Chronic acute lung disease. Chronic obstructive pulmonary disease

In the early stages of the disease, it is episodic, but later it bothers constantly, even in a dream. The cough is accompanied by phlegm. Usually it is a little, but in the stage of exacerbation, the amount of discharge increases. Purulent sputum is possible.

Another symptom of COPD is shortness of breath. It appears late, in some cases even 10 years after the onset of the disease.

COPD sufferers are divided into two groups - "pink puffers" and "cyanotic edema". "Pink puffers" (emphysematous type) are often thin, their main symptom is shortness of breath. Even after a little physical exertion, they puff, puffing out their cheeks.

"Cyanotic edema" (bronchitic type) are overweight. COPD manifests itself mainly in a severe cough with phlegm. Their skin is cyanotic, their legs are swollen. This is due to cor pulmonale and stagnation of blood in the systemic circulation.

Description

According to the World Health Organization (WHO), 9 men out of 1000 and about 7 women out of 1000 suffer from COPD. There are about 1 million people suffering from this disease in Russia. Although there is reason to believe that there are many more.

In severe COPD, the blood gas composition is determined.

If therapy is ineffective, sputum is taken for bacteriological analysis.

Treatment

Chronic obstructive pulmonary disease is an incurable disease. However, adequate therapy can reduce the frequency of exacerbations and significantly prolong the patient's life. For the treatment of COPD, drugs are used that expand the lumen of the bronchi and mucolytic drugs that thin the phlegm and promote its excretion from the body.

To relieve inflammation, glucocorticoids are prescribed. However, their long-term use is not recommended due to serious side effects.

During the period of exacerbation of the disease, if its infectious nature is proven, antibiotics or antibacterial agents are prescribed, depending on the sensitivity of the microorganism.

Patients with respiratory failure are prescribed oxygen therapy.

Those suffering from pulmonary hypertension and COPD in the presence of edema are prescribed diuretics, with arrhythmias - cardiac glycosides.

A COPD patient is referred to a hospital if he has:

It is also important to treat respiratory infections in a timely manner.

Those working in hazardous industries must strictly observe safety precautions and wear respirators.

Unfortunately, in big cities it is impossible to exclude one of the risk factors - a polluted atmosphere.

COPD is best treated early. For the timely diagnosis of this disease, you need to undergo medical examination on time.

Chronic obstructive pulmonary disease (COPD) is a disease characterized by progressive, partially reversible bronchial obstruction associated with inflammation of the airways, which occurs under the influence of adverse environmental factors (smoking, occupational hazards, pollutants, etc.). It was found that morphological changes in COPD are observed in the central and peripheral bronchi, pulmonary parenchyma and vessels. This explains the use of the term "chronic obstructive pulmonary disease" instead of the usual "chronic obstructive bronchitis", implying a predominant lesion of the patient's bronchi.

The incidence and mortality of patients from COPD continues to rise worldwide, primarily due to the widespread prevalence of smoking. It has been shown that 4-6% of men and 1-3% of women over 40 suffer from this disease. In European countries, it annually causes the death of 200-300 thousand people. The high medical and social significance of COPD has become the reason for the publication, at the initiative of WHO, of an international agreement on its diagnosis, treatment, prevention and based on the principles of evidence-based medicine. Similar guidelines have been issued by the American and European Respiratory Societies. Our country has recently published the 2nd edition of the Federal COPD Program.

The goals of COPD therapy are to prevent the progression of the disease, reduce the severity of clinical symptoms, achieve better exercise tolerance and improve the quality of life of patients, prevent complications and exacerbations, and reduce mortality.

The main areas of treatment for COPD are reducing the impact of unfavorable environmental factors (including quitting smoking), teaching patients, using drugs and non-drug therapy (oxygen therapy, rehabilitation, etc.). Various combinations of these methods are used in patients with COPD in remission and exacerbation.

Reducing the influence of risk factors on patients is an integral part of the treatment of COPD, allowing to prevent the development and progression of this disease. It has been established that smoking cessation slows down the growth of bronchial obstruction. Therefore, the treatment of tobacco dependence is relevant for all patients with COPD. The most effective in this case are conversations of medical personnel (individual and group) and pharmacotherapy. There are three programs for the treatment of tobacco dependence: short (1-3 months), long-term (6-12 months) and a program to reduce smoking intensity.

Prescribing drugs is recommended for patients with whom the doctor's interviews were not effective enough. Their use should be carefully considered in people who smoke less than 10 cigarettes a day, adolescents and pregnant women. Contraindications to the appointment of nicotine replacement therapy are unstable angina pectoris, untreated peptic ulcer of the duodenum, recent acute myocardial infarction and cerebrovascular accident.

Raising patients' awareness allows them to increase their performance, improve their health, form the ability to cope with illness, and increase the effectiveness of treatment of exacerbations. The forms of patient education vary - from distribution of printed materials to seminars and conferences. The most effective interactive training, which is carried out in the framework of a small workshop.

The principles of treatment for stable COPD are as follows.

