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Mixed asthma (J45.8)

Gastroenterology

general information

Short description

Bronchial asthma*(BA) is a chronic inflammatory disease of the respiratory tract, which involves many cells and cellular elements. Chronic inflammation causes bronchial hyperreactivity leading to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing (especially at night or in the early morning). These episodes are usually associated with widespread but variable airway obstruction in the lungs, which is often reversible spontaneously or with treatment.

Mixed bronchial asthma is diagnosed when the patient has symptoms of both allergic asthma and idiosyncratic asthma.
Diagnostic difficulties can be caused by cases of mixed asthma, when asthma develops in an elderly person or against the background of cardiovascular pathology.
In a number of chronic lung diseases (diffuse pneumosclerosis, emphysema, bronchiectasis, pneumoconiosis, especially silicosis, lung cancer), there is a gradual increase in dyspnea, which is expiratory in nature. Shortness of breath is noted in patients at rest, breathing is accompanied by wheezing.

Bronchial hyperreactivity -increased sensitivity of the lower respiratory tract to various irritating stimuli, which, as a rule, are contained in the inhaled air. These stimuli are indifferent to healthy people. Clinically, bronchial hyperreactivity is most often manifested by episodes of wheezing shortness of breath in response to the action of an irritating stimulus in individuals with a hereditary predisposition.
Latent bronchial hyperreactivity is also distinguished, which is detected only by provocative functional tests with histamine and methacholine.
Bronchial hyperreactivity can be specific and nonspecific.

Specific hyperreactivity occurs in response to exposure to certain allergens, mainly contained in the air (plant pollen, house dust, wool and epidermis of domestic animals, fluff and feathers of poultry, spores and other elements of fungi).

Nonspecific hyperreactivity is formed under the influence of various stimuli of non-allergenic origin (aeropollutants, industrial gases and dust, endocrine disorders, physical activity, neuropsychic factors, respiratory infections, etc.).

Note. Excluded from this subsection are:

Asthmatic status - J46;
- Other chronic obstructive pulmonary disease - J44;
- Lung diseases caused by external agents - J60-J70;
- Pulmonary eosinophilia, not elsewhere classified - J82.

* Definition according to GINA (Global Initiative for Asthma) - Revision 2011.

Classification

Classification of asthma is based on a joint assessment of the symptoms of the clinical picture and indicators of lung function. There is no generally accepted classification of bronchial asthma. Below are examples of the most commonly used classifications.

Classification of bronchial asthma (BA) according to Fedoseev G. B. (1982)

1. Stages of BA development:

1.1The state of betrayal- conditions that threaten the onset of asthma (acute and chronic bronchitis, pneumonia with elements of bronchospasm, combined with vasomotor rhinitis, urticaria, vasomotor edema, migraine and neurodermatitis in the presence of eosinophilia in the blood and an increased content of eosinophils in sputum, due to immunological or non-immunological mechanisms of pathogenesis) .

1.2 Clinically diagnosed BA- after the first attack or asthma status (this term is used mainly in screening studies).

2. BA forms(not included in the formulation of the clinical diagnosis):

immunological form.
- non-immunological form

3. Pathogenetic mechanisms of AD:
3.1 Atonic - indicating the allergenic allergen or allergens.
3.2 Infection-dependent - indicating infectious agents and the nature of infectious dependence, which can be manifested by stimulation of an atopic reaction, infectious allergy and the formation of a primary altered bronchial reactivity (if the infection is an allergen, BA is defined as infectious-allergic).
3.3 Autoimmune.
3.4 Dishormonal - indicating the endocrine organ, the function of which is changed, and the nature of dishormonal changes.
3.5 Neuro-psychic - indicating options for neuro-psychic changes.
3.6 Adrenergic imbalance.
3.7 Primarily altered bronchial reactivity, which is formed without the participation of altered reactions of the immune, endocrine and nervous systems. May be congenital or acquired. Manifested under the influence of chemical, physical and mechanical irritants and infectious agents. Attacks of suffocation are characteristic during physical exertion, exposure to cold air, medicines and other things.

Note to point 3. A patient may have one pathogenetic mechanism of BA or various combinations of mechanisms are possible (by the time of the examination, one of the mechanisms is the main one). During the development of AD, a change in the main and secondary mechanisms is possible.

The separation of BA according to pathogenetic mechanisms and the isolation of the main one are significantly difficult. Nevertheless, this is justified due to the fact that each of the pathogenetic mechanisms involves a certain, unique nature of drug therapy.

4. Severity of BA(in some cases, such a division is conditional; for example, with a mild course, the patient may die from a suddenly developed asthmatic status, and with a rather severe course, a "spontaneous" remission is possible):

4.1 Easy flow: exacerbations are not long, occur 2-3 times a year. Attacks of suffocation are stopped, as a rule, by taking various bronchodilator drugs inside. In the interictal period, signs of bronchospasm, as a rule, are not detected.

4.2 Moderate course: more frequent exacerbations (3-4 times a year). Attacks of suffocation are more severe and are stopped by injections of drugs.

4.3 Severe flow: exacerbations occur frequently (5 or more times a year), differ in duration. The attacks are severe, often turning into an asthmatic state.

5. Phases of the course of bronchial asthma:

1. Aggravation- this phase is characterized by the presence of pronounced signs of the disease, primarily recurring attacks of asthma or an asthmatic condition.

2. fading exacerbation - in this phase, seizures are more rare and not severe. Physical and functional signs of the disease are less pronounced than in the acute phase.

3. Remission - typical manifestations of BA disappear (no asthma attacks occur, bronchial patency is fully or partially restored).

6. Complications:

1. Pulmonary: emphysema, pulmonary insufficiency, atelectasis, pneumothorax and others.

2. Extrapulmonary: myocardial dystrophy, cor pulmonale, heart failure and others.

Classification of asthma according to the severity of the disease and clinical signs before treatment

Step 1 Mild intermittent asthma:
- symptoms less than once a week;
- short exacerbations;
- nocturnal symptoms no more than 2 times a month;
- FEV1 or PSV>= 80% of the expected values;
- variability in FEV1 or PSV< 20%.

Step 2 Mild persistent asthma:

Symptoms more than 1 time per week, but less than 1 time per day;

- nocturnal symptoms more than 2 times a month FEV1 or PEF>= 80% of the expected values;
- variability of FEV1 or PSV = 20-30%.

Step 3 Persistent moderate asthma:

daily symptoms;
- exacerbations can affect physical activity and sleep;
- nocturnal symptoms more than once a week;
- FEV1 or PSV from 60 to 80% of the proper values;
- variability in FEV1 or PSV > 30%.

Step 4 Severe persistent asthma:
- daily symptoms;
- frequent exacerbations;
- frequent nocturnal symptoms;
- restriction of physical activity;
- FEV 1 or PSV<= 60 от должных значений;
- variability in FEV1 or PSV > 30%.

Additionally, the following are BA course phases:
- exacerbation;
- unstable remission;
- remission;
- stable remission (more than 2 years).

Classification according to the Global Asthma Initiative(GINA 2011)
The classification of asthma severity is based on the amount of therapy required to achieve disease control.

1. Mild asthma - disease control can be achieved with a small amount of therapy (low doses of inhaled corticosteroids, antileukotriene drugs or cromones).

2. Severe asthma - A large amount of therapy is needed to control the disease (eg, GINA grade 4) or control cannot be achieved despite a large amount of therapy.

Patients with different AD phenotypes have different responses to conventional treatment. With the advent of specific treatments for each phenotype, AD that was previously considered severe can become mild.
The ambiguity of the terminology associated with the severity of asthma is due to the fact that the term "severity" is also used to describe the severity of bronchial obstruction or symptoms. Severe or frequent symptoms do not necessarily indicate severe asthma, as they may be the result of inadequate treatment.

Classification according to ICD-10

J45.0 Asthma with a predominance of an allergic component (if the disease is associated with an established external allergen) includes the following clinical variants:

allergic bronchitis;

Allergic rhinitis with asthma;

atopic asthma;

Exogenous allergic asthma;

Hay fever with asthma.

J45.1 Non-allergic asthma (when the disease is associated with external factors of a non-allergenic nature or unspecified internal factors) includes the following clinical variants:

Idiosyncratic asthma;

Endogenous non-allergic asthma.

J45.8 Mixed asthma (with signs of the first two forms).

J45.9 Asthma, unspecified, which includes:

asthmatic bronchitis;

Late onset asthma.

J46 Status asthmaticus.

The formulation of the main diagnosis should reflect:
1. The form of the disease (for example, atopic or non-allergic asthma).
2. The severity of the disease (eg, severe persistent asthma).
3. The phase of the course (for example, exacerbation). In remission with steroids, it is reasonable to indicate a maintenance dose of the anti-inflammatory drug (eg, remission at a dose of 800 µg of beclomethasone per day).
4. Complications of asthma: respiratory failure and its form (hypoxemic, hypercapnic), especially asthmatic status.

Etiology and pathogenesis

According to GINA-2011, bronchial asthma (BA) is a chronic inflammatory disease of the respiratory tract, which involves a number of inflammatory cells and mediators, which leads to characteristic pathophysiological changes.

1. Inflammatory cells in the airways in asthma.

1.1 Mast cells. Under the action of allergens with the participation of high-affinity IgE receptors and under the influence of osmotic stimuli, mucosal mast cells are activated. Activated mast cells release mediators that cause bronchospasm (histamine, cysteinyl leukotrienes, prostaglandin D2). An increased number of mast cells in airway smooth muscle may be associated with bronchial hyperreactivity.

1.2 Eosinophils. In the airways, the number of eosinophils is increased. These cells secrete the main proteins that can damage the epithelium of the bronchi. Also, eosinophils may be involved in the release of growth factors and airway remodeling.

1.3 T-lymphocytes. In the respiratory tract, there is an increased number of T-lymphocytes that release specific cytokines that regulate the process of eosinophilic inflammation and the production of IgE by B-lymphocytes. The increase in Th2 cell activity may be partly due to a decrease in the number of regulatory T cells that normally inhibit Th2 lymphocytes. It is also possible to increase the number of inKT cells that secrete Th1 and Th2 cytokines in large quantities.

1.4 Dendritic cells capture allergens from the surface of the bronchial mucosa and migrate to regional lymph nodes, where they interact with regulatory T cells and ultimately stimulate the conversion of undifferentiated T lymphocytes into Th2 cells.

