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Bronchial asthma (BA) is a chronic lung disease of an allergic nature. For bronchial asthma, treatment recommendations are necessary in the same way as a consultation with an allergist. Choking attacks occur due to stress, inflammation or allergic agents.

The cause of the development of this disease has not yet been clarified, but it is possible to control the occurrence of attacks. By following your doctor's recommendations, you will maintain an active lifestyle; even such a serious disease as asthma can be treated.

The goal of effective treatment of patients with asthma is:

• complete elimination of attacks and prevention of manifestations of the disease;
• improving quality of life;
• reducing the need for the use of β 2 agonists;
• maintaining normal pulmonary function;
• prevention of exacerbations;
• reducing the risk of side effects of the therapy.

Drug therapy

The basis for maintaining a long period without attacks is taking medications.

N.B. You cannot select medications yourself; only a doctor can prescribe them!

Drugs are divided into two types:

• immediate action;
• prolonged action.

The first of them are used to quickly relieve symptoms. These include sprays and aerosols, which reach the bronchi as quickly as possible and have a bronchodilator effect. Nebulizers can be used for children. They have a finer spray than inhalers, and delivery of the drug to the lungs is much faster.

Long-acting medications are taken daily for moderate to severe asthma. Depending on the severity, therapy is divided into stages. Severity is assessed by the number of attacks during the month, as well as the presence of night attacks. If exacerbations occur at least 2 times within a month or 1 time at night, it is recommended to start treatment with low-dose hormonal drugs - glucocorticoids.

If therapy does not significantly reduce attacks, the dosage of drugs is increased. Daily use does not cause addiction.

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Elimination of provoking factors

It is very important to identify the allergen when treating bronchial asthma. The cause of the attack is an allergic reaction of the body to a foreign agent. An attack can be triggered by medications, viral and bacterial diseases, household and food allergens.

You should change the pillows in your home, carry out wet cleaning often, and avoid using chemical detergents. If funds allow, purchase a humidifier for your home - it will reduce the amount of dust, purify the air and make breathing easier. You need to protect yourself not only from factors you know, but also from potentially dangerous ones.

Eliminate the appearance of pets in the house, remove interior items that are dust collectors. Do not smoke in the house under any circumstances. When plants bloom in spring and summer, start taking antiallergic medications in advance.

Physical activity can only be started with the permission of a doctor if he considers that the course of the disease is well controlled.

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Breathing exercises and diet therapy

Special exercises will help alleviate the condition and avoid exacerbations. It is better to conduct classes outdoors or in well-ventilated areas.

The recommendation for patients with bronchial asthma is that you should not exercise if:

• there has been an exacerbation recently;
• you don’t feel well or are sick.

Proper breathing will not only help for preventive purposes, but will also help you calm down during attacks. You need to alternate shallow breaths and forceful exhalations.

Gymnastics will help strengthen the respiratory muscles and diaphragm, and expand the lumen of the lungs. Strengthens the cardiovascular system and improves the patient's condition as a whole.

If there is no reaction to food, the diet should be complete and balanced. To regulate metabolic processes in the body, fractional meals are recommended. Strong broths should be avoided and salt intake should be reduced.

Avoid products containing dyes and preservatives - they can cause allergic reactions. Carefully study the composition of products before purchasing; many artificial additives can provoke an exacerbation of the disease.

Remove strong-smelling spices from your diet; onions and garlic should be heat-treated before use.

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Supervision by the attending physician

Even in the absence of exacerbations, you need to visit an allergist at least 3 times a year. The doctor will be responsible for the appropriateness of the prescribed treatment and monitoring the effectiveness of therapy. If your doctor advises you to increase the number of visits, follow his recommendation.

Visit your treating allergist if attacks become more frequent or if the attacks cannot be controlled with available medications. Keep a diary, note in it all the exacerbations, and against what background they arose. This will help the doctor navigate the nature of the disease.

It is extremely important to teach the person suffering from bronchial asthma how to behave during attacks. This type of work with children is especially important: you should contact a psychologist who will tell you how to behave correctly during an attack and not be afraid of suffocation. It is also important to get into the habit of carrying an inhaler with you, even if you haven’t had an attack for a long time.

Inform your loved ones about your illness and what medications you need to give in an emergency. Report drug intolerances to health care providers in advance.

Behavior during an attack:

1. Stop contact with the offending agent.
2. Take the prescribed immediate bronchodilator medication. Strictly follow the dosage recommended by your doctor.
3. Stay calm, lie down for at least one hour. Make sure your breathing is normal.
4. If you cannot stop the attack on your own, immediately call an ambulance.

Panic attacks often occur during suffocation; try to control your emotions and make all assistance techniques automatic. Close people should also know where the medications you need are located and the doctor’s phone number if unforeseen situations arise.

You should immediately visit a doctor if:

• the number of attacks has increased;
• nocturnal exacerbations appeared;
• your health has worsened;
• lips and nail plates turn blue, heart rate increases;
• The prescribed drug does not cause the desired effect for suffocation.