• The amount of treatment increases as the severity of the disease increases. Its reduction in COPD, in contrast to bronchial asthma, is usually impossible.
• Drug therapy is used to prevent complications and reduce the severity of symptoms, frequency and severity of exacerbations, increase exercise tolerance and quality of life of patients.
• It should be borne in mind that none of the available drugs affects the rate of decrease in bronchial patency that is a hallmark of COPD.
• Bronchodilators are central to the treatment of COPD. They reduce the severity of the reversible component of bronchial obstruction. These funds are used on demand or regularly.
• Inhaled glucocorticoids are indicated for severe and extremely severe COPD (with a forced expiratory volume in 1 s (FEV 1) less than 50% of the due and frequent exacerbations, as a rule, more than three in the last three years or one or two in one year, for treatment which use oral steroids and antibiotics.
• Combined therapy with inhaled glucocorticoids and long-acting β 2 -adrenomimetics has a significant additional effect on pulmonary function and clinical symptoms of COPD compared with monotherapy with each drug. The greatest impact on the frequency of exacerbations and quality of life is observed in patients with COPD with FEV 1<50% от должного. Эти препараты предпочтительно назначать в ингаляционной форме, содержащей их фиксированные комбинации (салметерол/флутиказон пропионат, формотерол/будесонид).
• Long-term use of tableted glucocorticoids is not recommended due to the risk of systemic side effects.
• At all stages of COPD, physical training programs that increase exercise tolerance and reduce the severity of shortness of breath and fatigue are highly effective.
• Long-term administration of oxygen (more than 15 hours per day) to patients with respiratory failure increases their survival.

Medication for stable COPD

Bronchodilators. These include β 2 -adrenomimetics, anticholinergics, and theophylline. The release forms of these drugs and their effect on the course of COPD are given in and .

The principles of bronchodilator therapy for COPD are as follows.

• The preferred route of administration of bronchodilators is inhalation.
• Changes in lung function after short-term administration of bronchodilator drugs is not an indicator of their long-term effectiveness. A relatively small increase in FEV 1 can be combined with significant changes in lung volumes, including a decrease in residual lung volume, which helps to reduce the severity of shortness of breath in patients.
• The choice between β 2 -adrenomimetics, anticholinergics, theophylline depends on their availability, the individual sensitivity of patients to their action and the absence of side effects. In elderly patients with concomitant diseases of the cardiovascular system (IHD, heart rhythm disturbances, arterial hypertension, etc.), anticholinergics are preferred as first-line drugs.
• Xanthines are effective for COPD, but due to the potential for side effects, they are second-line drugs. When prescribing them, it is recommended to measure the concentration of theophylline in the blood. It should be emphasized that only long-acting theophyllines (but not aminophylline and theofedrine!) Have a positive effect on the course of COPD.
• Long-acting inhaled bronchodilators are more convenient but also more expensive than short-acting drugs.
• Regular treatment with long-acting bronchodilators (tiotropium bromide, salmeterol and formoterol) is indicated for moderate, severe and extremely severe COPD.
• The combination of several bronchodilators (for example, anticholinergics and β 2 -adrenomimetics, anticholinergics and theophyllines, β 2 -adrenomimetics and theophyllines) can increase the effectiveness and reduce the likelihood of side effects compared to single-drug monotherapy.

For the delivery of β 2 -adrenomimetics and anticholinergics, metered-dose aerosols, powder inhalers and nebulizers are used. The latter are recommended in the treatment of exacerbations of COPD, as well as in patients with severe disease who have difficulties using other delivery systems. In case of stable COPD, metered-dose and dry powder inhalers are preferred.

Glucocorticoids. These drugs have a pronounced anti-inflammatory activity, although in patients with COPD it is significantly less pronounced than in patients with asthma. Short (10-14 days) courses of systemic steroids are used to treat exacerbations of COPD. Long-term use of these drugs is not recommended due to the risk of side effects (myopathy, osteoporosis, etc.).

Data on the effect of inhaled glucocorticoids on the course of COPD are summarized in ... It was shown that they have no effect on the progressive decrease in bronchial patency in patients with COPD. Their high doses (for example, fluticasone propionate 1000 mcg / day) can improve the quality of life of patients and reduce the frequency of exacerbations of severe and extremely severe COPD.

The causes of the relative steroid resistance of airway inflammation in COPD are the subject of intense research. Perhaps it is due to the fact that corticosteroids increase the life span of neutrophils by inhibiting their apoptosis. The molecular mechanisms underlying glucocorticoid resistance are poorly understood. There have been reports of a decrease in the activity of histone deacetylase, which is a target for steroid action, under the influence of smoking and free radicals, which can reduce the inhibitory effect of glucocorticoids on the transcription of "inflammatory" genes and weaken their anti-inflammatory effect.

Recently, new data have been obtained on the effectiveness of combination drugs (fluticasone propionate / salmeterol 500/50 μg, 1 inhalation 2 times a day and budesonide / formoterol 160 / 4.5 μg, 2 inhalations 2 times a day, budesonide / salbutamol 100/200 mgk 2 inhalations 2 times a day) in patients with severe and extremely severe COPD. It has been shown that their long-term (12 months) administration improves bronchial patency, reduces the severity of symptoms, the need for bronchodilators, the frequency of moderate and severe exacerbations, and also improves the quality of life of patients compared to monotherapy with inhaled glucocorticoids, long-acting β 2 -adrenomimetics and placebo ...

Vaccines... Vaccination against influenza reduces the severity and mortality of COPD patients by about 50%. Vaccines containing killed or inactivated live influenza viruses are usually given once in October - early November.

There are insufficient data on the effectiveness of pneumococcal vaccine containing 23 virulent serotypes of this microorganism in patients with COPD. However, some experts recommend its use in this disease to prevent pneumonia.

Antibiotics There is currently no conclusive evidence of the effectiveness of antibacterial agents in reducing the frequency and severity of non-infectious exacerbations of COPD.

Antibiotics are indicated for the treatment of infectious exacerbations of the disease, directly affect the duration of the elimination of COPD symptoms, and some contribute to the lengthening of the relapse interval.

Mucolytics (mucokinetics, mucoregulators). Mucolytics (ambroxol, carbocisteine, iodine preparations, etc.) can be used in a small proportion of patients with viscous sputum. The widespread use of these agents in patients with COPD is not recommended.