1.5 macrophages. The number of macrophages in the respiratory tract is increased. Their activation may be associated with the action of allergens with the participation of IgE receptors with low affinity. Due to the activation of macrophages, inflammatory mediators and cytokines are released, which enhance the inflammatory response.

1.6 Neutrophils. In the respiratory tract and sputum of patients with severe asthma and smokers, the number of neutrophils increases. Their pathophysiological role has not been elucidated. It is assumed that an increase in their number may be a consequence of GCS therapy. GCS (glucocorticoids, glucocorticosteroids) - drugs one of the leading properties of which is to inhibit the early stages of the synthesis of the main participants in the formation of inflammatory processes (prostaglandins) in various tissues and organs.
.

2.mediators of inflammation. Currently, more than 100 different mediators are known that are involved in the pathogenesis of asthma and the development of a complex inflammatory response in the airways.

3.Structural changes in the airways - are detected in the airways of patients with asthma and are often considered as a process of bronchial remodeling. Structural changes may be the result of repair processes in response to chronic inflammation. Due to the deposition of collagen fibers and proteoglycans under the basement membrane, subepithelial fibrosis develops, which is observed in all patients with asthma (including children) even before the onset of clinical manifestations of the disease. The severity of fibrosis may decrease with treatment. The development of fibrosis is also observed in other layers of the bronchial wall, in which collagen and proteoglycans are also deposited.

3.1 Smooth muscle of the bronchial wall. due to hypertrophy Hypertrophy - the growth of an organ, part of it or tissue as a result of cell multiplication and an increase in their volume
and hyperplasia Hyperplasia - an increase in the number of cells, intracellular structures, intercellular fibrous formations due to enhanced organ function or as a result of a pathological tissue neoplasm.
there is an increase in the thickness of the smooth muscle layer, which contributes to the overall thickening of the bronchus wall. This process may depend on the severity of the disease.

3.2Blood vessels. Under the influence of growth factors, such as vascular endothelial growth factor (VEGF), there is a proliferation Proliferation - an increase in the number of cells of a tissue due to their reproduction
vessels of the bronchial wall, contributing to the thickening of the bronchial wall.

3.3 Mucus hypersecretion observed as a result of an increase in the number of goblet cells in the epithelium of the respiratory tract and an increase in the size of the submucosal glands.

4. Narrowing of the airways- the universal final stage of the pathogenesis of AD, which leads to the onset of symptoms of the disease and typical physiological changes.

Factors causing narrowing of the airways:

4.1 Contraction of the smooth muscles of the bronchial wall in response to the bronchoconstrictor action of various mediators and neurotransmitters is the main mechanism of airway constriction; almost completely reversible under the action of bronchodilators.

4.2 Airway edema resulting from increased permeability of the microvascular bed, which is caused by the action of inflammatory mediators. Edema can play a particularly important role in exacerbations.

4.3 Thickening of the bronchus wall as a result of structural changes. This factor may be of great importance in severe asthma. Bronchial wall thickening is not fully reversible with existing drugs.

4.4 Mucus hypersecretion can lead to occlusion Occlusion is a violation of the patency of some hollow formations in the body (blood and lymphatic vessels, subarachnoid spaces and cisterns), due to the persistent closure of their lumen in any area.
bronchial lumen ("mucus plugs") and is the result of increased secretion of mucus and the formation of an inflammatory exudate.

Features of the pathogenesis are described for the following forms of AD:
- exacerbation of BA;
- night BA;
- irreversible bronchial obstruction;
- BA, difficult to treat;
- BA in smokers;
- aspirin triad.

Epidemiology

In the world, about 5% of the adult population suffers from bronchial asthma (1-18% in different countries). In children, the incidence varies from 0 to 30% in different countries.

The onset of the disease is possible at any age. Approximately half of the patients develop bronchial asthma before the age of 10 years, in a third - up to 40 years.
Among children with bronchial asthma, there are twice as many boys as girls, although the sex ratio levels off by the age of 30.

Factors and risk groups

Factors affecting the risk of developing AD are divided into:
- factors causing the development of the disease - internal factors (primarily genetic);
- factors that provoke the onset of symptoms - external factors.
Some factors belong to both groups.
The mechanisms of influence of factors on the development and manifestations of AD are complex and interdependent.

Internal factors:

1. Genetic (for example, genes predisposing to atopy and genes predisposing to bronchial hyperreactivity).

2. Obesity.

External factors:

1. Allergens:

Room allergens (house dust mites, pet hair, cockroach allergens, fungi, including mold and yeast);

External allergens (pollen, fungi, including molds and yeasts).

2. Infections (mainly viral).

3. Professional sensitizers.

4. Tobacco smoking (passive and active).

5. Air pollution indoors and outdoors.

6. Nutrition.

Examples of substances that cause the development of asthma in certain occupations

Profession	Substance
	Proteins of animal and vegetable origin
Bakers	Flour, amylase
Cattle farmers	Warehouse tongs
Detergent production	Bacillus subtilis enzymes
Electrical soldering	Rosin
Crop farmers	soy dust
Production of fish products
Food production	Coffee dust, meat tenderizers, tea, amylase, shellfish, egg whites, pancreatic enzymes, papain
Granary workers	Warehouse mites, Aspergillus. Weed particles, ragweed pollen
Medical workers	Psyllium, latex
poultry farmers	Poultry mites, bird droppings and feathers
Researchers-experimenters, veterinarians	Insects, dander and animal urine proteins
Sawmill workers, carpenters	wood dust
Movers/transport workers	grain dust
Silk workers	Butterflies and silkworm larvae
	inorganic compounds
Beauticians	Persulfate
Platters	Nickel salts
Oil refinery workers	Salts of platinum, vanadium organic compounds
Car painting	Ethanolamine, diisocyanates
Hospital workers	Disinfectants (sulfathiazole, chloramine, formaldehyde), latex
Pharmaceutical production	Antibiotics, piperazine, methyldopa, salbutamol, cimetidine
Rubber processing	Formaldehyde, ethylenediamide
Plastics production	Acrylates, hexamethyl diisocyanate, toluine diisocyanate, phthalic anhydride

Elimination of risk factors can significantly improve the course of asthma.

In patients with allergic asthma, elimination of the allergen is of paramount importance. There is evidence that in urban areas in children with atopic asthma, individual complex measures for the removal of allergens in the homes led to a decrease in soreness.

Clinical picture

Clinical Criteria for Diagnosis

Unproductive hacking cough, prolonged expiration, dry, wheezing, usually treble, wheezing in the chest, more at night and in the morning, attacks of expiratory choking, chest congestion, dependence of respiratory symptoms on contact with provoking agents.

Symptoms, course

Clinical diagnosis of bronchial asthma(BA) is based on the following data:

1. Identification of bronchial hyperreactivity, as well as reversibility of obstruction spontaneously or under the influence of treatment (decrease in response to appropriate therapy).
2. Unproductive hacking cough; prolonged exhalation; dry, whistling, usually treble, rales in the chest, more marked at night and in the morning; expiratory dyspnea, attacks of expiratory suffocation, congestion (stiffness) of the chest.
3. Dependence of respiratory symptoms on contact with provoking agents.

Also of great importance are the following factors:
- the appearance of symptoms after episodes of contact with the allergen;
- seasonal variability of symptoms;
- a family history of asthma or atopy.

When diagnosing, you need to find out the following questions:
- Does the patient have episodes of wheezing, including recurring ones?

Does the patient have a cough at night?

Does the patient have wheezing or cough after exercise?

Does the patient have episodes of wheezing, chest congestion, or coughing after exposure to aeroallergens or pollutants?

Does the patient report that the cold "goes down to the chest" or continues for more than 10 days?

Does the severity of symptoms decrease after the use of appropriate anti-asthma drugs?

On physical examination, there may be no symptoms of asthma, due to the variability in the manifestations of the disease. The presence of bronchial obstruction is confirmed by wheezing that is detected during auscultation.
In some patients, wheezing may be absent or detected only during forced exhalation, even in the presence of severe bronchial obstruction. In some cases, patients with severe exacerbations of asthma do not wheeze due to severe limitation of airflow and ventilation. In such patients, as a rule, there are other clinical signs indicating the presence and severity of an exacerbation: cyanosis, drowsiness, difficulty in speaking, swollen chest, participation of auxiliary muscles in the act of breathing and retraction of the intercostal spaces, tachycardia. These clinical symptoms can only be observed when examining the patient during the period of pronounced clinical manifestations.

Variants of clinical manifestations of AD

1.Cough variant of BA. The main (sometimes the only) manifestation of the disease is a cough. Cough asthma is most common in children. The severity of symptoms increases at night, and during the day the manifestations of the disease may be absent.
For such patients, it is important to study the variability of lung function or bronchial hyperreactivity, as well as the determination of eosinophils in sputum.
The cough variant of asthma is differentiated from the so-called eosinophilic bronchitis. In the latter, patients present with cough and sputum eosinophilia, but have normal lung function on spirometry and normal bronchial reactivity.
In addition, cough can occur due to the use of ACE inhibitors, gastroesophageal reflux, postnasal drip syndrome, chronic sinusitis, dysfunction of the vocal cords.

2. Bronchospasm induced by physical activity. Refers to the manifestation of non-allergic forms of asthma, when the phenomena of airway hyperreactivity dominate. In the majority of cases, physical activity is an important or only cause of the onset of symptoms of the disease. Bronchospasm as a result of physical activity, as a rule, develops 5-10 minutes after the cessation of exercise (rarely - during exercise). Patients have typical symptoms of asthma or sometimes a prolonged cough that resolves on its own within 30-45 minutes.
Forms of exercise such as running cause asthma symptoms more frequently.
Exercise-induced bronchospasm often develops when inhaling dry, cold air, more rarely in hot and humid climates.
In favor of asthma is evidenced by the rapid improvement in the symptoms of post-exercise bronchospasm after inhaled β2-agonist, as well as the prevention of the development of symptoms due to inhaled β2-agonist before exercise.
In children, asthma can sometimes manifest itself only during exercise. In this regard, in such patients or in the presence of doubts about the diagnosis, it is advisable to conduct a test with physical activity. Diagnosis is facilitated by a protocol with an 8-minute run.

Clinical picture of an asthma attack quite typical.
In case of allergic etiology of BA, before the development of suffocation, itching (in the nasopharynx, auricles, in the chin area), nasal congestion or rhinorrhea, feelings of lack of "free breathing", dry cough can be observed. elongated; the duration of the respiratory cycle increases and the respiratory rate decreases (up to 12-14 per minute).
During listening to the lungs in the bulk of cases, against the background of an extended expiration, a large number of scattered dry rales, mostly whistling, are determined. As the asthma attack progresses, wheezing wheezes on expiration are heard at a certain distance from the patient in the form of "wheezing" or "bronchial music".

