LECTURE No. 7. Diseases of the respiratory system. Chronical bronchitis

Chronic obstructive bronchitis is a diffuse non-allergic inflammatory lesion of the bronchial tree, caused by prolonged irritating effects on the bronchi of various agents, which has a progressive course and is characterized by obstructive pulmonary ventilation, mucus formation and the draining function of the bronchial tree, which is manifested by cough, sputum and shortness of breath.

According to the WHO definition, if a patient coughs up sputum on most days for at least 3 consecutive months for more than 2 consecutive years, the disease is considered chronic bronchitis (CB).

Chronic bronchitis is divided into primary and secondary.

Primary chronic bronchitis is an independent disease that is not associated with other bronchopulmonary processes or damage to other organs and systems, in which there is a diffuse lesion of the bronchial tree.

Secondary CB develops against the background of other diseases - both pulmonary (tuberculosis, bronchiectasis, etc.) and extrapulmonary (uremia, congestive heart failure, etc.).

Most often it is local in nature (segmental).

Consider primary HB.

Etiology. Both exogenous factors (tobacco smoke, air pollution, unfavorable professional conditions, climatic and infectious factors) and endogenous factors (pathology of the nasopharynx, impaired breathing through the nose, repeated acute respiratory diseases, acute bronchitis and focal infection of the upper respiratory tract) play a role in the development of CB. pathways, hereditary predisposition, metabolic disorders (obesity)).

Pathogenesis. Under the influence of exogenous and with the participation of endogenous factors in the tracheobronchial tree, the structural and functional properties of the mucous membrane and submucosal layer change, inflammation of the mucous membrane develops, and the patency and drainage function of the bronchi are disrupted.

Structural and functional changes in the mucous membrane and submucosal layer are expressed in hyperplasia and hyperfunction of goblet cells, bronchial glands, hypersecretion of thick and viscous mucus, which leads to disruption in the mucociliary transport system. The amount of secretory IgA-lysozyme and lactoferrin produced is reduced. Edema of the mucous membrane develops, and then - atrophy and metaplasia of the epithelium.

Inflammation of the mucous membrane is caused by various irritants in combination with infection (viral and bacterial). Chemical substances (pollutants) contained in the air have a damaging effect on the respiratory tract, swelling of the mucous membrane occurs and inhibition of the activity of the ciliated epithelium occurs. This leads to a violation of the evacuation and a decrease in the barrier function of the bronchial mucosa. Catarrhal contents are replaced by catarrhal-purulent, and then purulent.

The spread of the inflammatory process to the distal sections of the bronchial tree disrupts the production of surfactant and reduces the activity of alveolar macrophages that phagocytize foreign particles.

If the bronchospasm that occurs in case of inflammation is pronounced, then a bronchospastic (non-allergic) component develops. The associated infection during exacerbation of inflammation contributes to the development of an asthmatic (allergic) component, which makes it possible to attribute such CB to pre-asthma.

Obstructive syndrome develops due to a combination of a number of factors:

1) spasm of smooth muscles of the bronchi as a result of irritating effects of exogenous factors and inflammatory changes in the mucous membrane;

2) hypersecretion of mucus, changes in its rheological properties, leading to disruption of mucociliary transport and blockage of the bronchi with a viscous secret;

3) epithelium metaplasia from cylindrical to stratified squamous and its hyperplasia;

4) violations of the production of surfactant;

5) inflammatory edema and mucosal infiltration;

6) collapse of small bronchi and obliteration of bronchioles;

7) allergic changes in the mucous membrane.

If large-caliber bronchi are involved in the process (proximal bronchitis), bronchial obstruction is not expressed.

But in case of damage to small and medium bronchi, a pronounced violation of bronchial patency occurs. However, with an isolated lesion of small bronchi (distal bronchitis), devoid of cough receptors, shortness of breath may be the only evidence of developed bronchitis, and cough appears when larger bronchi are involved in the process.

Various ratios of changes in the mucous membrane cause the formation of a certain clinical form:

1) with catarrhal non-obstructive bronchitis, superficial changes in the structural and functional properties of the mucous membrane prevail;

2) with mucopurulent (purulent) bronchitis, the processes of infectious inflammation predominate.

However, a situation is also possible when long-term catarrhal bronchitis due to the addition of an infection can become mucopurulent, etc. In the non-obstructive variant of all clinical forms of chronic bronchitis, ventilation disorders are slightly pronounced;

3) obstructive disorders initially appear only against the background of an exacerbation of the disease and are caused by inflammatory changes in the bronchi, hyper- and dyskrinia, bronchospasm (reversible components of obstruction), but then they persist constantly, while the obstructive syndrome grows slowly.