For those who have experienced asthma attacks, it is useful to know about GINA. This is the short name given to a group of specialists who have been working on the diagnosis and treatment of this disease since 1993.

Its full name is Global Initiative for Asthma.

GINA explains what to do to the doctor, the patient and his family with bronchial asthma, and already in the new millennium introduced December 11, which reminds the whole world of this problem.

Medical science is constantly evolving. Research is being conducted that is forming a new perspective on the causes of diseases.

Periodically, GINA publishes the document “Global Treatment Strategy”, for which group members select the latest and most reliable materials on how bronchial asthma is diagnosed and treated.

They strive to make scientific achievements accessible to medical specialists and ordinary people of all countries.

Definition of asthma according to GINA

According to GINA, bronchial asthma is a multi-type disease in which chronic inflammation develops in the airways.

Infection is not always the cause of inflammation. And this is exactly the case when a wide range of allergens and irritating factors can become the culprit.

With this disease, the bronchi become overly sensitive. In response to irritation, they spasm, swell and become clogged with mucus. The lumen of the bronchi becomes very narrow, breathing problems arise, including suffocation, which can be fatal.

Classification of bronchial asthma according to GINA

This disease manifests itself differently in different people. Symptoms depend on age, lifestyle and individual characteristics of the body.

For example, allergies play a separate role in the development of the disease. For some reason, the immune defense system reacts to things that do not threaten the body.

But the allergic component is not detected in all patients. In women, bronchial asthma does not proceed quite the same as in men.

The many faces of bronchial asthma prompted GIN specialists to classify its variants.

Classification of bronchial asthma according to GINA:

1. Allergic bronchial asthma manifests itself already in childhood. Usually boys start getting sick earlier than girls. Since allergies are associated with genetic characteristics, the varieties may differ between the child and his blood relatives. For example, atopic dermatitis, eczema, allergic rhinitis, food allergies, medications.
2. There is no connection with allergies.
3. In mature women (this happens less often in men), bronchial asthma occurs with a late onset. With this option, there is usually no allergy.
4. After several years of illness, bronchial asthma with a fixed obstruction of bronchial patency may develop. With prolonged inflammation, irreversible changes develop in them.
5. Bronchial asthma due to obesity.

The recommendations pay special attention to children. It also specifically addresses pregnant women, the elderly and obese patients, and those who smoke or have quit smoking. A special group consists of athletes and people who have... Onset of the disease in adulthood may indicate exposure to hazardous substances at work. Here the serious question of changing jobs or professions arises.

Causes of bronchial asthma development and provoking factors

The mechanism of development of bronchial asthma is too complex to be triggered by only one factor. And while researchers still have many questions.

According to the GINA concept, genetic predisposition and environmental influences play a major role in the occurrence of bronchial asthma.

Allergies, obesity, pregnancy and diseases of the respiratory system can trigger or aggravate the disease.

Factors that provoke the appearance of symptoms of bronchial asthma have been identified:

• physical exercise;
• allergens of different nature. These could be dust mites, cockroaches, animals, plants, molds, etc.;
• irritation of the respiratory tract from tobacco smoke, polluted or cold air, strong odors, industrial dust;
• weather and climatic factors;
• acute respiratory disease (cold, flu);
• strong emotional arousal.

Diagnosis verification

When diagnosing, the doctor questions and examines the patient, and then prescribes an examination.

GINA has identified the characteristic symptoms of bronchial asthma. These include whistling and wheezing, a feeling of heaviness in the chest, shortness of breath, suffocation, and coughing.

As a rule, not one, but several symptoms (two or more) occur at once. They become stronger at night or immediately after sleep, provoked by the above factors.

They can go away on their own or under the influence of medications, and sometimes do not appear for weeks. A history of these symptoms and spirometry data help distinguish bronchial asthma from similar diseases.

With bronchial asthma, exhalation becomes difficult and slows down. It is its strength and speed that spirometry evaluates.

After inhaling as deeply as possible, the doctor asks the patient to exhale sharply and forcefully, thus assessing forced vital capacity (fVC) and forced expiratory volume (FEV1).

If the disease is not advanced, the bronchi often narrow and then widen. This is influenced by a huge number of factors, for example, the period of the disease or the time of year.

Therefore, the FEV1 value may differ with each new examination. This should not be surprising; this is very typical for asthma.

Moreover, to assess the variability of this indicator, a test is carried out with a bronchodilator - a drug that dilates the bronchi.

There is also a measure of peak expiratory flow (PEF), although it is less reliable. You can only compare the results of studies carried out using the same device, since the readings from different devices can vary greatly.

The advantage of this method is that with the help of a peak flow meter a person can assess the degree of narrowing of his bronchi.

Therefore, the signs most characteristic of bronchial asthma are considered to be a decrease in the FEV1/fVC ratio (less than 0.75 in adults and less than 0.90 in children) and variability in FEV1.

Other tests that may be performed with spirometry include an exercise test and a bronchoprovocation test.

With young children the situation is more complicated. Viral infections also cause wheezing and coughing.

If these symptoms do not occur randomly but are associated with laughter, crying or physical activity, if they also occur while the child is sleeping, this suggests asthma.