With a prolonged attack of suffocation, which lasts more than 12-24 hours, there is a blockage of the small bronchi and bronchioles with an inflammatory secret. The general condition of the patient is significantly aggravated, the auscultatory picture changes. Patients experience excruciating shortness of breath, aggravated by the slightest movement. The patient takes a forced position - sitting or half-sitting with fixation of the shoulder girdle. All auxiliary muscles participate in the act of breathing, the chest expands, and the intercostal spaces are drawn in during inspiration, cyanosis of the mucous membranes, acrocyanosis, arises and intensifies. It is difficult for the patient to speak, the sentences are short and jerky.
During auscultation, there is a decrease in the number of dry rales, in some places they are not heard at all, as well as vesicular breathing; so-called silent lung zones appear. Above the surface of the lungs, percussion is determined by a pulmonary sound with a tympanic shade - a box sound. The lower edges of the lungs are lowered, their mobility is limited.
The completion of an asthma attack is accompanied by a cough with a discharge of a small amount of viscous sputum, easier breathing, a decrease in shortness of breath and the number of auscultated wheezing. Even for a long time, a few dry rales can be heard while maintaining an elongated exhalation. After the cessation of the attack, the patient often falls asleep. Signs of asthenia persist for a day or more.

Exacerbation of asthma(attacks of asthma, or acute asthma) according to GINA-2011 is divided into mild, moderate, severe, and such an item as "breathing is inevitable." The severity of the course of BA and the severity of exacerbation of BA are not the same thing. For example, with mild asthma, exacerbations of mild and moderate severity can occur; with asthma of moderate severity and severe, exacerbations of mild, moderate, and severe are possible.

The severity of BA exacerbation according to GINA-2011

	Lung	Middle gravity	heavy	Stopping breathing is inevitable
Dyspnea	When walking. May lie	When talking; children crying getting quieter and shorter having difficulty feeding. Prefers to sit	At rest, children stop eating. Sitting leaning forward
Speech	Offers	Phrases	words
Level wakefulness	May be aroused	Usually aroused	Usually aroused	Inhibited or confused mind
Breathing rate	Increased	Increased	More than 30 min.
Participation of auxiliary muscles in the act of breathing and retraction of the supraclavicular fossae	Usually no	Usually there	Usually there	Paradoxical movements chest and abdominal walls
wheezing	Moderate, often only exhale	Loud	Usually loud	Missing
Pulse (in min.)	<100	>100	>120	Bradycardia
Paradoxical pulse	Absent <10 мм рт. ст.	May have 10-25 mmHg st	Often available >25 mmHg Art. (adults) 20-40 mmHg Art. (children)	Absence allows assume fatigue respiratory muscles
PSV after the first injection bronchodilator in % of due or the best individual value	>80%	About 60-80%	<60% от должных или наилучших individual values (<100 л/мин. у взрослых) or the effect lasts<2 ч.	Impossible to rate
PaO 2 in kPa (when breathing air)	Normal. Analysis is usually not needed.	>60 mmHg Art.	<60 мм рт. ст. Possible cyanosis
PaCO 2 in kPa (when breathing air)	<45 мм рт. ст.	<45 мм рт. ст.	>45 mmHg Art. Possible respiratory failure
SatO 2,% (when breathing air) - oxygen saturation or the degree of saturation of arterial blood hemoglobin with oxygen	>95%	91-95%	< 90%

Notes:
1. Hypercapnia (hypoventilation) develops more often in young children than in adults and adolescents.
2. Normal heart rate in children:

Infant (2-12 months)<160 в минуту;

Younger age (1-2 years old)<120 в минуту;

Preschool and school age (2-8 years)<110 в минуту.
3. Normal respiratory rate in awake children:

Under 2 months< 60 в минуту;

2-12 months< 50 в минуту;

1-5 years< 40 в минуту;

6-8 years old< 30 в минуту.

Diagnostics

Fundamentals of diagnosing bronchial asthma(BA):
1. Analysis of clinical symptoms, which are dominated by periodic attacks of expiratory suffocation (for more details, see the "Clinical picture" section).
2. Determination of indicators of pulmonary ventilation, most often with the help of spirography with registration of the "flow-volume" curve of forced expiration, identification of signs of reversibility of bronchial obstruction.
3. Allergological research.
4. Identification of nonspecific bronchial hyperreactivity.

The study of indicators of the function of external respiration

1. Spirometry Spirometry - measurement of vital capacity of the lungs and other lung volumes using a spirometer
. In patients with asthma, signs of bronchial obstruction are often diagnosed: a decrease in indicators - PEF (peak expiratory volumetric velocity), MOS 25 (maximum volumetric velocity at the point of 25% FVC, (FEF75) and FEV1.

To assess the reversibility of bronchial obstruction is used pharmacological bronchodilation test with short-acting β2-agonists (most often salbutamol). Before the test, you should refrain from taking short-acting bronchodilators for at least 6 hours.
Initially, the initial curve "flow-volume" forced breathing of the patient is recorded. Then the patient makes 1-2 inhalations of one of the short and fast acting β2-agonists. After 15-30 minutes, the flow-volume curve is recorded. With an increase in FEV1 or FOS ex by 15% or more, airway obstruction is considered reversible or bronchodilator-reactive, and the test is considered positive.

For asthma, it is diagnostically important to identify a significant daily variability in bronchial obstruction. For this, spirography (when the patient is in the hospital) or peak flowmetry (at home) is used. The spread (variability) of FEV1 or POS ex more than 20% during the day is considered to confirm the diagnosis of BA.

2. Peakflowmetry. It is used to evaluate the effectiveness of treatment and to objectify the presence and severity of bronchial obstruction.
Peak expiratory flow rate (PEF) is estimated - the maximum speed at which air can exit the respiratory tract during a forced expiration after a full breath.
The patient's PSV values ​​are compared with normal values ​​and with the best PSV values ​​observed in this patient. The level of decrease in PSV allows us to draw conclusions about the severity of bronchial obstruction.
The difference between PSV values ​​measured during the day and in the evening is also analyzed. A difference of more than 20% indicates an increase in bronchial reactivity.

2.1 Intermittent asthma (stage I). Daytime attacks of shortness of breath, cough, wheezing occur less than 1 time per week. Duration of exacerbations - from several hours to several days. Night attacks - 2 or less times a month. In the period between exacerbations, lung function is normal; PSV - 80% of normal or less.

2.2 Mild persistent asthma (stage II). Daytime attacks are observed 1 or more times a week (not more than 1 time per day). Night attacks are repeated more often than 2 times a month. During an exacerbation, the activity and sleep of the patient may be disturbed; PSV - 80% of normal or less.

2.3 Persistent asthma of moderate severity (stage III). Daily attacks of suffocation, once a week there are nocturnal attacks. As a result of exacerbations, the patient's activity and sleep are disturbed. The patient is forced to use short-acting inhaled beta-adrenergic agonists daily; PSV - 60 - 80% of the norm.

2.4 Severe course of persistent asthma (stage IV). Daytime and nighttime symptoms are permanent, which limits the patient's physical activity. The PSV index is less than 60% of the norm.

3. Allergological study. Allergological history is analyzed (eczema, hay fever, family history of asthma or other allergic diseases). Positive skin tests with allergens and elevated blood levels of total and specific IgE testify in favor of AD.

4. Provocative Tests with histamine, methacholine, physical activity. They are used to detect nonspecific bronchial hyperreactivity, manifested by latent bronchospasm. Performed in patients with suspected asthma and normal spirography.

In the histamine test, the patient inhales nebulized histamine in progressively increasing concentrations, each of which is capable of causing bronchial obstruction.
The test is assessed as positive if the air flow rate deteriorates by 20% or more as a result of histamine inhalation at a concentration one or more orders of magnitude lower than that which causes similar changes in healthy people.
Similarly, a test with methacholine is carried out and evaluated.

5. Additional research:
- radiography of the chest in two projections - most often show signs of emphysema (increased transparency of the lung fields, depletion of the lung pattern, low standing of the domes of the diaphragm), while the absence of infiltrative and focal changes in the lungs is important;
- fibrobronchoscopy;

Electrocardiography.
Additional studies are being carried out in atypical asthma and resistance to anti-asthma therapy.

Main diagnostic criteria for AD:

1. The presence in the clinical picture of the disease of periodic attacks of expiratory suffocation, which have their beginning and end, passing spontaneously or under the influence of bronchodilators.
2. Development of status asthmaticus.
3. Determination of signs of bronchial obstruction (FEV1 or POS vyd< 80% от должной величины), которая является обратимой (прирост тех же показателей более 15% в фармакологической пробе с β2-агонистами короткого действия) и вариабельной (колебания показателей более 20% на протяжении суток).
4. Identification of signs of bronchial hyperreactivity (hidden bronchospasm) in patients with initial normal indicators of pulmonary ventilation using one of three provocative tests.
5. The presence of a biological marker - a high level of nitric oxide in the exhaled air.

Additional diagnostic criteria:
1. The presence in the clinical picture of symptoms that may be "small equivalents" of an attack of expiratory suffocation:
- unmotivated cough, often at night and after exercise;
- recurring sensations of chest tightness and / or episodes of wheezing;
- the fact of awakening at night from the indicated symptoms strengthens the criterion.
2. Aggravated allergic history (presence of eczema, hay fever, pollinosis in a patient) or aggravated family history (BA, atopic diseases in the patient's family members).

3. Positive skin tests with allergens.
4. An increase in the patient's blood level of general and specific IgE (reagins).

Professional BA

Bronchial asthma due to professional activity is often not diagnosed. Due to the gradual development of occupational asthma, it is often regarded as chronic bronchitis or COPD. This leads to incorrect treatment or its absence.

Occupational asthma should be suspected when symptoms of rhinitis, cough and/or wheezing appear, especially in nonsmokers. Establishing a diagnosis requires a systematic collection of information about work history and environmental factors in the workplace.

Criteria for the diagnosis of occupational asthma:
- well-established occupational exposure to known or suspected sensitizing agents;
- the absence of symptoms of asthma before employment or a clear worsening of the course of asthma after employment.

