Hoble exacerbation treatment new scientific articles. Chronic obstructive pulmonary disease: a focus on mucolytics

Medical and social significance of exacerbations chronic obstructive pulmonary disease(COPD) can be fully understood if we turn to the results of well-known epidemiological studies conducted in Western Europe and North America (unfortunately, such studies have not been conducted in the Russian Federation). So, in particular, it was found that patients with COPD suffer from one to four or more exacerbations of the disease during the year, which for a country like the United States, in total, is 15-60 million episodes of exacerbation during a calendar year. Hospital mortality among patients with exacerbations of COPD reaches 10%; moreover, the long-term prognosis for hospitalized patients with severe exacerbation is assessed as very unfavorable: within the next year, the mortality rate among this contingent may be 40%.

Consideration of modern therapeutic approaches to patients undergoing exacerbation of COPD, it is advisable to preface the definition of the very concept of "exacerbation of COPD". One of the possible options for such a definition is as follows: exacerbations of COPD are understood as acute, episodically arising worsening, superimposed on the stable course of the disease and accompanied by increased shortness of breath, decreased daytime performance, changes in the volume and color of expectorated sputum (or without such), increased cough, increased body temperature and / or impaired memory and intelligence. And although the pathophysiology of acute exacerbation of COPD remains not entirely clear, its primary mechanism is obvious: it is a progressive deterioration of existing ventilation-perfusion disorders, which, from a clinical point of view, indicates an aggravation of respiratory failure.

Among the most relevant causes of exacerbation of COPD, the following should be mentioned. First of all, these are respiratory infections - bacterial or viral (the so-called primary causes). Traditionally, secondary causes include: a) pneumonia; b) right and / or left ventricular failure; c) transient heart rhythm disturbances; G) pulmonary embolism; e) pneumothorax; f) inadequate oxygen replacement therapy; g) taking medications - hypnotics, tranquilizers, diuretics; h) gastroesophageal reflux and / or aspiration; i) metabolic diseases (decompensated diabetes mellitus, delectrolyte disorders); j) a decline in nutrition; k) myopathy; l) fatigue of the respiratory muscles; m) other diseases and pathological conditions (in particular, gastrointestinal bleeding).

Respiratory infections are of the greatest importance among the variety of causes that "trigger" the actual exacerbation of COPD. Their development is associated with up to half of all cases of exacerbation of the disease (below we will discuss in more detail the actual respiratory pathogens responsible for the development of exacerbations of COPD). However, in about 1/3 of cases, the cause (s) of exacerbation of COPD has not been established.

If we try to determine the key tactical tasks that face the attending physician caring for a patient with exacerbation of COPD, then they obviously boil down to the following:

Assessment of the severity and establishment of specific causes of the current exacerbation of COPD;

Where (meaning the outpatient or inpatient stage) and how to treat the patient?

Correct and timely medical monitoring (when treating at home, it is advisable to assess the dynamics of the leading pathological manifestations of an exacerbation in the next 48 hours; in the event of a severe exacerbation, manifested by progressive respiratory failure and requiring urgent hospitalization, at first, when carrying out oxygen replacement therapy, it is necessary to monitor the patient every half hour ).

Assessment of the severity of exacerbation of COPD is based on the following factors:

a) the patient's condition preceding the exacerbation;

b) the severity of clinical symptoms, the results of a physical examination;

c) data laboratory methods research.

An indication of the stable condition of the patient that preceded the exacerbation is extremely important, since it makes it possible to assess his daytime performance. Also important are the duration of the actual exacerbation of COPD, the severity of the progressive worsening of the symptoms of the disease, the assessment of the regularity of treatment, the ascertaining of possible sleep disturbances and problems with food intake. Among the symptoms that make it possible to most adequately assess the severity of exacerbation of COPD, attention should be paid to cough, volume and color of sputum, as well as the severity of shortness of breath. However, cough and phlegm may not change during the exacerbation, since, as already mentioned, respiratory infection is not always at the origin of exacerbation of COPD.

Evidence of severe exacerbation of COPD are:

The inclusion of auxiliary muscles in the act of breathing;

Increased cyanosis;

The appearance or progression of signs of cor pulmonale;

Tachypnea (> 25 / min);

Tachycardia (> 110 / min);

Fever (> 38.5 ° C).

If there are data characterizing the state of bronchial patency and the gas composition of arterial blood that preceded the exacerbation, then it is extremely important to compare them with the actual ones. In the absence of such a possibility, a decrease in the values ​​of the peak expiratory flow rate (PSV) less than 100 l / min or the forced expiratory volume in the first second (FEV 1) less than 1.0 l indicate severe ventilation disorders (it is more correct to correlate the actual values ​​of the analyzed parameters of bronchial patency with the proper values ). A decrease in oxygen saturation (less than 90%) and / or partial tension of oxygen in arterial blood (less than 60 mm Hg) also indicates severe respiratory failure.

Let us consider modern unified standards for the management of patients with mild and severe exacerbation of COPD.

Management of a patient with mild exacerbation of COPD

In this clinical situation, the following approaches appear among the key ones:

Antibacterial therapy;

Bronchodilator therapy;

Adequate hydration, relief of sputum discharge;

Unconditional refusal to take sedatives;

Patient education.

At the same time, the most debated issues are related to antibiotic therapy of exacerbations of COPD: a) wide and not always justified practice of prescribing antibiotics in exacerbations of COPD; b) assessment of the prevalence of microbial colonization of the lower respiratory tract; c) interpretation of microbiological "findings" in sputum in persons suffering from exacerbation of COPD.

As you know, a significant number of cases of exacerbation of COPD are based on non-infectious or infectious viral origin and therefore should not be treated with antibiotics. In practice, most physicians and pulmonologists prescribe antibiotics for exacerbation of COPD and it is interesting that this trend, based on clinical experience, but not supported by strictly scientific data, is reflected in the well-known conciliatory recommendations of the American Thoracic Society (ATO, 1995), Thoracic Society of Australia and New Zealand (TOANZ, 1995), European Respiratory Society (EPO, 1995).

