In elderly patients, both the diagnosis of bronchial asthma and the assessment of the severity of its course are difficult due to the large number of concomitant diseases, for example, chronic obstructive bronchitis, emphysema, ischemic heart disease with signs of left ventricular failure. In addition, with age, the number of β₂-adrenergic receptors in the bronchi decreases, so the use of β-adrenergic agonists in the elderly is less effective.
· Occupational bronchial asthma accounts for an average of 2% of all cases of this disease. More than 200 substances used in production (from highly active low-molecular compounds, such as isocyanates, to known immunogens, such as platinum salts, plant complexes and animal products) are known to contribute to the occurrence of bronchial asthma. Occupational asthma can be either allergic or non-allergic. An important criterion for diagnosis is the absence of symptoms of the disease before the onset of this disease. professional activity, a confirmed connection between their appearance at the workplace and their disappearance after leaving it. The diagnosis is confirmed by the results of measuring PEF at work and outside the workplace, and specific provocative tests. It is necessary to diagnose occupational asthma as early as possible and stop contact with the damaging agent.
· Seasonal bronchial asthma is usually combined with seasonal allergic rhinitis. During the period between seasons when exacerbation occurs, manifestations of bronchial asthma may be completely absent.
· Cough variant of bronchial asthma: a dry paroxysmal cough is the main, and sometimes the only symptom of the disease. It often occurs at night and is usually not accompanied by wheezing.
Asthmatic status
Status asthmaticus (life-threatening exacerbation) is unusual in severity for this patient on bronchodilator therapy. Status asthmaticus also refers to severe exacerbation of bronchial asthma requiring medical treatment. medical care in a hospital setting.
The development of status asthmaticus can be facilitated by the inaccessibility of constant medical care, the lack of objective monitoring of the condition, including peak flowmetry, the patient’s inability to self-control, inadequate previous treatment (usually the absence of basic therapy), a severe attack of bronchial asthma, aggravated by concomitant diseases.
Clinically status asthmaticus characterized by pronounced expiratory shortness of breath, a feeling of anxiety up to the fear of death. The patient takes a forced position with the torso tilted forward and emphasis on the arms (shoulders raised). The muscles of the shoulder girdle take part in the act of breathing, chest and abdominals. The duration of exhalation is sharply prolonged, dry whistling and buzzing rales are heard, and as the patient progresses, breathing becomes weakened to the point of “silent lungs” (absence of breathing sounds on auscultation), which reflects the extreme degree of bronchial obstruction.
Complications
Pneumothorax, pneumomediastium, pulmonary emphysema, respiratory failure, cor pulmonale.
Differential diagnosis
The diagnosis of bronchial asthma should be excluded if, when monitoring external respiration parameters, no disturbances in bronchial obstruction are detected, there are no daily fluctuations in PEF, bronchial hyperactivity and coughing attacks.
In the presence of broncho-obstructive syndrome, differential diagnosis is carried out between the main nosological forms that are characterized by this syndrome.
· When carrying out differential diagnosis of broncho-obstructive conditions, it is necessary to remember that bronchospasm and cough can be caused by certain chemicals, including drugs: NSAIDs (most often acetylsalicylic acid), sulfites (found, for example, in chips, shrimp, dried fruit, beer, wine, as well as metoclopramide, injectable forms of epinephrine, lidocaine), beta-blockers (including eye drops), tartrazine (yellow food coloring), ACE inhibitors . Cough caused by ACE inhibitors, usually dry, poorly controlled by antitussives, β-adrenergic agonists and inhaled glucocorticosteroids, completely disappears after discontinuation of ACE inhibitors.
· Bronchospasm can also be triggered by gastroesophageal reflux. Rational treatment of the latter is accompanied by the elimination of attacks of expiratory dyspnea.
· Symptoms similar to bronchial asthma occur with dysfunction of the vocal cords (“pseudoasthma”). In these cases, consultation with an otolaryngologist and phoniatrist is necessary.
· If infiltrates are detected during chest radiography in patients with bronchial asthma, a differential diagnosis should be made with typical and atypical infections, allergic bronchopulmonary aspergillosis, pulmonary eosinophilic infiltrates of various etiologies, allergic granulomatosis in combination with angiitis (Churg-Strauss syndrome).
Treatment
Bronchial asthma is an incurable disease. The main goal of therapy is to maintain a normal quality of life, including physical activity.
Treatment tactics
Treatment goals:
· Achieving and maintaining control of disease symptoms.
· Preventing exacerbation of the disease.
· Maintain lung function as close to normal as possible.
· Maintenance normal level activity, including physical activity.
· Exception side effects anti-asthmatic drugs.
· Prevention of the development of irreversible bronchial obstruction.
· Prevent asthma-related mortality.
Asthma control can be achieved in most patients and can be defined as follows:
· Minimal severity (ideally absence) of chronic symptoms, including nighttime ones.
· Minimal (infrequent) exacerbations.
· No need for ambulance or emergency care.
· Minimal need (ideally none) for the use of β-adrenergic agonists (as needed).
· No restrictions on activity, including physical activity.
· Normal (close to normal) PEF indicators.
· Minimal severity (or absence) of undesirable effects of the drug.
Management of patients with bronchial asthma has six main components.