Laboratory diagnostics

Non-invasive determination of markers of airway inflammation

1. The study of spontaneously produced or induced by inhalation of hypertonic sputum solution on inflammatory cells - eosinophils or neutrophils. It is used to assess the activity of inflammation in the airways in asthma.

2. Determination of levels of nitric oxide (FeNO) and carbon monoxide (FeCO) in exhaled air. In patients with BA, there is an increase in the level of FeNO (in the absence of inhaled corticosteroids) compared with individuals without BA, however, these results are not specific for this disease. The role of FeNO in the diagnosis of AD has not been evaluated in prospective studies.

3. Skin tests with allergens - are the main method for assessing allergic status. Such samples are highly sensitive, easy to use and do not require much time. It should be borne in mind that incorrect sample performance can lead to false positive or false negative results.

4. The determination of specific IgE in blood serum is a more expensive method than skin tests, which does not surpass them in reliability.
In some patients, specific IgE may be detected in the absence of any symptoms and play no role in the development of AD. Thus, positive test results do not necessarily indicate the allergic nature of the disease and the association of the allergen with the development of asthma.
The presence of allergen exposure and its association with asthma manifestations should be supported by history data. The measurement of total IgE in serum is not a method of diagnosing atopy.

Clinical Tests

1. Complete blood count: during the period of exacerbation, an increase in ESR and eosinophilia are noted. Eosinophilia is not determined in all patients and cannot serve as a diagnostic criterion.

2. General sputum analysis:
- a large number of eosinophils;
- Charcot-Leiden crystals;
- Kurshman's spirals (formed due to small spastic contractions of the bronchi);
- neutral leukocytes - in patients with infectious-dependent BA in the stage of an active inflammatory process;
- release of Creole bodies during an attack.

3. Biochemical analysis of blood: changes are of a general nature. BAC is not the main diagnostic method and is prescribed to monitor the patient's condition during an exacerbation.

Differential Diagnosis

1. Differential diagnosis of BA variants.

The main differential diagnostic features of atopic and infection-dependent variants of BA(according to Fedoseev G. B., 2001)

signs	Atopic variant	infection dependent variant
Allergic diseases in the family	Often	Rare (except asthma)
Atopic disease in a patient	Often	Rarely
Connection of an attack with an external allergen	Often	Rarely
Features of an attack	Acute onset, rapid onset, usually of short duration and mild course	Gradual onset, long duration, often severe
Pathology of the nose and paranasal sinuses	Allergic rhinosinusitis or polyposis without signs of infection	Allergic rhinosinusitis, often polyposis, signs of infection
Bronchopulmonary infectious process	Usually absent	Often chronic bronchitis, pneumonia
Eosinophilia of blood and sputum	Usually moderate	Often high
Specific IgE antibodies to non-infectious allergens	Present	Missing
Skin tests with extracts of non-infectious allergens	Positive	Negative
Exercise test	More often negative	More often positive
Allergen Elimination	Possible, often effective	Impossible
Beta-agonists	Very effective	Moderately effective
Cholinolytics	Ineffective	Effective
Eufillin	Very effective	Moderately effective
Intal, Thailed	Very effective	Less effective
Corticosteroids	Effective	Effective

2. Differential diagnosis of BA is carried out with chronic obstructive pulmonary disease(COPD), which is characterized by more permanent bronchial obstruction. In patients with COPD, there is no spontaneous lability of symptoms typical of BA, there is no or significantly less daily variability in FEV1 and POS exud, complete irreversibility or less reversibility of bronchial obstruction is determined in the test with β2-agonists (increase in FEV1 is less than 15%).
Sputum in COPD is dominated by neutrophils and macrophages rather than eosinophils. In patients with COPD, the effectiveness of bronchodilator therapy is lower, more effective bronchodilators are anticholinergics, and not short-acting β2-agonists; pulmonary hypertension and signs of chronic cor pulmonale are more common.

Some features of diagnosis and differential diagnosis (according to GINA 2011)

1.In children aged 5 years and younger wheezing episodes are common.

Types of wheezing in the chest:

1.1 Transient early wheezing, which children often "outgrow" in the first 3 years of life. Such wheezing is often associated with prematurity of children and smoking parents.

1.2 Persistent wheezing with early onset (under 3 years of age). Children usually have recurrent episodes of wheezing associated with acute respiratory viral infections. At the same time, children do not have signs of atopy and there is no family history of atopy (in contrast to children of the next age group with late onset wheezing/bronchial asthma).
Wheezing episodes typically continue into school age and are still detected in a significant proportion of children as young as 12 years of age.
The cause of wheezing episodes in children under 2 years of age is usually a respiratory syncytial virus infection, in children 2-5 years of age - other viruses.

1.3 Late-onset wheezing/asthma. Asthma in these children often lasts throughout childhood and continues into adulthood. Such patients are characterized by a history of atopy (often manifested as eczema) and airway pathology typical of asthma.

With repeated episodes of wheezing, it is necessary to exclude other causes of wheezing:

Chronic rhinosinusitis;

Gastroesophageal reflux;

Recurrent viral infections of the lower respiratory tract;

cystic fibrosis;

bronchopulmonary dysplasia;

Tuberculosis;

Aspiration of a foreign body;
- immunodeficiency;

Syndrome of primary ciliary dyskinesia;

Malformations causing narrowing of the lower respiratory tract;
- Congenital heart defect.

The possibility of another disease is indicated by the appearance of symptoms in the neonatal period (in combination with insufficient weight gain); wheezing associated with vomiting, signs of focal lung damage or cardiovascular pathology.

2. Patients over 5 years of age and adults. Differential diagnosis should be carried out with the following diseases:

Hyperventilation syndrome and panic attacks;

Obstruction of the upper respiratory tract and aspiration of foreign bodies;

Other obstructive pulmonary diseases, especially COPD;

Non-obstructive lung disease (eg, diffuse lesions of the lung parenchyma);

Non-respiratory diseases (for example, left ventricular failure).

3. Elderly patients. BA should be differentiated from left ventricular failure. In addition, BA is underdiagnosed in the elderly.

Risk Factors for Underdiagnosis of AD in Elderly Patients

3.1 From the side of the patient:
- depression;
- social isolation;
- impaired memory and intelligence;


- Decreased perception of dyspnea and bronchoconstriction.

3.2 From the doctor's point of view:
- misconception that asthma does not start in old age;
- difficulties in examining lung function;
- perception of asthma symptoms as signs of aging;
- accompanying illnesses;
- underestimation of dyspnea due to a decrease in the patient's physical activity.

Complications

Complications of bronchial asthma are divided into pulmonary and extrapulmonary.

Pulmonary complications: chronic bronchitis, hypoventilation pneumonia, pulmonary emphysema, pneumosclerosis, respiratory failure, bronchiectasis, atelectasis, pneumothorax.

Extrapulmonary complications:"pulmonary" heart, heart failure, myocardial dystrophy, arrhythmia; in patients with a hormone-dependent variant of BA, complications associated with prolonged use of systemic corticosteroids may occur.

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Treatment

Objectives of the treatment of bronchial asthma(BA):

Achieve and maintain control of symptoms;

Maintaining a normal level of activity, including physical activity;

Maintaining lung function at a normal or as close to normal level as possible;

Prevention of asthma exacerbations;

Prevention of unwanted effects of anti-asthma drugs;

Prevention of deaths from AD.

BA control levels(GINA 2006-2011)

Characteristics	controlled BA(all of the above)	Partially controlled asthma(presence of any manifestation within a week)	uncontrolled asthma
daytime symptoms	None (≤ 2 episodes per week)	> 2 times a week	3 or more signs of partially controlled asthma in any week
Activity restriction	No	Yes - any expression
Night symptoms/ awakenings	No	Yes - any expression
Need for emergency medicines	None (≤ 2 episodes per week)	> 2 times a week
Pulmonary function tests (PSV or FEV1) 1	Norm	< 80% от должного (или от наилучшего показателя для данного пациента)
Exacerbations	No	1 or more times a year 2	Any week with aggravation 3

1 Pulmonary function testing not reliable in children 5 years of age and younger. Periodic assessment of the level of control over BA in accordance with the criteria indicated in the table will allow individual selection of a pharmacotherapy regimen for the patient.
2 Each exacerbation requires an immediate review of maintenance therapy and an assessment of its adequacy
3 By definition, the development of any exacerbation indicates that asthma is not controlled

Medical therapy

Medications for the treatment of AD:

1. Drugs that control the course of the disease (maintenance therapy):
- inhalation and systemic corticosteroids;
- anti-leukotriene agents;
- long-acting inhaled β2-agonists in combination with inhaled corticosteroids;
- sustained release theophylline;
- cromones and antibodies to IgE.
These drugs provide control over the clinical manifestations of AD; they are taken daily and for a long time. The most effective for maintenance therapy are inhaled corticosteroids.

2. Rescue drugs (to relieve symptoms):
- inhaled β2-rapid agonists;
- anticholinergics;
- short-acting theophylline;
- short-acting oral β2-agonists.
These drugs are taken to relieve symptoms as needed. They have a fast action, eliminate bronchospasm and stop its symptoms.

Drugs for the treatment of asthma can be administered in various ways - inhalation, oral or injection. Advantages of the inhalation route of administration:
- delivers drugs directly to the respiratory tract;
- a locally higher concentration of the medicinal substance is achieved;
- Significantly reduces the risk of systemic side effects.

For maintenance therapy, inhaled corticosteroids are most effective.

The drugs of choice for the relief of bronchospasm and for the prevention of exercise-induced bronchospasm in adults and children of any age are fast-acting inhaled β2-agonists.

Increasing use (especially daily) of rescue drugs indicates worsening asthma control and the need to reconsider therapy.

Inhaled corticosteroids are most effective for the treatment of persistent asthma:
- reduce the severity of asthma symptoms;
- improve quality of life and lung function;
- reduce bronchial hyperreactivity;
- inhibit inflammation in the respiratory tract;
- reduce the frequency and severity of exacerbations, the frequency of deaths in asthma.

Inhaled corticosteroids do not cure BA, and when they are canceled in some patients, a worsening of the condition is observed within weeks or months.
Local undesirable effects of inhaled corticosteroids: oropharyngeal candidiasis, dysphonia, sometimes cough due to irritation of the upper respiratory tract.
Systemic side effects of long-term therapy with high doses of inhaled corticosteroids: a tendency to bruising, inhibition of the adrenal cortex, a decrease in bone mineral density.