It is also more difficult for a child to perform spirometry, so GINA provides for additional studies for children.

Treatment of asthma according to GINA

Unfortunately, it is impossible to completely cope with this disease. GINA recommendations for the treatment of bronchial asthma are aimed at prolonging life and improving its quality.

To do this, the patient needs to strive to control the course of bronchial asthma. The doctor not only prescribes medications, but also helps to adjust your lifestyle. He develops an action plan for the patient in different situations.

As a result of successful treatment, a person returns to his favorite job or sport, and women can give birth to a healthy child. Olympic champions, political leaders, and media figures lead active, rich lives with this diagnosis.

GINA offers three types of drugs for the drug treatment of bronchial asthma:

• inhaled non-hormonal drugs relieve an asthma attack and prevent suffocation caused by physical exertion or other reasons. They quickly expand the bronchi and allow you to restore breathing;
• inhaled glucocorticosteroids are hormones that suppress inflammation. With this method of use, they are safer and do not cause serious complications;
• additional medications for severe disease.

Drug therapy consists of several stages. The more severe the disease, the higher the level, the more drugs are prescribed and the higher their doses.

In mild cases, medications are used only to eliminate an attack of suffocation; at subsequent stages, drugs from other groups are added to them.

Most medications come in aerosol form. The doctor explains and shows how to properly use the medication administration devices. It happens that they give a weak effect precisely because of errors in application.

Without which treatment will not be effective

But the fight against the disease is not limited to medications alone. A person needs to organize his life in such a way as to reduce the manifestations of the disease. The following measures will help with this:

• quitting smoking, avoiding the company of smokers;
• regular physical activity;
• eliminating allergens and air pollution at work and at home;
• caution when taking medications that may aggravate bronchial asthma. Some people may be intolerant to pain relievers such as aspirin (non-steroidal anti-inflammatory drugs, or NSAIDs). The decision to take beta blockers is made by the doctor, taking into account the situation and individual characteristics of the patient;
• breathing exercises;
• healthy eating, plenty of vegetables and fruits in the diet;
• correction of body weight;
• influenza vaccination for severe and moderate asthma;
• bronchial thermoplasty. With a long course of the disease, the muscles of the bronchi hypertrophy. Bronchial thermoplasty removes part of the muscle layer, the lumen of the bronchi increases. This procedure allows you to reduce the frequency and dosage of inhaled glucocorticoids. It is held in several countries: USA, Germany, Israel;
• emotional state management training;
• allergen-specific immunotherapy. With allergen-specific immunotherapy, the patient is given microdoses of the allergen, gradually increasing the dosage. This treatment should reduce sensitivity to this allergen in everyday life. Treatment is not suitable for everyone and should be carried out with caution.

It is important to assess symptom control. When a patient comes for a routine check-up, the doctor asks him to answer questions about his health over the past 4 weeks:

1. Did symptoms of bronchial asthma occur during the day more than twice a week?
2. Do manifestations of the disease bother you at night?
3. Are medications used to relieve an attack more than twice a week (this does not include taking emergency medications before exercise).
4. Does asthma limit usual activities?

The questions may be worded slightly differently, but the main thing is to assess how the disease affects the person's daily life.

GINA recommendations for the prevention of bronchial asthma

It is believed that there is a period of time during a woman’s pregnancy and the first months of a child’s life when environmental factors can trigger the development of the disease.

To reduce risks, GINA suggests the following actions to prevent bronchial asthma:

• the expectant mother urgently needs to stop smoking during pregnancy, or better before it, and abstain from cigarettes after childbirth;
• if possible, do not resort to caesarean section;
• It is preferable to feed the baby with mother's milk;
• Do not use broad-spectrum antibiotics in the first year of a child’s life unless absolutely necessary.

As for the effects of allergens, not everything is clear here. Dust mite allergens definitely cause allergies. Research into pet allergens has produced conflicting results.

It is important to maintain a good psychological environment in the family. This always helps to cope with any illness.

To summarize, we can say that development prevention comes down to the following points:

• Quit smoking as quickly as possible and do not allow others to smoke. Tobacco smoke not only maintains chronic inflammation in the respiratory tract, but, most dangerously, provokes asthma attacks. It can cause another disease - chronic obstructive pulmonary disease (COPD). The combination of both pathologies worsens the condition and also complicates the diagnosis and selection of treatment;
• eliminate contact with allergens as much as possible;
• avoid smoke, exhaust gases, cold air, strong odors;
• get a flu vaccine if there are no contraindications, try not to catch a cold;
• choose the right medications. Taking painkillers (NSAIDs) and beta blockers is possible only with the consent of a doctor
• regular exercise in permitted sports, taking into account the doctor’s recommendations (prophylactic medication may be necessary to prevent an attack of suffocation);

Finally

Bronchial asthma prevents you from fully experiencing the taste of life. It is dangerous because the complete absence of symptoms is suddenly replaced by an attack of suffocation, sometimes fatal.

In different countries, it is detected in 1–18% of the population, often starting in childhood.

