LECTURE No. 7. Diseases of the respiratory system. Classification, clinic, diagnosis, treatment

1. Acute bronchitis

Acute bronchitis is an acute, diffuse inflammation of the tracheobronchial tree. Classification: acute bronchitis (simple), acute obstructive bronchitis, acute bronchiolitis, acute bronchiolitis obliterans, recurrent bronchitis, recurrent obstructive bronchitis, chronic bronchitis, chronic bronchitis with obliteration.

Etiology. The disease is caused by viral infections (influenza viruses, adenoviruses, parainfluenza, respiratory syncytial, measles, pertussis, etc.) and bacterial infections (staphylococci, streptococci, pneumococci, etc.); physical and chemical factors (dry, cold, hot air, nitrogen oxides, sulfur dioxide, etc.). Cooling, chronic focal infection in the nasopharyngeal area, impaired nasal breathing, and chest deformation predispose to the disease.

Pathogenesis. The damaging agent penetrates the trachea and bronchi with inhaled air through hematogenous and lymphogenous routes. Acute inflammation of the bronchial tree is accompanied by a violation of bronchial patency by an edematous-inflammatory or bronchospastic mechanism. Characterized by hyperemia, swelling of the mucous membrane, mucous, mucopurulent or purulent secretion on the walls of the bronchi in their lumen, and degenerative changes in the ciliated epithelium. In severe forms, the inflammatory process affects not only the mucous membrane, but also the deep tissues of the bronchial wall.

Clinic. Bronchitis of infectious etiology begins with rhinitis, nasopharyngitis, moderate intoxication, increased body temperature, weakness, a feeling of weakness, rawness behind the sternum, dry cough turning into wet. Auscultatory signs are absent, or harsh breathing and dry wheezing are detected over the lungs. There are no changes in peripheral blood. This course is observed more often with damage to the trachea and large bronchi.

With a moderate course, general malaise, weakness are significantly expressed, a strong dry cough appears with difficulty breathing and shortness of breath, pain in the lower parts of the chest and abdominal wall associated with muscle strain when coughing. Cough gradually becomes wet, sputum acquires a mucopurulent or purulent character. In the lungs during auscultation, hard breathing, dry and moist small bubbling rales are heard. Body temperature subfebrile. There are no pronounced changes in peripheral blood.

A severe course of the disease is observed with a predominant lesion of the bronchioles. Acute symptoms of the disease subside by the 4th day and, with a favorable outcome, completely disappear by the 7th day. Acute bronchitis with impaired bronchial patency tends to protracted course and transition to chronic bronchitis.

Acute bronchitis of toxic-chemical etiology is severe. The disease begins with a painful cough with the release of mucous or bloody sputum, bronchospasm quickly joins (dry whistling rales are heard against the background of an extended exhalation), shortness of breath progresses (up to suffocation), symptoms of respiratory failure and hypoxemia increase. Radiological symptoms of acute pulmonary emphysema can be determined.

Diagnostics based on clinical and laboratory data.

Treatment. Bed rest, plenty of warm drinks with honey, raspberries, linden blossom. Prescribe antiviral and antibacterial therapy, vitamin therapy (ascorbic acid up to 1 g per day, vitamin A 3 mg 3 times a day), mustard plasters, chest cups. For severe dry cough, antitussive drugs codeine, libexin, etc. are prescribed.

For wet cough - mucolytic drugs bromhexine, ambrobene, etc. Inhalation of expectorants, mucolytics, heated mineral alkaline water, eucalyptus, anise oil using a steam inhaler is indicated. Inhalations are carried out for 5 minutes 3-4 times a day (for 3-5 days). Bronchospasm is relieved by prescribing aminophylline (0,15 g 3 times a day). Antihistamines are indicated.

Prevention. Elimination of the etiological factor of acute bronchitis (hypothermia, chronic and focal infection in the respiratory tract, etc.).

2. Chronic bronchitis

Chronic bronchitis is a progressive, diffuse inflammation of the bronchi, not associated with local or generalized lung damage and manifested by cough. It is customary to talk about the chronic nature of the process if the cough lasts at least 3 months in the first year for 2 years in a row.

Etiology. The disease is associated with prolonged irritation of the bronchi by various harmful factors (inhalation of air contaminated with dust, smoke, carbon monoxide, sulfur dioxide, nitrogen oxides and other chemical compounds), smoking, recurrent respiratory infection (the main role is played by respiratory viruses, Pfeiffer's bacillus, pneumococci), occurs less frequently in cystic fibrosis. Predisposing factors: chronic inflammatory, suppurative processes in the lungs, chronic foci of infection in the upper respiratory tract, decreased body reactivity, hereditary factors.