In obstructive chronic bronchitis, thickening of the mucous membrane and submucosal layer, edema and hypersecretion predominate, and persistent ventilation disorders are also characteristic. Developed obstruction of the small bronchi leads to emphysema.

In its course, HB undergoes a certain evolution. As a result of the development of emphysema and pneumosclerosis, uneven ventilation of the lungs is noted, hyper- and hypoventilated areas are formed. In combination with local inflammatory changes, this leads to impaired gas exchange, respiratory failure, arterial hypoxemia and pulmonary hypertension, followed by the development of the main life-threatening condition - right ventricular failure.

Classification. There is currently no generally accepted classification of CB. It is important to divide CB into obstructive and non-obstructive variants, with each of which a catarrhal (mucous), catarrhal-purulent or purulent inflammatory process can develop.

The classification also includes rare forms - hemorrhagic and fibrinous CB.

According to the level of bronchial damage, they distinguish: with a predominant lesion, large bronchi (proximal bronchitis) and with a predominant lesion of small bronchi (distal bronchitis) (N. R. Paleev, 1985).

clinical picture. The main symptoms of CB are cough, sputum production, and shortness of breath. During an exacerbation of the disease or due to hypoxia with the development of pulmonary failure and other complications, general symptoms are identified (sweating, weakness, increased body temperature, fatigue, etc.). Cough is the most typical manifestation of the disease. Based on the nature and consistency of the sputum, one can assume a variant of the course of the disease. In the non-obstructive version of catarrhal bronchitis, the cough is accompanied by the release of a small amount of mucous, watery sputum (usually in the morning, after exercise or due to increased breathing). At the beginning of the disease, the cough does not bother the patient; the appearance of paroxysmal cough indicates the development of bronchial obstruction. The cough takes on a barking tone and is paroxysmal in nature with pronounced expiratory collapse of the trachea and large bronchi.

With purulent and mucopurulent bronchitis, patients are more concerned about coughing up sputum. In the event of an exacerbation of the disease, sputum acquires a purulent character, its amount increases, sometimes sputum is excreted with difficulty (due to bronchial obstruction during exacerbation).

In the obstructive variant of bronchitis, the cough is unproductive and hacking, accompanied by shortness of breath, with a small amount of sputum.

Shortness of breath occurs in all patients with chronic bronchitis at various times. The appearance of shortness of breath in "long-term coughing" patients initially with significant physical exertion indicates the addition of bronchial obstruction. As the disease progresses, shortness of breath becomes more pronounced and constant, i.e., respiratory (pulmonary) insufficiency develops.

In the non-obstructive variant, CB progresses slowly, shortness of breath usually appears 20-30 years after the onset of the disease. Such patients almost never fix the onset of the disease, but only indicate the appearance of complications or frequent exacerbations.

There is a history of hypersensitivity to cold, and most patients report long-term smoking. In a number of patients, the disease is associated with occupational hazards at work.

When analyzing a cough history, it is necessary to make sure that the patient has no other pathology of the bronchopulmonary apparatus (tuberculosis, tumors, bronchiectasis, pneumoconiosis, systemic diseases of the connective tissue, etc.), accompanied by the same symptoms.

Sometimes a history indicates hemoptysis due to mild vulnerability of the bronchial mucosa. Recurrent hemoptysis indicates a hemorrhagic form of bronchitis. In addition, hemoptysis in chronic, long-term bronchitis may be the first symptom of lung cancer or bronchiectasis.

Diagnostics. Auscultation reveals hard breathing (with the development of emphysema it can become weakened) and dry wheezing of a scattered nature, the timbre of which depends on the caliber of the affected bronchi (wheezing, well audible on exhalation, is characteristic of damage to small bronchi).

Changes in auscultation data will be minimal in chronic non-obstructive bronchitis in remission and most pronounced during exacerbation of the process (wet rales of various calibers that may disappear after a good cough and sputum production).

With an exacerbation of obstructive bronchitis, shortness of breath increases, the phenomena of respiratory failure increase. A purulent viscous secret further complicates the patency of the bronchi.

The obstructive component that has joined both the catarrhal and mucopurulent forms of bronchitis, and during the period of exacerbation or in the course of their evolution, significantly aggravates the course of bronchitis.