Perhaps, for the first time, the relationship between the severity of an actual exacerbation of COPD and the effectiveness of antibiotic therapy was demonstrated by N.R. Anthonisen et al. within the framework of a large-scale placebo-controlled examination of 350 patients who met the "Winnipeg criteria" - increased dyspnea, an increase in the volume of expectorated sputum, purulent sputum (Table 1). And today there is no longer any doubt about the fact that with exacerbation of COPD, which meets all three "Winnipeg criteria", antibiotic therapy is undoubtedly indicated. In this case, the choice of antibiotics should be correlated with the actual respiratory pathogens responsible for the development of exacerbation of COPD - Streptococcus pneumoniae (pneumococci), Haemophilus influenzae and Moraxella (Branhamella) catarrhalis (Table 2), data on the local prevalence of resistant clinical isolates from topical pathogens, and an acceptable price / performance balance.

Note. Type I - the presence of all three "Winnipeg criteria" for exacerbation of chronic bronchitis (see text); Type II - the presence of any two of the "Winnipeg criteria"; Type III - one of the "Winnipeg criteria" in combination with symptoms of upper respiratory tract infection and / or fever; and / or increased cough, and / or an increase of 20% or more in heart rate or heart rate. H. d. - not reliable.

If in a specific clinical situation the question of prescribing antibiotics for exacerbation of COPD is resolved positively, then with an equally expected efficacy can be prescribed

As discussed on the Chronic Obstructive Pulmonary Disease page, the main goals of COPD treatment are:

  • prevention of further development of the disease and the appearance of complications;
  • relief of the course and severity of symptoms of COPD;
  • improving exercise tolerance;
  • improvement of the general condition of the patient with COPD;
  • prevention and treatment of complications of COPD;
  • prevention and treatment of exacerbations of COPD;
  • reduced mortality due to COPD;

This page deals with the treatment of COPD in the stable phase of the disease (outside the exacerbation period).

Communication with a COPD patient and role in treatment

It must be said right away that the diagnosis of COPD can play a huge role in a person's life, therefore, understanding the nature of the disease and its prognosis should not be underestimated. There are a variety of interpretations of the importance of COPD for the patient and different attitudes towards the disease. Many patients, for example, do not understand that the diagnosis of COPD essentially combines both the diagnosis of pulmonary emphysema and the diagnosis of chronic bronchitis. Therefore, the following key points should be discussed with each patient and his relatives:

  • risk factors for COPD;
  • the importance of smoking cessation, ways of assistance from the doctor;
  • reducing the effect of harmful environmental factors;
  • vaccination against influenza and pneumococcal infection;
  • the nature of COPD and prognosis in COPD;
  • medications - indications, dosage, possible side effects;
  • correct use of the inhaler;
  • continuity with previously prescribed treatment;
  • methods that make breathing easier and help manage shortness of breath;
  • the importance of regular exercise and communication with others;
  • early warning recognition of complications;
  • indications for oxygen therapy and correct use oxygen devices;
  • the possibility of surgical care according to indications;
  • features of management and assistance to a patient in the terminal phase of the disease;

Of course, there is no point and no need to try to address all of the above issues in one conversation. Meetings with the patient should be regular, and some important concepts and points should be explained over and over again. It is necessary to take into account and discuss the information received from the print media and the Internet, to help separate the "wheat from the chaff."

Special requirements are imposed on consultations of a patient with α1-antitrypsin deficiency and his family members. It is important to find out how necessary a genetic examination is in this case.

We must be prepared for the manifestation of the patient's feelings of guilt towards the people around him, because many consider only themselves to be guilty of the occurrence of COPD, and some patients or his family members see COPD as something shaming them. It is necessary to try to explain to the patient that the expressed nicotine dependence is quite explicable and cannot be a criterion for moral qualities and / or weakness of will of the patient.

The ideas and meaning of communication with a COPD patient should be realistic, but always contain a positive and optimistic message.

Prevention of further development and complications of COPD

Currently, there are no proven ways to prevent the development of COPD in patients who continue to smoke.... Cessation of smoking in patients with COPD, being the top priority for the attending physician, does not save the patient from all the troubles associated with the deterioration of lung function. Patients with mild and even moderate forms of COPD may either not know that they are already sick and that the development of the disease can be stopped by quitting smoking, or they may already get used to the unreasonable idea that it is too late to quit smoking. Even those who are very seriously ill can continue smoking or return to this addiction again after a while. The “tobacco history” should be clarified at EVERY meeting with the patient, for the patient himself, of course, “forgets” to inform the doctor that he began to smoke more or resumed smoking after a short break. The doctor must be able to really convince the patient that smoking is harmful, that smoking cessation is beneficial for every person, that, finally, it is actually possible to quit smoking.

At work and at home, you should avoid contact with substances that can irritate the respiratory tract and lungs... Although exposure to dust and hazardous substances in the workplace is rarely the leading cause of COPD, exposure to this kind can increase lung dysfunction in smokers and the severity of symptoms such as coughing and phlegm. It is imperative to use protective respirators. Although there is no threshold for FEV1 to prevent the use of respirators, it is known that patients with COPD often develop shortness of breath when using these devices due to increased dead space and increased inspiratory resistance. Thus, some people with COPD need to change their working conditions if they are unable to use such respirators and other protective equipment. If COPD is complicated by allergies or there is concomitant bronchial asthma, it is necessary, within available possibilities, to examine the patient's environment for the presence of allergens.

Vaccination against pneumococcal infection although there is still no direct evidence that it is particularly beneficial for COPD.

Annual influenza vaccination can prevent or seriously mitigate the manifestations of pneumococcal disease (pneumonia, otitis media, etc.) For the elderly and weakened with pulmonary disease, it is preferable to use a killed rather than an attenuated vaccine.

Unvaccinated during a flu epidemic can be recommended prophylactic use of amantadine or rimantadine, which often save from illness caused by influenza, A, although recent observations indicate that a significant number of resistant strains of the virus have appeared, and the number of side effects has also increased. All this can limit the use of these drugs.

During a flu epidemic, you can significantly reduce the severity of the disease and limit the spread of infection (both A and B types) with the use of the neuraminidase inhibitors zanamivir and oseltamivir... The drugs should be taken as early as possible (no later than 48 hours after the onset of the disease).