Pathogenesis. The main pathogenetic mechanism is hypertrophy and hyperfunction of the bronchial glands with increased mucus secretion, a decrease in serous secretion, a change in the composition of the secretion - an increase in acidic mucopolysaccharides in it, which increases the viscosity of sputum. Under these conditions, the ciliated epithelium does not ensure emptying of the bronchial tree and the normal renewal of the entire layer of secretion (emptying of the bronchi occurs only when coughing). Long-term hyperfunction leads to depletion of the mucociliary apparatus of the bronchi, dystrophy and atrophy of the epithelium.

In case of violation of the drainage function of the bronchi, a bronchogenic infection occurs, the activity and relapses of which depend on local immunity of the bronchi and the development of secondary immunological deficiency, bronchial obstruction develops due to hyperplasia of the epithelium of the mucous glands, edema and inflammatory infiltration of the bronchial wall, obstruction of the bronchi with an excess of viscous bronchial secretion, bronchospasm . Obstruction of the small bronchi leads to overstretching of the alveoli on expiration and disruption of the elastic structures of the alveolar walls and the appearance of hypoventilated or non-ventilated zones, and therefore the blood passing through them is not oxygenated, arterial hypoxemia develops.

In response to alveolar hypoxia, spasm of the pulmonary arterioles and an increase in total pulmonary and pulmonary arteriolar resistance occur, precapillary pulmonary hypertension occurs. Chronic hypoxemia leads to an increase in blood viscosity, accompanied by metabolic acidosis, which further enhances vasoconstriction in the pulmonary circulation. Inflammatory infiltration in large bronchi is superficial, and in medium and small bronchi, bronchioles - deep with the development of erosion and the formation of meso- and panbronchitis.

The remission phase is manifested by a decrease in inflammation, a significant decrease in exudation, proliferation of connective tissue and epithelium, especially with ulceration of the mucous membrane.

Clinic. The beginning is gradual. The first symptom is a cough in the morning with mucous sputum, gradually the cough begins to occur both at night and during the day, intensifies in cold weather and becomes constant over the years. The amount of sputum increases, it becomes mucopurulent or purulent. Shortness of breath appears.

With purulent bronchitis, purulent sputum is periodically released, but bronchial obstruction is not pronounced. Obstructive chronic bronchitis is characterized by persistent obstructive disorders. Purulent-obstructive bronchitis occurs with the release of purulent sputum and obstructive ventilation disorders.

Frequent exacerbations during periods of cold, damp weather: cough and shortness of breath increase, the amount of sputum increases, malaise and fatigue appear. The body temperature is normal or subfebrile, hard breathing and dry wheezing over the entire surface of the lungs can be determined.

Diagnostics. A slight leukocytosis with a rod-nuclear shift in the leukocyte formula is possible. With exacerbation of purulent bronchitis, the biochemical indicators of inflammation (C-reactive protein, sialic acids, seromucoid, fibrinogen, etc.) change slightly. Sputum examination: macroscopic, cytological, biochemical. With severe exacerbation, the purulent nature of the sputum is detected, predominantly neutrophilic leukocytes, an increase in the content of acidic mucopolysaccharides and DNA fibers that increase the viscosity of the sputum, a decrease in the content of lysozyme, etc. Bronchoscopy is indicated, with the help of which endobronchial manifestations of the inflammatory process are assessed (catarrhal, purulent, atrophic, hypertrophic, hemorrhagic) and its severity (but only to the level of the subsegmental bronchi).

Differential diagnosis carried out with chronic pneumonia, bronchial asthma, tuberculosis. Unlike chronic pneumonia, chronic bronchitis always proceeds with the gradual development of widespread bronchial obstruction and often emphysema, respiratory failure and pulmonary hypertension (chronic cor pulmonale). X-ray changes are also diffuse in nature: peribronchial sclerosis, increased transparency of the lung fields due to emphysema, expansion of the branches of the pulmonary artery.

Chronic bronchitis is distinguished from bronchial asthma by the absence of asthma attacks.

Differences with pulmonary tuberculosis are associated with the presence or absence of signs of tuberculosis intoxication, Mycobacterium tuberculosis in sputum, X-ray and bronchoscopic examination data, and tuberculin tests.

Treatment. In the phase of exacerbation of chronic bronchitis, therapy should be aimed at eliminating the inflammatory process in the bronchi, improving bronchial patency, and restoring impaired general and local immunological reactivity.

Bacterial therapy is prescribed, which is selected taking into account the sensitivity of the sputum microflora, administered orally or parenterally, sometimes combined with intratracheal administration. Showing inhalation.

Apply expectorant, mucolytic and bronchospasmolytic drugs, drink plenty of water to restore and improve bronchial patency. Phytotherapy using marshmallow root, coltsfoot leaves, plantain. Assign proteolytic enzymes (trypsin, chymotrypsin), which reduce the viscosity of sputum, but are now rarely used. Acetylcysteine ​​has the ability to break the disulfide bonds of mucus proteins and causes a strong and rapid liquefaction of sputum.

