Bronchial asthma in concomitant diseases of various organs – features of the clinical course of bronchial asthma in various concurrent diseases. The most common in patients with asthma are allergic rhinitis, allergic rhinosinusopathy, vasomotor rhinitis, nasal and sinus polyposis, arterial hypertension, various endocrine disorders, pathology of the nervous and digestive systems. The presence of arterial hypertension in patients with bronchial asthma is a generally recognized fact. The frequency of the combination of these diseases is increasing. The main factor in increasing systemic blood pressure is central and regional hemodynamic disorders: an increase in peripheral vascular resistance, a decrease in pulse blood supply to the brain, and hemodynamic disturbances in the pulmonary circulation. The increase in blood pressure is promoted by hypoxia and hypercapnia accompanying chronic bronchial obstruction, as well as the influence of vasoactive substances (serotonin, catecholamines and their predecessors). There are two forms of arterial hypertension in bronchial asthma: hypertension (25% of patients), which proceeds benignly and slowly progresses, and symptomatic “pulmonary” (the prevailing form, 75% of patients). In the “pulmonogenic” form, blood pressure rises mainly during severe bronchial obstruction (attack, exacerbation), and in some patients it does not reach the norm and increases with exacerbation (stable phase). Bronchial asthma is often combined with endocrine disorders. A known correlation of asthma symptoms with female genital function. In the puberty period in girls and premenopausal women, the severity of the disease increases. In women suffering from bronchial asthma, premenstrual asthmatic syndrome is often encountered: exacerbation 2-7 days before the onset of menstruation, less often – simultaneously with it; with the onset of menstruation, significant relief comes. Marked fluctuations in bronchial reactivity are not observed. Most patients have ovarian dysfunction. Severe asthma occurs when combined with hyperthyroidism, which significantly disrupts the metabolism of glucocorticosteroids. A particularly severe course of bronchial asthma is observed against the backdrop of Addison’s disease (a rare combination). Sometimes bronchial asthma is combined with myxedema and diabetes mellitus (about 0.1% of cases). Bronchial asthma is accompanied by disorders of the central nervous system of a different nature. In the acute stage, psychotic states with psychomotor agitation, psychoses, and coma are observed. In a chronic course, autonomic dystonia is formed with changes at all levels of the autonomic nervous system. Asthenoneurotic syndrome is manifested by irritability, fatigue, sleep disturbance. Vegetative-vascular dystonia is characterized by a number of signs: palm and foot hyperhidrosis , red and white “dermographism”, tremors, vegetative crises such as sympathoadrenal (sudden shortness of breath with a respiratory rate of 34-38 in 1 mn, fever, tachycardia up to 100-120 in 1 min , rise in blood pressure to 150 / 80-190 / 100 mm Hg. Art., frequent profuse urination, urge to defecate). Crises develop in isolation, mimic an asthmatic attack with a subjective sensation of suffocation, but there is no difficulty in exhaling and wheezing in the lungs. Symptoms of autonomic dystonia occur with the onset of bronchial asthma and become more frequent in parallel with its exacerbations. Autonomic dysfunction is manifested by weakness, dizziness, sweating, fainting and prolongs the period of coughing, asthma attacks, residual symptoms, more rapid progression of the disease and relative resistance to therapy. Concomitant diseases of the digestive system (pancreatic dysfunction, liver, intestinal dysfunction), which are found in a third of patients, especially with prolonged glucocorticosteroid therapy, can have a significant effect on the course of bronchial asthma. Concomitant diseases complicate the course of bronchial asthma, complicate its treatment and need appropriate correction. The treatment of arterial hypertension in bronchial asthma has certain features. “Pulmogenic” arterial hypertension, observed only during asthma attacks (labile phase), can normalize after bronchial obstruction has been eliminated without the use of antihypertensive drugs. In cases of stable arterial hypertension, the combined treatment uses hydralazine, ganglion blockers (arpenal, fubromegan, merpanite, temechin, peitamine), hypothiazide, veroshpiron (has the properties of an aldosterone blocker, corrects electrolyte metabolism disorders) 100-150 mg per day for three weeks . A-blocking adrenergic drugs, in particular pyrroxan, can be effective, calcium