Calculated equipotent daily doses of inhaled corticosteroids in adults(GINA 2011)

A drug	Low daily allowance doses(µg)	Medium daily allowance doses(µg)	High daily allowance doses(µg)
Beclomethasone dipropionate CFC*	200-500	>500-1000	>1000-2000
Beclomethasone dipropionate HFA**	100-250	>250-500	>500-1000
Budesonide	200-400	>400-800	>800-1600
Cyclesonide	80-160	>160-320	>320-1280
Flunisolide	500-1000	>1000-2000	>2000
fluticasone propionate	100-250	>250-500	>500-1000
mometasone furoate	200	≥ 400	≥ 800
Triamcinolone acetonide	400-1000	>1000-2000	>2000

*CFC - chlorofluorocarbon (freon) inhalers
** HFA - hydrofluoroalkane (CFC-free) inhalers

Calculated equipotent daily doses of inhaled corticosteroids for children over 5 years of age(GINA 2011)

A drug	Low daily allowance doses(µg)	Medium daily allowance doses(µg)	High daily allowance doses(µg)
beclomethasone dipropionate	100-200	>200-400	>400
Budesonide	100-200	>200-400	>400
Budesonide Neb	250-500	>500-1000	>1000
Cyclesonide	80-160	>160-320	>320
Flunisolide	500-750	>750-1250	>1250
fluticasone propionate	100-200	>200-500	>500
mometasone furoate	100	≥ 200	≥ 400
Triamcinolone acetonide	400-800	>800-1200	>1200

Antileukotriene drugs: subtype 1 cysteinyl leukotriene receptor antagonists (montelukast, pranlukast and zafirlukast), as well as a 5-lipoxygenase inhibitor (zileuton).
Action:
- weak and variable bronchodilatory effect;
- reduce the severity of symptoms, including cough;
- improve lung function;
- reduce the activity of inflammation in the respiratory tract;
- reduce the frequency of asthma exacerbations.
Anti-leukotriene drugs can be used as second-line drugs for the treatment of adult patients with mild persistent asthma. Some patients with aspirin asthma also respond well to therapy with these drugs.
Antileukotriene drugs are well tolerated; side effects are few or absent.

Long-acting inhaled β2-agonists: formoterol, salmeterol.
Should not be used as monotherapy for asthma because there is no evidence that these drugs reduce inflammation in asthma.
These drugs are most effective in combination with inhaled corticosteroids. Combination therapy is preferred in the treatment of patients in whom the use of medium doses of inhaled corticosteroids does not achieve control of asthma.
With regular use of β2-agonists, relative refractoriness to them may develop (this applies to both short- and long-acting drugs).
Therapy with inhaled long-acting β2-agonists is characterized by a lower incidence of systemic adverse effects (such as stimulation of the cardiovascular system, skeletal muscle tremor and hypokalemia) compared with oral long-acting β2-agonists.

Oral long-acting β2-agonists: sustained-release formulations of salbutamol, terbutaline, and bambuterol (a prodrug that is converted to terbutaline in the body).
Used in rare cases when additional bronchodilator action is required.
Undesirable effects: stimulation of the cardiovascular system (tachycardia), anxiety and skeletal muscle tremor. Undesirable cardiovascular reactions can also occur when oral β2-agonists are used in combination with theophylline.

Rapidly acting inhaled β2-agonists: salbutamol, terbutaline, fenoterol, levalbuterol HFA, reproterol and pirbuterol. Due to its rapid onset of action, formoterol (a long-acting β2-agonist) can also be used to relieve asthma symptoms, but only in patients receiving regular maintenance therapy with inhaled corticosteroids.
Fast-acting inhaled β2-agonists are emergency medicines and are the drugs of choice for the relief of bronchospasm during exacerbation of asthma, as well as for the prevention of exercise-induced bronchospasm. Should be used only as needed, with the lowest possible doses and frequency of inhalations.
The growing, especially daily, use of these drugs indicates a loss of control over asthma and the need to reconsider therapy. In the absence of a rapid and stable improvement after inhalation of a β2-agonist during an exacerbation of asthma, the patient should also continue to be monitored and, possibly, a short course of therapy with oral corticosteroids should be prescribed.
The use of oral β2-agonists in standard doses is accompanied by more pronounced than when using inhaled forms, undesirable systemic effects (tremor, tachycardia).

Short-acting oral β2-agonists(refer to emergency medicines) can be prescribed to only a few patients who are not able to take inhaled drugs. Side effects are observed more often.

Theophylline It is a bronchodilator and, when administered in low doses, has a slight anti-inflammatory effect and increases resistance.
Theophylline is available in sustained-release dosage forms that can be taken once or twice a day.
According to available data, sustained release theophylline has little efficacy as a first-line agent for the maintenance treatment of bronchial asthma.
The addition of theophylline may improve outcomes in patients in whom inhaled corticosteroid monotherapy does not achieve asthma control.
Theophylline has been shown to be effective as monotherapy and as a supplement to inhaled or oral corticosteroids in children over 5 years of age.
When using theophylline (especially at high doses - 10 mg / kg of body weight per day or more), significant side effects are possible (usually decrease or disappear with prolonged use).
Undesirable effects of theophylline:
- nausea and vomiting - the most common side effects at the beginning of the application;
- disorders of the gastrointestinal tract;
- liquid stool;
- heart rhythm disturbances;
- convulsions;
- death.

Sodium cromoglycate and nedocromil sodium(cromones) are of limited value in the long-term treatment of asthma in adults. There are known examples of the beneficial effects of these drugs in mild persistent asthma and exercise-induced bronchospasm.
Cromones have a weak anti-inflammatory effect and are less effective than low doses of inhaled corticosteroids. Side effects (cough after inhalation and sore throat) are rare.

Anti-IgE(omalizumab) are used in patients with elevated serum IgE levels. Indicated for severe allergic asthma, control over which is not achieved with the help of inhaled corticosteroids.
In a small number of patients, the appearance of an underlying disease (Churg-Strauss syndrome) was observed when glucocorticosteroids were discontinued due to anti-IgE treatment.

Systemic GCS in severe uncontrolled asthma, they are indicated as long-term therapy with oral drugs (recommended use for a longer period than with the usual two-week course of intensive therapy with systemic corticosteroids - standardly from 40 to 50 mg of prednisolone per day).
The duration of the use of systemic corticosteroids is limited by the risk of developing serious adverse effects (osteoporosis, arterial hypertension, depression of the hypothalamic-pituitary-adrenal system, obesity, diabetes mellitus, cataracts, glaucoma, muscle weakness, striae and a tendency to bruise due to thinning of the skin). Patients taking any form of systemic corticosteroids for a long time require the appointment of drugs for the prevention of osteoporosis.

Oral antiallergic drugs(tranilast, repyrinast, tazanolast, pemirolast, ozagrel, celatrodust, amlexanox and ibudilast) are offered for the treatment of mild to moderate allergic asthma in some countries.

Anticholinergic drugs - ipratropium bromide and oxitropium bromide.
Inhaled ipratropium bromide is less effective than inhaled rapid-acting β2-agonists.
Inhaled anticholinergics are not recommended for the long-term treatment of asthma in children.

Comprehensive treatment program BA (according to GINA) includes:

Patient education;
- clinical and functional monitoring;
- elimination of causative factors;
- development of a long-term therapy plan;
- prevention of exacerbations and drawing up a plan for their treatment;
- dynamic observation.

Drug Therapy Options

Treatment for AD is usually lifelong. It should be borne in mind that drug therapy does not replace measures to prevent the patient from coming into contact with allergens and irritants. The approach to the treatment of the patient is determined by his condition and the goal currently facing the doctor.

In practice, it is necessary to distinguish between the following therapy options:

1. Relief of an attack - is carried out with the help of bronchodilators, which can be used by the patient himself situationally (for example, for mild respiratory disorders - salbutamol in the form of a metered aerosol device) or by medical personnel through a nebulizer (for severe disorders of respiratory function).

Basic anti-relapse therapy: a maintenance dose of anti-inflammatory drugs (the most effective are inhaled glucocorticoids).

3. Basic anti-relapse therapy.

4. Treatment of status asthmaticus - is carried out using high doses of systemic intravenous glucocorticoids (SGK) and bronchodilators in the correction of acid-base metabolism and blood gas composition with the help of medications and non-drugs.

Long-term maintenance therapy for asthma:

1. Assessment of the level of control over BA.
2. Treatment aimed at achieving control.
3. Monitoring to maintain control.

Treatment aimed at achieving control is carried out according to step therapy, where each step includes therapy options that can serve as alternatives when choosing maintenance therapy for asthma. The effectiveness of therapy increases from stage 1 to stage 5.

Stage 1
Includes the use of rescue drugs as needed.
It is intended only for patients who have not received maintenance therapy and occasionally experience short-term (up to several hours) symptoms of asthma during the daytime. Patients with more frequent onset of symptoms or episodic worsening of the condition are indicated for regular maintenance therapy (see step 2 or higher) in addition to rescue drugs as needed.

Rescue drugs recommended in step 1: Rapid-acting inhaled β2-agonists.
Alternative drugs: inhaled anticholinergics, short-acting oral β2-agonists, or short-acting theophylline.

Stage 2
Relief drug + one disease control drug.
Drugs recommended as initial maintenance therapy for asthma in patients of any age at stage 2: low-dose inhaled corticosteroids.
Alternative agents for asthma control: antileukotriene drugs.

Step 3

3.1. Emergency drug + one or two drugs to control the course of the disease.
At step 3, children, adolescents and adults are recommended: a combination of a low dose of inhaled corticosteroids with a long-acting inhaled β2-agonist. Reception is carried out using one inhaler with a fixed combination or using different inhalers.
If control over BA has not been achieved after 3-4 months of therapy, an increase in the dose of inhaled corticosteroids is indicated.

3.2. Another treatment option for adults and children (the only one recommended in the management of children) is to increase the doses of inhaled corticosteroids to medium doses.

3.3. Step 3 treatment option: Combination of low dose inhaled corticosteroids with an antileukotriene drug. A low-dose extended-release theophylline may be used instead of an antileukotriene (these options have not been fully investigated in children 5 years of age and younger).

Step 4
Emergency drug + two or more drugs to control the course of the disease.
The choice of drugs in Step 4 depends on prior prescriptions in Steps 2 and 3.
Preferred option: combination of inhaled corticosteroids in a medium or high dose with a long-acting inhaled β2-agonist.