Bronchial drainage improves with the use of muco-regulators that affect the secretion and synthesis of glycoproteins in the bronchial epithelium (bromhexine). In case of insufficiency of bronchial drainage and the presence of symptoms of bronchial obstruction, bronchospasmolytic agents are added to therapy: eufillin, anticholinergics (atropine in aerosols), adrenergic stimulants (ephedrine, salbutamol, berotek).

In a hospital setting, intratracheal lavages for purulent bronchitis are combined with sanitation bronchoscopy (3-4 sanitation bronchoscopy with a break of 3-7 days). The restoration of the drainage function of the bronchi is also facilitated by physical therapy, chest massage, and physiotherapy.

In the event of allergic syndromes, calcium chloride is prescribed orally and intravenously with antihistamines. If there is no effect, it is possible to conduct a short (until the allergic syndrome is removed) course of glucocorticoids (daily dose should not exceed 30 mg). The risk of infection activation does not allow recommending long-term use of glucocorticoids.

In patients with chronic bronchitis complicated by respiratory failure and chronic cor pulmonale, the use of veroshpiron (up to 150-200 mg per day) is indicated. The diet should be high-calorie and fortified. Prescribe ascorbic acid in a daily dose of 1 g, B vitamins, nicotinic acid, aloe, if necessary, methyluracil.

When the disease is complicated by pulmonary and pulmonary heart failure, oxygen therapy, auxiliary artificial ventilation of the lungs are used. Anti-relapse and supportive therapy begins in the phase of subsiding exacerbation, is carried out in local and climatic sanatoriums, it is also prescribed during clinical examination.

It is recommended to distinguish three groups of dispensary patients. The first group includes patients with severe respiratory failure, cor pulmonale and other complications of the disease, with loss of ability to work; patients need systematic maintenance therapy, which is carried out in a hospital or by a local doctor. These patients are examined at least once a month. The second group consists of patients with frequent exacerbations of chronic bronchitis and moderate respiratory dysfunction. Patients are examined by a pulmonologist 3-4 times a year, anti-relapse courses are prescribed in spring and autumn, as well as after acute respiratory diseases. An effective method of taking medications is inhalation. According to indications, the bronchial tree is sanitized by intratracheal lavage and sanitary bronchoscopy. For active infection, antibacterial drugs are used. The third group consists of patients in whom anti-relapse therapy led to the subsidence of the process and the absence of relapses for 20 years. They are indicated for seasonal preventive therapy, including agents aimed at improving bronchial drainage and increasing reactivity.

3. Pneumonia

Pneumonia is an inflammation of the lungs, characterized by inflammation of the parenchymal, respiratory part of the lungs. Classification by form: acute pneumonia is divided into community-acquired, nosocomial, with perinatal infection and in patients with immunodeficiency. According to the morphological form: focal, focal - confluent, segmented, lobar, interstitial. Downstream: acute, protracted (in the absence of resolution of the pneumonic process within 6 to 8 weeks). According to the development of complications: pulmonary (synpneumonic pleurisy, metapneumonic pleurisy, pulmonary destruction, lung abscess, pneumothorax, pyopneumothorax), extrapulmonary (toxic shock, DIC, cardiovascular insufficiency, respiratory distress syndrome).

Etiology. Various bacteria act as the etiological factor: pneumococci, staphylococci, streptococci, Klebsiella pneumoniae, gram-negative flora and mycoplasmas (community-acquired form); staphylococcus, Pseudomonas aeruginosa (nosocomial form); chlamydia, cytomegalovirus (for perinatal infection); various bacteria in patients with immunodeficiency.

In the occurrence of the disease, an important role can be played by viral-bacterial associations, chemical and physical agents - exposure to light chemicals (gasoline, etc.), thermal factors (cooling or burns), radioactive radiation (etiological factors are usually combined with infectious ones). Pneumonia can be the result of allergic reactions in the lungs or a manifestation of a systemic disease (interstitial pneumonia in connective tissue diseases).

Pathogenesis. The pathogen penetrates into the lung tissue by bronchogenic, hematogenous and lymphogenous routes from the upper respiratory tract, usually in the presence of acute or chronic foci of infection or from infectious foci in the bronchi (chronic bronchitis, bronchiectasis). A special role in pathogenesis is played by violations of the protective mechanisms of the bronchopulmonary system, as well as the state of humoral and tissue immunity. The survival of bacteria in the lungs, their reproduction and spread through the alveoli depend on their aspiration with mucus from the upper respiratory tract and bronchi (which is favored by cooling), on the excessive formation of edematous fluid, covering an entire lobe or several lobes of the lungs in lobar (pneumococcal) pneumonia. At the same time, immunological damage and inflammation of the lung tissue is possible due to a reaction to the antigenic material of microorganisms and other allergens.