antagonists (corinfar, isoptin) are used. Ganglioblockers and anticholinergics can affect the neurogenic components of an attack of bronchial asthma (can be used in combination with bronchodilators: arpenal or fubromegan – 0.05 g three times a day; halidor – 0.1 g three times a day; temehin – 0.001 g three times a day day), which are recommended for mild attacks of a reflex or conditioned reflex nature, with a combination of bronchial asthma with arterial hypertension and pulmonary hypertension. These drugs must be used under the control of blood pressure; they are contraindicated in case of hypotension. For the treatment of patients with a predominance of the neurogenic component in pathogenesis, various variants of novocaine blockades are used (provided novocaine is tolerable), psychotherapy, hypnotic suggestive therapy, electrosleep, reflexology, and physiotherapy. These methods can eliminate the state of fear, conditioned reflex mechanisms of attacks, anxious mood. Treatment of concomitant diabetes is carried out according to the general rules: diet, antidiabetic drugs. Moreover, for the correction of carbohydrate metabolism, it is not recommended to use biguanides, which, due to the increase in anaerobic glycolysis (sugar-lowering mechanism), can aggravate the clinic of the underlying disease. The presence of esophagitis, gastritis, gastric and duodenal ulcers creates difficulties for glucocorticosteroid therapy. In cases of acute gastrointestinal bleeding, it is more advisable to use parenteral glucocorticosteroid drugs, an alternative treatment regimen is preferred. The optimal way to treat bronchial asthma, complicated by diabetes mellitus and peptic ulcer, is the appointment of glucocorticosteroid maintenance inhalation therapy. With hyperthyroidism, there may be a need for increased doses of glucocorticosteroid drugs, since an excess of thyroid hormones significantly increases the speed and changes the metabolic pathways of the latter. Treatment of hyperthyroidism improves the course of bronchial asthma. In cases of concomitant arterial hypertension, angina pectoris, and other cardiovascular diseases, as well as hyperthyroidism, it is necessary to use B-stimulating adrenergic drugs with great care. It is advisable to prescribe enzyme preparations (festal, digestin, panzinorm) for people with impaired digestive function, which reduce the absorption of food allergens and can help reduce shortness of breath, especially in the presence of food allergies. Patients with a positive result of tuberculin tests and a history of tuberculosis during prolonged glucocorticosteroid therapy are prescribed prophylactically tuberculostatic drugs (isoniazid). The use of adrenergic preparations of B-stimulating and methylxanthines in elderly patients is undesirable due to their side effects on the cardiovascular system, especially in coronary atherosclerosis. In addition, the bronchodilating effect of adrenergic drugs decreases with age. When a significant amount of liquid sputum is excreted in patients with bronchial asthma of this age group, anticholinergics are useful, which in some cases are more effective than other bronchodilators. There are recommendations on the use of synthetic androgens for older men suffering from bronchial asthma with a sharp decrease in the androgenic activity of the sex glands (Sustanon-250 – 2 ml intramuscularly with an interval of 14-20 days, course – three to five injections); while remission is achieved faster and the maintenance dose of glucocorticosteroid drugs is reduced. There are indications of the advisability of using antiplatelet agents, in particular dipyridamole (curantyl) – 250,300 mg per day – and acetylsalicylic acid (in the absence of contraindications) – 1.53.0 g per day, especially in elderly patients who have bronchial asthma associated with cardiac pathology -vascular system. In case of microcirculatory disorders and changes in the rheological properties of blood, heparin is used in a dose of 10-20 thousand units per day for 510 days. Concomitant pathology of the upper respiratory tract is being treated.
Diagnosis is based on data from an allergological history, clinic, specific diagnostics, radiological, immunological, and bnochem. and special bronchological and functional studies.
The most characteristic radiological changes in bronchial asthma are emphysema, stiffness of the roots, increased pulmonary pattern, mooring, fusion in the sinuses, and other changes in the pleura. Normal pulmonary pattern is rare. In the presence of an active inflammatory process in the lungs, peribronchial type infiltration predominates; focal and mixed types of infiltration are observed in 89% of patients.
