihistamines;
anti-inflammatory compounds;
drugs to combat bronchial manifestations;
ASIT (allergen-specific immunotherapy).

When eliminating asthmatic phenomena, a test is mandatory to determine the causative allergen, under the influence of which bronchial obstruction occurs. If concomitant diseases are present, therapy is aimed at their urgent treatment. The entire therapeutic process in young patients should be controlled by the attending physician. On an outpatient basis, several specialists are involved in monitoring: a pulmonologist, a pediatrician, an allergist.

Prevention of bronchial asthma

There are primary and secondary prevention of bronchial asthma. The first measure is taken against people at risk (mainly children) who have previously had allergic reactions, croup, bronchitis. Secondary prevention aims to reduce the general symptoms of the disease.

Both types of prevention involve following several recommendations:

Daily walks in the fresh air.
Elimination of contact with the causative agent of asthma.
Prevention of chronic pathologies.
Rejection bad habits and poor quality food.
Passing courses of physiotherapy exercises.

To prevent exacerbations of the disease in the room where the patient lives, it is necessary to provide optimal conditions:

regularly carry out wet cleaning;
remove carpets and soft bedspreads;
periodically wash bed and underwear;
use special covers for pillows;
conduct preventive pest control.

Bronchial asthma is considered a common disease at the present time. They affect both adults and children. The disease is chronic, therefore, it can proceed in a state of remission or exacerbation. For the treatment and prevention of asthma attacks, it is recommended to use medical preparations different groups. It is also possible to take phytotherapeutic agents. The most effective scheme for pathology is considered to be stepwise therapy of bronchial asthma.

Medications for treatment

Includes the use of drugs to prevent relapses and relieve symptoms. Pharmacotherapy of bronchial asthma consists in the use of the following groups of drugs in all degrees of the course of the disease:

Anti-inflammatory drugs. These funds eliminate the inflammatory processes occurring in the bronchi. Allocate antihistamines and corticosteroid inhalers. Popular antihistamines are Cromoglycic acid, Nedocromil, Tailed, Intal. Among the corticosteroid inhalers, fluticasone, Beclomethasone, Dexamethasone are most often prescribed.
Bronchodilators. They are used to expand the lumen of the bronchial passages. They help to stop asthma attacks. Beta1-2-agonists are used (Formoterol, Ipradol, Terbutaline, Salbutamol, Salmefamol, Salmeterol), theophylline-based drugs (Aminophylline, Teopec), parasympathetic innervation blockers (Ipratropium Bromide, Troventol, Berodual), combined drugs (Combivent, Berodual).
Means that block receptors for leukotrienes. With bronchial asthma among the medicines of this group, Montelukast, Zafirlukast are used.

Among the necessary drugs that are often prescribed by specialists are. Bekodit, Betlomet, Pulmicort, Ingakort, Budesonide, Dlixotide, Nasobek are considered popular inhalers.

These drugs are prescribed for both basic and gradual therapy of the disease. Basic treatment consists in the use of funds for constant therapy and medications that will help with exacerbation of the symptoms of the pathology.

Basic therapy of bronchial asthma in children is based on the following principles:

Control over the signs of the disease;
Exacerbation prevention;
Prevention of development of irreversible complications such as obstruction;
Support for the functioning of the respiratory system;
Selection individual program physical loads.

For this, drugs are used to relieve the symptoms of the disease and relieve suffocation. For life, special basic medicines are prescribed, which do not depend on periods of remission or exacerbation.

In this way, basic treatment is a controlling, suppressing signs of a pathological condition, as well as the prevention of exacerbations.

Treatment step by step

Step therapy for bronchial asthma is a treatment that is approved by international standards. Application medicinal products, which depends on the severity of the course of the disease - the main principle of this technique. The advantage of this treatment is the ability to control the disease.

There are four degrees of severity of the pathological condition:

Intermittent light. It is characterized by a minimum number of seizures - about two per month. As a rule, they occur at night.
Persistent mild. Attacks are also observed in the daytime - up to once.
Average. At night, attacks occur once a week, during the day - every day.
Heavy. Asthma symptoms occur more than once daily. In addition, physical activity is particularly difficult.

Depending on the degree of bronchial asthma, there are five stages of therapy.

1 step. It is used for mild illness. Often drugs are not used, bronchodilators may be prescribed once a day. Salbutamol and Fenoterol are suitable for stopping an attack.
2 step. In this case, basic therapy is prescribed, which consists in the use of one or more medications for permanent use. Agonists-2-adrenergic receptors, antileukotrienes are prescribed. They are used as inhalers for daily use. To prevent relapses, glucocorticoids are sometimes prescribed.
3 step. This stage consists in the use of inhaled glucocorticoids and anti-inflammatory drugs. To the medicines used in the second stage, a long-acting beta-agonist, for example, Salmeterol or Formoterol, is added. The third stage is typical for bronchial asthma, which occurs in the middle form.
4 step. Every day, inhaled glucocorticoids and bronchodilators are used. Long-acting Theophylline or Ipratropium Bromide may also be given. Systemic hormonal anti-inflammatory drugs that are used in this case include Methylprednisolone and Prednisolone.
5 step. The severe form is treated with inhaled bronchodilators and systemic glucocorticoids in high dosages.

Patients are prescribed treatment by a specialist, depending on the severity of the condition. If for three months the course of the disease can be controlled, then they switch to therapy a step lower. In addition, treatment for any degree of disease also includes patient education.