A viral infection, causing inflammation of the upper respiratory tract and bronchi, and in some cases pneumonia, even more often favors the activation of a bacterial infection and the occurrence of bacterial focal or lobar pneumonia. The appearance of bacterial pneumonia usually at the end of the first or at the beginning of the second week after a respiratory viral disease corresponds to a significant decrease in the bactericidal activity of the alveolar-macrophage system of the lungs. Chronic pneumonia can occur due to unresolved acute pneumonia with slowing down and stopping the resorption of exudate in the alveoli and the formation of pneumosclerosis, inflammatory cell changes in the interstitial tissue, often of an immunological nature (lymphocytic and plasma cell infiltration).

The protracted course of acute pneumonia, their transition to a chronic form is facilitated by immunological disorders that are caused by repeated respiratory viral infection, chronic infection of the upper respiratory tract (chronic tonsillitis, sinusitis, etc.) and bronchi.

Clinic. Depends on the etiology, nature and phase of the course, morphological substrate of the disease and its prevalence in the lungs, as well as complications (pulmonary suppuration, pleurisy, etc.). Acute pneumonia usually begins abruptly, often after cooling: the patient experiences tremendous chills; body temperature rises to febrile levels of 39-40 ° C, less often to 38 or 41 ° C; pain when breathing on the side of the affected lung increases with coughing, first dry, then wet, with purulent viscous sputum. The patient's condition is serious. The skin of the face is hyperemic and cyanotic. Breathing is rapid, shallow, with flaring of the wings of the nose.

After the application of antibiotic therapy, the high temperature gradually decreases. The chest lags behind in the act of breathing on the side of the affected lung, the percussion of which, depending on the morphological stage of the disease, reveals dull tympanitis (tide stage), shortening (dulling) of the pulmonary sound (stage of red and gray hepatization) and pulmonary sound (resolution stage).

Depending on the staging nature of morphological changes, auscultation reveals, respectively, increased vesicular respiration, bronchial respiration, and vesicular or weakened vesicular respiration. In the hepatization phase, increased voice trembling and bronchophony are determined. Due to the uneven development of morphological changes in the lungs, percussion and auscultatory patterns can be variegated.

Due to the defeat of the pleura (parapneumonic serous-fibrinous pleurisy), a pleural friction rub is heard. At the height of the disease, the pulse is quickened, soft, corresponds to reduced blood pressure, from the side of the cardiovascular system, the first tone is muffled and the second tone is accentuated on the pulmonary artery. In the blood test - neutrophilic leukocytosis, increased ESR, anemia.

On x-ray, homogeneous shading of the entire affected lobe or part of it is determined, especially on lateral radiographs. Fluoroscopy may be insufficient in the early hours of illness. Similar to pneumococcal, staphylococcal pneumonia can occur. More often it proceeds more severely, accompanied by destruction of the lungs with the formation of thin-walled air cavities, lung abscesses.

With the phenomena of severe intoxication, staphylococcal (usually multifocal) pneumonia occurs, complicating a viral infection of the bronchopulmonary system (viral-bacterial pneumonia). This kind of pneumonia is characterized by a pronounced intoxication syndrome, manifested by hyperthermia, chills, hyperemia of the skin and mucous membranes, dizziness, headache, severe shortness of breath, hemoptysis, tachycardia, nausea, and vomiting.

With severe infectious-toxic shock, vascular insufficiency develops (BP 90 - 80 / 60-50 mm Hg, pallor of the skin, cold extremities, the appearance of sticky sweat). With the progression of intoxication syndrome, cerebral disorders, an increase in heart failure, cardiac arrhythmias, the development of shock lung, hepatorenal syndrome, disseminated intravascular coagulation syndrome, and toxic enterocolitis are revealed. Such pneumonia can lead to rapid death.

Focal pneumonia, bronchopneumonia arise as a result of complications of acute or chronic inflammation of the upper respiratory tract and bronchi, in patients with congestive lungs, severe diseases that debilitate the body, in the postoperative period, as a result of fat embolism in injuries, and thromboembolism. The disease may begin with chills, but not as severe as with lobar pneumonia. Body temperature rises to 38-38,5 °C, rarely higher. A cough appears and intensifies, dry, then with mucopurulent sputum. Chest pain may occur when coughing and when inhaling.

With confluent focal (usually staphylococcal) pneumonia, the condition worsens: severe shortness of breath, cyanosis, shortening of the lung sound, breathing can be enhanced vesicular with bronchial foci, foci of fine and medium bubbling rales are heard.

On the radiograph (sometimes only on the tomogram), lobular, subsegmental and segmental shadows, increased lung pattern are revealed, bullae and foci of abscess formation can be detected radiologically.

Diagnostics. Based on clinical and laboratory data, shortening of the percussion sound is taken into account, an increase in vesicular breathing is noted, sometimes with foci of bronchial breathing, crepitus, small- and medium-bubble rales, and focal shadowing on radiographs (sometimes on tomograms). Examine sputum or throat swabs for bacteria, including Mycobacterium tuberculosis, viruses, and Mycoplasma pneumoniae.