Syndrome of bronchial obstruction during an attack is accompanied by characteristic changes in pulmonary volumes: an increase in OOL and its share in the OEL, as well as a sharp increase in bronchial resistance on exhalation, a decrease in FVC of the MVL and Tiffno index. These disorders are caused by bronchial obstruction (the main cause) and a deterioration in the elastic properties of the lung. Due to the unevenness of alveolar ventilation and violations of the ratio of ventilation and blood flow, ventilation and alveolar respiratory failure develop. The severity of respiratory failure in the interictal period depends on the severity of the disease; in accordance with this, obstructive changes of varying degrees are observed. The chronic course of bronchial asthma is characterized by a complex set of ventilation defects associated with obstruction of the bronchi. An objective measurement of the partial pressures of oxygen and carbon dioxide allows you to judge blood gases and ventilation status. In the acute stage of uncomplicated bronchial asthma, the severity of obstruction is associated with hypoxemia, respiratory alkalosis, a decrease in partial pressure and oxygen transport, and in some patients, respiratory acidosis. These disorders are especially pronounced with asthmatic status. Changes in peripheral blood are not characteristic. During seizures, the number of red blood cells and hemoglobin increases; white blood cell count depends on the activity of inflammation; eosinophilia is noted (bone marrow eosinophilia is more pronounced and constant), lymphocytosis. Leukocytosis and eosinophilia are evaluated with caution after administration of adrenaline and glucocorticosteroid drugs. Very high eosinophilia requires differential diagnosis with allergic bronchopulmonary aspergillosis, parasitic infections, Leffler’s syndrome. ESR and biochem. indicators of inflammation activity depend on the phase of the inflammatory process. Diagnostic value are proteinogram, C-reactive protein, serum glycoproteins, a2-globulinemia, hypergammaglobulinemia.
Eosinophilia is detected in sputum, there may be Kurshman spirals, Charcot-Leiden crystals (may be absent in freshly isolated sputum and appear when it is defended); increased activity of acid phosphatase (ten times higher than in serum), which indicates deep damage to the lysosomal membranes of neutrophils and macrophages. Histological examination reveals non-mucoid and degenerated cell elements, as well as eosinophilic detritus. In bronchial contents (bronchoalveolar lavage) with atopic asthma there is a decrease in the number of macrophages in two – two and a half times, an increase in the number of eosinophils in 5-10, neutrophils – in two to three times. In infectious bronchial asthma, macrophages prevail, there are few eosinophils, there are neutrophils. Bronchoscopy reveals diffuse catarrhal inflammation (in 50% of patients), diffuse catarrhal endobronchitis of the II degree (about 20% of patients), atrophic bronchitis (about a third of patients). Biochem. violations are different. They to a certain extent depend on the form, stage and severity of bronchial asthma and are characterized by changes in the blood levels of adaptive hormones, allergy mediators, proteolytic enzymes and other factors. Changes in cellular and humoral immunity are heterogeneous. In some patients, secondary immunological deficiency is noted; some have a relationship between the degree of immunity disorders and the severity of the disease and there is an improvement as a result of immunocorrective therapy.
Differential diagnosis. Bronchial asthma is differentiated with other allergic lung diseases (allergic bronchopulmonary aspergillosis, allergic exogenous bronchioalveolitis, chronic bronchitis, many bronchospastic syndromes that develop in various pathological conditions). Within the framework of bronchial asthma itself, various forms and variants are diagnosed.
Differential diagnosis of allergic and bacterial inflammation in the bronchopulmonary system in bronchial asthma is difficult. Activation of the bacterial inflammatory process in bronchial asthma is accompanied by an increase in the number of microbes in sputum (the main pathogens are pneumococcus and hemophilic bacillus, there is a significantly higher frequency of detection of opportunistic microorganisms, especially staphylococcus, than with other chronic non-specific lung diseases).
The treatment of bronchial asthma is still difficult. There are four basic rules for the treatment of bronchial asthma, an
individual approach with the determination of the leading factor in the etiology, pathogenesis and clinic of the disease;
elimination of the cause (complete or partial elimination of antigen), non-specific irritants, provoking factors;
the implementation of specific hyposensitization when it is impossible to eliminate the antigen;
conducting complex nonspecific therapy with an unknown etiology and the presence of contraindications for hypersensitivity.