Antioxidants N-acetylcysteine, which has antioxidant and mucolytic activity, can reduce the duration and frequency of exacerbations of COPD. This drug can be used in patients for a long time (3-6 months) at a dose of 600 mg / day.

Immunoregulators (immunostimulants, immunomodulators). Regular use of these drugs is discouraged due to the lack of conclusive evidence of effectiveness.

Patients with genetically determined α 1 -antitrypsin deficiency who develop COPD at a young age (under 40 years of age) are possible candidates for replacement therapy. However, the cost of such treatment is very high and it is not available in all countries.

Non-drug treatment of stable COPD

Oxygen therapy

It is known that respiratory failure is the leading cause of death in patients with COPD. Correction of hypoxemia with oxygen supply is a pathogenetically justified treatment method. Distinguish between short-term and long-term oxygen therapy. The first is used for exacerbations of COPD. The second is used for extremely severe COPD (with FEV 1<30% от должного) постоянно или ситуационно (при физической нагрузке и во время сна). Целью оксигенотерапии является увеличение парциального напряжения кислорода (РаO 2) в артериальной крови не ниже 60 мм рт. ст. или сатурации (SaO 2) не менее чем до 90% в покое, при физической нагрузке и во время сна.

With a stable course of COPD, continuous long-term oxygen therapy is preferable. It has been proven that it increases the survival rate of patients with COPD, reduces the severity of shortness of breath, the progression of pulmonary hypertension, reduces secondary erythrocytosis, the frequency of episodes of hypoxemia during sleep, increases exercise tolerance, quality of life and neuropsychiatric status of patients.

Indications for long-term oxygen therapy in patients with extremely severe COPD (with FEV 1< 30% от должного или менее 1,5 л):

• PaO 2 less than 55% of the due, SaO 2 less than 88% in the presence or absence of hypercapnia;
• PaO 2 - 55-60% of the due, SaO 2 - 89% in the presence of pulmonary hypertension, peripheral edema associated with decompensation of pulmonary heart disease or polycythemia (hematocrit is more than 55%).

Gas exchange parameters should be assessed only against the background of a stable course of COPD and no earlier than 3-4 weeks after exacerbation with optimally selected therapy. The decision to prescribe oxygen therapy should be based on indicators obtained at rest and during exercise (for example, during a 6-minute walk). A reassessment of arterial blood gases should be done 30 to 90 days after starting oxygen therapy.

Long-term oxygen treatment should be carried out at least 15 hours a day. The gas flow rate is usually 1-2 l / min, if necessary, it can be increased to 4 l / min. Oxygen therapy should never be prescribed to patients who continue to smoke or suffer from alcoholism.

Compressed gas cylinders, oxygen concentrators, and liquid oxygen cylinders are used as oxygen sources. Oxygen concentrators are the most economical and convenient for home use.

Oxygen delivery to the patient is carried out using masks, nasal cannulas, transtracheal catheters. The most convenient and widely used nasal cannulas, which allow the patient to receive an oxygen-air mixture with 30-40% O2. Oxygen delivery to the alveoli is carried out only in the early phase of inspiration (the first 0.5 s). The gas that comes later is used only to fill the dead space and does not participate in gas exchange. To improve delivery efficiency, there are several types of oxygen-saving devices (reservoir cannulas, devices that deliver gas only during inspiration, transtracheal catheters, etc.). In extremely severe COPD patients with daytime hypercapnia, the combined use of long-term oxygen therapy and non-invasive ventilation with positive inspiratory pressure is possible. It should be noted that oxygen therapy is one of the most expensive treatments for patients with COPD. Its introduction into everyday clinical practice is one of the most pressing medical and social tasks in Russia.

Rehabilitation

Rehabilitation is a multidisciplinary individualized care program for COPD patients designed to improve their physical, social adaptation and autonomy. Its components are physical training, patient education, psychotherapy and good nutrition.

In our country, spa treatment is traditionally referred to it. Pulmonary rehabilitation should be prescribed for moderate, severe and extremely severe COPD. It has been shown that it improves work capacity, quality of life and survival of patients, reduces shortness of breath, frequency of hospitalizations and their duration, suppresses anxiety and depression. The effect of rehabilitation persists after its completion. Optimal classes with patients in small (6-8 people) groups with the participation of specialists of various profiles for 6-8 weeks.

In recent years, much attention has been paid to rational nutrition, since a decrease in body weight (\u003e 10% within 6 months or\u003e 5% during the last month) and especially loss of muscle mass in patients with COPD is associated with high mortality. Such patients should be recommended a high-calorie diet with a high protein content and dosed physical activity with anabolic effect.

Surgery

The role of surgical treatment in COPD patients is currently the subject of research. The possibilities of using bullectomy, lung volume reduction surgery and lung transplantation are currently being discussed.

The indication for bullectomy in COPD is the presence of bullosa pulmonary emphysema with large bullae that cause shortness of breath, hemoptysis, lung infections, and chest pain. This surgery results in less shortness of breath and improved lung function.

The value of lung volume reduction surgery in the treatment of COPD has not yet been adequately studied. The results of a recently completed National Emphysema Therapy Trial show a positive effect of this surgery compared with drug therapy on exercise performance, quality of life and mortality in COPD patients with predominantly severe upper lobe pulmonary emphysema and an initial low level of performance. Nevertheless, this operation remains an experimental palliative procedure that is not recommended for widespread use.

Lung transplantation improves the quality of life, lung function and physical performance of patients. The indications for its implementation are FEV1 ё25% of the due, PaCO2\u003e 55 mm Hg. Art. and progressive pulmonary hypertension. Among the factors limiting the performance of this operation are the problem of donor lung selection, postoperative complications, and high cost (110-200 thousand US dollars). Operational mortality in foreign clinics is 10-15%, 1-3-year survival rates are 70-75 and 60%, respectively.