This article provides only general information about the view of this international organization on bronchial asthma. Only a doctor can correctly recognize and prescribe treatment for each patient.

Bronchial asthma is a chronic respiratory tract pathology. The basis of the disease is inflammation, as a result of which hyperreactivity of the respiratory organs develops.

Manifestations of bronchial asthma include a feeling of tightness in the chest at night and in the morning.

There are special documents from scientific societies that contain general and concise recommendations for identifying and treating diseases. Such indicative materials are compiled to help practitioners treating various diseases, including bronchial asthma.

An organization that solves the problem of bronchial asthma at the international level - this is GINA. The disease is incurable and occurs throughout the world in people of all ages.

The organization has developed general rules of treatment that are followed by doctors all over the world. In 2016, an international structure presented a new report suggesting a way to get rid of the disease. based on current best practices for using clinical guidelines. The GINA plan is designed to be implemented in virtually any healthcare system

Latest GINA updates

In 2016, the following were included in the GINA document:

• hacking cough;
• feeling of tightness in the chest;
• wheezing;
• sweating;
• feeling of anxiety, panic;
• dyspnea.

Also in 2016, the organization was created. The disease is divided into several phenotypes that differ according to the degree of manifestation and the age of the patient. The following types are distinguished:

1. Allergic. This phenotype is the most common. Compared to other types, it is the easiest to both identify and treat. ICS – inhaled corticosteroid drugs – are used for treatment.
2. Non-allergic. ICS drugs are not able to cure this type of asthma.
3. Asthma with delayed onset. It occurs mainly in women of mature age.
4. Bronchial asthma in obese patients.
5. A phenotype characterized by respiratory tract obstruction syndrome. Occurs as a result of frequent and long-term treatment of bronchial asthma.

Treatment

The main treatment for asthma is. There are five degrees of severity of the disease, for each of which special treatment is indicated. In this case, the severity of the disease is determined by the degree of therapy used.

Attention! The effectiveness of therapy should be assessed every six months. If asthma symptoms do not go away and the risks of exacerbation increase, then it is recommended to intensify therapy, moving to the next step.

If the threat decreases and the patient’s well-being improves within 3 months, then the volume of therapy should be reduced. In this case, the number of ICS is reduced from 25% to 50% every 3 months. However, for such a step it is necessary to ensure the complete absence of respiratory dysfunction in the patient and be sure that there is no danger to health. It is not recommended to completely exclude ICS to avoid the threat of exacerbations.

Following a stepwise approach, GINA has developed treatments for each step:

1. At the first stage, beta-2 antagonists are used. These drugs have a short effect and are indicated for patients with mild disease. These people experience asthma symptoms less than twice a month and improve with appropriate treatment, but research into the safety of such treatment is still underway.
2. At the second stage there are patients who have high risk of exacerbations. They are recommended to take reduced doses of ICS (inhaled glucocorticosteroids) and SABA (short-acting beta2 agonists), if necessary, supplementing them with drugs that relieve asthmatic symptoms.
3. Third-stage therapy involves taking low-dose ICS combined with LABAs (long-acting beta2-agonists) and CDBAs. However, during exacerbation, this strategy is not effective.
4. At the fourth stage it is recommended to combine medium and high doses of ICS, LABA and SABA, focusing on the needs of the patient.
5. At the fifth stage, the use of the anti-IgE drug Omalizumab is required. This treatment is indicated for patients who have not responded to therapy with maximum doses of inhaled drugs.

Thus, the main treatment method is the use of ICS, in some cases in combination with a LABA. This therapy helps relieve inflammation quite quickly.

Important! At the moment there are no drugs to completely get rid of bronchial asthma. However, there are medications that relieve symptoms and destroy the allergen.

There is also a scheme for the course of treatment in several stages. This scheme includes the following recommendations:

• it is necessary to teach the patient basic self-help skills to apply them during the onset of symptoms of the disease;
• required treatment of concomitant diseases and getting rid of bad habits;
• Attention should also be paid to non-drug therapy, for example, physical activity.

Bronchial asthma is the most common. However, it is difficult to diagnose – asthma has symptoms similar to a cold.

Helps differentiate asthma from colds temperature measurement– in asthma, its increase is not observed. Symptoms are preceded by:

• discharge of watery mucus from the nose upon waking in the morning, accompanied by sneezing;
• severe dry cough several hours after waking up;
• the appearance of a wet and stronger cough during the day;
• the manifestation of asthma symptoms after a day or several days, by this time the cough becomes paroxysmal.

The symptoms themselves include:

• paroxysmal cough after sleep;
• dyspnea;
• intermittent breathing;
• pressure in the chest area;
• difficulty breathing;
• dry cough when inhaling through the mouth;

Aimed at preventing the development of allergies. For prevention, it is advisable to give preference to breastfeeding and isolate the child from exposure to tobacco smoke.

The Russian medical community has its own strategies for the treatment of bronchial asthma. The document in which basic approaches to the diagnosis and treatment of pathology, are “Federal clinical guidelines for the diagnosis and treatment of bronchial asthma.” Basically, these recommendations coincide with the points of the GINA strategy.