1. Education of patients to form partnerships in the process of their management
2. Assess and monitor the severity of the disease, both by recording symptoms and, if possible, measuring lung function; For patients with moderate and severe disease, daily peak flowmetry is optimal.
3. Elimination of exposure to risk factors.
4. Development individual plans drug therapy for long-term management of the patient (taking into account the severity of the disease and the availability of anti-asthmatic drugs).
5. Development of individual plans for relieving exacerbations.
6. Ensuring regular dynamic monitoring.
Educational programs
The basis of the educational system for patients in pulmonology is the “School” of asthma. According to specially developed programs, patients are explained in an accessible form the essence of the disease, methods of preventing attacks (elimination of triggers, preventive use of drugs). During implementation, it is considered mandatory to teach the patient to independently manage the course of bronchial asthma in various situations, to develop for him a written plan for overcoming a severe attack, to ensure access to a medical professional, to teach how to use a peak flow meter at home and to maintain a daily PEF curve, as well as to correctly use dosing inhalers. Asthma schools are most effective among women, nonsmokers, and patients with high socioeconomic status.
Drug therapy
To administer drugs, metered-dose inhalers and nebulization are used. For correct application metered dose inhalers, the patient needs certain skills, since in otherwise only 10-15% of the aerosol enters the bronchial tree. Correct technique application is as follows.
Remove the cap from the mouthpiece and shake the bologna well.
Exhale completely.
Turn the can upside down.
Place the mouthpiece in front of your mouth wide open.
Start inhaling slowly, at the same time press the inhaler and continue taking a deep breath until the end (the inhalation should not be sharp!).
Hold your breath for at least 10 seconds.
After 1-2 minutes, inhale again (for 1 breath, you need to press the inhaler only 1 time)
When using the system " easy breath» (used in some dosage forms of salbutamol and beclomethasone), the patient should open the mouthpiece cap and take a deep breath. There is no need to press the canister or coordinate your inhalation.
If the patient is unable to follow the above recommendations, a spacer should be used (a special plastic flask into which an aerosol is sprayed before inhalation) or a spacer with a valve - an aerosol chamber from which the patient inhales the drug.
The correct technique for using a spacer is as follows.
Remove the cap from the inhaler and shake it, then insert the inhaler into the special hole in the device.
Place the mouthpiece in your mouth.
Press the canister to receive a dose of the drug.
Take a slow and deep breath.
Hold your breath for 10 seconds and then exhale into the mouthpiece.
Inhale again, but without pressing on the can.
Move the device away from your mouth.
Wait 30 seconds before taking the next inhalation dose.
According to the conducted scientific research, older people with asthma often face serious risks to their health. For what reason does this happen and why can bronchial asthma in old age cause many problems?
It turns out that bronchial asthma is especially dangerous not only for children. If a person develops asthma after age 65, they often face an uphill battle for their own health.
The number of asthma patients in the world is growing every year. Currently, the number of asthmatics has exceeded 300 million. Children most often suffer from asthma. In addition, an increase in incidence is observed among people aged 65 to 75 years. Previously, experts paid virtually no attention to this. However, now the number of people who die from bronchial asthma in old age is increasing.
One reason that is particularly challenging is that asthma is often misdiagnosed in adults. If an elderly person begins to suffer from shortness of breath, doctors often consider this a manifestation of age or a consequence of abnormalities in the functioning of the heart.
In addition, in old age, many people accumulate many other health problems, and this negatively affects the course of asthma. Such problems include, first of all, cardiovascular diseases (angina pectoris, arrhythmia, hypertension, etc.) and diseases of the gastrointestinal tract. Asthma is also aggravated by its own long-term experience, since patients more often require dose adjustments and supervision by pulmonologists, therapists, and cardiologists.
Causes of the disease
Heart failure.
Chronic course of obstructive pulmonary disease.
Acute respiratory diseases.
Pneumonia.
Complications after taking medications.
Systemic vasculitis.
Aging is an inevitable process characterized by the development of functional limitations in the reserves of the body, all its organs and systems, including the respiratory system. As a person ages, the musculoskeletal framework of the chest and airways change, and the cough reflex decreases, which disrupts the self-cleaning of the airways. Such changes contribute to the development of chronic diseases of the bronchopulmonary system.
In the absence of timely and competent treatment of bronchial asthma in old age, as a rule, there is a sharp deterioration in the patient’s condition, and complications often arise.
Diagnosis of the disease
To diagnose an elderly patient with bronchial asthma, the doctor needs to pay attention to the presence of the following symptoms:
wheezing;
Frequent cough;
Feeling of tightness in the chest;
Attacks of suffocation.
The specialist should ask the patient in detail about the symptoms and try to establish possible reasons development of the disease. Often in older people, bronchial asthma occurs after acute respiratory infections.
An important part of the diagnosis are indicators of the increase in forced expiratory volume and expiratory flow. At the same time, the doctor must take into account that elderly patients cannot always perform correctly the first time. this test, sometimes retries are required.
In some cases, to definitively confirm the diagnosis, they resort to cytological analysis of sputum, spontaneously isolated or induced by inhalation of a hypertonic solution.
Treatment of the disease
If a person from time to time has a feeling of difficulty breathing and tightness in the chest, wheezing, then, regardless of age, he should consult with a specialist. If you are elderly, seeing a doctor is especially important.