Stepwise therapy for stable COPD is shown in the figure.

Pulmonary heart disease treatment

Pulmonary hypertension and chronic cor pulmonale are complications of severe and extremely severe COPD. Their treatment includes optimal therapy for COPD, long-term (\u003e 15 h) oxygen therapy, use of diuretics (in the presence of edema), digoxin (only with atrial fibrillation and concomitant left ventricular heart failure, since cardiac glycosides do not affect the contractility and ejection fraction of the right ventricle) ... The appointment of vasodilators (nitrates, calcium antagonists and angiotensin-converting enzyme inhibitors) is controversial. Their reception in some cases leads to a deterioration in blood oxygenation and arterial hypotension. Nevertheless, calcium antagonists (nifedipine SR 30-240 mg / day and diltiazem SR 120-720 mg / day) can probably be used in patients with severe pulmonary hypertension with insufficient effectiveness of bronchodilators and oxygen therapy.

Treating exacerbations of COPD

Exacerbation of COPD is characterized by an increase in the patient's shortness of breath, cough, changes in the volume and nature of sputum and requires changes in treatment tactics. ... Distinguish between mild, moderate and severe exacerbations of the disease (see. ).

Treatment of exacerbations involves the use of drugs (bronchodilators, systemic glucocorticoids, antibiotics for indications), oxygen therapy, and respiratory support.

The use of bronchodilators involves an increase in their doses and frequency of administration. Dosing regimens for these drugs are given in and ... Introducing $ beta; 2 -adrenomimetics and short-acting anticholinergics are carried out using compressor nebulizers and metered-dose inhalers with a large volume spacer. Some studies have shown the equivalent effectiveness of these delivery systems. However, with moderate and severe exacerbations of COPD, especially in elderly patients, nebulizer therapy should probably be preferred.

Due to the difficulty of dosing and the large number of potential side effects, the use of short-acting theophyllines in the treatment of exacerbations of COPD is a matter of debate. Some authors admit the possibility of their use as "second-line" drugs with insufficient effectiveness of inhaled bronchodilators, others do not share this point of view. Probably, the appointment of drugs of this group is possible subject to the rules of administration and determination of the concentration of theophylline in the blood serum. The most famous of them is the drug aminophylline, which is theophylline (80%), dissolved in ethylenediamine (20%). Its dosage scheme is given in ... It should be emphasized that the drug should only be administered intravenously. This reduces the likelihood of developing side effects. It cannot be administered intramuscularly or by inhalation. The introduction of aminophylline is contraindicated in patients receiving long-acting theophyllines, because of the danger of its overdose.

Systemic glucocorticoids are effective in treating exacerbations of COPD. They shorten the recovery time and allow faster recovery of lung function. They are prescribed simultaneously with bronchodilators for FEV 1<50% от должного уровня. Обычно рекомендуется 30-40 мг преднизолона per os или эквивалентная доза внутривенно в течение 10-14 дней. Более длительное его применение не приводит к повышению эффективности, но увеличивает риск развития побочных эффектов. В последние годы появились данные о возможности использования ингаляционных глюкокортикоидов (будесонида), вводимых с помощью небулайзера, при лечении обострений ХОБЛ в качестве альтернативы системным стероидам .

Antibiotic therapy is indicated for patients with signs of an infectious process (an increase in the amount of sputum secreted, a change in the nature of sputum, the presence of an increased body temperature, etc.). Its options for various clinical situations are given in .

The benefits of antibiotic therapy are as follows.

• Reducing the duration of exacerbations of the disease.
• Prevention of the need for hospitalization of patients.
• Reduction of terms of temporary disability.
• Prevention of pneumonia.
• Prevention of progression of airway damage.
• Increased duration of remission.

In most cases, antibiotics are given by mouth, usually within 7-14 days (with the exception of azithromycin).

Oxygen therapy is usually prescribed for moderate and severe exacerbations of COPD (with RaO 2< 55 мм рт. ст., SaO 2 <88%). Применяются в этих случаях носовые катетеры или маска Вентури. Для оценки адекватности оксигенации и уровня РаСО 2 контроль газового состава крови должен осуществляться каждые 1-2 ч . При сохранении у больного ацидоза или гиперкапнии показана искусственная вентиляция легких. Продолжительность оксигенотерапии после купирования обострения при наличии гипоксемии обычно составляет от 1 до 3 мес.

If the patient is in serious condition, non-invasive or invasive mechanical ventilation (ALV) should be performed. They differ in the way the patient and respirator are connected.

Non-invasive mechanical ventilation consists in providing the patient with ventilation support without tracheal intubation. It provides for the delivery of oxygen-enriched gas from a respirator through a special mask (nasal or mouthpiece) or mouthpiece. This method of treatment differs from invasive mechanical ventilation in that it reduces the likelihood of mechanical damage to the oral cavity and respiratory tract (bleeding, strictures, etc.), the risk of developing infectious complications (sinusitis, nosocomial pneumonia, sepsis), and does not require the administration of sedatives. muscle relaxants and analgesics, which can have an adverse effect on the course of an exacerbation.

The most commonly used non-invasive ventilation mode is positive pressure respiratory support.

It has been established that non-invasive mechanical ventilation reduces mortality, reduces the time of hospital stay and the cost of treatment. It improves pulmonary gas exchange, reduces the severity of shortness of breath and tachycardia.

Indications for non-invasive mechanical ventilation:

• respiratory rate\u003e 25 per minute;
• acidosis (pH 7.3-7.35) and hypercapnia (PaCO 2 - 45-60 mm Hg).