Physiotherapeutic procedures are also used in bronchial asthma. Effective non-drug treatments include:

Breathing exercises;
Acupuncture;
Thoracic massage;
Speleotherapy;
Thermotherapy;
Aerophytotherapy;
barotherapy;
Mountain climatic treatment;
halotherapy;
Electrophoresis.

These methods are performed in the physiotherapy department of the polyclinic. However, most of these procedures are carried out in spa treatment.

Folk remedies for bronchial asthma

Is it possible to use? Certainly. Phytotherapy for bronchial asthma is usually used in the first three stages of the disease.

Among the effective alternative methods provide the following funds:

Collection of coltsfoot, licorice roots and plantain in a ratio of 4:3:3. A tablespoon of this mixture is poured with a glass of boiling water and left to infuse for fifteen minutes. Use 100 grams of infusion three times a day. Such a remedy effectively relieves the inflammatory process and eliminates spasms, contributes to the expansion of the bronchial lumen.
A mixture of plantain leaves, pine buds and coltsfoot. Take medicinal plants and pour the collection cold water, after which they insist for about two hours. After this, the product should be boiled, insisted and filtered. Take three times a day. Such a folk medicine promotes expectoration of sputum and has an anti-allergic effect.
Wild rosemary and stinging nettle. Crushed herbs are poured with a glass of boiling water and left to infuse for twenty minutes. Drink the infusion in three doses daily. Plants that are part of this medicine prevent asthma attacks and improve excretion from respiratory tract sputum.

It is important to remember that the application medicinal herbs as a treatment for bronchial asthma must be approved by a specialist, as patients may be intolerant to some plants.

Disease prevention

Asthma prevention is a measure that aims to prevent the development of the disease, as well as its symptoms. Distinguish between primary and secondary methods of prevention.

Primary preventive methods

Primary prevention of bronchial asthma is to follow the following recommendations:

Clean your house more often.
Live in an ecologically clean area. If this is not possible, then the situation needs to be changed more often, for example, to go to the sea.
Get rid of sources of allergens (soft toys, carpets, feather pillows, animals).
Use hypoallergenic detergents for cleaning, washing and washing.
Lead a healthy lifestyle, namely quit smoking and drinking alcoholic beverages.
With a tendency to develop allergic reactions, it is necessary to periodically use antihistamines to prevent the aggravation of the effects of allergies on the respiratory system.
Take a daily walk in the fresh air. The best place for this there will be a forest, a park, a forest plantation.
Strengthen immune system by performing hardening procedures. This item is especially important for the prevention of bronchial asthma in children.
Eat right and rationally. In this case, products that cause allergic reactions must be excluded.
Lead an active lifestyle: play sports, exercise.
Avoidance of stressful situations is another preventive method that is used to prevent bronchial asthma.

To prevent the onset of asthma is also the treatment of diseases that affect respiratory system, since their development can provoke asthmatic bronchitis, which later develops into asthma.

Prevention of bronchial asthma in children should be done even before they are born. To do this, you must follow the basic recommendations regarding primary preventive methods.

The first measure to prevent asthma in a child is the elimination of diathesis and allergic rashes in infancy. For this, when breastfeeding mothers are forbidden to eat foods that can lead to allergies, such as citrus fruits, chocolate, nuts. Also, to prevent bronchial asthma in children, prevention is the restriction of such food in complementary foods.

Experts point out that mother's milk protects children in the future from the development of various diseases, including bronchial asthma.

Secondary prevention

Sometimes primary prevention measures fail. When the child nevertheless acquired the disease, then secondary prevention of bronchial asthma is necessary to avoid asthma attacks and the occurrence of relapses.

The main principle in this case is the use of the necessary medications in order to prevent the development of seizures and the progression of the disease. This is called basic therapy, which consists in the prevention of exacerbation of bronchial asthma.

Also, with secondary methods of prevention, they also follow the recommendations that are necessary for primary prevention of the disease. It is also important to be careful during the flowering period of plants whose pollen is a strong allergen. Insect bites are considered dangerous for some asthmatics.

In secondary prevention, self-massage of points associated with the respiratory tract, chest massage is recommended. The patient can perform breathing exercises according to the methods of Buteyko or Strelnikova. Useful inhalation with a nebulizer.

Includes physiotherapy treatments, Spa treatment. It will also be important to use alternative means from asthma.

The principles of the treatment of bronchial asthma are based on a stepwise approach, recognized in the world since 1995. The goal of this approach is to achieve the most complete control of the manifestations of bronchial asthma with the use of the least amount of drugs. The amount and frequency of medications increases (step up) as the disease worsens and decreases (step down) as treatment is effective. At the same time, it is necessary to avoid or prevent exposure to triggers.

Stage 1

Treatment of intermittent bronchial asthma includes prophylactic administration (if necessary) of drugs before exercise (short-acting inhaled beta2-agonists, cromolyn sodium, nedocromil, their combined drugs, such as diteka or intala-plus). Instead of inhaled beta2-adrenergic agonists, m-anticholinergics or short-acting theophylline preparations can be prescribed, but their action begins later and / or they cause side effects more often. With an intermittent course, it is possible to conduct specific immunotherapy with allergens, but only by specialists in allergology.