Thus, the domestic document also notes a stepwise approach to treating the disease. Determination of the volume of therapy depends on the severity of clinical manifestations of asthma. Attention is paid to checking the correct inhalation technique, clarifying the diagnosis and eliminating concomitant diseases. All these conditions are necessary to advance to the next stage of treatment. Environmental factors that have a significant impact on the effectiveness of therapy should also be controlled.

About diagnostics

Diagnosis of pathology in adults is based on identifying the corresponding symptoms. Symptoms and degree of airway obstruction requires accurate assessment. Thus, a complete and accurate clinical picture of the disease is obtained.

Examples that increase the risk of asthma include:

• suffocation, chest congestion and morning cough, wheezing;
• symptoms during physical activity, under the influence of allergens, low temperature;
• the appearance of signs of illness after taking aspirin;
• atopic diseases present in the anamnesis;
• hereditary factor.

There are also signs that reduce the risk of having the disease:

• dizziness and darkening of the eyes;
• regular normal chest examination results;
• productive cough of a chronic nature;
• voice change;
• symptoms due to a cold;
• heart diseases.

Bronchial asthma is a long-term chronic disease, in the manifestation of which hereditary factors and exposure to allergens play a significant role. The main goal of therapy is disease control. Correct drug treatment can only be prescribed by a specialist after a thorough diagnosis. However, in addition to drug treatment, it is important to pay attention to proper nutrition, moderate physical activity and environmental conditions.

Each patient diagnosed with bronchial asthma is registered at the clinic, where his medical card is located, which allows him to monitor the treatment of asthmatic attacks and keep statistics on changes in the patient’s condition. The medical history of bronchial asthma is described in a special diary. It begins with the person’s passport data and contains information about the initial manifestations of the diagnosis, complaints, frequency of attacks and diagnosis.

All medical records are stored in the hospital archive for another 25 years after discharge. Therefore, each new specialist can see a report on the work done by the doctors who treated the patient previously - a therapist, an allergist, a pulmonologist. To carry out therapeutic procedures, the type of asthma is initially determined - allergic, non-allergic or mixed, and its severity.

Forms of bronchial asthma

• Allergic bronchial asthma. Medical history Asthma in this form often develops from childhood, and is caused by the course of diseases such as atopic dermatitis or allergic rhinitis. Moreover, heredity plays a significant role in this case - if close relatives have asthma, then the risk of developing the disease in the child increases. The allergic form of asthma is the easiest to recognize. Before starting treatment, it is necessary to examine induced sputum to detect inflammation of the respiratory tract. Patients with this disease phenotype have a good response to inhaled corticosteroids.

• Non-allergic bronchial asthma. This phenotype can occur as a result of exposure to medications, as is the case with aspirin-induced asthma. Also, the development of the disease can occur against the background of hormonal changes in the body of women, for example, during pregnancy.

To begin adequate treatment for the mixed form of the disease, it is necessary to study the patient’s complaints, find out about the time and conditions of the first attack. It is necessary to find out what medications were used to suppress the attack, and how effective the prescribed treatment was.

The medical history of bronchial asthma, mixed form, may contain the following information:

• Complaints: Sudden attacks of suffocation, repeated several times a day. At night, there is increased shortness of breath. Symptoms completely disappear after taking beta-agonists. After an attack of suffocation, a short-term cough begins with the discharge of sputum.
• Initial onset of symptoms: The first attack happened unexpectedly, during a trip in a crowded trolleybus. The patient could not fully inhale air, and shortness of breath began. After he went outside, the symptoms disappeared within 15 minutes. Subsequently, the symptoms began to recur 1-2 times a month under various conditions. The patient was in no hurry to consult a doctor, because he believed that the cause of such symptoms was bronchitis, and was treated independently.
• Factors provoking the onset of the disease: bad habits, place of work and degree of harmfulness of production conditions, food addictions, previous diseases, allergic reactions, heredity.
• General examination of the patient: the patient’s physique, condition of nails, hair, skin, mucous membranes. The condition of the lymph nodes and tonsils is taken into account. The musculoskeletal system is studied: joint mobility, problems with the spine. The respiratory and cardiovascular systems are studied most thoroughly.

An integrated approach will allow us to identify what exactly provokes breathing problems and, on this basis, make the correct diagnosis. The mixed form of asthma is characterized by frequent attacks of suffocation, difficulty breathing with hoarseness. More often, the development of such a disease is facilitated by a hereditary factor.

Determining the severity of bronchial asthma

To successfully diagnose a disease, a clinical picture is drawn up with the study of characteristic features, symptoms and signs that are not characteristic of other diseases. The medical history of bronchial asthma therapy begins with the initial diagnosis, in which the doctor assesses the degree of airway obstruction. If the likelihood of asthma is high, it is necessary to immediately begin a trial treatment, and then, if there is no effect of therapy, additional studies should be prescribed.

In low to moderate cases of asthma, the characteristic symptoms may be caused by another diagnosis.