The main goal of treating bronchial asthma in old age is to control the symptoms of the disease, as well as maintain normal lung function, prevent side effects of medications, and exacerbations.
Treatment methods for asthma are selected based on the severity of the disease. Older people should be vaccinated against influenza annually, as they are at risk due to age and the presence of bronchial asthma.
Treatment of asthma should be rational and as gentle as possible, taking into account the patient’s existing diseases. As a rule, this requires additional medications.
In the early stages of the disease, immunotherapy is effective. However, sometimes there are contraindications, and the older the patient, the higher the likelihood of their occurrence.
Most often, complex therapy is prescribed for bronchial asthma, which includes anti-inflammatory drugs and bronchospasmolytics. In addition, long-term disease control requires the use of long-acting inhaled bb2-adrenergic receptor agonists. And to eliminate or prevent shortness of breath, cough, suffocation, short-acting inhaled b2-agonists are used.
Asthma patients should remember that this disease is not a death sentence. With timely and competent treatment, it can be successfully controlled.
In recent years, the incidence of diseases such as bronchial asthma in older people has increased sharply. This can be attributed to three main factors. Firstly, allergic reactivity has increased. Secondly, due to the development of the chemical industry, environmental pollution and other circumstances, contact with allergens is increasing. Thirdly, chronic respiratory diseases are becoming more frequent, creating preconditions for the development of bronchial asthma. The age structure of the disease has also changed. Currently, elderly and senile people make up 44% of the total number of patients with this disease.
What causes bronchial asthma in older people?
In the elderly and old age The infectious-allergic form of the disease occurs predominantly. Bronchial asthma in older people occurs more often as a result of inflammatory diseases of the respiratory system (chronic pneumonia, chronic bronchitis, etc.). From this infectious focus, the body is sensitized by the breakdown products of its own tissues, bacteria and toxins. Bronchial asthma in older people can begin simultaneously with an inflammatory process in the lungs, more often with bronchitis, bronchiolitis, and pneumonia.
How does bronchial asthma manifest in older people?
In most cases, bronchial asthma in older people has a chronic course and is characterized by constant difficulty wheezing and shortness of breath, which worsens with physical activity (due to the development of obstructive pulmonary emphysema). Periodic exacerbations are manifested by the occurrence of asthma attacks. There is a cough with the release of a small amount of light, thick, mucous sputum. Most often, infectious and inflammatory processes in the respiratory system (acute respiratory viral infections, exacerbations of chronic bronchitis) play a dominant role in the occurrence of attacks of suffocation and exacerbation of the disease.
An attack of bronchial asthma usually begins at night or early in the morning. This is due, first of all, to the accumulation of secretions in the bronchi during sleep, which irritates the mucous membrane, receptors and leads to an attack. An increase in the tone of the vagus nerve plays a certain role. In addition to bronchospasm, which is the main functional impairment with asthma at any age, in elderly and old people its course is complicated by age-related pulmonary emphysema. As a result, pulmonary failure is quickly joined by cardiac failure.
Once it occurs at a young age, it can persist in older people. In this case, the attacks are less acute. Due to the duration of the disease, pronounced changes in the lungs are observed (obstructive emphysema, chronic bronchitis, pneumosclerosis) and of cardio-vascular system(cor pulmonale - pulmonary heart).
During an acute attack, the patient experiences wheezing, shortness of breath, cough and cyanosis. The patient sits leaning forward, leaning on his hands. All muscles involved in the act of breathing are tense. Unlike people young During an attack, rapid breathing is observed due to severe hypoxia. During percussion, a box sound is detected, auscultated large quantities sonorous buzzing, whistling wheezing, and moist rales can also be detected. At the beginning of the attack, the cough is dry, often painful. After the end of the coughing attack, it is released into small quantity viscous mucous sputum. Reaction to bronchodilators (eg, theophylline, isadrine) during an attack in older people age group slow, incomplete.
Heart sounds are muffled, tachycardia is noted. At the height of the attack, acute heart failure may occur due to reflex spasm of the coronary vessels, increased pressure in the pulmonary artery system, reduced myocardial contractility, as well as due to concomitant diseases of the cardiovascular system (hypertension, atherosclerotic cardiosclerosis).
How is bronchial asthma treated in older people?
To relieve bronchospasm both during an attack and in the interictal period, purines (aminophylline, diaphylline, diprofilpine, etc.) deserve attention, which can be administered not only parenterally, but also in the form of aerosols. The advantage of prescribing these drugs over adrenaline is that their administration is not contraindicated for hypertension, cardiac asthma, coronary heart disease, and cerebral atherosclerosis. In addition, aminophylline and other drugs from this group improve coronary and renal circulation. All this determines their widespread use in geriatric practice.
Despite the fact that adrenaline usually provides rapid relief of bronchospasm and, thereby, stopping an attack, it must be prescribed to elderly and elderly people with caution due to their increased sensitivity to hormonal drugs. You can resort to subcutaneous or intramuscular injection of adrenaline only if the attack cannot be stopped by any medications. The dose of the drug should not exceed 0.2-0.3 ml of a 0.1% solution. If there is no effect, the administration of adrenaline can be repeated in the same dose only after 4 hours. The administration of ephedrine provides a less rapid but more lasting effect. It should be noted that ephedrine is contraindicated in prostate adenoma.