Stage 2

With a persistent course of bronchial asthma, daily long-term prophylactic medication is necessary. Assign inhaled glucocorticoids at 200-500 mcg / day (based on beclomethasone dipropionate), nedocromil or long-acting theophylline preparations. Short-acting inhaled beta2-adrenergic agonists continue to be used as needed (with proper basic therapy, the need should be reduced until they are canceled).

If, during treatment with inhaled glucocorticoids (while the doctor is sure that the patient is inhaling correctly), the frequency of symptoms does not decrease, the hormone dose should be increased to 750-800 mcg / day or, in addition to glucocorticoids (at a dose of at least 500 mcg), prolonged bronchodilators should be prescribed. actions at night (especially to prevent night attacks).
If asthma symptoms cannot be achieved with the help of prescribed drugs (the symptoms of the disease occur more often, the need for short-acting bronchodilators increases, or PSV values decrease), treatment should be started according to step 3.

Step 3

Daily use of anti-asthma anti-inflammatory drugs. Assign inhaled glucocorticoids at 800-2000 mcg / day (based on beclomethasone dipropionate); use of an inhaler with a spacer is recommended. You can additionally prescribe long-acting bronchodilators, especially to prevent nocturnal attacks, for example, oral and inhaled long-acting beta2-adrenergic agonists, long-acting theophylline preparations (controlled by the concentration of theophylline in the blood; therapeutic concentration is 5-15 mcg / ml). You can stop the symptoms with short-acting beta2-agonists. For more severe exacerbations, a course of treatment with oral glucocorticoids is carried out. If pharmacological control of the manifestations of bronchial asthma cannot be achieved (symptoms of the disease occur more often, the need for short-acting bronchodilators increases, or PEF values decrease), treatment should be started according to step 4.

Step 4

In severe cases of bronchial asthma, it is not possible to completely control it. The goal of treatment is to achieve the maximum possible results: the least number of symptoms, the minimum need for short-acting beta2-adrenergic agonists, the best possible PEF values and their minimum variation, the smallest number side effects drugs. Usually many drugs are used: inhaled glucocorticoids in high doses (800-2000 mcg / day in terms of beclomethasone dipropionate), glucocorticoids orally continuously or in long courses, long-acting bronchodilators. You can prescribe m-anticholinergics (ipratropium bromide) or their combinations with beta2-adrenergic agonists (berodual). Short-acting inhaled beta2-agonists can be used as needed to relieve symptoms, but not more than 3-4 times a day.

Step up and step down

Step up (deterioration). They move to the next stage if treatment at this stage is ineffective. However, it should be taken into account whether the patient takes the prescribed medications correctly and whether he has contact with allergens and other provoking factors.
Step down (improvement). A decrease in the intensity of maintenance therapy is possible if the patient's condition is stabilized for at least 3 months. The volume of therapy should be reduced gradually. The transition to the step down is carried out under the control of clinical manifestations and respiratory function.

The above basic therapy should be accompanied by carefully performed elimination measures and supplemented with other drugs and non-drug methods treatment taking into account the clinical and pathogenetic variant of the course of asthma.

Patients with atopic asthma are recommended specific immune therapy with causally significant allergens, unloading and dietary therapy, barotherapy, and acupuncture.
Patients with infectious-dependent asthma need sanitation of foci of infection, mucolytic therapy, barotherapy, acupuncture.
Patients with autoimmune changes, in addition to glucocorticoids, can be prescribed cytotoxic drugs.
Patients with aspirin asthma may be recommended anti-leukotriene drugs.
Patients with hormone-dependent (glucocorticoid dependence) asthma need individual schemes for the use of glucocorticoids and control over the possibility of developing complications of therapy.
Patients with disovarian changes can be prescribed (after consultation with a gynecologist) synthetic progestins.
Patients with a pronounced neuropsychic variant of the course of bronchial asthma are shown psychotherapeutic methods of treatment.
In the presence of adrenergic imbalance, glucocorticoids are effective.
Patients with a pronounced cholinergic variant are shown anticholinergic drug iprotropium bromide.
Patients with bronchial asthma of physical effort need methods of physical therapy, antileukotriene drugs.
Various methods of psychotherapeutic treatment, psychological support are needed for all patients with bronchial asthma. In addition, all patients (in the absence of individual intolerance) are recommended multivitamins. When the exacerbation subsides and during the remission of bronchial asthma, physiotherapy exercises and massage are recommended.
Particular attention should be paid to teaching patients the rules of elimination therapy, the technique of inhalation, individual peak flowmetry and monitoring their condition.

First of all, foods that cause an allergic reaction should be excluded from the diet. With aspirin asthma, products containing salicylates and tartrazine are excluded. In all forms of bronchial asthma, limit the use of foods containing histamine (wine, canned food, smoked meats, spinach, tomatoes, sauerkraut), as well as promoting the release of histamine (eggs, crayfish, strawberries, chocolate, bananas, nuts, peanuts, alcohol, broths, seasonings, coffee, tea). It is advisable to use foods containing dietary fiber and pectins (whole grains, cereals, vegetables, berries and fruits, dried fruits, wild edible herbs). Most effective method treatment of bronchial asthma is set out in the Recommendations of the European Respiratory Society and National Institute health (USA) for the treatment of asthma. They consist in the constant and phased (stepwise) treatment of the patient.

Step number 1.