There are 4 stages of disease development:

1. Intermittent asthma– the safest stage of the disease. Short attacks occur rarely, no more than once a week. At night, exacerbations occur even less frequently.
2. Mild persistent asthma– attacks occur more often than once a week, but only once during the day. At night there are 2-3 attacks per month. Along with shortness of breath, sleep disturbances and decreased physical activity occur.
3. Moderate persistent asthma– the disease makes itself felt every day with acute attacks. Nighttime manifestations also become more frequent and occur more often than once a week.
4. Severe persistent asthma. The attacks are repeated daily, at night reaching several cases a week. Problems with sleep – the patient suffers from insomnia and physical activity. too difficult.

The patient, regardless of the severity of the disease, may experience mild, moderate and severe exacerbations. Even a patient with intermittent asthma can experience life-threatening attacks after a long time without any symptoms.

The severity of the patient's condition is not static and can change over many years.

Treatment and clinical recommendations

After the patient has been assigned asthmatic status, clinical recommendations for treatment are prescribed by the attending physician. Depending on the form and stage of the disease, the following methods can be used:

• Drug therapy aimed at maintaining the functioning of the bronchi, preventing inflammation, treating symptoms, and relieving asthma attacks.
• Isolation of the patient from conditions that cause deterioration of the condition (allergens, harmful working conditions, etc.).
• A diet that excludes fatty, salty, and junk foods.
• Measures to improve the health and strengthening of the body.

When treating asthma with medication, you cannot use only symptomatic drugs, since the body gets used to it and stops responding to the active ingredients. Thus, against the background of the development of pathological processes in the bronchi, treatment stops, which negatively affects the dynamics, delaying complete recovery.

There are 3 main groups of drugs that are used in the treatment and relief of asthma attacks:

• emergency aid - they provide quick assistance in case of suffocation;
• basic medications;
• control drugs.

All treatment is aimed at reducing the frequency of attacks and minimizing possible complications.

Mixed asthma (J45.8)

Pulmonology, Pediatric Pulmonology

general information

Short description

Russian Respiratory Society

DEFINITION

Bronchial asthma (BA)- a chronic inflammatory disease of the respiratory tract, in which many cells and cellular elements are involved. Chronic inflammation causes bronchial hyperresponsiveness, which leads to repeated episodes of wheezing, shortness of breath, chest tightness and cough, especially at night or in the early morning. These episodes are associated with widespread, variable airway obstruction in the lungs, which is often reversible spontaneously or with treatment.

At the same time, it should be emphasized that the diagnosis of asthma is primarily established on the basis of the clinical picture. An important feature is the lack of standardized characteristics of symptoms or laboratory or instrumental studies that would help accurately establish the diagnosis of bronchial asthma. In this regard, it is impossible to develop evidence-based recommendations for the diagnosis of AD.

Classification

Determining the severity of bronchial asthma

Classification of bronchial asthma by severity based on the clinical picture before the start of therapy (Table 6)

2 When determining the degree of severity, the presence of one of the signs of severity is sufficient: the patient must be assigned to the most severe degree at which any sign occurs. The characteristics noted in this table are general and may overlap, since the course of asthma is extremely variable, moreover, over time, the severity of a particular patient may change.

3 Patients with any severity of asthma may experience mild, moderate, or severe exacerbations. A number of patients with intermittent asthma experience severe and life-threatening exacerbations against the background of long asymptomatic periods with normal pulmonary function.

Diagnostics

PRINCIPLES OF DIAGNOSIS IN ADULTS AND CHILDREN

Diagnostics:
The diagnosis of BA is purely clinical and is established on the basis of the patient’s complaints and anamnestic data, clinical and functional examination assessing the reversibility of bronchial obstruction, specific allergological examination (skin tests with allergens and/or specific IgE in the blood serum) and exclusion of other diseases (GPP).
The most important diagnostic factor is a thorough collection of anamnesis, which will indicate the causes of occurrence, duration and resolution of symptoms, the presence of allergic reactions in the patient and his blood relatives, cause-and-effect features of the occurrence of signs of the disease and its exacerbations.

Factors influencing the development and manifestations of asthma (Table 3)

DIAGNOSIS OF BA IN CHILDREN

The diagnosis of bronchial asthma in children is clinical. It is based on observation of the patient and assessment of symptoms while excluding other causes of bronchial obstruction

Diagnosis at different age periods

Pulmonary function test:
. Peak flowmetry (determination of peak expiratory flow, PEF) - a method for diagnosing and monitoring the course of asthma in patients over 5 years old. Morning and evening PEF indicators and daily PEF variability are measured. Diurnal PEF variability is defined as the amplitude of PEF between the maximum and minimum values ​​during the day, expressed as a percentage of the average daily PEF and averaged over 2 weeks.

. Spirometry. Assessment of external respiratory function under conditions of forced expiration can be carried out in children over 5-6 years of age. A 6-minute jogging protocol is used to detect post-exercise bronchospasm (high sensitivity but low specificity). Bronchoconstrictor tests have diagnostic value in some doubtful cases in adolescence.