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People with COPD have different life expectancy, depending on a number of factors. The most important of these are the presence of concomitant complications in the form of heart disease and the level of pressure in the pulmonary artery. COPD has the following definition: chronic obstructive pulmonary disease. This pathology occurs mainly in experienced smokers. In addition, it is caused by exposure to harmful chemicals and dust. Genetic predisposition also plays a role. The disease is characterized by constant progression, and its exacerbation often occurs. Therefore, the question of how long such patients live is very relevant.

The disease has a chronic course and is characterized by a decrease in the volume of air entering the lungs. It is caused by a narrowing of the bronchial lumen. According to statistics, men over 40 years old, smokers with experience are more affected by this disease. But since in recent times the number of actively smoking women has sharply increased, and their proportion among sick people has also increased. Chronic obstructive pulmonary disease is not completely cured, you can only stop its progression and thus prolong the patient's life. The first symptom of the disease is shortness of breath.

Stages and symptoms of the disease affecting the patient's life

IN clinical picture COPD present symptoms such as increased production of phlegm, severe cough, and shortness of breath. This symptomatology is caused by inflammation in the lungs and obstruction. These symptoms are present in the initial stages of the disease, at later stages they are joined by problems in the work of the heart and pain in the bones. COPD often combines symptoms and signs of pulmonary emphysema and obstructive bronchitis.

At the onset of the disease, the cough bothers the patient mainly after a night's sleep, later it becomes permanent. Dry cough, accompanied by profuse expectoration. Shortness of breath is associated with difficulty breathing out.

Depending on the severity of the symptoms, there are 4 stages of the disease:

  1. The first stage of the disease is mild, manifested in episodic bouts of dry cough. Shortness of breath appears only with significant physical exertion. A pronounced deterioration in well-being is not observed. Detection of COPD at this stage and treatment will help maintain the patient's normal duration and quality of life. Reliable diagnosis during this period of the disease is carried out only by 25%.
  2. The stage of moderate severity is characterized by certain limitations that the disease imposes on the patient. So, there is a pronounced impairment of the functioning of the lungs and shortness of breath, even with minor loads. Cough worries more and more often, especially in the morning. The patient is prescribed medication. The prognosis for life at this stage is less favorable.
  3. Severe stage - the patient complains of symptoms such as constant shortness of breath and shortness of breath. Cyanosis of the skin and complications in the work of the heart are manifested, exacerbation often occurs. On average, patients with similar manifestations live no more than 8 years. In the case of the addition of additional diseases or if an exacerbation of COPD occurs, the mortality rate reaches 30%.
  4. The last is a very difficult stage of the disease: most of those sick at this stage live no more than a year. They need constant medication to keep them alive. Often there is a need for artificial ventilation. All symptoms of the disease, especially cough and shortness of breath, are most pronounced. In addition, all sorts of complications join.

There are also such forms of the disease as emphysematous, bronchitic and mixed.

Life expectancy of patients

What is the prognosis for the life expectancy of people with COPD? A timely diagnosis has a direct impact on the life expectancy of patients with such a diagnosis. Quite often, the reduction in the life expectancy of people with this disease occurs due to late diagnosis.

Most patients do not seek qualified medical care on time, and therefore late treatment and high premature mortality are observed. In the absence of proper treatment, the prognosis is always unfavorable, since the disease is steadily progressing. But if you consult a doctor in time and start adequate treatment, then the life expectancy of such patients increases significantly. COPD can be diagnosed through spirometry, X-ray, ultrasound of the heart, ECG, fibrobronchoscopy. In addition, the physician performs a physical examination and prescribes laboratory analysis blood.

Chronic obstructive pulmonary disease significantly impairs the patient's daily life, depriving him of the ability to fully perform basic household skills.

Nevertheless, the life of such patients is different, some live longer, others less. The prognosis depends on certain factors that directly affect the duration of their life. Among them:

  • the presence of heart hypertrophy;
  • the pressure of the pulmonary trunk is higher than normal;
  • heart rate level;
  • low oxygen content in the blood.

Since the methods and effectiveness of the treatment carried out directly affect the quality and duration of life of patients, they must strictly comply with all the prescriptions of the attending physician. In particular, they are strictly shown:

  • to give up smoking;
  • a special diet that includes food enriched with proteins and vitamins;
  • playing sports;
  • special breathing exercises;
  • weight loss in the presence of excess;
  • drug treatment.

How to increase life expectancy?

The incidence and mortality of people from chronic obstructive pulmonary disease throughout the world remains at a high level. Treatment measures are aimed at achieving the following goals:

  • lower mortality rates;
  • decrease in the severity of symptoms;
  • improving the quality of life of patients;
  • facilitating exercise tolerance;
  • prevention of exacerbations and complications.

As part of drug treatment, drugs are used that act to improve sputum discharge and bronchial patency (bronchodilators and mucolytics). Corticosteroids are also prescribed to reduce pulmonary edema (prednisone) and antibiotics, especially if there is an exacerbation.

Videos about COPD and how to detect it:

In the absence of positive dynamics under the influence of such treatment, surgical methods are used. They are aimed at reducing the volume of the lungs, thereby relieving acute symptoms, or lung transplantation.

Dronova O.I.

Chronic obstructive pulmonary disease (COPD)- an extremely widespread disease all over the world, which is one of the main causes of disability, disability, significantly reducing the quality of life of patients and occupying the fourth place among the causes of death in industrialized countries. Moreover, the urgency of this problem is increasing every day: if over the past decade, overall mortality and mortality from cardiovascular diseases has been decreasing, then mortality from COPD has increased by 28%. It is difficult to accurately determine the prevalence of COPD due to the terminological uncertainty that has existed for many years, but, according to some studies, this figure ranges from 10% to 30%. In the United States, about 14 million people suffer from COPD, in the UK - 900 thousand people (and 450 thousand have COPD, but are not diagnosed), in Russia - 11 million (although according to official medical statistics - about 1 million). ).

The term COPD appeared about 30 years ago and combined diseases characterized by slowly but steadily progressive irreversible bronchial obstruction with increasing symptoms of chronic respiratory failure. The COPD group includes chronic obstructive bronchitis, pulmonary emphysema, severe bronchial asthma, and in the United States and Great Britain also cystic fibrosis, bronchiolitis obliterans and bronchiectasis.