Invasive mechanical ventilation involves airway intubation or tracheostomy. Accordingly, the connection between the patient and the respirator is carried out through endotracheal or tracheostomy tubes. This creates a risk of mechanical damage and infectious complications. Therefore, invasive mechanical ventilation should be used when the patient is in serious condition and only when other methods of treatment are ineffective.

Indications for invasive ventilation:

• severe shortness of breath with the participation of accessory muscles and paradoxical movements of the anterior abdominal wall;
• respiratory rate\u003e 35 per minute;
• severe hypoxemia (pO 2< <40 мм рт. ст.);
• severe acidosis (pH<7,25) и гиперкапния (РаСО 2 > 60 mmHg Art.);
• respiratory arrest, impaired consciousness;
• hypotension, heart rhythm disturbances;
• the presence of complications (pneumonia, pneumothorax, pulmonary embolism, etc.).

Patients with mild exacerbations can be treated on an outpatient basis.

Outpatient treatment of mild exacerbations of COPD includes the following steps.

• Assessment of the level of education of patients. Checking the technique of inhalation.
• Prescription of bronchodilators: short-acting β 2 -adrenomimetic and / or ipratropium bromide via a metered-dose inhaler with a large volume spacer or via a nebulizer in the "on demand" mode. If ineffective, intravenous administration of aminophylline is possible. Discussion of the possibility of prescribing long-acting bronchodilators if the patient has not received these drugs before.
• Administration of glucocorticoids (doses may vary). Prednisolone 30-40 mg per os for 10-14 days. Discussion of the possibility of prescribing inhaled glucocorticoids (after completion of the course of treatment with systemic steroids).
• Prescribing antibiotics (according to indications).

Patients with moderate exacerbations usually need to be hospitalized. Their treatment is carried out according to the following scheme.

• Bronchodilators: short-acting β 2 -adrenomimetic and / or ipratropium bromide via a metered-dose inhaler with a large volume spacer or a nebulizer on demand. If ineffective, intravenous administration of aminophylline is possible.
• Oxygen therapy (with Sa< <90%).
• Glucocorticoids. Prednisolone 30-40 mg per os for 10-14 days. If oral administration is impossible, the equivalent dose is intravenous (up to 14 days). Discussion of the possibility of prescribing inhaled glucocorticoids through a metered-dose inhaler or nebulizer (after the completion of the course of treatment with systemic steroids).
• Antibiotics (according to indications).

The indications for referring patients to specialized departments are:

• a significant increase in the severity of symptoms (for example, the occurrence of shortness of breath at rest);
• lack of effect from the treatment;
• the appearance of new symptoms (for example, cyanosis, peripheral edema);
• severe concomitant diseases (pneumonia, heart rhythm disturbances, congestive heart failure, diabetes mellitus, renal and hepatic failure);
• new-onset heart rhythm disturbances;
• elderly and senile age;
• the inability to provide qualified medical care on an outpatient basis;
• difficulties in diagnosis.

The risk of death in a hospital is higher with the development of respiratory acidosis in patients, the presence of severe concomitant diseases and the need for ventilation support.

In severe exacerbations of COPD, patients are often hospitalized in the intensive care unit; indications for this are:

• severe shortness of breath, not controlled by bronchodilators;
• impaired consciousness, coma;
• progressive hypoxemia (RaO 2<50 мм рт. ст.), гиперкапния (РаСО 2 >60 mmHg Art.) and / or respiratory acidosis (pH<7,25), несмотря на использование оксигенотерапии и неинвазивной вентиляции легких.

Treatment of severe exacerbations of COPD in the emergency department includes the following steps.

• Oxygen therapy.
• Ventilation support (non-invasive, less often invasive).
• Bronchodilators. β 2 -adrenomimetic short-acting and / or ipratropium bromide via a metered-dose inhaler with a large volume spacer, two breaths every 2-4 hours or via a nebulizer. If ineffective, intravenous administration of aminophylline is possible.
• Glucocorticoids. Prednisolone 30-40 mg per os for 10-14 days. If oral administration is impossible, an equivalent intravenous dose (up to 14 days). Discussion of the possibility of prescribing inhaled glucocorticoids through a metered-dose inhaler or nebulizer (after completion of the course of treatment with systemic steroids).
• Antibiotics (according to indications).

In the next 4-6 weeks, the patient should be re-examined by a doctor, while his adaptation to everyday life, FEV 1, the correctness of the inhalation technique, understanding of the need for further treatment are assessed, blood gases or oxygen saturation are measured to study the need for long-term oxygen therapy. If it was prescribed only during an exacerbation in hospital treatment, then, as a rule, it should be continued for 1-3 months after discharge.

To prevent exacerbations of COPD, it is necessary to: reduce the impact of risk factors; optimal bronchodilator therapy; inhaled glucocorticoids in combination with long-acting β 2 -adrenomimetics (for severe and extremely severe COPD); annual flu vaccination. n

Literature

A. V. Emelyanov, d doctor of Medical Sciences, Professor
SPB GMU, Saint Petersburg

Chronic airway diseases are often exacerbated during cold, damp seasons. Deterioration occurs even in the presence of bad habits, poor environmental conditions. Basically, such ailments affect people with a weak immune system, children, the elderly. COPD: what is it and how is it treated? Chronic obstructive pulmonary disease is a dangerous pathology. She periodically reminds of herself between remissions. Get to know the inflammatory process and its features.