Intermittent bronchial asthma mild course (episodic asthma)

Clinical picture before treatment. Asthma symptoms (suffocation attacks) occur sporadically, quickly disappear and occur less than 1 time per week. Short-term exacerbations - from several hours to several days. Asthma symptoms occur at night and occur less frequently than twice a month.

no symptoms and normal function lungs between exacerbations. Peak maximum expiratory flow (PMEF), determined by a peak fluorometer, or forced expiratory volume in 1 s (FEV,) is normal or close to normal in the period between exacerbations: about 80% or more of the proper values, the deviation is less than 20%.

With the described clinical picture for the relief of rare attacks of suffocation and, above all, for their prevention, the following treatment is indicated:

Avoid contact with triggering (allergic, etc.) factors.
At the "request of the patient" in the presence of symptoms, inhalation of short-acting p2-agonists no more than 1 time per week: salbutamol (syn.: ventolin, salamol) in 10 ml aerosol cans containing 200 doses: 1 dose (OD mg), less often 2 doses (respectively 1-2 breaths of the drug); fenoterol (syn. berotek) in 15 ml aerosol cans containing 300 doses: one breath (0.2 mg of the drug); terbutaline (syn.: bricanil, arubendol) in aerosol cans: one breath.
Before physical activity or before the upcoming exposure to the allergen, inhale short-acting P2-adrenergic agonists (see paragraph 2) or cromolyn sodium (syn.: sodium cromoglycate, intal, cromolyn, lomuzol): inhale 1 capsule of the powder (0.02 g) with a pocket Turbo inhaler "Spingaler".

With a more pronounced clinical picture and, if necessary, the use of sympathomimetics more than 2-3 times a week, a transition to the second stage of bronchial asthma pharmacotherapy is recommended.

Step number 2.

Persistent bronchial asthma, mild course of the disease

Clinical picture before treatment. The frequency of exacerbations that disrupt the activity and sleep of the patient, 1-2 times a week. Asthma symptoms occur 1 time per week or more often, but less than 1 time per day, at night 1-2 times a month.

Symptoms are constant, not pronounced, but persistent. Chronic symptoms requiring almost daily administration of short-acting P2 agonists. PMPV or FEV, within more than 80% of the due values, the deviation is 20-30%.

Treatment. 1. Aerosol anti-inflammatory agent daily: first, inhaled corticosteroids (beclomethasone dipropionate, becotide, beclomet, beclat - aerosol for 200 inhalations: 200-500 mcg per day or nedocromil sodium (syn. Tiled) - aerosol in cylinders: 1-2 doses (in each dose of 2 mg) or cromolyn sodium (syn.: sodium cromoglycate, intal, cromolyn, lomuzol): inhale 1 capsule of the powder (0.02 g) with the Spingaler pocket turbo inhaler. Ketotifen (syn. : zaditen, astafen) in capsules and tablets: 0.001 g orally with meals 2 times a day.In children, treatment begins with the appointment of trial doses of cromolyn sodium.

2. In the absence of effect from the therapy or a slight effect, the dose of inhaled corticosteroids is increased from 250-500 mcg to 750 mcg per day. If the symptoms of asthma at night remain, then go to step number 3 with the addition of:

1) long-acting bronchodilators. Volmax in tablets of 0.008 g: 8 mg orally 2 times a day, formoterol 12-24 mg for inhalation 2 times a day or 20-40 mg orally 1-2 times a day, salmeterol (serevent) in powder 50 mcg for inhalation 2 times a day, as well as long-acting theophylline preparations:

a) preparations of theophylline of the 1st generation for oral administration: teodur, teotard in tablets and capsules: 300 mg 2 times a day; durophyllin capsules: 250 mg 2 times a day; ventax capsules, samofillin 200 mg 2 times a day; teopek, retafil tablets: 300 mg 2 times a day;

2) short-acting inhaled P2-agonists, which are administered at the request of the patient, but not more than 3-4 times a day: salbutamol, fenoterol, terbutaline (see step 2 of stage No. 1).

Step number 3.

Persistent bronchial asthma moderate

Clinical picture before treatment. Asthma symptoms occur almost daily. Asthma symptoms at night appear more often 1-2 times a week. Exacerbations cause disruption of activity and sleep. PMPV or FEV, within 60-80% of the due values, the deviation is more than 30%.

Treatment. 1. Enlarge daily dose anti-inflammatory drugs: inhaled corticosteroids - beclomethasone dipropionate, becotide, beclomet, beclat in aerosols for 200 inhalations: 200-800 mg, sometimes up to 1000 mcg per day (more than 1000 mcg under supervision).

a) preparations of theophylline of the 1st generation for oral administration: teodur, teotard in tablets and capsules: 300 mg 2 times a day; durophyllin capsules 0.25 g: 250 mg 2 times a day; ventax capsules, samofillin 200 mg 2 times a day; teopek, retafil tablets: 300 mg 2 times a day;

b) preparations of theophylline of the 2nd generation for oral administration: filocontin 100-350 mg 1 time per day; eufilong in capsules of 0.25 g: 250-500 mg 1 time per day; Unifil 200-400 mg once a day.

3. In the presence of night attacks, long-acting P2-agonists are prescribed orally: volmax in tablets of 0.008 g: 8 mg 2 times a day, formoterol 12-24 mg for inhalation 2 times a day or 20-40-80 mg inside 2 times a day.