Risk factors for developing COPD include:

- smoking (in 80–90% of cases), and secondhand smoke in childhood also plays a role. It has been proven that the highest mortality rates from COPD are observed precisely in smokers;

- pollutants environment(sulfur dioxide, nitrogen dioxide, ozone);

- occupational hazards (exposure to cadmium, silicon; mainly found in miners, builders and workers in contact with cement, during metal processing, etc.);

- genetic factors (deficiency of a1-antitrypsin, which leads to the development of emphysema, the formation of bronchiectasis), prematurity and, possibly, genetic predisposition - blood group A (II), lack of IgA;

- low socio-economic status, and in addition, probably adenovirus infection.

With exacerbation of COPD, the leading etiological factor is infectious. The main bacterial pathogens are H. influenzae, M. catarrhalis (much more often in the winter season), S. Pneumoniae, Str. Aureus, as well as Enterobactericae and P. aeruginosa. It is with these gram-negative microorganisms that the severity of the exacerbation is associated. It is also important to remember the role of viruses in infectious exacerbations of COPD (up to 30% of cases), among which rhinoviruses prevail, and influenza A and B viruses are much less frequently detected. In addition, viruses, disrupting the local lung defense system, contribute to the colonization of bacteria on the mucous membrane of the bronchial tract and thereby the development of bacterial infections. In the pathogenesis of an infectious exacerbation of COPD, suppression of cellular and humoral immunity plays a role - local destruction of immunoglobulins, a decrease in the level of interferon, lysozyme, lactoferrin, inhibition of the phagocytic activity of neutrophils and alveolar macrophages, active production of histamine and other pro-inflammatory stress mediators, a violation mucociliary clearance. In a healthy person, mucociliary clearance is provided by the work of the ciliated epithelium with normal rheology of bronchial mucus. Cigarette smoke, a1-antitrypsin deficiency, microorganism toxins cause destruction and decrease in the number of ciliated cells, decrease in cilia activity. In response to this, overproduction of mucus by goblet cells and glands of the submucous layer occurs, which becomes not a protective, but a pathogenic factor. At the same time, the rheology of bronchial mucus changes: its viscosity and adhesiveness increase, elasticity decreases, which also contributes to the deterioration of mucociliary clearance, mucostasis, and hence the development of microbial colonization, impaired bronchial patency, an increase in respiratory failure, etc. ...

In accordance with the recommendations of the European Respiratory Society, COPD is classified according to severity, with the main reference point being the indicators obtained with the function of external respiration (FRF). With COPD of mild severity FEV1> 70% of the required values, volumetric indicators are normal; with moderate severity - FEV1 - 50–69% of the proper values, there is an increase in the residual lung capacity; in severe cases, FEV1 is less than 50% of the proper values. This classification is recognized as working in Russia. GOLD specialists also distinguish stage zero COPD - a stage of the risk group, which includes patients with such chronic symptoms as cough and phlegm, but with normal spirometry results.

The main symptoms of COPD are precisely coughing up phlegm and shortness of breath, the degree of which ranges from shortness of breath with intense physical activity and occasional coughing to dyspnea at rest with signs of right ventricular failure and persistent cough.

When questioning the patient, attention should be paid to the characteristics of sputum (color, consistency, quantity, ease of discharge); the effect of symptoms on the patient's quality of life, the frequency, time and duration of exacerbations of COPD.

It is also undoubtedly important to carefully collect smoking history and calculate the “smoking person's index”: the product of the number of cigarettes smoked per day by the number of months in a year (ie 12). If the result is greater than 160, smoking in this patient is considered as posing a risk for the development of COPD; the result exceeding 200 allows the patient to be classified as a "hard smoker".

The basic diagnostic methods for COPD include:

- ECG - the ability to identify signs of overload in the right heart;

- blood test - erythrocytosis, polyglobulia are possible; leukocytosis and increased content of C-reactive protein are nonspecific signs, but they help to differentiate bacterial from viral infection;

- X-ray examination of the chest organs (excluding pneumonia);

- determination of the function of external respiration (FVD), which is of the greatest diagnostic value, in which some basic volumetric and velocity parameters are measured (vital capacity of the lungs - VC, forced vital capacity of the lungs - FVC, forced expiratory volume in the first second - FEV1, maximum expiratory flow rate at the level of 75, 50 and 25% - MSV 75,50,25). These indicators form the functional diagnosis of COPD and determine the severity of the disease, its progression and prognosis.

Also, for the diagnosis of COPD, echocardiography (identification of signs of pulmonary hypertension and chronic pulmonary heart disease), bacteriological examination of sputum (more often with the ineffectiveness of empirical therapy), a study of blood gas composition (with severe exacerbation of COPD), bronchological examination for differential diagnosis with other lung diseases, etc. ...

The treatment of COPD requires a comprehensive approach. Undoubtedly, smoking cessation is important as an established risk factor for the development of COPD and its progression. It requires not only the timely use of the right drugs, but also the education of patients in the correct use of them, as well as the basic rules of self-control and emergency self-help measures. An individual selection of gymnastics is necessary for training the respiratory muscles (and in some cases for the correction of respiratory failure and oxygen therapy) and the development of an individual rehabilitation program for each patient.

Of the drugs, bronchodilators constitute the basic therapy, since it is bronchial obstruction that plays a primary role in the pathogenesis of COPD. Nowadays, the most preferable appointment of inhaled forms of bronchodilators, which have a number of advantages and a minimum risk of developing side systemic effects (especially with the advent of new delivery methods - using nebulizers and spacers). Although there is irreversible bronchial obstruction in COPD, the use of bronchodilators can reduce the severity of shortness of breath and other symptoms of COPD in about 40% of patients and increase exercise tolerance. In accordance with the GOLD recommendations, the choice of one or another group of bronchodilators (M-anticholinergics, b2-agonists and methylxanthines) and their combinations is made for each individual patient individually, depending on the severity of the disease and the characteristics of its progression, the nature of the response to treatment and the risk of side effects and the availability of medicines.