Isopropylnorepinephrine preparations (isadrin, orciprenaline sulfate, novodrin, etc.) have bronchodilator properties.
When trypsin, chymotrypsin and other agents are used in aerosols to improve sputum discharge, allergic reactions are possible, mainly associated with the absorption of proteolysis products. Before their administration and during therapy, antihistamines should be prescribed. To improve bronchial patency, bronchodilators are used.
The drugs of choice are anticholinergics. In case of intolerance to adrenergic agonists (isadrine, ephedrine), excessive sputum production and combination with ischemic heart disease, occurring with bradycardia, impaired atrioventricular conduction, anticholinergics (atrovent, troventol, truvent, berodual) are prescribed.
Complex therapy for bronchial asthma includes antihistamines (diphenhydramine, suprastin, diprazine, diazolin, tavegil, etc.).
In some patients, novocaine has a beneficial effect: intravenously 5-10 ml of a 0.25-0.5% solution or intramuscularly 5 ml of a 2% solution. To stop an attack, unilateral novocaine vagosympathetic blockade according to A.V. can be successfully used. Vishnevsky. Bilateral blockade is not recommended, since it often causes side effects in such patients (impaired cerebral circulation, breathing, etc.).
Ganglion blockers are not recommended for elderly people due to the occurrence of a hypotensive reaction.
If bronchial asthma in elderly people is combined with angina pectoris, inhalation of nitrous oxide (70-75%) with oxygen (25-30%) is indicated at an administration rate of 8-12 l/min.
Along with bronchodilators, during an attack it is always necessary to use cardiovascular drugs, since an attack can quickly remove the cardiovascular system of an elderly person from a state of relative compensation.
Hormonal therapy (cortisone, hydrocortisone and their derivatives) gives a good effect, stopping an acute attack and preventing it. However, glucocorticosteroids should be administered to elderly and senile people in doses 2-3 times lower than those used for young people. When treating, it is important to establish the minimum effective dose. Hormonal therapy for longer than 3 weeks is not advisable due to the possibility side effects. The use of glucocorticosteroids does not at all exclude the simultaneous administration of bronchodilators, which, in some cases, can be reduced. dose of hormonal drugs. For secondary infections, antibiotics are indicated along with corticosteroids. When treated with even small doses of corticosteroids in older people, side effects are often observed. In this regard, glucocorticosteroids are used only for the following conditions:
- severe course that cannot be treated with other means;
- asthmatic condition;
- sharp deterioration of the patient's condition against the background of an intercurrent illness.
The administration of glucocorticosteroids in the form of aerosols is very promising, since with a lower dose of the drug a clinical effect is achieved and thereby the frequency of side effects is reduced. Day of acute attack relief hormonal drugs can also be administered intravenously.
Cromolyn sodium (Intal) has found widespread use in bronchial asthma. It inhibits the degranulation of mast cells (mast cells) and delays the release of mediator substances from them (bradykinin, histamine, and the so-called slow-reacting substances) that promote bronchospasm and inflammation. The drug has a preventive effect before the development of an asthmatic attack. Intal is used in inhalations at 0.02 g 4 times a day. After the condition improves, the number of inhalations is reduced by selecting a maintenance dose. The effect occurs after 2-4 weeks. Treatment should be long-term.
In case of bronchial asthma, if the allergen responsible for the disease is identified, it is necessary to exclude it if possible and carry out specific desensitization to this substance. Elderly patients are less sensitive to allergens, so their correct identification is more difficult. In addition, they are polyvalently sensitized.
With the development of heart failure, cardiac glycosides and diuretics are prescribed.
For very restless patients, it is possible to use tranquilizers (trioxazine), benzodiazepine derivatives (chlordiazepoxide, diazepam, oxazepam), carbomine propanediol esters (meprobamate, isoprotane), diphenylmethane derivatives (aminil, metamizil).
Bromhexine, acetylcysteine and physiotherapy are most often used as expectorants and secretolytics.
Prescribing mustard plasters and hot foot baths brings a known effect during an acute attack. Bronchial asthma in older people should also be treated with physical therapy, breathing exercises. Type and volume physical exercise are determined individually.
Bronchial asthma in old age
The modern way of life, unfortunately, is not at all conducive to maintaining health and preventing various types of diseases, rather the opposite. More and more environmental factors cause allergic reactions in us.
And due to the continuous growth of industrial production, air and environmental pollution, we are increasingly forced to deal with allergens. The number of respiratory system diseases is increasing, often resulting in bronchial asthma.
Bronchial asthma (BA) is an inflammation of the airways, a chronic disease. It is accompanied by attacks of acute oxygen deficiency (suffocation) up to asthmatic status - a severe, life-threatening complication that occurs as a result of a prolonged attack.
With this disease, the human respiratory system weakens, the airways narrow, not allowing the necessary air flow. The consequence of bronchial asthma can be both multiple complications and death.
Causes of the disease
As a rule, bronchial asthma develops more often in older people as a consequence of infectious and allergic diseases. According to statistics, about 44% of elderly people suffer from asthma, which occurs as a result of inflammatory diseases of the respiratory system of various types: from chronic bronchitis.
From this source of infection, asthma develops, most often simultaneously with other inflammations in the respiratory organs.