If asthma control is not achieved with a combination of a medium-dose inhaled glucocorticosteroid and a β2-agonist and/or a third maintenance drug (eg, antileukotriene or sustained-release theophylline), high-dose inhaled glucocorticosteroids are recommended, but only as trial therapy. duration 3-6 months.
With prolonged use of high doses of inhaled corticosteroids, the risk of side effects increases.

When using medium or high doses of inhaled corticosteroids, drugs should be prescribed 2 times a day (for most drugs). Budesonide is more effective when the frequency of administration is increased up to 4 times a day.

The effect of treatment increases by adding a long-acting β2-agonist to medium and low doses of inhaled corticosteroids, as well as the addition of antileukotriene drugs (less compared to a long-acting β2-agonist).
The addition of low doses of sustained release theophylline to inhaled corticosteroids in medium and low doses and a long-acting β2-agonist may increase the effectiveness of therapy.

Step 5
Emergency drug + additional options for the use of drugs to control the course of the disease.
The addition of oral corticosteroids to other maintenance drugs may increase the effect of treatment, but is accompanied by severe adverse events. Therefore, this option is only considered in patients with severe uncontrolled asthma on treatment at the appropriate stage 4, if the patient has daily symptoms that limit activity, and frequent exacerbations.

The use of anti-IgE in addition to other maintenance drugs improves the control of allergic asthma if it is not achieved during treatment with combinations of other maintenance drugs that include high doses of inhaled or oral corticosteroids.

Well antibiotic therapy indicated in the presence of purulent sputum, high leukocytosis, accelerated ESR. Taking into account antibiograms appoint:
- spiramycin 3,000,000 IU x 2 times, 5-7 days;
- amoxicillin + clavulanic acid 625 mg x 2 times, 7 days;
- clarithromycin 250 mg x 2 times, 5-7 days;
- ceftriaxone 1.0 x 1 time, 5 days;
- Metronidazole 100 ml IV drip.

Forecast

The prognosis is favorable with regular dispensary observation (at least 2 times a year) and rationally selected treatment.
The lethal outcome may be associated with severe infectious complications, progressive pulmonary heart failure in patients with cor pulmonale, untimely and irrational therapy.

The following points should be kept in mind:
- in the presence of bronchial asthma (BA) of any severity, the progression of dysfunctions of the bronchopulmonary system occurs faster than in healthy people;

With a mild course of the disease and adequate therapy, the prognosis is quite favorable;
- in the absence of timely therapy, the disease can go into a more severe form;

In severe and moderate BA, the prognosis depends on the adequacy of treatment and the presence of complications;
- comorbidities can worsen the prognosis of the disease.

X The nature of the disease and long-term prognosis depend on the age of the patient at the time of the onset of the disease.

In asthma that began in childhood, about long-term prognosis is favorable. As a rule, by puberty, children "outgrow" asthma, but they still have impaired lung function, bronchial hyperreactivity, and deviations in the immune status.
With asthma that began in adolescence, an unfavorable course of the disease is possible.
In asthma that began in adulthood and old age, the nature of the development and prognosis of the disease is more predictable.
The severity of the course depends on the form of the disease:
- allergic asthma is easier and prognostically more favorable;
- "pollen" asthma, as a rule, has a milder course compared to "dust";
- in elderly patients, a primary severe course is noted, especially in patients with aspirin BA.

AD is a chronic, slowly progressive disease. With adequate therapy, the symptoms of asthma can be eliminated, but treatment does not affect the cause of their occurrence. Remission periods can last for several years.

Hospitalization

Indications for hospitalization:
- severe attack of bronchial asthma;

There is no rapid response to bronchodilator drugs and the effect lasts less than 3 hours;
- no improvement within 2-6 hours after the start of oral corticosteroid therapy;
- there is a further deterioration - an increase in respiratory and pulmonary heart failure, "silent lung".

Patients at high risk of death:
- having a history of conditions close to lethal;
- requiring intubation, artificial ventilation, which leads to an increase in the risk of intubation during subsequent exacerbations;
- who have already been hospitalized or sought emergency care in the past year due to bronchial asthma;
- taking or recently discontinued oralglucocorticosteroids;
- using inhaled fast-acting β2-agonists in excess, especially more than one pack of salbutamol (or equivalent) per month;
- with mental illness, a history of psychological problems, including the abuse of sedatives;
Poor adherence to the asthma treatment plan.

Prevention

Preventive measures for bronchial asthma (BA) depend on the patient's condition. If necessary, it is possible to increase or decrease the activity of treatment.

Asthma control should begin with a thorough study of the causes of the disease, since the simplest measures can often have a significant impact on the course of the disease (it is possible to save the patient from the clinical manifestations of the atopic variant of asthma by identifying the causative factor and eliminating contact with it later).

Patients should be educated on proper drug administration and proper use of drug delivery devices and peak flow meters to monitor peak expiratory flow (PEF).

The patient must be able to:
- control PSV;
- to understand the difference between drugs of basic and symptomatic therapy;
- avoid asthma triggers;
- identify signs of deterioration of the disease and stop attacks on your own, as well as seek medical help in a timely manner to stop severe attacks.
The control of asthma over a long period requires a written treatment plan (algorithm of patient actions).

List of preventive measures:

Termination of contact with cause-dependent allergens;
- termination of contact with non-specific irritating environmental factors (tobacco smoke, exhaust gases, etc.);
- exclusion of occupational hazard;
- with aspirin form of BA - refusal to use aspirin and other NSAIDs, as well as compliance with a specific diet and other restrictions;
- refusal to take beta-blockers, regardless of the form of asthma;
- adequate use of any medicines;
- timely treatment of foci of infection, neuroendocrine disorders and other concomitant diseases;
- timely and adequate therapy of asthma and other allergic diseases;
- timely vaccination against influenza, prevention of respiratory viral infections;
- Carrying out therapeutic and diagnostic measures using allergens only in specialized hospitals and offices under the supervision of an allergist;
- carrying out premedication before invasive examination methods and surgical interventions - parenteral administration of drugs: GCS (dexamethasone, prednisolone), methylxanthines (aminophylline) 20-30 minutes before the procedure. The dose should be determined taking into account age, body weight, severity of asthma and the extent of intervention. Before carrying out such an intervention, a consultation with an allergist is indicated.

Information

Sources and literature

1. Global strategy for the treatment and prevention of bronchial asthma (revised 2011) / ed. Belevsky A.S., M.: Russian Respiratory Society, 2012
2. Russian therapeutic reference book / edited by acad.RAMN Chuchalin A.G., 2007
   1. pp 337-341
3. http://www.medkursor.ru/biblioteka/help/u/6147.html
4. http://lekmed.ru
5. http://pulmonolog.com

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Bronchial asthma of mixed genesis is becoming one of the most common diseases in the world that affect adults and children. Today, almost 300 million people have a confirmed diagnosis, and every decade the figure increases by 50%. The reason for the intensive spread of the disease is still unknown, but is directly related to the industrial development of civilization.

Irritation of the mucous membranes of the lungs provokes inflammation, swelling and muscle contraction. The walls of the airways are overproduced with mucus, blocking breathing and causing coughing. Outwardly, the attack is manifested by whistles, shortness of breath, heaviness in the chest, but not all symptoms occur simultaneously. Bronchospasm is provoked by infectious processes, stress, animal hair and plant allergens.

Chronic disease suggests the presence of bronchospasm or narrowing of the airways, inflammation, hypersensitivity to triggers (allergens and other provocations), and mucus hyperproduction.

In childhood, the lungs and bronchi are easily irritated by inhalation of pollen, cold air, fungi, or infection. Chronic inflammatory reactions disrupt the immune system, causing the first signs of asthma:

• frequent, intermittent cough;
• whistling or wheezing sound on exhalation;
• dyspnea;
• feeling of tightness in the chest;
• chest pain, especially in young children.

In adults, asthma remains after being diagnosed in childhood, but many outgrow the disease or can be cured with the help of detoxification and probiotics. Most often, attacks are caused by food and inhalation allergens, less often by drugs and bacteria. Psychogenic factors increase the impact of other triggers.

Throughout life, under the influence of various external and internal factors, immune responses are transformed in adults, which exacerbates the sensitivity of the respiratory tract. Functions change under the influence of internal causes:

• violation of the innervation of the mucous membranes of the respiratory system;
• shallow breathing;
• poor lymphatic drainage;
• past illnesses;
• chronic viral and fungal infections.

External stimuli, such as household chemicals, food additives, excess fatty foods, metabolic disorders, affect immune function and contribute to the progression of inflammation.

Food allergens are among the well-studied and controlled factors that can be effectively controlled by an elimination diet. However, inaccuracy and false-positive skin tests make it impossible to identify the exact cause of allergic asthma. Inhalation allergy is associated with contact with pollen. Desensitization is carried out against those substances that cannot be removed from the environment.

Abuse of "Dimedrol", barbiturates can lead to death against the background of bronchial asthma. In case of infection, it is necessary to take into account the danger of using "Sulfadiazine", "Penicillin", "Aureomycin" and "Chloramphenicol".

People with chronic bronchial asthma suffer from hyperventilation, which has been proven by research. With normal breathing, a person passes through the lungs up to 6 liters of air per minute, and with asthma - from 12 to 14 liters. With the development of the disease, the ventilation-perfusion mismatch increases and arterial hypercapnia occurs, which reduces the level of oxygen in the tissues.

Chronic hyperventilation reduces the amount of carbon dioxide in the alveoli and airways, which causes spasms. Therefore, it is hypocapnia against the background of hyperventilation that causes a bronchial reaction. Carbon dioxide is a powerful smooth muscle relaxant, or vasodilator. Its decrease leads to cellular hypoxia, which distorts the response of the immune system. Prerequisites for allergies and inflammation with excessive mucus release are created.

Respiratory failure is associated with the failure to use the full volume of the lungs, which affects the balance between diffusion and perfusion, as well as the exchange of oxygen and carbon dioxide. As a result, oxygenation of the body is suppressed and well-being worsens.

The first signs and main symptoms of pathology

Asthma develops predominantly before the age of 20, while lung x-rays do not show pathological disorders. The respiratory system in the periods between exacerbations works normally. Signs can vary in intensity from year to year. There are three main methods for establishing a diagnosis:

• taking antiallergic drugs eliminates symptoms;
• spirometry shows a reduced vital capacity of the lungs;
• inhalation sprays relieve choking.