Signs of bronchial obstruction: prolongation of the expiratory phase with calm and especially forced breathing; wheezing on expiration (better auscultated with forced breathing and in the supine position); symptoms of obstructive pulmonary emphysema.

In advanced cases of chronic bronchitis and with the addition of complications, signs of emphysema of the lungs, respiratory and cardiac (right ventricular) insufficiency - decompensated pulmonary heart appear: acrocyanosis, pastosity or swelling of the legs and feet, changes in the nails in the form of watch glasses, and the terminal phalanges of the hands and feet - in in the form of drumsticks, swelling of the cervical veins, pulsation in the epigastric region due to the right ventricle, accent of the II tone in the II intercostal space to the left of the sternum, liver enlargement.

Affects the picture of the disease and the addition of an asthmatic (allergic) component, when there is a resemblance to bronchial asthma.

Laboratory and instrumental indicators have a different degree of significance depending on the stage of the process. In the initial period of the disease or in the remission phase, there may be no changes. However, these indicators are of great importance for identifying the activity of the inflammatory process; clarification of the clinical form of the disease; identifying complications; differential diagnosis with diseases that have similar clinical symptoms.

X-ray examination of the chest organs is performed in all patients with chronic bronchitis, however, as a rule, there are no changes in the lungs on plain radiographs. There may be a mesh deformation of the lung pattern, due to the development of pneumosclerosis. With a long course of the process, signs of emphysema are revealed. With the development of the pulmonary heart, a bulging of the trunk of the pulmonary artery appears on the left contour of the shadow of the heart, expansion of the basal arteries, followed by their cone-shaped narrowing and a decrease in the diameter of peripheral branches. X-ray examination plays an important role in the diagnosis of complications (acute pneumonia, bronchiectasis) and in the differential diagnosis with diseases with similar symptoms. Bronchography is used only to diagnose bronchiectasis.

Bronchoscopy is of great importance in the diagnosis of chronic bronchitis and its differentiation from diseases that manifest a similar clinical picture. It confirms the presence of an inflammatory process; clarifies the nature of inflammation (the diagnosis of hemorrhagic or fibrinous bronchitis is made only after this study); reveals functional disorders of the tracheobronchial tree (it is especially important to identify expiratory collapse - dyskinesia of the trachea and large bronchi); helps in identifying organic lesions of the bronchial tree. In addition, bronchoscopy allows you to get the contents of the bronchi or washings for microbiological, parasitological and cytological studies.

The study of the function of external respiration is carried out to identify restrictive and obstructive disorders of pulmonary ventilation. According to the spirogram, the Tiffno index is calculated (the ratio of forced expiratory volume in 1 s - FEV₁ to the vital capacity of the lungs - VC as a percentage) and an indicator of air velocity - PSV (the ratio of maximum ventilation of the lungs - MVL to VC). With the development of obstructive syndrome, there is a decrease in the absolute speed indicators of external respiration (MVL and FEV₁), exceeding the degree of reduction of VC; the Tiffno index decreases and the bronchial resistance on expiration increases. According to pneumotachometry, the predominance of inspiratory power over expiratory power is revealed as an early sign of bronchial obstruction. Identification of violations of bronchial patency at different levels of the bronchial tree is possible with the help of special pneumotachographs, which make it possible to obtain a "flow-volume" curve. Peripheral obstruction is characterized by a significant decrease in the flow-volume curve in the area of ​​low volume.

The joint assessment of bronchial resistance and lung volumes also helps to determine the level of obstruction. In the case of obstruction at the level of the large bronchi, there is an increase in the residual volume of the lungs (RLV), and the total lung capacity (TLC) does not increase. With peripheral obstruction, a more significant increase in TRL and an increase in TRL are observed.

To identify the proportion of bronchospasm in the total proportion of bronchial obstruction, ventilation and respiratory mechanics are studied after a series of pharmacological tests. After inhalation of bronchodilator aerosols, ventilation performance improves in the presence of a spastic component of airway obstruction.

Radiopulmonography using the radioactive isotope 133Xe is performed to detect uneven ventilation associated with obstruction of the small bronchi. This is the earliest diagnostic sign of this type of bronchial obstruction.

Electrocardiography is necessary to detect hypertrophy of the right ventricle and right atrium developing in pulmonary hypertension.

A pronounced deviation of the QRS axis to the right, a shift of the transition zone to the left (R / S < 1 in V4-V6), S-type ECG are detected; high sharp P wave in leads VF, III, II.