Wear and tear of the respiratory organs and their aging are an inevitable phenomenon and one of the reasons for the development of bronchial asthma. A weakened body changes the musculoskeletal appearance of the chest, reduces muscle contractility and reflex response.
The airways and lungs, deprived of coughing, cannot cleanse themselves and repair themselves.
In addition to inflammatory processes in the respiratory system and aging of the body, one of the important reasons The possible development of bronchial asthma is also considered to be disorders in the human cardiovascular system: (do not forget that cardiovascular diseases are one of the most common).
The disease can also be caused by taking incorrectly prescribed medications.
Classification of asthma
Scientists offer several classifications of bronchial asthma according to various criteria: according to the forms of asthma, as well as according to severity. The forms of bronchial asthma are derived based on the causes that underlie the disease.
The following forms of BA are distinguished:
- Allergic (exogenous);
- Non-allergic (endogenous);
- Mixed.
Allergic form
The allergic form of bronchial asthma develops under the influence of external causes and factors and is characterized, first of all, by the increased sensitivity of the respiratory organs to a variety of allergens - this could be pollen, mold, dandruff, and so on.
When a pathogen enters the human body through the air, the immune system receives a signal from the brain and bronchial spasm occurs. An inflammatory process occurs in the respiratory system. The main signs of this form of the disease are considered to be the formation of viscous sputum, runny nose, sneezing, tearing and itching of the eyelids.
Non-allergic form
The non-allergic form of asthma is more common in older people as a result of infectious diseases.
Symptoms include increased coughing, increased sweating and body temperature, a general state of weakness and malaise, attacks of suffocation become more frequent and more severe. This form of the disease can also develop as a result of smoking or physical activity.
Video: Protracted cough and bronchial asthma
Mixed form
The mixed form of the disease combines the symptoms of the first two types of the disease and requires a combination of selected treatment.
Severity
According to the degree of severity, they are distinguished:
- 1st stage - intermittent asthma;
- 2nd stage - mild persistent asthma;
- Stage 3—persistent asthma of moderate severity;
- Stage 4 - severe persistent asthma.
Determination of the stages of asthma occurs on the basis of calculating the number of symptoms that appear over a certain period of time, indicating the level physical activity an elderly person and his sleep disorders.
Treatment
Treatment and diagnosis of asthma should be carried out under strict supervision good specialist: Selecting the wrong medications can lead to serious consequences. For example, drugs containing aspirin can cause severe suffocation.
For a complete and comprehensive examination, you need to undergo a test to determine the speed of inhalation and exhalation, check the composition of sputum, take a blood test, undergo x-rays, undergo tests for an allergic reaction - a specialist will help you do all this.
Don't neglect the fact that timely diagnosis can save your life.
In addition, you should not limit yourself to the instructions of a specialist - except drug treatment necessary to do . They cleanse the airways, removing accumulated bacteria and mucus, and facilitate the breathing process. You should also not overuse physical activity and smoking is contraindicated if asthma develops.
Video: Bronchial asthma
Conclusion
Combining all of the above, we can formulate some practical advice who will assist you in making the right decision. Be attentive to your health.
Even though you were not allergic to anything when you were young, it can develop and lead to serious consequences. The body ages and it becomes increasingly difficult for it to resist the microbes and viruses around it.
Respiratory diseases require careful and comprehensive treatment. One disease causes the next. Therefore, it is especially important to seek help from a specialist and undergo examinations if your body is bothering you.
This must be done at least once every six months.
If bronchial asthma of any form and severity occurs and develops, treatment should not be limited to the instructions of the attending physician - there is a huge list of folk remedies that have been trusted over the years. However, be careful about the components they contain.
L.A. Goryachkina, O.S. Shotgun
Russian Medical Academy of Postgraduate Education Department of Clinical Allergology, Moscow
Bronchial asthma (BA) is one of the most common human diseases, representing a serious social, epidemiological and medical problem. In the modern concept, bronchial asthma is a chronic inflammatory disease respiratory tract. Chronic inflammation causes a concomitant increase in airway hyperresponsiveness, leading to recurrent wheezing, shortness of breath, chest tightness, and coughing, especially at night or in the early morning. More often, the onset of asthma occurs in childhood and young age; less often, the disease begins in middle and old age. The severity of asthma symptoms depends on the activity of airway inflammation, which, although largely autonomous, can be aggravated by a number of factors (allergens, nonspecific triggers, viral and bacterial infections etc.). The severity of the clinical manifestations of the disease changes over time, which requires corresponding changes in the volume of therapy. The main principle of treatment of bronchial asthma is the constant implementation of anti-inflammatory therapy, which reduces the number of chronic symptoms and prevents exacerbation of the disease based on a stepwise approach. A stepwise approach to the basic therapy of bronchial asthma involves a different volume and intensity of therapeutic intervention, clearly regulated by symptoms, indicators of external respiratory function and response to therapy. Most effective means anti-inflammatory long-term basic therapy are inhaled glucocorticosteroids.