The presence of any of the following symptoms may indicate asthma:

1. Rattling or whistling-like vocalizations created by airflow turbulence. As a rule, sounds are observed in the exhalation phase.
2. Cough is unproductive, usually accompanied by wheezing and wheezing.
3. The cough worsens at night (in the morning) or against the background of physical activity. It may be the only symptom in the cough variant of asthma.
4. Confused breathing is not associated with physical activity.
5. Typical posture during an attack. The patient grabs the edge of the bed with effort, lowers his legs to the floor. Fixation with hands helps the chest to exhale.

With an exacerbation, the symptoms may differ depending on the severity of the course of the disease. In young children, asthma is recognized by the following signs:

• shortness of breath during sleep;
• refusal to feed;
• desire to sleep sitting;
• conversation in short sentences;
• excited state.

With bronchospasm, the child wakes up in the morning lethargic and tearful. In adolescents, such symptoms occur late, with the development of respiratory failure.

Classification

Bronchial asthma refers to chronic respiratory diseases and is classified by cause, severity and form.

When assessing the degree of the disease, the number of nocturnal and daytime attacks, the level of decreased physical activity, and sleep disturbances are taken into account. There are the following types of asthma:

1. Intermittent - mild, with daytime attacks less than once a week and night attacks - no more than twice a month. Attacks pass quickly, do not affect physical activity.
2. Mild persistent - exacerbations are observed more often than once a week, and nightly - twice a month. As a result, the quality of sleep suffers and physical activity is disturbed.
3. Medium persistent - daily exacerbations are typical at least once a week. The quality of sleep deteriorates significantly, the patient experiences weakness. Bronchial asthma of moderate severity is determined by the level of airway obstruction.
4. Severe asthma is complicated by attacks every day and every night, which significantly limits physical activity. Such a pathology is the reason for the registration of disability.

Initially, asthma was divided into endogenous and exogenous. But this classification was clarified, and now they distinguish:

• allergic;
• induced by physical activity and chemicals (external).

Exogenous asthma is provoked by allergens, when the immune system turns on a protective mechanism when faced with harmless substances (pollen, dust, gases), which leads to the development of rhinitis and asthma. In an asthmatic reaction, the lungs produce mucus that blocks the passage of air. Steroid inhalers suppress the immune response to allergens, limiting exposure to which reduces the severity of asthma.

Exogenous asthma in children develops in 90% of cases, while a family history of the disease increases the likelihood of pathology by almost 50%. The use of bronchodilators and antihistamines reduces the severity of symptoms. In severe cases, glucocorticosteroids and immunotherapy are prescribed.

Endogenous asthma is associated with extreme manifestations of emotions - laughter, crying - and is also due to contact with chemical agents (cigarette smoke, aspirin, disinfectants), physical exertion. The production of hormones, irritation of nerve receptors on the mucous membranes cause the production of norepinephrine, capillary constriction and spasm. Nocturnal asthma worsens from 2 to 4 in the morning, which is also associated with the activity of the parasympathetic nervous system.

Diagnosis and treatment

Before prescribing therapy, it is important to determine the type of disease. Most patients have mixed asthma, which is caused by allergens but responds to physical and chemical factors.

During the inspection, pay attention to the following parameters:

• breath frequency more than 30 times per minute;
• use of accessory muscles of inspiration;
• presence of suprapage retraction;
• heart rate above 120 beats per minute;
• wheezing;
• paradoxical pulse (against the background of reduced systolic pressure);
• blood saturation with oxyhemoglobin is less than 91%.

Asthmatic status is characterized by abnormal thoracoabdominal phenomena (on inspiration, the chest sinks), the absence of movement of the ribs, hypoxia and bradycardia, the disappearance of the paradoxical pulse with fatigue of the respiratory muscle.

To confirm the diagnosis, a number of manipulations are performed:

1. Pulmonary function tests - spirometry and plethysmography - as well as examination on a treadmill with a load accelerating the heart rate to 60% of the predicted maximum. Control of the electrocardiogram and saturation of oxyhemoglobin is required.
2. The fraction of exhaled nitric oxide is determined, which is a non-invasive marker of airway inflammation.
3. X-ray shows hyperinflation and an enlarged pattern of the bronchial tree. The method is used for differential diagnosis to rule out parenchymal disease, atelectasis, pneumonia, congenital anomalies or the presence of a foreign body.
4. Allergic tests indicate factors contributing to the development of seizures.
5. Histological evaluation of the airways reveals infiltration with inflammatory cells, airway narrowing, and mucus plugs.

The nature and long-term prognosis of the disease are determined by age parameters: childhood asthma is more favorable, and in old age a severe form of development is recorded. It is difficult to control a dangerous pseudo-allergic pathology - aspirin asthma. Reactions to industrial dust are more complex than those to plant pollen. The allergic form is easier to control when an allergen is identified.

Preparations

Pharmacological management of asthma involves the use of drugs that control attacks:

• inhaled corticosteroids;
• inhaled cromones;
• long-acting bronchodilators;
• "Theophylline";
• leukotriene modifiers;
• antibodies against immunoglobulin E ("Omalizumab").

To relieve symptoms, use:

• short-acting bronchodilators;
• systemic corticosteroids
• blocker of m-cholinergic receptors ("Ipratropium bromide").

Folk methods

For home treatment, as a bronchodilator to relieve an attack, herbal remedies are chosen - swollen lobelia, licorice root, ephedra. Modern drugs have a similar effect on cells. When choosing folk remedies for bronchial asthma, you need to consult a doctor to prevent cross-allergic reactions and other side effects.

You can turn to an osteopath who will help increase the mobility of the chest and thoracic spine for excursion of the diaphragm and lungs. The removal of spasm of the scalene muscles releases the phrenic nerve, improves the function of the autonomic nervous system, which relaxes the airways and smooth muscles. The opening of the lymphatic vessels helps to reduce swelling, relieve muscle tension. Relaxation of the muscles of the shoulder girdle reduces the load on the sympathetic nervous system, improves the innervation of the lungs. Osteopaths restore the mobility of the bones, especially the ethmoid, in the upper part of the nose, helping to normalize breathing. Homeopathy is an alternative and safe method to help the body adapt to allergens.

Speleotherapy and halotherapy

Sanatoriums, equipped in special natural conditions, offer climatotherapy services. Many have noticed that salty sea air has a beneficial effect on the frequency of bronchitis. Asthma shows karst caves, being in potash and salt mines, where the air is enriched with ions necessary for metabolic processes.

In sanatoriums and clinics, rooms are often equipped for halotherapy, where the microclimate of salt caves is artificially created. Spraying dry salt air restores the microflora of the respiratory organs, improves hormonal balance and the activity of the sympathetic-adrenal system, which serves as a good prevention of seizures.

Diet

An elimination diet involves more than just eliminating foods that directly cause allergic reactions. Changes in the diet also apply to other foods:

1. Exclude products with chemical additives (tartrazine, salicylates, benzoate, nitrites, monosodium glutamate). You should abandon canned food, convenience foods, sweets and pastries from the store.
2. It is important not to eat foods with the possible presence of mold fungi - cheeses, cottage cheese - and fruits and vegetables must be carefully processed.
3. An excess of animal fats enhances inflammatory reactions, so it is better to stew, boil and bake dishes. When cooking soups, you should use the third broth.
4. It is necessary to restore the normal intestinal microflora with the help of probiotics, sauerkraut.
5. You need to eat a balanced and complete diet, getting a sufficient level of vitamins and trace elements.

Bronchial asthma is a common disease of the lower respiratory tract with a variety of manifestations. Mixed asthma - one of them, is formed as a result of the combined influence of internal and external factors on the human body. The disease affects children older than 5 years, less often it occurs in adults.

What is a mixed type of asthma, why it occurs, how to recognize it and what to do when the disease appears, we will consider further.

A mixed form of bronchial asthma is a manifestation of a chronic inflammatory process in the respiratory system, which occurs in moderate and severe forms. It occurs due to the increased sensitivity of the bronchi, which leads to a narrowing of the bronchial lumen under the influence of various stimuli. This condition is caused by contraction of the smooth muscles of the bronchi, swelling of the mucous membrane and the accumulation of excess mucus on its walls.

This pathology is formed under the influence of factors of exogenous (allergic) and endogenous (non-allergic) types. If the disease combines both forms, then it has a mixed nature of origin.

With mixed asthma, there is a direct relationship not only with external stimuli (entering the body through the respiratory tract), but also with hidden infectious diseases (respiratory organs, teeth, stomach, intestines and other internal organs).

The disease is characterized by a relapsing course with multiple exacerbations and intractable attacks.

Classification of bronchial asthma

Mixed bronchial asthma is classified according to the following criteria: according to the severity of the course, the form of the disease, the controllability of the process.

• The severity of the disease.

Flow features:

1. Mild degree - characterized by minor exacerbations, which are easily eliminated with the help of bronchodilators.
2. The average severity leads to a decrease in the physical activity of a person, sleep disturbances. With it, the occurrence of more severe and prolonged exacerbations (several per week), sometimes accompanied by asthma attacks, is noted. To reduce the negative effects of asthma, daily intake of bronchodilator drugs is necessary.
3. The severe degree is the most dangerous. It is accompanied by partial or complete limitation of physical activity, difficulty in speech, panic, general weakness, frequent seizures. Attacks during this period can turn into asthmatic status, which poses a serious threat to the life of the patient.

Depending on the severity of the course, the disease can be episodic (developing gradually with rare attacks) or be permanent and proceed in a mild, moderate or severe form.

• Disease control.

According to the controllability of the process, asthma happens:

1. controlled - with the absence of negative manifestations and restrictions for any type of activity;
2. partially controlled - clinical signs appear with a moderate number of exacerbations;
3. uncontrolled - there are multiple symptoms, a significant number of exacerbations, the occurrence of asthmatic attacks.

To establish control over the disease, the patient needs to learn how to independently use a peak flow meter (to determine the maximum expiratory flow rate). This will help to determine the onset of an exacerbation, take the prescribed medications in a timely manner and reduce the risk of asthma attacks.

Causes of the disease

The genesis of mixed type bronchial asthma is based on various mechanisms that provoke the disease.

This pathology is the result of the simultaneous influence of allergic and non-allergic causes.

Exposure to exogenous factors leads to an allergic reaction to certain substances perceived by the body as foreign.

Asthma provocateurs are allergens that enter the respiratory tract from the external environment:

• wool and fluff of pets;
• dry food;
• household cleaning, laundry and dishwashing products;
• dust mites;
• pollen of flowering plants;
• fungal spores;
• insect bites;
• strong odors;
• smoking and inhaling tobacco smoke;
• allergenic foods.