M-anticholinergics (MHL) block muscarinic receptors of smooth muscles of the tracheobronchial tree and suppress reflex bronchoconstriction, and also prevent acetylcholine-mediated stimulation of sensory fibers of the vagus nerve under the influence of various factors, thereby providing bronchodilatory and prophylactic effects. Since parasympathetic tone is the only reversible component of bronchial obstruction in COPD, MCL is the first choice in the treatment of COPD. The most widely used now is the inhaled MHL ipratropium bromide. For mild COPD, MHL monotherapy is usually used, mainly with exacerbation, the duration of admission is at least 3 weeks. For moderate to severe COPD, MHL should be used continuously.

b2-agonists quickly act on bronchial obstruction (with its reversible component preserved), improving the well-being of patients in a short time. These drugs (fenoterol, salbutamol, etc.) are used on demand for mild COPD in combination with MHL, and can also be prescribed for continuous use at moderate and severe degrees, again as part of combination therapy (regular use of b2-agonists as monotherapy Not recommended). In addition, it is necessary to use this group of drugs with caution in elderly patients with concomitant cardiac pathology. Moderate to severe COPD requires modification of delivery methods for inhaled drugs.

The bronchodilating effect of methylxanthines (theophylline, etc.) is inferior to that of MHL and b2-agonists, but they are added with insufficient effectiveness of the first two groups of drugs. Methylxanthines are prescribed per os or parenterally and have a number of additional effects (reduction of systemic pulmonary hypertension, increased work of the respiratory muscles, etc.). If the maximum doses of bronchodilators are ineffective, glucocorticosteroid therapy is used, which improves bronchial patency in 10-30% of patients and requires trial treatment before prescribing for a long-term administration.

Antibiotic therapy is carried out exclusively during the exacerbation of COPD. Recently, the annual prophylactic vaccination of all COPD patients with an influenza vaccine has come to the fore, which reduces the mortality rate of patients by about 50%, which makes it possible to reduce the number of exacerbations of the disease, their duration and severity of the course, and therefore, improve bronchial patency, reduce the number of days of disability and improve the quality of life of patients.

For the treatment of COPD, mucolytic agents are widely used, the main therapeutic effect of which is to directly liquefy the pathologically viscous secretion by changing the composition and amount of mucus glycoprotein secreted by the cells of the epithelial lining of the respiratory tract. The goal of mucolytic therapy is to reduce coughing and relieve sputum discharge. In addition, in some cases, patients also notice a weakening of shortness of breath. The results of a systematic Cochrane review show that the use of mucolytics is associated with a lower incidence of acute exacerbations of COPD (29% less frequently). NICE recommends that mucolytic therapy should be given to patients with chronic productive cough and should be continued when symptoms improve. With an unstable nature of a productive cough (for example, mainly in the winter months), the duration of taking mucolytics is 3-6 months. It is advisable to conduct an initial trial treatment when mucolytics are prescribed for 4-6 weeks at the initial prescribed dose and the patient is monitored for 4-6 weeks. In this case, the observation criteria are quite subjective and are based on the patient's own assessment of the changes in the nature of the cough with sputum. In the presence of symptoms throughout the year, longer courses may be required with a decrease in the dose of the drug to the minimum, which allows you to effectively control the patient's condition. Long-term treatment with mucolytic drugs is usually clinically effective in the case of repeated, prolonged or severe exacerbations of COPD.

All mucolytics can be roughly divided into 2 groups.

Direct-acting mucolytics include drugs that destroy mucus polymers: thiols (cysteine, acetylcysteine, thiopronine, etc.), enzymes (trypsin, chymotrypsin, ribonuclease, deoxyribonuclease) and others (ascorbic acid, inorganic iodides, etc.). Proteolytic enzymes were previously used topically - in inhalation or instillation. However, they are not widespread due to the high risk of complications - hemoptysis, aggravated bronchial obstruction, allergic reactions and increased destruction of interalveolar septa with a1-antitrypsin deficiency, which potentiates the development of centriacinar pulmonary emphysema characteristic of COPD.

Indirect-acting drugs include drugs that change the biochemical composition and production of mucus (S-carboxymethylcysteine, sobrerol), affect the ash layer and hydration (water, sodium, potassium salts), volatile substances and balms (terpenes) and change the adhesion of the gel-like layer (ambroxol , bicarbonate of soda). The mechanism of action of mucolytic drugs of indirect action (or secretomotor) is aimed mainly at increasing the physiological activity of the ciliated epithelium and the motility of the respiratory bronchioles. They are divided into reflex means (preparations of thermopsis, istode, marshmallow, licorin, essential oils and others) and resorptive (sodium and potassium iodide, ammonium chloride, etc.) action.

To date, the most frequently and successfully used drugs are acetylcysteine, carbocysteine ​​and ambroxol.

Acetylcysteine ​​has been widely used since the mid-1960s as a mucolytic agent, the sulfhydryl groups of the molecule of which break the disulfide bonds of mucopolysaccharides in sputum. And since its discovery in 1989, O.T. Aruoma et al. its nonspecific activity began to be used as an antioxidant, which has both a direct effect due to the presence of a free thiol group, and indirect due to the fact that it is a precursor of glutathione.

Carbocisteine ​​also destroys the disulfide bonds of mucopolysaccharides of sputum, and also normalizes the quantitative ratio of acidic and neutral sialomucins of bronchial secretions, which restores the viscosity and elasticity of mucus. Under the influence of the drug, the mucous membrane of the tracheobronchial tree is regenerated, its structure is restored, the secretion of immunologically active IgA and the number of sulfhydryl groups are stimulated, and mucociliary clearance is improved. Thus, carbocisteine ​​has both mucolytic and muco-regulating effects.