. During the period of remission of bronchial asthma (i.e. in children with a controlled course of the disease), pulmonary function indicators may be slightly reduced or correspond to normal parameters.

Allergy examination

. Chest X-ray (to rule out alternative diagnoses)
. Trial treatment (response to asthma therapy)
. There are no characteristic changes in blood tests for asthma. Eosinophilia is often detected, but it cannot be considered a pathognomonic symptom
. Eosinophils and Kurshman spirals may be detected in the sputum of children with bronchial asthma
. The following methods are used in differential diagnosis: bronchoscopy, computed tomography. The patient is referred for consultations with specialists (otorhinolaryngologist, gastroenterologist, dermatologist)

Algorithm for diagnosing bronchial asthma in children
When bronchial asthma is suspected in children, emphasis is placed on the presence of key information in the history and symptoms on examination, with careful exclusion of alternative diagnoses.

DIAGNOSIS OF BA IN ADULTS

Primary examination:
Diagnosis of asthma is based on the detection of characteristic features, symptoms and signs in the absence of an alternative explanation for their occurrence. The main thing is to obtain an accurate clinical picture (history).
When making an initial diagnosis, base your diagnosis on a thorough assessment of symptoms and the degree of airway obstruction.
· In patients with a high risk of asthma, begin a trial of treatment immediately. Consider additional studies if the effect is insufficient.
· In patients with a low likelihood of asthma whose symptoms are suspected to be the result of another diagnosis, evaluate and treat accordingly. Reconsider the diagnosis in those patients for whom treatment is unsuccessful.
· The preferred approach for patients with an intermediate likelihood of asthma is to continue evaluation while initiating a trial of treatment for a period of time until the diagnosis is confirmed and maintenance treatment is determined.

Clinical signs that increase the likelihood of having asthma:
· Having more than one of the following symptoms: wheezing, shortness of breath, chest tightness and cough, especially if:
- worsening symptoms at night and early in the morning;
- the occurrence of symptoms during physical activity, exposure to allergens and cold air;
- the occurrence of symptoms after taking aspirin or beta blockers.
· History of atopic diseases;
· Presence of asthma and/or atopic diseases in relatives;
· Widespread dry wheezing when listening (auscultation) of the chest;
· Low peak expiratory flow or forced expiratory volume in 1 second (retrospectively or in a series of studies), unexplained by other reasons;
Peripheral blood eosinophilia unexplained by other causes.

Clinical signs that reduce the likelihood of having asthma:
· Severe dizziness, darkening of the eyes, paresthesia;
· Chronic productive cough in the absence of wheezing or suffocation;
· Consistently normal chest examination in the presence of symptoms;
· Voice change;
· The occurrence of symptoms exclusively against the background of colds;
· Having a significant smoking history (more than 20 packs/years);
· Heart diseases;
· Normal peak expiratory flow or spirometry in the presence of symptoms (clinical manifestations).

SPIROMETRY AND REVERSIBILITY TESTS

Patients with bronchial obstruction
Tests for peak expiratory flow variability, lung volumes, gas diffusion, bronchial hyperresponsiveness, and airway inflammation have limited ability to differentiate patients with bronchial obstruction due to asthma and other pulmonary diseases. Patients may have other medical conditions that cause obstruction, making test interpretation difficult. Asthma and COPD can especially often be combined.

Patients with bronchial obstruction and an average likelihood of asthma should undergo a reversibility test and/or a trial of therapy over a specified period:
· If the reversibility test is positive or if a positive effect is achieved during a therapeutic test, the patient should be treated in the future as a patient with asthma
· In case of negative reversibility and no positive response during a trial course of therapy, further examination should be continued to clarify the diagnosis

Algorithm for examining a patient with suspected asthma (Fig. 1).

Therapeutic trials and reversibility tests:

Patients with no bronchial obstruction:
In patients with spirometry within the normal range, additional testing should be performed to identify bronchial hyperresponsiveness and/or airway inflammation. These tests are sensitive enough that normal results obtained from them can confirm the absence of asthma.
· Patients without signs of bronchial obstruction and with an average probability of asthma should undergo additional studies before prescribing therapy

Study of bronchial hyperreactivity:
· Bronchial hyperreactivity (BHR) tests are not widely used in clinical practice. Typically, detection of BHR is based on measuring the FEV1 response to inhalation of increasing concentrations of methacholine. The response is calculated as the concentration (or dose) of the challenge agent causing a 20% fall in FEV1 (PC20 or PD20) using linear interpolation of the logarithm of the concentration of the dose-response curve.
· The distribution of BHR indicators in the population is normal, 90-95% of the healthy population have PC20 indicators > 8 mg/ml (equivalent to PD20 > 4 micromol). This level has a sensitivity rate of 60-100% for detecting clinically diagnosed asthma.
· In patients with normal pulmonary function, BHR testing has an advantage over other tests in identifying patients with asthma (Table 4). On the contrary, BHR tests play a minor role in patients with established bronchial obstruction, because the specificity of the test is low.
· Other bronchoconstrictor tests used are with indirect provocative agents (mannitol, exercise stress test). A positive response to these stimuli (i.e., a fall in FEV1 of more than 15%) is a specific indicator of asthma. However, these tests are less specific than methacholine and histamine tests, especially in patients receiving anti-asthma therapy.