4. It is possible to use inhaled m-anticholinergic agents: ipratropium bromide (syn.: atrovent, itrop) in aerosol cans of 15 ml: 2 breaths (2 times 20 mcg) 3-4 times a day; troventol (Truvent) in aerosol cans of 21 ml: 1-2 breaths 2 times a day.

5. Short-acting inhaled P2-agonists (salbutamol in 10 ml aerosol cans, fenoterol in 10 ml aerosol cans, fenoterol in 15 ml aerosol cans, terbutaline; see step 2 of stage No. 1) are administered at the request of the patient up to 3 -4 times a day.

Step number 4.

Persistent bronchial asthma, severe course

Clinical picture before treatment. Frequent exacerbations.

Persistent presence of daytime symptoms. Frequent occurrence of asthma symptoms (attacks) at night. Physical activity limited. PMPV or FEV, less than 60% of the due values, the deviation is more than 30%.

Treatment. 1. Increase the daily dose of anti-inflammatory drugs: inhaled corticosteroids - beclomethasone dipropionate, becotide, beclomet, beclat, budesonide, fluticasone propionate, flixotide in aerosol cans: 800-1000 mg each (from 1000 to 2000 mcg under medical supervision).

2. If symptoms are present at night, long-acting theophylline is prescribed (see step 1 of step No. 2):

a) preparations of theophylline of the 1st generation for oral administration: teodur, teotard 300 mg 2 times a day; durophyllin capsules 0.25 g: 250 mg 2 times a day; ventax capsules, samofillin 200 mg 2 times a day; teopek, retafil tablets: 300 mg 2 times a day;

b) preparations of theophylline of the 2nd generation for oral administration: filocontin 100-350 mg 1 time per day; eufilong in capsules of 0.25 g: 250-500 mg 1 time per day; dilatran, unifil 200-400 mg 1 time per day; theo-24 1200-1500 mg 1 time per day.

3. In the presence of night attacks appoint:

a) long-acting oral p2-agonists (see step 3 of step No. 3): volmax in tablets of 0.008 g: 8 mg 2 times a day, formoterol 12-24 mg for inhalation 2 times a day or 20- 40-80 mg orally twice a day or

b) long-acting inhaled P2-agonists: formoterol 12-24 mg for inhalation 2 times a day or 20-40 mg orally 1-2 times a day, salmeterol (serevent) in powder: 50 mcg for inhalation 2 times a day day.

4. Short-acting inhaled P2-agonists: salbutamol in aerosol cans of 10 ml, fenoterol in aerosol cans of 15 ml, terbutaline in aerosol cans (see step 2 of stage No. 1) is administered at the request of the patient, but not more often than 3-4 once a day. An increase in the need for these drugs indicates the need for increased anti-inflammatory therapy.

5. It is possible to use inhaled anticholinergics (see paragraph 4 of stage No. 3): ipratropium bromide (syn.: atrovent, itrop) in aerosol cans of 15 ml: 2 breaths (2 times 20 mcg) 3-4 times a day ; troventol (Truvent) in aerosol cans of 21 ml: 1-2 breaths 3 times a day.

6. Corticosteroids by mouth every other day or once a day for a long time:

a) short-acting: cortisone in tablets of 0.025-0.05 g, prednisolone in tablets of 0.001-0.005 g, methylprednisolone (metipred, urbazone) in tablets of 0.004 g;

b) medium duration of action: triamcinolone in tablets of 0.004 g;

c) long-acting: dexamethasone in tablets of 0.0005 g.

"Step down". If a good therapeutic effect is obtained at one or another stage and it persists for several months, then a cautious transition to a lower stage is possible in order to determine the minimum amount of therapy required to maintain the achieved effect. If the control of symptoms and functional disorders of the respiratory system is not possible, you should move to a higher level of treatment. Tell the patient about the symptoms that indicate a deterioration in the condition, as well as about the measures to be taken in such cases. In addition to the outlined scheme for the treatment of bronchial asthma, entero, hemo, immuno, plasma sorption, hemofiltration, plasma, and lymphopheresis are effective in some cases. UVI of autologous blood, intravascular laser irradiation of blood, extracorporeal perfusion of xenospleen. Sometimes antihistamines are prescribed (see Ascariasis of the lungs), acupuncture, barotherapy, spa treatment are used. All patients are recommended psychotherapeutic treatment, sometimes in combination with tranquilizers: chlozepid (syn.: librium, napoton, elenium) in tablets of 0.005 g: 0.005-0.01 g per day, mezapam (syn. rudotel) in tablets of 0, 01 g: 0.02-0.03 g per day, meprotan (syn.: meprobamate, andaxin) in tablets of 0.2 g: 0.2-0.4 g orally 2-3 times a day.