What is COPD

The wording looks like this: chronic obstructive airway disease, which is characterized by a partially irreversible restriction of air in the respiratory tract. What is COPD? It combines chronic bronchitis and pulmonary emphysema. According to medical statistics, 10% of the world's population over 40 years old suffer from manifestations of COPD. Obstructive pulmonary disease is classified as the bronchitis / emphysematous type. COPD code according to ICD 10 (international classification of diseases):

• 43 Emphysema;
• 44 Another chronic obstructive disease.

Etiology of the disease (causes of appearance):

• the main source of the onset of pathology is active / passive smoking;
• polluted atmosphere of settlements;
• genetic predisposition to the disease;
• the specifics of the profession or place of residence (inhalation of dust, chemical vapors, polluted air over a long period of time);
• a large number of transferred infectious diseases of the respiratory system.

COPD: what is it and how is it treated? Let's talk about the symptoms of pathology. The main signs of the inflammatory process include:

• repeated recurrence of acute bronchitis;
• frequent daily coughing fits;
• constant sputum discharge;
• cOPD is characterized by an increase in temperature;
• shortness of breath, which worsens over time (at the time of ARVI or during physical exertion).

COPD classification

COPD is divided into stages (degrees) depending on the severity of the disease and its symptoms:

• the first mild stage has no signs, practically does not make itself felt;
• the stage of moderate severity of the disease is distinguished by shortness of breath with little physical activity, it is possible that a cough with phlegm or without it in the morning appears;
• COPD grade 3 is a severe form of chronic pathology, accompanied by frequent shortness of breath, bouts of wet cough;
• the fourth stage is the most serious, because it carries an open threat to life (shortness of breath in a calm state, persistent cough, sharp weight loss).

Pathogenesis

COPD: what is it and how is it treated? Let's talk about the pathogenesis of a dangerous inflammatory disease. In the event of a disease, irreversible obstruction begins to develop - fibrous degeneration, compaction of the bronchial wall. This is the result of prolonged inflammation, which is non-allergic in nature. The main manifestations of COPD are coughing up phlegm and progressive shortness of breath.

Life span

Many people are concerned about the question: how long do people live with COPD? It is completely impossible to recover. The disease develops slowly but surely. It is "frozen" with the help of drugs, prophylaxis, recipes of traditional medicine. Positive prognosis for chronic obstructive disease depends on the degree of pathology:

1. When the ailment is detected at the first, initial stage, the complex treatment of the patient allows you to maintain a standard life expectancy;
2. Second-degree COPD does not have such a good prognosis. The patient is prescribed the constant use of medications, which limits normal life.
3. The third stage is 7-10 years of life. If obstructive pulmonary disease worsens or additional diseases appear, then death occurs in 30% of cases.
4. The last degree of chronic irreversible pathology has the following prognosis: in 50% of patients, life expectancy is no more than a year.

Diagnostics

The formulation of the diagnosis of COPD is carried out on the basis of a set of data on the inflammatory disease, the results of the examination by means of visualization, and physical examination. The differential diagnosis is carried out with heart failure, bronchial asthma, bronchiectasis. Sometimes asthma and chronic lung disease are confused. Bronchial dyspnea has a different history, gives a chance for a complete cure of the patient, which cannot be said about COPD.

The diagnosis of chronic disease is carried out by a general practitioner and a pulmonologist. A detailed examination of the patient, tapping, auscultation (analysis of sound phenomena) is carried out, breathing over the lungs is heard. The primary study for the detection of COPD includes testing with a bronchodilator to make sure that there is no bronchial asthma, the secondary - X-ray. The diagnosis of chronic obstruction is confirmed by spirometry, a test that measures how much air the patient is breathing out and in.

Home treatment

How is COPD treated? Doctors say that this type of chronic pulmonary disease cannot be completely cured. The development of the disease is stopped by timely prescribed therapy. In most cases, it helps to improve the condition. Only a few are achieving complete restoration of the normal functioning of the respiratory system (lung transplantation is indicated in severe COPD). After confirming the medical opinion, the lung disease is eliminated with drugs in combination with folk remedies.

Drugs

The main "doctors" in the case of respiratory pathology are bronchodilator drugs for COPD. For a complex process, other medicines are also prescribed. The approximate course of treatment looks like this:

1. Beta2 agonists. Long-acting drugs - Formoterol, Salmeterol; short - salbutamol, terbutaline.
2. Methylxanthines: "Aminophylline", "Theophylline".
3. Bronchodilators: tiotropium bromide, oxitropium bromide.
4. Glucocorticosteroids. Systemic: "Methylprednisolone". Inhalation: "Fluticasone", "Budesonide".
5. Patients with severe and maximally severe COPD are prescribed inhaled medications with bronchodilators and glucocorticosteroids.

Folk remedies

1. We take 200 g of linden blossom, the same amount of chamomile and 100 g of flaxseeds. Dry the herbs, grind, insist. On one glass of boiling water, put 1 tbsp. l. collection. Take once a day for 2-3 months.
2. Grind 100 g of sage and 200 g of nettle into powder. Pour the mixture of herbs with boiled water, insist for an hour. We drink for 2 months, half a glass twice a day.
3. Collection for the removal of sputum from the body with obstructive inflammation. We need 300 g of flaxseeds, 100 g of anise berries, chamomile, marshmallow, licorice root. Pour the collection with boiling water, leave for 30 minutes. We filter and drink half a glass every day.

Respiratory gymnastics for COPD

Special breathing exercises contribute to the treatment of COPD:

1. Starting position: lie on your back. As you exhale, we pull our legs towards ourselves, bend at the knees, grab them with our hands. We exhale the air to the end, inhale with the diaphragm, return to the starting position.
2. We collect water in a jar, insert a cocktail straw. We collect the maximum possible amount of air while inhaling, slowly exhaling it into the tube. Perform the exercise for at least 10 minutes.
3. We count to three, exhaling more air (draw in the stomach). On "four" we relax the abdominal muscles, inhale with the diaphragm. Then we sharply contract the abdominal muscles, cough.