A clinical blood test reveals secondary erythrocytosis resulting from chronic hypoxia with the development of severe pulmonary insufficiency. "Acute phase" indicators are expressed moderately: ESR is normal or moderately increased, leukocytosis is small, as well as the shift of the leukocyte formula to the left.

As evidence of allergic manifestations, eosinophilia is possible.

The study of sputum and bronchial contents helps to establish the severity of inflammation. With severe inflammation, the contents are purulent or purulent-mucous, contain many neutrophils and single macrophages, dystrophically altered cells of the ciliated and squamous epithelium are poorly represented.

For moderate inflammation, the contents are closer to mucopurulent; the number of neutrophils is reduced, the number of macrophages, mucus and bronchial epithelial cells increases.

With mild inflammation, the bronchial contents are mucous, desquamated cells of the epithelium and bronchi predominate; macrophages and neutrophils are few.

Microbiological examination of sputum and bronchial contents is important to identify the etiology of exacerbation of chronic bronchitis and the choice of antimicrobial therapy.

Differential diagnostics.

Table 10

Differential diagnostic criteria for CB

Treatment. Includes a set of measures that differ during the period of exacerbation and remission of the disease. During the period of exacerbation of chronic disease, two directions of treatment are distinguished: etiotropic and pathogenetic.

Etiotropic treatment is aimed at eliminating the inflammatory process in the bronchi: therapy with antibiotics, sulfanilamide drugs, antiseptics, phytoncides, etc. is indicated. Treatment is started with antibiotics of the penicillin series (penicillin, ampicillin) or a group of cephalosporins (cefamesin, tseporin), and in the absence of effect, antibiotics of the group are used reserve (gentamicin, etc.). The most preferred route of administration is intratracheal (aerosol or fill with a laryngeal syringe through a bronchoscope).

Pathogenetic treatment is aimed at improving pulmonary ventilation; restoration of bronchial patency; control of pulmonary hypertension and right ventricular failure.

The restoration of pulmonary ventilation, in addition to the elimination of the inflammatory process in the bronchi, is facilitated by oxygen therapy and exercise therapy.

The main thing in the treatment of chronic bronchitis - the restoration of bronchial patency - is achieved by improving their drainage and eliminating bronchospasm.

To improve bronchial drainage, expectorants are prescribed (hot alkaline drink, decoctions of herbs, mukaltin, etc.), mucolytic drugs (acetylcysteine, bromhexine; with purulent viscous secretion - aerosols of proteolytic enzymes - chymopsin, trypsin); therapeutic bronchoscopy is used. To eliminate bronchospasm, eufillin is used (intravenously, in suppositories, tablets), ephedrine, atropine; single appointments in an aerosol of sympathomimetic drugs are possible: fenoterol, orciprenaline sulfate (asthmopenta) and a new domestic drug "Soventol", anticholinergic drugs: atrovent, troventol. Effective preparations of prolonged aminophylline (teopec, teodur, theobelong, etc.) - 2 times a day.

In the absence of the effect of such therapy, small doses of corticosteroids are administered orally (10-15 mg of prednisolone per day) or intratracheally (hydrocortisone suspension - 50 mg).

As an additional therapy, appoint:

1) antitussive drugs: with an unproductive cough - libexin, tusuprex, bromhexine, with a hacking cough - codeine, dionin, stoptussin;

2) drugs that increase the body's resistance: vitamins A, C, group B, biogenic stimulants.

Currently, in the treatment of chronic bronchitis, immunocorrective drugs are increasingly being used: T-activin or thymalin (100 mg subcutaneously for 3 days); inside - catergen, sodium nucleinate or pentoxyl (within 2 weeks), levamisole (decaris).

Physiotherapy treatment: prescribe diathermy, calcium chloride electrophoresis, quartz on the chest area, chest massage and breathing exercises.

With moderate and severe bronchitis, along with anti-relapse and sanatorium treatment, many patients are forced to constantly receive supportive drug treatment. Maintenance therapy is aimed at improving bronchial patency, reducing pulmonary hypertension and combating right ventricular failure. The same drugs are prescribed as in the period of exacerbation, only in smaller doses, in courses.

Forecast. The prognosis for complete recovery is unfavorable. The least favorable prognosis is for obstructive CB and CB with predominant damage to the distal bronchi, which quickly leads to the development of pulmonary failure and the formation of cor pulmonale. The most favorable prognosis is for superficial (catarrhal) CB without obstruction.

Author: Mostovaya O.S.

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