Sanitation of ENT organs and foci of chronic infection is mandatory. In the presence of viscous and stubborn sputum, expectorants and mucolytic agents are recommended (see Acute Bronchitis). In atopic asthma, etimizol is recommended in tablets of 0.1 g: 100 mg 3 times a day. Specific hyposensitization is carried out with histoglobulin 2 ml (up to 3 ml) under the skin with an interval of 2-3 days, for a course of treatment 7-10 injections. To prevent the formation of microthrombi, heparin is shown (in 5 ml vials): 5000-10,000 IU 2-3 times a day, dipyridamole (syn. Curantil) in tablets of 0.025 g: 0.025-0.05 g orally 3 times a day day. In the interictal period, electrophoresis of calcium and bromine according to Vermel (the anode is placed between the shoulder blades) for 20-30 minutes every other day or magnesium and sulfur (the anode is placed between the shoulder blades) for 20-30 minutes every other day is prescribed. Electropyrexia is shown with a UHF field for 1.5-3 hours 1 time in 3 days (for a course of treatment 5-10 sessions, before starting the session, find out the patient's tolerance high temperature body), anteroposterior diathermy on the chest area or inductothermy for 20 minutes every other day. With severe sensitization, diathermy is prescribed to the spleen area for 10-20 minutes every other day. Also shown are ultrasound on the lateral surfaces of the chest and paravertebral regions, electrosleep (5-10 pulses per 1 s) for 30 minutes daily, general UVR to stimulate the activity of the adrenal cortex or UVR of the chest region, as well as air ionization of the respiratory tract with the necessary medicinal solutions (alkalis, antiseptics, herbal decoctions).

In severe autoimmune processes, despite glucocorticosteroid therapy, they rarely resort to the use of azathioprine (syn. Imuran) in tablets of 0.05 g, mercaptopurine in tablets of 0.05 g: first, 50 mg per day, then after 3 days with in the absence of leukopenia and thrombocytopenia, the daily dose of the drug is increased to 100 mg, and after another 3 days to 150 mg per day. The course of treatment is 3-4 weeks, if the number of leukocytes and platelets in the peripheral blood allows, which is monitored every 3 days. Surgery bronchial asthma did not justify itself.

For citation: Princely N.P. DIAGNOSIS AND STEP APPROACH TO THE CLASSIFICATION AND TREATMENT OF BRONCHIAL ASTHMA // RMJ. 1997. No. 22. S. 1

Despite the clear definition of bronchial asthma, the rather vivid symptoms and the possibilities of functional research methods cause difficulties in diagnosing the disease.

The article shows modern approaches to the diagnosis, classification and treatment of bronchial asthma using a stepwise method.

Despite the fact that bronchial asthma is well, its rather obvious symptoms and the capacities of functional techniques present some difficulties defined in diagnosing the disease. The paper outlines currently available approaches to making the diagnosis of bronchial asthma, its classification, and treatment by applying a stepwise approach.

N. P. Knyazheskaya, Department of Hospital Therapy, Faculty of Pediatrics, Russian State Medical University, Moscow
N.P. Knyazhevskaya, Department of Hospital Therapy, Russian State Medical University

B ronchial asthma - chronic inflammatory disease respiratory tract, in which many cells take part: mast cells, zosinophils, T-lymphocytes. In predisposed persons, this inflammation leads to repeated episodes of wheezing, shortness of breath, heaviness in chest and coughing, especially at night and/or early morning. These symptoms are usually accompanied by widespread but variable obstruction of the bronchial tree, which is partially or completely reversible spontaneously or under the influence of treatment.
As epidemiological studies show, despite a clear definition of the disease, rather bright symptoms and great possibilities of functional research methods, bronchial asthma is poorly diagnosed, and therefore poorly treated. Asthma is most commonly diagnosed as a form of bronchitis and, as a result, treated ineffectively and inadequately with courses of antibiotics and antitussives. Thus, the common thesis that "anything accompanied by wheezing is not yet bronchial asthma" should be changed to a more appropriate one: "anything accompanied by wheezing should be considered asthma until proven otherwise." ".
In the diagnosis of bronchial asthma, significant importance is attached to the anamnesis and assessment of the symptoms of the disease. The most common symptoms are episodic choking, shortness of breath, wheezing, a feeling of heaviness in the chest, and coughing. However, these symptoms alone are not a diagnosis. An important clinical marker of bronchial asthma is the disappearance of symptoms spontaneously or after the use of bronchodilators and anti-inflammatory drugs. In assessing and taking anamnesis, importance is attached to the following facts: repeated exacerbations, most often provoked by allergens, irritants, exercise or viral infection, as well as seasonal variability in symptoms and the presence of atopic diseases in relatives.
Since asthma symptoms change throughout the day, a normal physical examination may be obtained. During an exacerbation of asthma, spasm of smooth muscles, edema and hypersecretion lead to obstruction of the small bronchi, auscultatory doctor most often listens to dry rales. However, it must be remembered that in some patients, even during an exacerbation during auscultation rales may not be audible, while objective studies will register significant bronchial obstruction, probably due to the predominant involvement of small airways in the process. Therefore, the measurement of respiratory function (RF) provides an objective assessment of bronchial obstruction, and the measurement of its fluctuations provides an indirect assessment of airway hyperreactivity. There is a wide range of different methods for assessing the degree of bronchial obstruction, but the measurement of forced expiratory volume in 1 s (FEV1) and the associated measurement of forced vital capacity (FVC), as well as the measurement of forced (peak) expiratory flow (FEF) have been most widely used. .
Probably the most important innovation in the diagnosis and management of asthma is the introduction of the peak flow meter. Regular home monitoring is helpful as it helps doctors and patients identify early signs worsening condition and take the necessary medications.
Many studies have shown that complaints made by patients do not correspond to the degree of bronchial obstruction.
Incorrect assessment of the severity of asthma by the patient and his doctor is the main factor causing insufficiently adequate anti-inflammatory treatment, and can lead to severe exacerbation or even to lethal outcome. The use of peak flowmetry makes it possible to accurately diagnose and classify the severity of the course of bronchial asthma and, accordingly, prescribe anti-inflammatory maintenance therapy, taking into account the severity of the disease, i.e., to implement the so-called stepwise approach.
Along with the assessment of symptoms, anamnesis of physical data and respiratory function indicators for making a diagnosis, it has great importance study of allergic status. The most commonly used are scarification, intradermal and prick (prick test) tests.
However, in some cases, skin tests lead to false-negative or false-positive results. Therefore, a study of specific IgE antibodies in the blood serum is often carried out.