Ambroxol (Ambrobene and others) has a pronounced muco-regulating and expectorant effect, which is associated with depolymerization of mucoprotein and mucopolysaccharide molecules of sputum, normalization of the function of secretory cells and ciliated epithelium of the bronchial mucosa. In addition, ambroxol (Ambrobene) has antioxidant and anti-inflammatory properties, and also stimulates the synthesis of surfactant by alveolar pneumocytes of the second order (and blocks its decay under the influence of adverse factors), which prevents the penetration of pathogenic microorganisms into the epithelial cells, enhances the ciliary activity of the ciliated epithelium, promotes the separation of the structure of bronchial mucus into gel and sol phases (as a result of which its adhesiveness decreases), which leads to the restoration of mucociliary clearance. It is extremely important that with the simultaneous appointment of ambroxol (Ambrobene) and some antimicrobial drugs (amoxicillin, cefuroxime, doxycycline, erythromycin), it enhances their penetration into the bronchial secretions and the bronchial mucosa, increasing the effectiveness of antibacterial therapy and reducing its duration. It was found that ambroxol stimulates local immunity (promotes an increase in macrophage activity and an increase in s – IgA concentration), and with prolonged use (3–6 months), a decrease in the number of exacerbations of COPD, their duration and severity is noted. The presence of various dosage forms of Ambro-ben (tablets, retard capsules, syrup, solutions for oral administration, inhalation and injections) allows the use of different, including combined, methods of drug delivery, which is its undoubted advantage.

Literature

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COPD (chronic obstructive pulmonary disease) is a disease that develops as a result of an inflammatory reaction to the action of certain environmental stimuli, with damage to the distal bronchi and the development of emphysema, and which is manifested by a progressive decrease in the air flow rate in the lungs, an increase, as well as damage to other organs.

COPD is the second leading chronic noncommunicable disease and the fourth leading cause of death, and the rate is growing steadily. Due to the fact that this disease is inevitably progressive, it occupies one of the first places among the causes of disability, as it leads to a violation of the main function of our body - the function of breathing.

The problem of COPD is truly global. In 1998, an initiative group of scientists created the Global Initiative for Chronic Obstructive Lung Disease (GOLD). The main tasks of GOLD are the wide dissemination of information about this disease, systematization of experience, explanation of the causes and corresponding preventive measures. The main message that doctors want to convey to humanity: COPD can be prevented and treated by this postulate is even included in the modern working definition of COPD.

The reasons for the development of COPD

COPD develops with a combination of predisposing factors and provoking environmental agents.

Predisposing factors

  1. Hereditary predisposition. It has already been proven that congenital deficiency of certain enzymes predisposes to the development of COPD. This explains the family history of this disease, as well as the fact that not all smokers, even with long experience, get sick.
  2. Gender and age. Men over 40 suffer more from COPD, but this can be explained by the aging of the body and the duration of smoking experience. The data show that now the incidence rate among men and women is almost equal. The reason for this may be the spread of smoking among women, as well as increased sensitivity female body to passive smoking.
  3. Any negative impacts, that affect the development of the child's respiratory system in the prenatal period and early childhood, increase the risk of COPD in the future. In itself, physical underdevelopment is also accompanied by a decrease in lung volume.
  4. Infections. Frequent respiratory infections in childhood, as well as increased susceptibility to them at an older age.
  5. Hyperreactivity of the bronchi. Although bronchial hyperreactivity is the main mechanism of development, this factor is also considered a risk factor for COPD.

Provoking factors

COPD pathogenesis

Exposure to tobacco smoke and other irritating substances leads to chronic inflammation in the walls of the bronchi in susceptible individuals. The key is the defeat of their distal parts (that is, located closer to the pulmonary parenchyma and alveoli).

As a result of inflammation, there is a violation of the normal secretion and discharge of mucus, blockage of small bronchi, infection easily joins, inflammation spreads to the submucous and muscle layers, muscle cells die and are replaced by connective tissue (bronchial remodeling process). At the same time, the destruction of the parenchyma of the lung tissue occurs, the bridges between the alveoli - emphysema develops, that is, the hyper-airiness of the lung tissue. The lungs seem to be inflated with air, their elasticity decreases.

On exhalation, small bronchi do not expand well - air hardly leaves the emphysematous tissue. Normal gas exchange is impaired, as the volume of inspiration also decreases. As a result, the main symptom of all patients with COPD arises - shortness of breath, especially aggravated by movement, walking.

Respiratory failure results in chronic hypoxia. The whole organism suffers from this. Prolonged hypoxia leads to a narrowing of the lumen of the pulmonary vessels - it occurs, which leads to the expansion of the right heart (cor pulmonale) and the addition of heart failure.

Why is COPD a separate nosology?

The awareness of this term is so low that most of the patients already suffering from this disease do not know that they have COPD. Even if such a diagnosis is presented in the medical documentation, in the everyday life of both patients and doctors, "emphysema", which was habitual earlier, still prevail.

The main components in the development of COPD are indeed chronic inflammation and emphysema of the lungs. So why, then, is COPD singled out as a separate diagnosis?

In the name of this nosology, we see the main pathological process- chronic obstruction, that is, narrowing of the airway lumen. But the process of obstruction is also present in other diseases.

The difference between COPD and bronchial asthma is that in COPD, obstruction is almost or completely irreversible. This is confirmed by spirometric measurements using bronchodilators. In bronchial asthma, after the use of bronchodilators, there is an improvement in FEV1 and PSV by more than 15%. This obstruction is interpreted as reversible. In COPD, these numbers do not change significantly.

Chronic bronchitis may precede or accompany COPD, but it is an independent disease with well-defined criteria (prolonged cough and), and the term itself assumes damage to only the bronchi. With COPD, all structural elements of the lungs are affected - bronchi, alveoli, blood vessels, pleura. Obstructive disorders are not always associated with chronic bronchitis. On the other hand, increased sputum production is not always observed in COPD. That is, in other words, there may be chronic bronchitis without COPD, and COPD does not quite fall under the definition of bronchitis.

Chronic obstructive pulmonary disease

Thus, COPD is now a separate diagnosis, has its own criteria, and in no way replaces other diagnoses.

Diagnostic criteria for COPD

COPD can be suspected if there is a combination of all or several of the symptoms, if they occur in people over 40:

A reliable confirmation of COPD is the spirometric indicator of the ratio of the forced expiratory volume in 1 s to the forced vital capacity of the lungs (FEV1 / FVC), carried out 10-15 minutes after the use of bronchodilators (beta-sympathomimetics salbutamol, beroteka or 35-40 minutes after short-acting anticholinergics –Ipratropium bromide). The value of this indicator<0,7 подтверждает ограничение скорости воздушного потока и в сочетании с подтвержденными факторами риска является достоверным критерием диагноза ХОБЛ.