Differential diagnosis carried out with acute bronchitis and exacerbation of chronic bronchitis (in contrast to pneumonia, intoxication is less pronounced, foci of shading are not detected radiologically).

Treatment pneumonia with mild course and favorable living conditions can be carried out at home, but most patients need inpatient treatment. According to emergency indications, patients with lobar and other pneumonias and severe infectious-toxic syndrome are hospitalized. At the height of the disease, bed rest is shown, a mechanically and chemically sparing diet with limited salt and a sufficient amount of vitamins, especially A and C. With the disappearance or a significant decrease in the phenomena of intoxication, the regimen is expanded, physiotherapy exercises are prescribed, in the absence of contraindications (diseases of the heart, digestive organs) the patient is transferred to diet No. 15.

Immediately after taking sputum, swabs or swabs for bacteriological examination, etiotropic antibiotic therapy is started, which is carried out under the control of clinical efficacy, and subsequently, taking into account the inoculated microflora and its sensitivity to antibiotics.

With community-acquired pneumonia, semi-synthetic penicillins, penicilli, macrolides of a new generation are prescribed; with nosocomial pneumonia, "protected" penicillins, aminoglycosides, second-third generation cephalosporins, fluoroquinolones and other antibiotics of the reserve group are prescribed; for pneumonia with intrauterine infection - new generation macrolides (spiromycin, roxithromycin, azithromycin); in pneumonia in patients with immunodeficiencies, third-fourth generation cephalosporins, fluoroquinolones are prescribed.

For severe viral-bacterial pneumonia, which often occurs as a result of the interaction of the influenza virus and staphylococcus, along with intravenously administered broad-spectrum antibiotics, the administration of specific donor anti-influenza γ-globulin 3-6 ml is indicated. Combinations of antibiotics for the treatment of complicated pneumonia: cephalosporins + semisynthetic penicillins; semisynthetic penicillins + aminoglycosides; cephalosporins + aminoglycosides. Detoxification agents (hemodesis, etc.) are also used. Mucolytic therapy, bronchodilator therapy, physiotherapy, immunocorrective therapy, exercise therapy are prescribed.

With severe tachycardia, a decrease in systolic pressure to 100 mm Hg. Art. and below, patients with pneumonia are prescribed strophanthin, sulfokamphokain. Discharged from the hospital during the period of clinical recovery or remission, persons who have had pneumonia should be taken under dispensary observation. For rehabilitation, they are sent to local sanatoriums. The prognosis for pneumonia has improved significantly since the start of the use of antibacterial agents. But it remains serious with staphylococcal and Friedlander pneumonias, with often recurrent chronic pneumonias complicated by an obstructive process, respiratory and pulmonary heart failure, as well as with the occurrence of pneumonia in people with severe diseases of the cardiovascular and other systems. Mortality from pneumonia in these cases remains high.

4. Bronchial asthma

Bronchial asthma is a chronic relapsing disease with a primary lesion of the respiratory tract, which is based on chronic allergic inflammation of the bronchi, accompanied by their hyperreactivity and intermittent attacks of shortness of breath or suffocation as a result of widespread bronchial obstruction, which is caused by bronchospasm, mucus hypersecretion, swelling of the bronchial wall.

There are two forms of bronchial asthma - immunological and non-immunological - and a number of clinical and pathogenetic variants: atopic, infectious-allergic, autoimmune, dyshormonal, neuropsychic, adrenergic imbalance, primary altered bronchial reactivity (including "aspirin" asthma and asthma of physical effort ), cholinergic.

Etiology and risk factors for the occurrence of bronchial asthma in children: atopy, bronchial hyperreactivity, heredity. Causes (sensitizing): household allergens (house dust, house dust mites), epidermal allergens of animals, birds, and insects, fungal allergens, pollen allergens, food allergens, drugs, viruses and vaccines, chemicals.

Pathogenesis. The general pathogenetic mechanism is a change in the sensitivity and reactivity of the bronchi, determined by the reaction of bronchial patency in response to the influence of physical and pharmacological factors.

It is believed that in 1/3 of patients (mainly in persons suffering from an atonic variant of the disease), asthma is of a hereditary origin. The most studied allergic mechanisms of asthma, which are based on IgE- or IgG-mediated reactions. The central place in the pathogenesis of "aspirin" asthma is given to leukotrienes. With asthma of physical effort, the process of heat transfer from the surface of the respiratory tract is disturbed.

Clinic. The disease often begins with a paroxysmal cough, accompanied by shortness of breath with the discharge of a small amount of glassy sputum (asthmatic bronchitis). The full picture of bronchial asthma is characterized by the appearance of mild, moderate or severe attacks of suffocation. An attack may begin with a precursor (profuse discharge of watery secretion from the nose, sneezing, paroxysmal cough, etc.).