Nonspecific complex therapy consists in the rehabilitation of infectious and inflammatory processes in the bronchopulmonary system (antibacterial agents, bronchial tree sanitation) and foci of infection outside the respiratory tract, the elimination of airway obstruction, the improvement of alveolar ventilation, the effective dilution and evacuation of sputum using hydrating and mucolytic drugs immunocorrecting and desensitizing non-specific therapy, sanatorium and other treatment.
One of the main places is the treatment of bronchial obstruction, which in bronchial asthma has a complex nature. Medicines of various classes contribute to its elimination: bronchodilators (relieve bronchospasm), expectorants (dilute and remove sputum), glucocorticosteroid drugs (eliminate allergic inflammation), antibacterial agents (eliminate bacterial inflammation).
Due to the pronounced allergenic properties of many drugs, especially antibiotics and sulfonamides, as well as the tendency of patients to drug allergies, a careful choice of therapy is necessary in each case. Drug allergy in bronchial asthma is most often manifested by an increase and aggravation of asthma attacks, the formation of asthmatic status. The treatment failure, especially in the absence of activation of the infectious and inflammatory process in the lungs and steroid dependence, indicates the need to review the therapy in terms of the possibility of drug allergy.
Treatment of individual forms and options A. b has featurs.
Mild attacks are stopped by oral administration of theophedrine or ephedrine, as well as by inhalation of adrenergic drugs, especially B2 stimulants. At the same time, distracting means (banks, mustard plasters, hot foot baths) are used. In the absence of effect, ephedrine or adrenaline is administered subcutaneously, and in the case of contraindications to their use, aminophylline is administered intravenously, atropine is subcutaneous. Highly effective B2-stimulants with parenteral administration. Adequate hydration is required, moistened oxygen is used. In severe bronchial asthma, resistance to adrenergic drugs is often observed. In this case, euphyllium is introduced (4 mg per 1 kg of body weight) – slowly intravenously, moistened oxygen is given. With resistance to adrenergic drugs and methylxanthines, parenteral administration of glucocorticosteroid drugs is indicated, especially for patients receiving maintenance doses of these drugs. It is preferable to use hydrocortisone (hemisuccinate, phosphate), since a high plasma concentration is achieved within a short time. In patients not receiving hormones, an infusion of 100-200 mg of hydrocortisone every 6 hours can give a satisfactory result . For steroid-dependent patients, large doses are required, in some cases the effect does not occur until the concentration of glucocorticosteroid drugs in the plasma reaches 1 μg / ml (corresponds to dose of 4 mg per 1 kg of body weight every 2 hours). The response to glucocorticosteroid drugs correlates with a decrease in the number of eosinophils (absolute amount) by 50% or more. Treatment of severe, non-stopping attacks of asthma, passing into asthmatic status, is in the nature of intensive care.
Specific hyposensitization in the treatment of bronchial asthma refers to pathogenetic methods of therapy, is carried out according to general rules in the absence of exacerbation of bronchial asthma and inflammatory processes in the foci of infection after thorough rehabilitation. Most allergist clinicians assess hyposensitization as the primary treatment for atopic bronchial asthma. It is most developed and effective in atopic dust bronchial asthma and pollen etiology. The effectiveness of treatment with food extracts in cases of suspected food allergies has not been confirmed. the number and frequency of allergen injections depend on the severity of sensitization and patient tolerance. The duration of specific desensitization is at least two years, with a significant decrease in symptoms, a break is made, when symptoms return, treatment is resumed. There are a number of reports on the greater effectiveness of inhalation immunotherapy for asthma with dust etiology (carried out according to the same scheme as injection, aerosols are sprayed with AI-1 inhalers), note a long duration of remission, and it is recommended to conduct three courses of local immunotherapy in a row. There are no reliable criteria for determining the duration of treatment: in each case this is determined by the clinical situation. The specific hyposensitization of infectious bronchial asthma is less developed and less effective. The points of view on the effectiveness of bacterial vaccines are different. There is evidence in favor of both auto and hetero vaccines. Significantly more often than with atopic bronchial asthma, exacerbations during hypersensitivity by microbial allergens are described.