As already mentioned, bronchial asthma is often misdiagnosed and, as a result, the wrong therapy is prescribed. It is especially difficult to diagnose asthma in children, the elderly, as well as when exposed to occupational risk factors, the seasonality of the disease, and in the cough variant of asthma.
Diagnosis of asthma in children is most often very difficult due to the fact that episodes of wheezing and coughing are the most common symptoms of childhood illnesses. Assistance in making a diagnosis is provided by the clarification of a family history, an atopic background. Repeated bouts of nocturnal coughing in otherwise healthy children almost certainly confirm the diagnosis of bronchial asthma. In some children, asthma symptoms are provoked by physical activity.
Another group of patients in which the diagnosis of asthma (with a late onset) the doctor either does not make or misses is the elderly. It is difficult for them not only to diagnose asthma, but also to assess the severity of its course. Careful history taking, examination aimed at excluding other diseases accompanied by similar symptoms (primarily coronary disease heart with signs of left ventricular failure), as well as functional research methods, including also the registration of electrocardiograms and X-ray examination, usually clarify the picture.
Diagnosis of occupational asthma also presents a certain difficulty. It is known that many chemical compounds present in environment cause asthma.
They range from highly active low molecular weight compounds such as isocyanates, to known small molecular weight compounds such as isocyanates, to known immunogens such as platinum salts, plant complexes and animal products. Diagnosis requires a clear history: no symptoms before starting work, a confirmed association between the development of asthma symptoms at the workplace and their disappearance after leaving the workplace. It is possible to accurately confirm the diagnosis of bronchial asthma with the help of a study of respiratory function indicators: measuring PSV at work and outside the workplace, conducting specific provocative tests. It should be taken into account that even with the termination of exposure to the damaging agent, the course of bronchial asthma persists and continues to worsen. Therefore, early diagnosis of occupational asthma, termination of contact with the damaging agent, as well as rational pharmacotherapy are very important.
Seasonal asthma is usually associated with allergic rhinitis. In the period between seasons, the symptoms of bronchial asthma may be completely absent. When making a diagnosis, anamnesis and an in-depth allergy examination are of great importance, as well as measuring respiratory function and conducting inhalation tests with b 2 -agonists during an exacerbation.
The cough variant of asthma presents a significant difficulty in diagnosis. this disease. Cough is practically the main, and sometimes the only symptom. In such patients, cough often occurs at night and, as a rule, is not accompanied by wheezing. In the study of indicators of respiratory function in the daytime, normal values are often recorded. For the correct diagnosis, it is of great importance to determine the variability of respiratory function parameters in combination with the search for eosinophils in sputum and diagnostic tests. tests to detect hypersensitivity.
The classification of bronchial asthma is based on the etiology, severity of the course and features of the manifestation of bronchial obstruction. In past years, due to the lack of understanding of the underlying processes that occur in asthma, the focus has been on the more obvious manifestations of bronchial asthma, namely acute inflammation, bronchospasm and airflow limitation. This has led to the predominant use of bronchodilators to correct all manifestations of asthma. Airway inflammation is now known to imply both exacerbation and chronicity of asthma. In this regard, there has been a change in approaches to the treatment of the disease towards the long-term use of anti-inflammatory drugs. To select adequate anti-inflammatory therapy, it is important to determine the severity of the course of bronchial asthma. No test will accurately classify the severity of asthma. However, the combination of symptom scores and indicators of respiratory function characterizes the disease depending on the severity.
It has been established that the assessment of the course of bronchial asthma, based on the clinical manifestations of the disease, is associated with indicators of the degree of airway inflammation.
Both the level of obstruction and the degree of its reversibility allow asthma to be subdivided according to severity into intermittent, mild persistent (chronic), moderate (moderate) and severe. In the treatment of asthma, a stepwise approach is currently used, in which the intensity of therapy increases as the severity of asthma increases (Fig. 1).

After determining the severity of the patient's asthma (see Fig. 1), the doctor must decide whether to begin with the maximum treatment for the fastest achievement of asthma control, followed by a decrease in drugs (step down) or start treatment with a small amount of drugs, and then amplify it (step up) if necessary. In any case, if asthma symptoms can be controlled within 3 months, then a decrease in therapy (step down) can be carefully considered. The transition to a lower level allows you to set the smallest amount of therapy needed for control.
Approaches to treatment, depending on the severity of asthma, are shown in Fig. 2. It should be taken into account that the lowest severity of asthma is presented in the 1st stage, and the greatest - in the 4th stage. A stepwise approach to treatment involves moving up to a higher level if asthma control is not achieved or is lost. However, it is necessary to take into account whether the patient is taking medications of the appropriate level correctly and whether there is contact with allergens or other provoking factors.