An attack of bronchial asthma is characterized by a short inhalation and an extended exhalation, accompanied by wheezing audible at a distance. The chest is in the position of maximum inspiration, the patient takes a forced position, sitting on the bed, hanging his legs down, tilting his body slightly forward. The muscles of the shoulder girdle, back, and abdominal wall take part in breathing. On percussion over the lungs, a box sound is determined, and a lot of dry rales are heard during auscultation. The attack often ends with the separation of viscous sputum.

Severe prolonged attacks can turn into an asthmatic state - one of the most formidable options for the course of the disease.

5. Asthmatic condition

The asthmatic condition is manifested by increasing resistance to bronchodilatory therapy and unproductive cough. There are two forms of asthmatic condition - anaphylactic and metabolic. In the anaphylactic form, caused by immunological or pseudo-allergic reactions with the release of a large number of mediators of an allergic reaction (most often in people with hypersensitivity to drugs), an acute severe asthma attack occurs.

The metabolic form, due to the functional blockade of β-adrenergic receptors, occurs as a result of an overdose of sympathomimetics during a respiratory tract infection, and is formed within a few days.

In the initial, stage I, sputum ceases to come out, pain appears in the muscles of the shoulder girdle, chest and in the abdominal area. Hyperventilation, loss of moisture with exhaled air leads to an increase in the viscosity of sputum and obstruction of the bronchial lumen with a viscous secret.

The formation of mute lung areas in the posterior lower sections of the lungs indicates the transition of the status to stage II with a clear discrepancy between the severity of remote wheezing and their absence during auscultation. The condition of the patients is extremely serious. The chest is emphysematous, swollen. Pulse exceeds 120 beats per minute. Arterial pressure tends to increase. On the ECG - signs of overload of the right heart. Respiratory or mixed acidosis is formed.

In stage III (with hypoxic-hypercapnic coma), shortness of breath and cyanosis increase, sudden excitement is replaced by loss of consciousness, convulsions are possible. The pulse is paradoxical, blood pressure decreases. The course of the disease is cyclical: an exacerbation phase with characteristic symptoms and data from laboratory and instrumental studies is replaced by a remission phase. Complications of bronchial asthma: emphysema, often the addition of infectious bronchitis, with a long and severe course of the disease, the appearance of cor pulmonale.

Diagnostics is carried out on the basis of a carefully collected anamnesis, typical attacks of expiratory dyspnea, eosinophilia in the blood, especially in sputum, an allergological examination with skin and in some cases provocative inhalation tests, an examination of immunoglobulins E and G. A good analysis of anamnestic, clinical, radiological and laboratory data allows exclude bronchial obstruction syndrome in nonspecific and specific inflammatory diseases of the respiratory system, connective tissue diseases, helminthic invasions, bronchial obstruction (foreign body, tumor), endocrine-humoral pathology (hypoparathyroidism, etc.), hemodynamic disorders in the pulmonary circulation, affective pathology and etc.

Treatment in bronchial asthma, it should be strictly individualized, taking into account the variant of the course, the phase of the disease, the presence of complications, concomitant diseases, the tolerance of drugs to patients and the most rational use of them during the day. A polyclinic - an allergological office - a specialized department of a hospital and, subsequently, constant monitoring in an allergological office - are approximate stages of continuity in the treatment of such patients.

In atonic bronchial asthma, first of all, alimination therapy is prescribed - the most complete and permanent cessation of contact with the allergen. If the allergen is identified, but the patient cannot be isolated from it, specific hyposensitization is indicated in specialized allergological institutions in the remission phase. Patients with atonic asthma (especially in uncomplicated forms of the disease) are prescribed sodium cromolyn (Intal), spraying it with a special inhaler.

If asthma is combined with other allergic manifestations, oral ketotifen 1 mg 2 times a day is preferable. The effect of both drugs comes gradually.

If there is no effect, glucocorticoids are prescribed; in moderate cases, it is advisable to administer them in the form of inhalations (becotide 50 mcg every 6 hours). For severe exacerbations, oral glucocorticoids are indicated, starting with prednisolone 15-20 mg per day; after achieving a clinical effect, the dose is gradually reduced. For food allergies, the use of fasting-dietary therapy carried out in a hospital is indicated. Patients with an infectious-allergic form of asthma are recommended treatment with autovaccine, sputum autolysate, heterovaccines, which are currently being prepared using new technology. Vaccine treatment is carried out in a specialized hospital.

In case of violations in the immune system, appropriate immunocorrective therapy is prescribed. During the period of remission, sanation of foci of chronic infection is carried out. With an infectious-dependent form of asthma, recreational activities are indicated: physical activity, regular therapeutic exercises, tempering procedures.