Prevention of COPD

Preventive measures for COPD require compliance with the following factors:

• it is necessary to stop using tobacco products (a very effective, proven method for rehabilitation);
• vaccination against influenza helps to avoid another exacerbation of obstructive pulmonary disease (it is better to be vaccinated before winter);
• revaccination against pneumonia reduces the risk of exacerbation of the disease (shown every 5 years);
• it is advisable to change the place of work or residence if they have a detrimental effect on health, increasing the development of COPD.

Complications

Like any other inflammatory process, obstructive pulmonary disease sometimes leads to a number of complications, such as:

• pneumonia (pneumonia);
• respiratory failure;
• pulmonary hypertension (increased pressure in the pulmonary artery);
• irreversible heart failure;
• thromboembolism (blockage of blood vessels by blood clots);
• bronchiectasis (development of functional inferiority of the bronchi);
• pulmonary heart disease (an increase in pressure in the pulmonary artery, leading to a thickening of the right heart);
• atrial fibrillation (heart rhythm disorder).

Video: COPD disease

Chronic obstructive pulmonary disease is one of the most serious pathologies. During the identified COPD and its complex treatment, the patient will feel much better. From the video it will become clear what COPD is, what its symptoms look like, and how the disease is triggered. The specialist will tell you about the therapeutic and preventive measures of the inflammatory disease.

Attention! The information presented in the article is for informational purposes only. The materials of the article do not call for self-treatment. Only a qualified doctor can diagnose and give recommendations for treatment, based on the individual characteristics of a particular patient.

Discuss

What is COPD and how to treat it

COPD - what is it, how is it treated? Chronic obstructive pulmonary disease is a deadly disease. Mortality from COPD reaches 6% of all deaths in the world.

Today, COPD is considered an incurable disease. Continuous therapy can only reduce the severity of exacerbations; it will not be possible to cure obstructive disease forever.

With COPD, obstruction appears in the airways, airflow is limited in movement, and the functioning of the lungs deteriorates, which leads to chronic respiratory failure.

COPD - the lot of smokers with many years of experience, for whom sooner or later it becomes simply difficult to breathe.

The mechanism of development of chronic obstructive pulmonary disease

With many years of smoking experience, there is a regular irritation of the lung tissues with toxins and their subsequent infection with pathogenic microorganisms, as a result of which chronic inflammation of COPD develops.

Previously, the disease was known as chronic obstructive bronchitis, but due to the fact that in almost 90% of cases chronic obstructive bronchitis is the cause of COPD, it was decided to separate its last stages in combination with pulmonary emphysema separately under the name COPD.

In the USA and Great Britain, the group of COPD diseases also includes cystic fibrosis, bronchiolitis obliterans, bronchiectasis.

The inflammatory process leads to narrowing of the bronchi with gradual destruction of the alveoli. Thus, over time, the respiratory tract, lung tissue and blood vessels are affected, which leads to irreversible pathologies and hypoxia of the internal organs and the brain.

COPD develops slowly and steadily, constantly progressing over several years. If untreated, obstructive pulmonary disease leads to disability and death.

Features of the development of COPD:

• Slow progression;
• The lower part of the respiratory tract and lung tissue are affected;
• There is a reversible / irreversible decrease in the air flow rate;
• Continuous inflammation.

The main causes of chronic obstructive pulmonary disease

There are several different reasons why chronic obstructive pulmonary disease develops:

• Smoking causes up to 90% of all cases;
• Occupational risks - work in hazardous industries, work activities associated with the inhalation of silicon and cadmium-containing dust: miners, construction workers, railway workers, workers in the pulp processing, metallurgical, cotton processing industries, agriculture are susceptible to the development of the disease;
• Poor ecology in the place of residence: air pollution from industrial emissions, car exhaust, elements of soil dust;
• Frequent untreated and untreated respiratory tract infections;
• Hereditary factors - congenital α1-antitrypsin deficiency.

COPD leads to chronic obstructive bronchitis, severe bronchial asthma, pulmonary emphysema, which developed as a result of alpha1-antitrypsin deficiency.

Symptoms of the disease

The main symptoms include:

1. The most important and very first symptom of COPD is coughing. Unfortunately, patients do not immediately pay attention to it. At first, the cough bothers the patient periodically, then it becomes daily, sometimes it manifests itself only at night.
2. In the early stages of obstructive pulmonary disease, sputum usually appears in the morning as a small amount of mucus. The more COPD develops, the more abundant and more viscous it becomes.
3. Dyspnea is detected 10 years after the onset of the disease. At first, she begins to bother only with physical exertion, then the feeling of lack of air begins to bother even with minor household movements, even later, progressive respiratory failure appears and shortness of breath begins to bother not only at rest, but also at night.

COPD patients also complain about:

• sleepiness during the day, sleeplessness at night;
• morning headache;
• constant fatigue;
• decrease in body weight;
• irritability.

Classification

Chronic obstructive disease is classified by severity:

1. Pre-illness - symptoms are already making themselves felt, but COPD is not diagnosed.
2. A mild degree is characterized by slightly pronounced functional disorders of the lungs, a slight cough. At this stage, obstructive pulmonary disease is rarely detected and diagnosed.
3. Moderate severity - obstructive disorders in the lungs are increasing. Shortness of breath appears during physical exertion. To this degree, the disease is easier to diagnose, as patients begin to complain to a doctor.
4. In severe cases, the supply of air to the lungs is already limited. The person is already suffering from significant shortness of breath and frequent exacerbations.
5. In extremely severe COPD, severe bronchial obstruction is diagnosed. The state of health is seriously deteriorating, exacerbations begin to threaten life, disability is established.