Anti-inflammatory therapy. In asthma, the basis of drug treatment is anti-inflammatory therapy with inhaled glucocorticosteroids (ICS). Modern inhaled glucocorticosteroids are the basic drugs in the treatment of patients with bronchial asthma. ICS prevent the development of symptoms and exacerbations of BA, improve functional parameters of the lungs, reduce bronchial hyperreactivity and inhibit bronchial wall remodeling (in particular, thickening of the epithelial basement membrane and angiogenesis of the mucous membrane). The anti-inflammatory effect of ICS is associated with their effect on biological membranes and a decrease in capillary permeability. They stabilize lysosomal membranes, which leads to limitation of the release of various proteolytic enzymes beyond the lysosomes and prevents destructive processes in the wall of the bronchial tree. In addition, glucocorticosteroids inhibit the proliferation of fibroblasts and reduce collagen synthesis, which slows down the rate of development of the sclerotic process in the bronchial wall. Inhaled glucocorticosteroids suppress the formation of antibodies and immune complexes, reduce the sensitivity of effector tissues to allergic reactions, promote bronchial ciliogenesis and restoration of damaged bronchial epithelium, reduce nonspecific bronchial hyperreactivity. The results of numerous studies have proven the ability of ICS to suppress the ongoing inflammatory process of the respiratory tract and prevent the development of structural changes (fibrosis, smooth muscle hyperplasia, etc.) that occur as a result of chronic inflammation. ICS are indicated for the treatment of persistent asthma of any severity. The basic rule of glucocorticosteroid therapy is the use of drugs in the minimum effective dose and for the shortest period of time necessary to achieve maximum effect. To select the optimal dose and regimen for using inhaled glucocorticosteroids, one should focus on the patient’s respiratory function indicators, ideally daily monitoring of peak flow measurements. To achieve asthma control, long-term continuous use of ICS is required in doses adequate for the individual patient. The dose of the drug should be selected individually, since the optimal dose varies in individual patients and may change over time. The effectiveness of ICS is confirmed by a decrease in symptoms and exacerbations of asthma, improvement in functional pulmonary parameters, a decrease in bronchial hyperreactivity, a decrease in the need for taking short-acting bronchodilators, as well as an improvement in the quality of life of patients with asthma. Thus, the criterion for the clinical adequacy of the dose of ICS is the achievement of complete or good control of asthma. Bronchial asthma is under control if the patient has no nighttime or daytime symptoms, no severe exacerbations, no need or reduced need for fast-acting symptomatic drugs (β2-agonists), normal vital activity is maintained, including physical activity, and normal ( or near-normal) values of respiratory function indicators.
In connection with the management of patients with asthma in accordance with a stepwise approach, questions arise about the place of new anti-asthmatic drugs at these steps, such as leukotriene receptor antagonists, 5-lipoxygenase inhibitors, phosphodiesterase inhibitors, new types of inhaled steroids, combination drugs (including long-acting β2 -agonists and inhaled steroids). According to the concept of stepwise therapy for persistent asthma symptoms, basic anti-inflammatory therapy should begin with the prescription of ICS, and only if there is no effect (if control of asthma symptoms is not achieved), it is necessary to move to the next step and prescribe treatment with a combination of ICS + long-acting β2-agonist (other options: ICS + antileukotriene drug, increasing the daily dose of ICS). The most effective is ICS + long-acting β2-agonist. Adding long-acting β2-agonists to low- and moderate-dose ICS provides better asthma control than doubling the dose of ICS. The effect of ICS is dose-dependent, and asthma control can be achieved more quickly when using higher doses, however, as the dose of ICS increases, the risk of developing undesirable effects increases. Long-acting β2-agonists (salmeterol, formoterol) are recommended in combination therapy with inhaled corticosteroids, when a synergistic effect is achieved and it becomes possible to reduce the dose of steroids with good control of bronchial asthma.
When prescribing basic therapy for asthma, including ICS, I would like to highlight a special group of elderly patients with this diagnosis. In everyday clinical practice, a doctor encounters two groups of elderly patients with asthma: those who are suspected of having this disease for the first time, and those who have been ill for a long time. BA, first identified in old age, is often difficult to diagnose, which is due to the relative rarity of the onset of the disease at this age, the vagueness and non-specificity of manifestations, the presence of concomitant diseases, which are often accompanied by similar clinical picture (shortness of breath, cough, decreased exercise tolerance). The second group of patients includes people who have suffered from asthma for many years, and in old age, asthma is often accompanied by a second disease - chronic obstructive pulmonary disease (COPD). Bronchial asthma and chronic obstructive pulmonary disease are two independent chronic diseases of the respiratory system, but when an irreversible component of bronchial obstruction appears in patients with asthma, the differential diagnosis between these diseases loses its meaning. The addition of COPD to asthma can be considered the situation when, in a stable state of asthma - controlled symptoms, low variability of peak expiratory flow (PEF) - a reduced forced expiratory volume in 1 second (FEV1) remains, even if there is a high increase in the test with β2 -agonist. With long-term observation of these patients, there is a progression of respiratory failure, which is steady in nature, and the effectiveness of corticosteroids, which were previously highly effective, decreases. Combining asthma and COPD are mutually aggravating factors that significantly modify the symptoms of the disease; also, possible negative effects due to the interaction of the medications used often significantly complicate the treatment of elderly and senile patients. When prescribing topical anti-inflammatory therapy to elderly patients, it should be taken into account that all known and most commonly used ICS have anti-inflammatory activity sufficient for a clinical effect. Inhalation of ICS in elderly patients is best done using a spacer. The most common side effects in elderly patients are hoarseness, oral candidiasis and skin bleeding. High doses of ICS may contribute to the progression of osteoporosis in old age. A method to prevent side effects is also to use a minimum dose of ICS. This can be achieved in combination with long-acting β2-agonists. The combined use of these drugs in elderly patients with asthma provides more effective control of asthma, reduces the frequency of hospitalizations and deaths to a greater extent than monotherapy with each drug separately. In recent years, fixed combinations of salmeterol/fluticasone (Seretide) and formoterol/budesonide (Symbicort) have been created. They are more convenient, improve patient discipline and adherence to treatment, and guarantee the use of ICS along with bronchodilators. At the same time, such a method of combination therapy as budesonide/formoterol, 160/4.5 mcg (Symbicort turbuhaler), the use of the same inhaler as a basic therapy in a submaximal dose, and to relieve symptoms of bronchial asthma (smart method) is necessary prescribe carefully, taking into account the patient’s individual medical history, taking into account the presence of concomitant chronic pathology and the patient’s ability to objectively assess his condition.