In connection with the violation of mucociliary clearance, sputum thinning therapy is necessary: ​​plentiful warm drink, alkaline warm inhalations, decoction of herbs - rosemary, coltsfoot and others, mucolytic agents. Physical training is advisable: swimming or a quiet run in a warm room. With good tolerance, every week increase the load by 1 minute (up to 60 minutes).

With "aspirin" asthma, foods containing acetylsalicylic acid (berries, tomatoes, potatoes, citrus fruits) are excluded from the diet. Non-steroidal anti-inflammatory drugs are strictly prohibited.

If necessary, appoint intal, zaditen or corticosteroids.

With severe emotional disorders, a qualified examination and treatment by a psychotherapist with an individual selection of psychotropic drugs is necessary. Assign psychotherapy, reflexology.

For the relief of asthma attacks, an individually selected bronchodilator therapy is prescribed. The optimal dose of bronchodilators is selected empirically (from a small dose to the most effective). Selective stimulants β have a positive effect in most patients.₂-adrenergic receptors (salbutamol, berotek, etc.), which are produced in the form of metered-dose manual (pocket) inhalers.

During an attack, two breaths of an aerosol help. In mild cases, such drugs can be used in the form of tablets.

For more severe attacks, intravenous aminophylline injections are used (5-10 ml of a 2,4% solution, the drug is also used in the form of tablets (0,15 g) and suppositories (0,3 g)). An overdose of these drugs (especially during hypoxia) can have a cardiotoxic effect; in addition, frequent use of sympathomimetics causes blockade of β-receptors.

Anticholinergics (atropine, belladonna, platyphylline) are preferable for the infectious-allergic form of the disease, especially with obstruction of large bronchi. Often these drugs are combined with other bronchodilators. An effective drug in this group is Atrovent, produced in metered dose inhalers; it can be used to prevent attacks by taking two breaths 3-4 times a day.

The drug has little effect on mucociliary clearance. Different mechanisms of bronchial obstruction in each patient determine the appropriateness of a combination of drugs. An effective drug is berodual - a combination of berotek and atrovent in the form of a metered dose inhaler.

Treatment of status asthmaticus carried out differentially depending on its stage, form, cause of occurrence. In case of anaphylactic form, a subcutaneous solution of adrenaline is administered and glucocorticoids are immediately used, prescribing 100 mg of hydrocortisone intravenously. If no obvious improvement occurs in the next 15-30 minutes, the hydrocortisone infusion is repeated and intravenous drip administration of aminophylline (10-15 ml of a 2,4% solution) is started. At the same time, oxygen therapy is administered through a nasal catheter or mask (2-6 l/min). Treatment should be carried out in an intensive care unit. Treatment of the metabolic form of status asthmaticus is carried out depending on its stage. First, it is necessary to eliminate an unproductive cough, improve sputum discharge through warm alkaline inhalations and plenty of warm drinks. If the asthmatic condition is caused by withdrawal or overdose of sympathomimetics, drip administration of prednisolone 30 mg every 3 hours IV is indicated until the status is relieved. If acidosis develops, it is necessary to administer an intravenous infusion of a 2% sodium bicarbonate solution. Rehydration must be carried out by administering large amounts of fluid. At stage II of the asthmatic condition, the dose of glucocorticoids is increased (prednisolone to 60 - 90-120 mg every 60 - 90 minutes). If the picture of a silent lung does not disappear within the next 1,5 hours, controlled ventilation with active liquefaction and suction of sputum is indicated. In stage III, intensive therapy is carried out together with a resuscitator. After recovery from the asthmatic state, the dose of glucocorticoids is immediately reduced by half, and then gradually reduced to maintenance. It is necessary to monitor such patients, to reduce the maintenance dose of glucocorticoids as much as possible, to switch to inhaled use if possible, to combine them with other drugs (Zaditene, Intal, bronchospasmolytics, etc.), and to intermittently use glucocorticoids. The use of psychotropic medications and physical rehabilitation can minimize complications of glucocorticoid therapy.

During the period of remission, hyposensitizing therapy, sanitation of foci of infection, physiotherapy exercises, physical training (walking, swimming), physiotherapy, and spa treatment are carried out. Treatment at local resorts is of the greatest importance, since it has become obvious that the processes of adaptation to new climatic conditions and after a short time readaptation do not have a training effect. Qualified psychotherapy significantly improves the effect of complex therapy.

Forecast. With clinical observation (at least 2 times a year) and rationally selected treatment, the prognosis is favorable. Death may be associated with severe infectious complications, untimely and irrational therapy, and progressive pulmonary heart failure in patients with cor pulmonale.

Author: Gavrilova N.V.