The rest of the spirometry indicators - peak expiratory flow rate, as well as the measurement of FEV1 without a test with bronchodilators can be performed as a screening examination, but do not confirm the diagnosis of COPD.

Other methods prescribed for COPD, in addition to the usual clinical minimum, include chest radiography, pulse oximetry (determination of blood oxygen saturation), blood gas analysis (hypoxemia, hypercapnia), bronchoscopy, chest CT, sputum examination.

COPD classification

There are several classifications of COPD by stages, severity, clinical options.

Stage classification takes into account the severity of symptoms and spirometry data:

  • Stage 0. Risk group. Exposure to adverse factors (smoking). There are no complaints, the lung function is not impaired.
  • Stage 1. Mild course of COPD.
  • Stage 2. Moderate course of COPD.
  • Stage 3. Heavy course.
  • Stage 4. Extremely severe course.

In the latest GOLD report (2011), it was proposed to exclude the classification by stages, it remains classification by severity based on FEV1 indicators:

In patients with FEV1 / FVC<0,70:

  • GOLD 1: Light FEV1 ≥80% of due
  • GOLD 2: Moderate 50% ≤ FEV1< 80%.
  • GOLD 3: Heavy 30% ≤ FEV1< 50%.
  • GOLD 4: Extremely Severe FEV1<30%.

It should be noted that the severity of symptoms does not always correlate with the degree of bronchial obstruction. Patients with a mild degree of obstruction may be disturbed by a rather pronounced shortness of breath, and, conversely, patients with GOLD 3 and GOLD 4 may feel rather satisfactory for a long time. To assess the severity of shortness of breath in patients, special questionnaires are used, the severity of symptoms is determined in points. It is also necessary to focus on the frequency of exacerbations and the risk of complications in assessing the course of the disease.

Therefore, in this report, it is proposed, based on the analysis of subjective symptoms, spirometry data and the risk of exacerbations, to divide patients into clinical groups - A, B, C, D.

Practitioners also distinguish clinical forms of COPD:

  1. Emphysematous variant of COPD. Of the complaints in such patients, dyspnea prevails. Coughs are less common, and there may be no sputum. Hypoxemia and pulmonary hypertension come late. Such patients, as a rule, have a low body weight, the skin color is pink-gray. They are called "pink puffers".
  2. Bronchitic option. Such patients mainly complain of coughing up sputum, shortness of breath worries less, they quickly develop cor pulmonale with a corresponding picture of heart failure - blueness, edema. Such patients are called "blue edema".

The division into emphysematous and bronchitic variants is rather arbitrary, more often mixed forms are observed.

During the course of the disease, a phase of a stable course and an exacerbation phase are distinguished.

Exacerbation of COPD

An exacerbation of COPD is an acutely developing condition when symptoms of the disease go beyond its normal course. There is an increase in shortness of breath, cough and deterioration of the general condition of the patient. The usual therapy, which he used earlier, does not relieve these symptoms to the usual state, a change in the dose or treatment regimen is required. Hospitalization is usually required for an exacerbation of COPD.

Diagnosis of exacerbations is based solely on complaints, history, clinical manifestations, and can also be confirmed by additional studies (spirometry, complete blood count, microscopy and bacteriological examination of sputum, pulse oximetry).

The causes of exacerbation are most often respiratory viral and bacterial infections, less often other factors (exposure to harmful factors in the ambient air). A common event in a patient with COPD is an event that significantly decreases lung function, and it can take a long time to return to baseline or stabilize at more severe disease.

The more often exacerbations occur, the worse the prognosis of the disease and the higher the risk of complications.

Complications of COPD

Due to the fact that patients with COPD exist in a state of constant hypoxia, they often develop the following complications:

COPD treatment

The basic principles of treatment and preventive measures for COPD:

  1. To give up smoking. At first glance, a simple, but the most difficult moment
  2. Pharmacotherapy. Early initiation of basic drug treatment can significantly improve the patient's quality of life, reduce the risk of exacerbations and increase life expectancy.
  3. The drug therapy regimen should be selected individually, taking into account the severity of the course, the patient's adherence to long-term treatment, the availability and cost of drugs for each individual patient.
  4. Vaccinations against influenza and pneumococcal infections should be offered to patients with COPD.
  5. The positive effect of physical rehabilitation (training) has been proven. This method is under development, as long as there are no effective therapeutic programs. The easiest way that can be offered to the patient is to walk for 20 minutes daily.
  6. In the case of a severe course of the disease with severe respiratory failure, prolonged oxygen inhalation as a means of palliative care can improve the patient's condition and prolong life.

To give up smoking

It has been proven that smoking cessation has a significant impact on the course and prognosis of COPD. Although chronic inflammation is considered irreversible, smoking cessation slows its progression, especially in the early stages of the disease.

Tobacco addiction is a serious problem that requires a lot of time and effort not only for the patient himself, but also for doctors and relatives. A special long-term study was conducted with a group of smokers, in which various measures were proposed to combat this addiction (conversations, beliefs, practical advice, psychological support, visual agitation). With such an investment of attention and time, it was possible to achieve smoking cessation in 25% of patients. Moreover, the longer and more often the conversations are held, the more likely they are to be effective.

Anti-tobacco programs are becoming national goals. It became necessary not only to promote a healthy lifestyle, but also to legally punish smoking in public places. This will help limit the harm from at least secondhand smoke. Tobacco smoke is especially harmful for pregnant women (both active and passive smoking) and children.

In some patients, tobacco addiction is akin to drug addiction, and conducting interviews in this case will not be enough.

In addition to agitation, there are also medicinal ways to combat smoking. These are nicotine replacement tablets, sprays, chewing gums, skin patches. The effectiveness of some antidepressants (bupropion, nortriptyline) in the formation of long-term smoking cessation has also been proven.

Pharmacotherapy for COPD

Drug therapy for COPD is aimed at relieving symptoms, preventing flare-ups, and slowing the progression of chronic inflammation. It is impossible to completely stop or cure the destructive processes in the lungs with existing drugs.

The main drugs used to treat COPD are:

Bronchodilators

Bronchodilators used to treat COPD relax the smooth muscles of the bronchi, thereby expanding their lumen and making it easier for air to pass as you exhale. All bronchodilators have been proven to increase exercise tolerance.