Bronchodilator therapy. When combining two inflammatory processes characteristic of asthma and COPD, the progressive nature of COPD should be taken into account, which is manifested, on the one hand, by an increase in respiratory failure, and on the other, by a decrease in the effectiveness of controlling the disease with anti-inflammatory therapy and bronchodilators. The mechanism of loss of sensitivity to these drugs is realized gradually, mainly due to the increase in pulmonary emphysema and bronchial remodeling, which is demonstrated by an increase in the irreversible component of bronchial obstruction. In bronchodilator therapy, various theophylline preparations, β2-agonists, and anticholinergics are most widely used. Taking tableted theophyllines (aminophylline, theophylline, etc.) and oral β2-agonists (salbutamol, etc.) can lead to the development of side effects. Due to potential toxicity, in most cases they should not be prescribed to elderly and senile patients. When treating elderly and senile patients with concomitant diseases of the cardiovascular system, it is necessary to use β2-agonists with caution.
Short-acting β2-agonists. Short-acting inhaled β2-agonists are used to relieve or prevent episodes of difficulty breathing, suffocation, or paroxysmal cough in patients with asthma. Symptomatic therapy - selective short-acting β2-blockers are used only to resolve acute symptoms bronchial asthma and in combination with planned anti-inflammatory therapy. During exacerbation of asthma in the elderly, it is preferable to use bronchodilators through a nebulizer. In elderly and senile people, b2-agonists can naturally cause adverse events, since a significant proportion of patients have concomitant cardiovascular diseases. Short-acting sympathomimetics (salbutamol, fenoterol), especially when used repeatedly during the day, can aggravate coronary insufficiency and cause side effects such as tachycardia, cardiac arrhythmias, arterial hypertension, hypokalemia. When developing treatment tactics, one should take into account the possibility of coronary heart disease and arterial hypertension, which significantly limits the therapeutic potential of β2-agonists. In addition, with their long-term use, loss of effectiveness is possible due to blockade of β2 receptors.
Anticholinergic drugs. β2-agonists are the most effective drugs to relieve an attack of suffocation in patients with isolated asthma, in case of asthma + COPD, they are inferior to anticholinergic drugs. An important advantage of inhaled anticholinergic drugs is the minimal frequency and severity of adverse events. The most common of these, dry mouth, does not usually lead to stopping taking medications. They are well tolerated and can be used for long periods of time without a noticeable decrease in effectiveness (tachyphylaxis). The most well-known and widely used inhaled anticholinergic drug is currently ipratropium bromide. Ipratropium bromide is an M-cholinergic receptor blocker, eliminates bronchospasm associated with the influence of the vagus nerve, and when administered by inhalation causes bronchodilation, which is mainly due to local rather than systemic anticholinergic effects. Does not have a negative effect on mucus secretion in the respiratory tract, mucociliary clearance and gas exchange. The drug is well tolerated, effective and safe with long-term use, does not cause the development of tachyphylaxis, and has no cardiotoxic effects. The bronchodilator effect after one dose of ipratropium bromide usually occurs within 30-45 minutes and is not always subjectively felt by the patient. Typically, the bronchodilator effect of ipratropium bromide increases within 3 weeks of continuous use, and then stabilization occurs, allowing you to switch to a maintenance dose, determined individually. The advantage of this group of drugs is the absence of side effects from the cardiovascular and nervous system. Anticholinergics are indicated for elderly patients in cases where asthma is combined with COPD, taking into account the characteristics of the course of bronchial asthma in this category of people. With age, there is a partial decrease in the quantity and quality of β2-adrenergic receptors, their sensitivity decreases, while the sensitivity of M-cholinergic receptors does not decrease with age. Short-acting anticholinergic drugs (ipratropium bromide) rarely cause side effects, are not cardiotoxic, and with long-term use more clearly improve the ventilation function of the lungs and inhibit reflex bronchoconstriction. The use of anticholinergic drugs can help improve patency in the peripheral parts of the bronchopulmonary system by limiting the secretion of bronchial mucus. The onset of action of anticholinergic substances is slightly later, but the duration of the effect achieved is longer. They do not cause tachyphylaxis. It has been proven that in patients with stable COPD, a combination of β2-agonists and anticholinergic drugs is more effective than either of them alone.