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The existence of an entropy rule for quantum entanglement has been proven 09.05.2024

Quantum mechanics continues to amaze us with its mysterious phenomena and unexpected discoveries. Recently, Bartosz Regula from the RIKEN Center for Quantum Computing and Ludovico Lamy from the University of Amsterdam presented a new discovery that concerns quantum entanglement and its relation to entropy. Quantum entanglement plays an important role in modern quantum information science and technology. However, the complexity of its structure makes understanding and managing it challenging. Regulus and Lamy's discovery shows that quantum entanglement follows an entropy rule similar to that for classical systems. This discovery opens new perspectives in the field of quantum information science and technology, deepening our understanding of quantum entanglement and its connection to thermodynamics. The results of the study indicate the possibility of reversibility of entanglement transformations, which could greatly simplify their use in various quantum technologies. Opening a new rule ... >>

Mini air conditioner Sony Reon Pocket 5 09.05.2024

Summer is a time for relaxation and travel, but often the heat can turn this time into an unbearable torment. Meet a new product from Sony - the Reon Pocket 5 mini-air conditioner, which promises to make summer more comfortable for its users. Sony has introduced a unique device - the Reon Pocket 5 mini-conditioner, which provides body cooling on hot days. With it, users can enjoy coolness anytime, anywhere by simply wearing it around their neck. This mini air conditioner is equipped with automatic adjustment of operating modes, as well as temperature and humidity sensors. Thanks to innovative technologies, Reon Pocket 5 adjusts its operation depending on the user's activity and environmental conditions. Users can easily adjust the temperature using a dedicated mobile app connected via Bluetooth. Additionally, specially designed T-shirts and shorts are available for convenience, to which a mini air conditioner can be attached. The device can oh ... >>

Energy from space for Starship 08.05.2024

Producing solar energy in space is becoming more feasible with the advent of new technologies and the development of space programs. The head of the startup Virtus Solis shared his vision of using SpaceX's Starship to create orbital power plants capable of powering the Earth. Startup Virtus Solis has unveiled an ambitious project to create orbital power plants using SpaceX's Starship. This idea could significantly change the field of solar energy production, making it more accessible and cheaper. The core of the startup's plan is to reduce the cost of launching satellites into space using Starship. This technological breakthrough is expected to make solar energy production in space more competitive with traditional energy sources. Virtual Solis plans to build large photovoltaic panels in orbit, using Starship to deliver the necessary equipment. However, one of the key challenges ... >>

Random news from the Archive The benefits and harms of video games 12.08.2017 Researchers from the University of Montreal invited XNUMX volunteers, who were roughly equal in size to men and women, to walk through a virtual maze. There were several paths in the labyrinth where it was necessary to collect certain items, and this task could be completed faster if you memorized the routes that you had already walked - that is, you should pay attention to various surrounding signs, such as stone, wood, etc. . With such an orientation to the terrain, the hippocampus is triggered in our brain - a special area in the brain that serves as one of the main memory centers and at the same time plays the role of a cartographer, that is, it builds maps of the surrounding landscape. But in the labyrinth it was possible to do otherwise - just remember the sequence of turns to the right and left. In this case, another area of ​​the brain comes into play, partly duplicating the functions of the hippocampus - the caudate nucleus, which is part of the striatum. The caudate nucleus works as an autopilot, allowing us to perform certain automatic actions, and at the same time it is included in the reinforcement system - this is the name of a large complex of nerve centers that controls our motivation, our desires and feelings of pleasure. You can also follow the route with the help of the caudate nucleus, however, here it will not be so much a map of the area as remembering the actions that need to be performed for a reward: remembering how many times and where you turned before, you can get to the next desired item in the maze and get a portion pleasant sensations. The maze search made it possible to separate those who build maps with the help of the hippocampus and those who follow the route with the help of the caudate nucleus, an autopilot that seeks pleasure. Then some of the participants in the experiment were put into playing shooter games, while others took up 3-D platform games in the Super Mario Bros series; both those and others had to "play enough" for about 90 hours. And it turned out that games have different effects on the brain. If a person who walked along the route, obeying the reinforcement system, played a shooter game, then as a result, the amount of gray matter in his hippocampus decreased. The authors of the work explain this by the fact that such games, in principle, tend to encourage the reinforcement system, so that in "chronic players" the hippocampus can shrink quite strongly, as if it is unnecessary. We say "as if" because the hippocampus, whatever one may say, is still needed outside the video shooter, and the consequences of a lack of gray matter in it can be quite serious - it is known that a decrease in the hippocampus accompanies depression, schizophrenia, Alzheimer's syndrome, etc. d. On the other hand, for those players who navigated the terrain, combining in their minds different elements of the landscape - that is, for those who initially were more involved in the navigational skills of the hippocampus - the gray matter in it, on the contrary, became larger; that is, even in a shooter, they were guided by a neutral map, and not by anticipation of pleasure. Finally, the platformer about the Mario brothers contributed to the strengthening of the hippocampus in both categories of players - obviously, the very structure of such games forces you to build maps in your mind.

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