Methods for assessing airway inflammation (Table 4)

PC20 = challenge concentration of methacholine causing a 20% drop in FEV1; FENO = exhaled nitric oxide concentration
*those. provocation by physical activity, inhalation of mannitol;# in untreated patients ; **with double measurements during the day; ***for more than four measurements

PEF monitoring:
· The best indicator is recorded after 3 attempts to perform a forced maneuver with a pause not exceeding 2 seconds after inhalation. The maneuver is performed while sitting or standing. More measurements are performed if the difference between the two maximum PEF values ​​exceeds 40 l/min.
· PEF is used to assess airflow variability across multiple measurements taken over at least 2 weeks. Increased variability can be recorded with double measurements during the day. More frequent measurements improve the score. An increase in measurement accuracy in this case is achieved especially in patients with reduced compliance.
· PEF variability is best calculated as the difference between the maximum and minimum values ​​as a percentage of the average or maximum daily PEF value.
· The upper limit of normal values ​​for variability in % of the maximum value is about 20% when using 4 or more measurements during the day. However, it may be lower when using double measurements. Epidemiological studies have shown a sensitivity of 19% and 33% for identifying clinically diagnosed asthma.
· PEF variability may be increased in diseases with which the differential diagnosis of asthma is most often carried out. Therefore, in clinical practice there is a lower level of specificity for increased PEF variability than in population studies.
· Frequent recording of PEF in the workplace and outside of work is important if a patient is suspected of having occupational asthma. Currently, there are computer programs for analyzing PEF measurements in and outside the workplace, for automatic calculation of the effects of occupational exposure.
· PEF values ​​should be interpreted with caution based on the clinical situation. The PEF study is more useful for monitoring patients with an established diagnosis of asthma than for the initial diagnosis.

Occupational asthma is a disease characterized by the presence of reversible obstruction and/or hyperreactivity of the airways, which are caused by inflammation caused solely by factors in the work environment and in no way related to irritants outside the workplace.


Classification of occupational asthma:
1) immunoglobulin (Ig)E-mediated;
2) irritant asthma, including reactive airway dysfunction syndrome, which developed as a result of contact with extremely high concentrations of toxic substances (vapors, gases, smoke);
3) asthma caused by unknown pathogenetic mechanisms.

According to the ERS Guidelines (2012), occupational-related or work-related asthma has the following phenotypes:


Fig.1. Clinical variants of bronchial asthma caused by working conditions
· There are several hundred substances that can cause the development of occupational asthma.
· When inhaled in high doses, some immunologically active sensitizers behave as irritants.
A dose-response relationship has been proven for anhydrides, acrylates, cimetidine, rosin, enzymes, green coffee and castor bean dust, baking allergens, pollen, seafood, isocyanates, laboratory animal allergens, piperazine, platinum salts, cedar wood dust. between the incidence of occupational asthma and the concentration of these substances in the workplace.

Rice

Prognosis and risk factors (endo- and exogenous) for an unfavorable outcome:

The role of medical examinations:

Step-by-step algorithm for diagnosing occupational asthma:

Figure 2. Algorithm for diagnosing occupational asthma.

· When collecting an anamnesis from an employee with asthma, it is necessary to find out whether he has contact with adverse factors in the workplace.
A connection between the symptoms of allergic asthma and work can be assumed in cases where at least one of the following criteria is present:
· increased symptoms of the disease or their manifestation only at work;
· relief of symptoms on weekends or during the holiday period;
Regular manifestation of asthmatic reactions after a work shift;
Increase in symptoms towards the end of the work week;
· improvement of well-being, up to the complete disappearance of symptoms, when changing the nature of the work performed (cessation of contact with causative agents).
· For the irritant form of occupational asthma, it is necessary to indicate in the anamnesis the first developed asthma-like symptoms within 24 hours after inhalation of irritant gases, vapors, smoke, aerosols in high concentrations with persistence of symptoms from several days to 3 months.
· Methods for diagnosing occupational asthma are similar to those for non-occupational asthma.

Patient management tactics and prevention of occupational asthma:

- The definition, classification, basic concepts and answers to key questions regarding recommendations for the diagnosis of occupational asthma given in this section are formulated by the working group based on existing recommendations from the British Occupational Medicine Research Foundation (British Occupational Health Research Foundation) , a review by the American College of Chest Physicians (American College of Chest Physicians), manualsAAgency for Healthcare Research and Quality (Agency for Healthcare Research and Quality). When describing the etiological factors, a meta-analysis of 556 publications on occupational asthma was used, conducted byX. Baur (2013).

Prevention

Prevention and rehabilitation of patients with asthma

Prospects for secondary prevention of asthma (Table 12)

Alternative and alternative medicine (Table 13)

Education and training of patients with asthma (Table 14)

Information

Sources and literature

1. Clinical recommendations of the Russian Respiratory Society

Information

METHODOLOGY