Combined bronchodilator therapy. It has now been proven that combination therapy with short-acting β2-agonists and ipratropium is more effective in preventing exacerbations of COPD in combination with asthma than monotherapy with either of these drugs. Also, the use of combination bronchodilator therapy may be advisable in patients with asthma refractory to β2-agonist monotherapy. The administration of combined drugs allows them to act on different receptors and, accordingly, on different parts of the bronchi (anticholinergic drugs - mainly on the proximal ones, β2-agonists - on the distal ones). This combination makes it possible to enhance the pharmacological effect of each component: it has been proven that the addition of anticholinergics to β2-agonists potentiates the bronchodilator effect. The combined drug is effective even if the effect of any of its components is insufficient (the bronchodilator effect occurs faster and its duration is longer). It is important that when prescribing combination drugs, fewer side effects occur, since a smaller dose of each drug is administered compared to doses of the drug during monotherapy to achieve the same effect. They do not cause tachyphylaxis.
The leading place among this group is occupied by a fixed combination of fenoterol and ipratropium bromide (the drug Berodual-N). Berodual-N is a combined bronchodilator drug, the components of which have different mechanisms and localization of action. The mechanism of action of the β2-adrenergic agonist fenoterol is associated with the activation of adenylate cyclase coupled to the receptor, which leads to an increase in the formation of c-AMP, which stimulates the calcium pump, resulting in a decrease in calcium concentration in myofibrils and bronchodilation. Ipratropium bromide is an M-cholinergic receptor blocker that eliminates bronchospasm associated with the influence of the vagus nerve. When administered by inhalation, it causes bronchodilation, mainly due to local rather than systemic anticholinergic effects. Does not have a negative effect on mucus secretion in the respiratory tract, mucociliary clearance and gas exchange.
Berodual-N is available in the form of a metered-dose freon-free inhaler and a solution for nebulizer therapy. The Berodual-N metered dose inhaler contains ipratropium bromide – 20 mcg and fenoterol hydrobromide – 50 mcg in one dose. When using it, side effects are less common because the dose of β2-agonist in this drug is half that of standard inhalers; in this case, the combination of two drugs potentiates the effect of each other. Fenoterol begins to act after 4 minutes, the maximum effect is observed after 45 minutes, the duration of action is 5-6 hours. Long-term use of this combination has shown its high effectiveness and safety, including in patients with concomitant diseases of the cardiovascular system. Side effects are extremely minor and occur mainly in overdose; even in excessively high doses, no cardiotoxic reactions are observed.
The combination of pharmacological components provides Berodual-N:
A more pronounced and long-lasting bronchodilator effect than each of the components;
a wide range of indications, including bronchial asthma, chronic obstructive bronchitis and a combination of these diseases in one patient;
greater safety when combined with cardiac pathology than monotherapy with β2-agonists;
convenience for patients and cost-effectiveness of treatment compared to the use of two separate aerosols;
Possibility of use both using a metered aerosol and a nebulizer;
absence of tachyphylaxis with long-term use.
For bronchial asthma, Berodual inhalation should not be recommended for continuous use as basic therapy. Berodual is prescribed on an “on demand” basis, in combination with basic ICS therapy. Berodual inhalations are effective in preventing bronchospasm caused by physical activity and contact with an allergen. When bronchial obstruction increases, Berodual inhalations using a nebulizer are performed to provide emergency care, although it should be noted that in case of exacerbation of BA, this medicinal product is a second-line drug.
Using a nebulizer for inhalation therapy avoids the need to coordinate inhalation with drug release, which has important for elderly and elderly people who have difficulty performing this maneuver. Nebulized therapy with a combination of a β2-agonist and an anticholinergic agent (ipratropium bromide) may provide a greater bronchodilator effect than the drugs alone (Evidence Level B) and should precede the administration of methylxanthines. The use of a combination of a β2-agonist and an anticholinergic drug is associated with a reduction in hospitalization (evidence level A) and a greater increase in PEF and FPV1 (evidence level B) (GINA, revised 2006). In addition, this ensures minimal penetration of the drug into the oropharynx and systemic circulation, thereby reducing the risk of side effects. The solution for inhalation via a nebulizer contains 100 mcg of fenoterol and 250 mcg of ipratropium bromide in 1 ml; The therapeutic dose, depending on the severity of the exacerbation, ranges from 20 to 80 drops (1-4 ml of solution). The onset of action of the drug is 30 seconds, maximum – 1-2 hours, duration – 6 hours.
Indications for the use of Berodual solution through a nebulizer:
If necessary, use high doses of bronchodilators;
in the absence of the ability to coordinate inhalation and pressing the metered dose inhaler canister;
at FEV1
Basic therapy with bronchodilators through a nebulizer at home is carried out when it is necessary to prescribe high doses of bronchodilators, when it is impossible to use metered-dose aerosols, or when there is a subjective preference for a nebulizer. In this case, it is necessary to monitor patients receiving bronchodilators at home through a nebulizer.
Thus, of great importance in the management of patients with bronchial asthma, especially in old age, is an individual approach to prescribing basic therapy, which should be carried out taking into account concomitant diseases and assessing the possible influence of the drugs used on their course.
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