Stage 1. Patients with mild intermittent asthma- these are patients whose asthma symptoms appear only when they come into contact with allergens (for example, pollen or animal hair) or are caused by physical activity, as well as children whose wheezing occurs during a respiratory viral infection of the lower respiratory tract.
Intermittent asthma is not a common form of the disease. The severity of exacerbations can vary significantly in different patients at different times. Such exacerbations can even be life-threatening, although this is extremely rare in the intermittent course of the disease.
Long-term therapy with anti-inflammatory drugs, such as usually not indicated for these patients. Treatment includes prophylactic medication before exercise if needed (inhalation b 2 -agonists or cromohycate, or underfed). As an alternative to short-acting inhaled b 2 -agonists, anticholinergics, short-acting oral b 2 -agonists or short-acting tnophyllines can be offered, although these drugs have a later onset of action and / or they have a higher risk of adverse events.
Occasionally, more severe and prolonged exacerbations require a short course of oral corticosteroids (see Fig. 2).
Stage 2. Patients with mild persistent asthmaneed daily long-term preventive medication to achieve and maintain asthma control. Primary therapy is the administration of anti-inflammatory drugs. Treatment may be initiated with inhaled corticosteroids, sodium cromoglycate, or nedocromil sodium. The suggested dose of corticosteroids is 200 to 500 micrograms of beclomethasone dipropionate or budesonide or Ingacort or equivalent per day. Long-acting theophylline therapy may be suggested. However, the need to control its plasma concentration (therapeutic range 5-15 mg/l) can make such treatment is not always possible. inhalation b 2 -agonists can be used to relieve symptoms, but the frequency of their intake should not exceed 3 to 4 times a day. As an alternative for inhaled b 2 -short-acting agonists may be offered anticholinergics, oral b 2 -short-acting agonists or short-acting theophyllines, although these drugs have a later onset of action and/or have a higher risk of adverse events. If the patient is taking long-acting theophyllines, the plasma concentration of theophylline should first be determined before prescribing short-acting theophyllines. For more severe and prolonged exacerbations, a short course of oral corticosteroids is required.
If symptoms persist despite the initial dose of inhaled corticosteroids and the clinician is confident that the patient is using the drugs correctly, the dose of inhaled drugs should be increased from 400 to 500 to 750 to 800 mcg per day (beclomethasone dipropionate or equivalent). A possible alternative to increasing the dose of inhaled hormones, especially to control nocturnal asthma symptoms (to a dose of at least 500 micrograms of inhaled corticosteroids), may be to give long-acting bronchodilators at night.
If control cannot be achieved, which is expressed by more frequent symptoms, an increase in the need for bronchodilators, or a drop in PEF, then treatment should be started at the 3rd stage.
Stage 3. Patients with moderate asthma course require daily intake of prophylactic anti-inflammatory drugs to establish and maintain asthma control. The dose of inhaled corticosteroids should be at the level of 800 - 2000 micrograms of beclomethasone diprotionate or its equivalent. It is recommended to use an inhaler with a spacer. Long-acting bronchodilators may also be given in addition to inhaled corticosteroids, especially to control nocturnal symptoms. Long-acting theophyllines, oral and inhaled long-acting b 2 -agonists can be used. It is necessary to monitor the concentration of long-acting theophylline (the usual range of therapeutic concentrations is 5-15 micrograms per 1 ml). Symptoms should be treated with short-acting b 2 -agonists or alternative drugs, as described in step 2. For more severe exacerbations, a course of oral corticosteroids can be given.
If control cannot be achieved, which is expressed by more frequent symptoms, an increase in the need for bronchodilators, or a drop in PEF, then treatment should be started at the 4th stage.

Rice. 1. Long-term asthma control: diagnose and classify the severity of the course

Fig.2. Long-term asthma control: treatment with a stepwise approach

Stage 4. Patients with severe course bronchial asthma Asthma cannot be completely controlled. The goal of treatment is to achieve the best possible results: the minimum number of symptoms, the minimum need for b 2 -short-acting agonists, the best possible PSV values, the minimum spread of PSV and the minimum side effects from taking drugs. Treatment is usually with a large number of asthma-controlling drugs.
Primary Treatment includes high-dose inhaled corticosteroids (between 800 and 2000 micrograms per day of beclomethasone dipropionate or equivalent). Long-acting bronchodilators are recommended in addition to inhaled corticosteroids. To achieve the effect, you can also apply 1 time per day b 2 short-acting agonists. An anticholinergic drug (Atrovent) may be tried, especially in patients who report side effects at the reception b 2 -agonists. If necessary, inhalers can be used to relieve symptoms. b 2 -short-acting agonists, but the frequency of their intake should not exceed 3-4 times a day. A more severe exacerbation may require a course of oral corticosteroids.
Long term treatment oral corticosteroids should be administered in minimal doses or, if possible, every other day. Treatment with high-dose inhaled corticosteroids is administered via a spacer, which improves control and reduces some side effects.
Step down. Reduced supportive carepossible if asthma remains under control for at least 3 months. This helps reduce the risk side effects and increases the patient's susceptibility to the planned treatment. Reduce therapy should be stepped, lowering or canceling the last dose or additional drugs. You need to watch for symptoms clinical manifestations and indicators of FVD.
Thus, although bronchial asthma is an incurable disease, it is reasonable to expect that the majority of patients can and should achieve control over the course of the disease.
It is also important to note that the approach to the diagnosis, classification and treatment of asthma, taking into account the severity of its course, allows you to create flexible plans and special treatment programs depending on the availability of anti-asthma drugs, the regional healthcare system and the characteristics of a particular patient.

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