Bronchodilator drugs include:

  1. Short-acting beta stimulants ( salbutamol, fenoterol).
  2. Long-acting beta stimulants ( salmoterol, formoterol).
  3. Short-acting anticholinergics ( ipratropium bromide - atrovent).
  4. Long-acting anticholinergics ( tiotropium bromide - spiriva).
  5. Xanthines ( euphylline, theophylline).

Almost all existing bronchodilators are used in inhalation form, which is a preferred method over oral administration. There are different types of inhalers (metered-dose aerosol, powder inhalers, inhalation-activated inhalers, liquid forms for nebulizer inhalation). In severe patients, as well as in patients with intellectual disabilities, inhalation is best done through a nebulizer.

This group of drugs is the main one in the treatment of COPD, it is used at all stages of the disease as monotherapy or (more often) in combination with other drugs. For continuous therapy, the use of long-acting bronchodilators is preferable. If it is necessary to prescribe short-acting bronchodilators, preference is given to combinations fenoterol and ipratropium bromide (berodual).

Xanthines (aminophylline, theophylline) are used in the form of tablets and injections, have many side effects, and are not recommended for long-term treatment.

Glucocorticosteroid hormones (GCS)

GCS are a powerful anti-inflammatory agent. They are used in patients with severe and extremely severe degrees, and are also prescribed in short courses for exacerbations in the moderate stage.

The best form of application is inhaled corticosteroids ( beclomethasone, fluticasone, budesonide). The use of such forms of GCS minimizes the risk of systemic side effects of this group of drugs, which inevitably occur when they are taken orally.

Monotherapy with corticosteroids is not recommended for patients with COPD, more often they are prescribed in combination with long-acting beta-agonists. The main combination drugs: formoterol + budesonide (symbicort), salmoterol + fluticasone (seretide).

In severe cases, as well as during an exacerbation, systemic corticosteroids can be prescribed - prednisone, dexamethasone, kenalog... Long-term therapy with these agents is fraught with the development of severe side effects (erosive and ulcerative lesions of the gastrointestinal tract, Itsenko-Cushing's syndrome, steroid diabetes, osteoporosis, and others).

Bronchodilators and GCS (and more often a combination of them) are the main most affordable drugs that are prescribed for COPD. The doctor selects the treatment regimen, doses and combinations individually for each patient. In the choice of treatment, not only the recommended GOLD regimens for different clinical groups matter, but also the patient's social status, the cost of drugs and its availability for a particular patient, the ability to learn, and motivation.

Other drugs used for COPD

Mucolytics(sputum-thinning agents) are prescribed for viscous, difficult-to-cough up sputum.

Phosphodiesterase-4 inhibitor roflumilast (Daxas) Is a relatively new drug. Has a prolonged anti-inflammatory effect, is a kind of alternative to GCS. It is used in tablets of 500 mg once a day in patients with severe and extremely severe COPD. Its high efficiency has been proven, but its use is limited due to the high cost of the drug, as well as a rather high percentage of side effects (nausea, vomiting, diarrhea, headache).

There are studies that the drug fenspiride (Erespal) has an anti-inflammatory effect similar to GCS, and can also be recommended for such patients.

From physiotherapeutic methods of treatment, the method of intrapulmonary percussion ventilation of the lungs is becoming widespread: a special device generates small volumes of air that are supplied to the lungs with rapid jerks. From such pneumomassage, the collapsed bronchi are straightened and ventilation of the lungs is improved.

Treating an exacerbation of COPD

The goal of treating exacerbations is the maximum possible relief of the current exacerbation and prevention of their occurrence in the future. Depending on the severity, the treatment of exacerbations can be carried out on an outpatient basis or in a hospital.

Basic principles of exacerbation treatment:

  • It is necessary to correctly assess the severity of the patient's condition, exclude complications that can be disguised as exacerbations of COPD, and promptly refer to hospitalization in life-threatening situations.
  • With an exacerbation of the disease, the use of short-acting bronchodilators is preferable to long-acting. Doses and frequency of administration tend to be higher than usual. It is advisable to use spacers or nebulizers, especially in critically ill patients.
  • With insufficient effect of bronchodilators, intravenous administration of aminophylline is added.
  • If monotherapy was previously used, a combination of beta-stimulants with anticholinergics (also short-acting) is used.
  • In the presence of symptoms of bacterial inflammation (the first sign of which is the appearance of purulent sputum), broad-spectrum antibiotics are prescribed.
  • Connection of intravenous or oral glucocorticosteroids. An alternative to the systemic use of corticosteroids is inhalation of pulmicort through a nebulizer 2 mg twice a day after inhalation of berodual.
  • Dosed oxygen therapy in the treatment of patients in a hospital through nasal catheters or a Venturi mask. The oxygen content in the inhaled mixture is 24-28%.
  • Other measures are maintenance of water balance, anticoagulants, treatment of concomitant diseases.

Caring for patients with severe COPD

As already mentioned, COPD is a steadily progressive disease and inevitably leads to the development of respiratory failure. The speed of this process depends on many things: the patient's refusal to smoke, adherence to treatment, the patient's material capabilities, his mental abilities, and the availability of medical care. Starting with a moderate degree of COPD, patients are referred to MSEC to receive a disability group.

With an extremely severe degree of respiratory failure, the patient cannot even perform the usual household load, sometimes he cannot even take a few steps. Such patients need constant outside care. Inhalation for seriously ill patients is carried out only with the help of a nebulizer. The condition is greatly facilitated by long-term low-flow oxygen therapy (more than 15 hours a day).

For these purposes, special portable oxygen concentrators have been developed. They do not require refueling with pure oxygen, but concentrate oxygen directly from the air. Oxygen therapy increases the life expectancy of these patients.

Prevention of COPD

COPD is a preventable disease. It is important that the level of prevention of COPD very little depends on the doctors. The main measures should be taken either by the person himself (quitting smoking) or by the state (anti-tobacco laws, improving the environment, promoting and promoting a healthy lifestyle). It has been proven that the prevention of COPD is economically beneficial by reducing the incidence and disability of the working population.

Video: COPD in the Healthy Living Program

Video: what is COPD and how to detect it in time

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