Endogenous (internal) causes are the results of an unstable physiological state of a person:

• complication of viral infections;
• endocrine disorders;
• chronic diseases of internal organs;
• physical and emotional overload;
• hypothermia of the body;
• climatic conditions;
• side effects from taking medications.

Since bronchial asthma of a mixed form develops under the influence of allergens and infection, it belongs to a complicated form of the disease and needs a special approach.

Mixed Asthma Symptoms

Asthma of the mixed form is characterized by periods of exacerbation, remission of inflammatory processes and remission.

The disease is accompanied by certain clinical signs:

• labored breathing;
• the occurrence of suffocation;
• the appearance of an itchy rash;
• violation of sputum excretion;
• feeling of squeezing the chest;
• wheezing wheezing on exhalation;
• coughing (especially at night);
• deterioration in general well-being;
• the appearance of subfebrile temperature;
• allergic manifestations.

The main manifestation of bronchial asthma of mixed genesis are prolonged attacks of suffocation. During an asthma attack, there is a narrowing of the bronchi, coughing and impaired respiratory function.

This condition can last for minutes or hours and can be managed with an inhaler. If the medicine does not work and the attack does not stop, it is necessary to hospitalize the patient.

Diagnostics

Diagnostic measures are the main method for detecting mixed type bronchial asthma.

They include:

A feature of the course of mixed asthma is a combination of allergic and non-allergic manifestations, which implies the use of complex treatment. It includes taking systemic and symptomatic drugs.

Systemic treatment is carried out for a long time (sometimes throughout life). It provides long-term relief by preventing flare-ups and helping to control the condition.

Basic therapy

Basic therapy includes the following medications:

• corticosteroid drugs in tablets or injections - used to thin sputum and discharge it with moderate severity of the disease, as well as with prolonged bronchospasm and status asthmaticus;
• long-term beta-2-agonists - contribute to the expansion of the lumen of the bronchi. In moderate or severe disease, a combination of an inhaled hormone with a beta-agonist is used;
• anticholinergics - contribute to the expansion of the bronchi, reduce the production of mucus, eliminate cough and shortness of breath;
• glucocorticosteroid drugs (inhalation hormones) - relieve inflammation, which reduces bronchial hyperactivity and eliminates bronchospasm, reduces swelling of the mucous membrane. They are prescribed when the disease is severe and difficult to treat. They are used in short courses, as they have serious side effects.

Each person has individual harbingers of an asthma attack, so it is important to learn how to recognize the onset of this moment.

Its main symptoms are:

• chills;
• headache;
• anxiety;
• a sore throat;
• sneezing
• paroxysmal cough;
• weakness.

The use of symptomatic quick response agents - aerosols and inhalers - at the right time will help improve the patient's condition and prevent the development of an attack.

Auxiliary treatment

Physiotherapy is used as an auxiliary treatment:

• massotherapy;
• electrophoresis;
• ultrasound;
• magnetotherapy;
• amplipulse;
• cryotherapy.

Carrying out the procedures improves the functionality of the respiratory tract, reduces inflammation, normalizes blood circulation, and also reduces the body's susceptibility to the effects of allergens.

It should be remembered that all medications must be used strictly according to the doctor's prescription.

It is not recommended to interrupt the treatment on your own with an improvement in general well-being and the disappearance of symptoms of the disease. This can lead to the progression of the disease and the return of all manifestations in a more severe form.

Forecast

It is not possible to predict the result of treatment, since mixed type asthma can provoke serious disturbances in the functioning of the respiratory system and cause complications.

However, timely treatment and the implementation of all doctor's prescriptions can stop the development of the disease and lead to prolonged remission.

Prevention of mixed asthma

Preventive measures are an integral part of the fight against a mixed form of bronchial asthma. They help prevent the progression of asthma or alleviate its symptoms.

• the use of protective equipment when using household and construction chemicals;
• frequent exposure to fresh air;
• hardening and increasing the protective properties of the body;
• refusal of heavy physical exertion;
• exclusion from the diet of foods that are allergens;
• carrying out daily wet cleaning of the premises;
• limiting or completely refusing contact with pets;
• mastering breathing exercises;
• quitting smoking and excessive alcohol consumption;
• application of methods of self-monitoring of the state of the disease.

Bronchial asthma cannot be completely cured. But proper treatment and regular implementation of certain rules will help to establish control over the disease. This will allow a person to return to a full life.

Bronchial asthma stands out sharply among other diseases with a variety of types, causes and mechanisms of development. Moreover, all these signs vary within such a wide range that for each specific case the diagnosis is simply impossible to describe with a standard phrase. That is why the classification of bronchial asthma is so difficult. In addition, the treatment of this pathology requires an individual approach to each patient. And such a detailed formulation is very helpful in this.

Scheme of a healthy bronchus and asthma

According to the ICD document, bronchial asthma was classified based on its etiology and severity. But such information was not enough to understand the overall picture. Therefore, the modern approach to the formulation of the diagnosis includes the following parameters:

• severity at the time of detection of the disease;
• indicator of the effectiveness of the therapy;
• the possibility of stabilizing the course of the disease for a long time;
• the relationship between the etiology of bronchial asthma and the characteristics of its clinical manifestations;
• complications and their causes.

By clinical form

According to etiology, regardless of the age of the patient, there are such clinical forms of bronchial asthma:

exogenous

Attacks of exogenous, or allergic, bronchial asthma occur after various external pathogens enter the respiratory tract. Most often, the reaction begins in its upper sections, the so-called pre-asthma condition develops - the larynx, tracheal mucosa and nasal sinuses become inflamed, and allergic rhinitis is pronounced. Over time, this leads to full-fledged bronchial asthma. There are a huge number of irritants, the most common of which are:

Some people have a genetic predisposition to reactions to certain stimuli, which can also cause an asthma attack. This is the so-called atopic asthma.

Risk Factors for Asthma

Sometimes an asthmatic attack occurs on the background of a food allergy. The body is especially sensitive to foods such as citrus fruits, chicken eggs, chocolate, peanut butter, soybeans, and others. Such a reaction of the body is very dangerous, because in some cases it causes anaphylactic shock.

Endogenous

Endogenous, or non-allergic, bronchial asthma most often develops as a complication of viral or bacterial respiratory infections. This form of the disease occurs mainly in children. In addition, endogenous asthma can be provoked by excessive physical or psychological stress, as well as the banal inhalation of cold air.

mixed genesis

Mixed genesis bronchial asthma is a disease caused by both allergens and other external factors. This form is typical for residents of areas with poor environmental performance or an unfavorable climate. Also, the situation is aggravated by various chemical irritants, bad habits, constant psychological stress and other reasons.

There is a dual disease - how and why does it develop? Everything is covered in our article.

The right one is the key to recovery, complex treatment always has a positive effect on recovery.

It is extremely important for nurses, they know it very well, and therefore asthma treatment is carried out under the supervision of qualified personnel.

special shapes

There are other types of asthma. Some physicians distinguish them into independent categories, while others classify them as diseases of mixed genesis:

Classification of bronchial asthma

• Professional. It develops with prolonged contact with certain substances at work, if the employee has an allergy to them or a hereditary predisposition to it. Most often observed in doctors, hairdressers, bakers, as well as in people who are constantly in contact with animals.
• Physical stress. It is mainly manifested by individual asthmatic attacks, although a full-fledged disease also occurs. People suffering from atopic asthma are especially predisposed to this type.
• Reflux-induced. Associated with aspiration of stomach contents into the respiratory tract. One of its most common causes is gastroesophageal reflux, which is especially common among children (50-60% of asthma patients).
• Aspirin. The mechanisms of its development have not yet been studied, but it is reliably known that this form is hereditary. It develops after prolonged use of non-steroidal anti-inflammatory drugs. Unlike the previous one, it is less common in childhood (usually manifests itself by the age of 30-50).

By severity

Knowing the etiology of asthma is not enough to understand which treatment will be most effective. It is also necessary to find out the severity of its course, determined by the following parameters:

• the number of seizures at different times of the day for a certain period (day, week, month);
• the degree of their influence on the patient's condition during periods of sleep and wakefulness;
• the best indicators of external respiration functions and their changes throughout the day, measured by spirometry methods - forced inspiratory volume (FEV), and peak flowmetry - peak expiratory flow rate (PEF).

Classification of bronchial asthma according to severity

Based on the data obtained, 4 degrees of severity of the disease can be distinguished, and the percentage indicators of respiratory functions allow us to calculate them in a standard way for all ages:

• Intermittent. It is characterized by episodic attacks (less than once a week during the day and twice a month at night) and short exacerbations. FEV, PSV>80% of the original value. Spread PSV<20%.
• Mild persistent. Symptoms are regular (up to several times a week during the day and 2-3 times a month at night), periods of exacerbations are more pronounced. FEV, PSV> 80% of the norm. The spread of PSV is 20 - 30%.
• Persistent moderate. Attacks are observed almost every day. Exacerbations markedly affect physical activity and cause insomnia. FEV, PSV 60 - 80% of the due. Spread PSV>30%.
• Persistent severe. In the daytime, symptoms appear daily, at night - very often. The disease greatly affects the quality of life and activity of the patient. FEV, PSV approximately 60% of the original value. Spread PSV>20%.

It is worth noting here that mild asthma should be taken very seriously. No wonder people with such a diagnosis are not taken into the army (even if the symptoms were absent for more than 5 years with the remaining changes in bronchial reactivity). After all, an attack can be caused by both excessive physical exertion and nervous experiences, as well as other factors inherent in army life.

Other types

One of the most important parameters taken into account when adjusting therapeutic methods is the body's response to the treatment. Based on this, there are the following types of bronchial asthma:

• Controlled. FEV or PSV are normal, exacerbations are not observed. Changes for the better are recorded even in patients with moderate and severe degrees.
• Partially controlled. Respiratory functions are reduced to 80%. Attacks occur more than twice a week, with at least one exacerbation per year.
• Uncontrollable. Here, the effectiveness of therapy is practically absent, which gives rise to a detailed study of the causes of such a reaction of the body.

In bronchial asthma, like many other chronic diseases, there are two phases: exacerbation and remission (in the absence of attacks for more than 2 years, it is called a rack). The possible presence of complications is also taken into account - respectively, complicated or uncomplicated forms.

Based on the above classifications, a clearly structured diagnosis is made. For example: bronchial asthma, mixed form, moderate severity, exacerbation of chronic bronchitis. Such a formulation greatly facilitates the understanding of the etiology and course of the disease.