Also, chronic obstructive pulmonary disease can be divided into phases:

• Calm flow;
• Exacerbation lasting longer than 5 days.

Doctors conditionally share the forms of COPD:

1. Bronchitic - centroacinar emphysema develops (patients - blue edema). This is a severe variant of COPD - the development of respiratory failure and the occurrence of cor pulmonale occurs in a short time.
2. Emphysematous form of chronic obstructive disease - panacinar emphysema is formed (patients are pink puffers). Symptoms increase slowly.

Diagnostics

First of all, the doctor collects anamnesis - asks the patient about the presence of risk factors, collects a description of the symptoms. In smokers, the smoker's IR index is analyzed: the number of cigarettes smoked per day is multiplied by the years of smoking and divided by 20.

If the IC is more than 10, it means that with a high degree of probability it develops COPD.

During the examination, the doctor looks at:

• The tint of the skin is usually bluish;
• The presence of a barrel-shaped inactive deformity of the chest;
• The fingers on the hands are like drumsticks;
• When the lungs are tapped, a boxed sound is heard;
• When listening, weakened or hard breathing with a whistle is noted.

To confirm the diagnosis of obstructive chronic disease, the doctor prescribes the following studies:

1. To assess the work of the lungs, spirometry is prescribed, which shows the amount of inhaled and exhaled air, the speed of its entry and exit.
2. A test with a bronchodilator is performed, showing the likelihood of reversibility of the narrowing of the bronchus.
3. X-rays determine the severity of changes in the lungs and allow a diagnosis of sarcoidosis of the lungs.
4. For the selection of antibiotics, sputum analysis is performed.

Also, from additional methods for diagnosing COPD, CT of the lungs, ECG, ultrasound of the heart, a test with physical activity can be prescribed.

Laboratory diagnosis of COPD includes:

• Coagulogram;
• Determination of blood gas composition;
• Immunological tests.

By the nature of shortness of breath, COPD should be differentiated from bronchial asthma. Shortness of breath with asthma during exertion appears after a while, with COPD - instantly.

X-rays help differentiate COPD from bronchiectasis and heart failure. Bronchoscopy and sputum analysis help differentiate chronic obstructive disease from tuberculosis.

Treatment

COPD is still considered an incurable disease, therefore the main tasks of therapy are to relieve symptoms, improve the quality of life, and inhibit the progression of a chronic disease.

After the diagnosis of obstructive pulmonary disease, smoking should be quit immediately and permanently. Otherwise, no treatment will be effective.

When working in hazardous industries, it is imperative to use PPE, and even better, change your occupation.

You need to pay attention to nutrition: if the body mass index is exceeded, it is necessary to return it to normal. Light but regular physical activity will be useful: swimming, walking, breathing exercises. Be sure to walk in the fresh air every day.

The doctor will prescribe the treatment of obstructive disease with medications:

1. Inhalers are used primarily to facilitate breathing in COPD. In the form of inhalations, they are administered to stimulate the expansion of the bronchi. The treatment standards include medicines based on: tiotropium bromide - Tiotropium-Nativ, Spiriva; formoterol - Atimos, Foradil, Oxis Turbuhaler; salmeterol - salmeterol, serevent. All of these drugs are available in the form of ready-made inhalers or nebulizer solutions. Of the tablets, theophylline-based medicines can be mentioned - Teotard, Teopek.
2. If basic therapy is ineffective, hormone treatment is used. For the treatment of chronic obstructive disease, systemic and inhaled glucocorticosteroids are prescribed - Beklazon-ECO, Flixotide, Pulmicort. Fixed combinations of hormonal and bronchodilating medications can be prescribed: Seretide and Symbicort.
3. In case of chronic obstructive disease, it is imperative to regularly vaccinate the body against influenza - the annual vaccination is carried out in October - November.
4. The prescription of mucolytics - bromhexine, ambroxol, chymotrypsin, trypsin, etc. will facilitate mucus elimination. Mucolytics are prescribed only for patients with COPD with viscous sputum.
5. With an exacerbation of chronic obstructive disease, antibiotics are prescribed - penicillins, cephalosporins, fluoroquinolones.
6. In courses of up to six months, you can take antioxidants to reduce the frequency and duration of exacerbations.

For severe COPD, surgical treatments may be prescribed:

1. To improve the functionality of the lungs, the removal of large bulls is performed - bullectomy.
2. To significantly improve the quality of life, lung transplantation is performed (if a donor is available).

In severe exacerbations of obstructive pulmonary disease, oxygen therapy (inhalation with humidified oxygen) is performed. The procedure is carried out to stabilize respiratory failure: with exacerbations - short-term, with the fourth degree - long-term.

In some cases, continuous long-term oxygen therapy is prescribed - 15 hours every day.

If the family has a patient with COPD, it is very important to know how to behave during an exacerbation of the disease with severe shortness of breath. First aid in this condition is inhalation of short-acting drugs - Atrovent, Salbutamol, Berodual.

If there is a nebulizer in the house (and its use is considered more effective), you can use the medicines Atrovent and Berodual N. Also, in case of an attack of chronic obstructive disease, you should ensure the flow of fresh air into the room.

Video

Prevention

There is no specific prophylaxis against obstructive pulmonary disease, since the mechanism of its development is not fully understood. Of course, a person who monitors their health should completely quit smoking, participate in the annual flu and pneumococcal vaccination.

Also, awareness of the population about COPD allows a person at risk to listen more carefully to their body and identify the disease at the initial stage.

Chronic obstructive pulmonary disease (COPD) - symptoms and treatment

What is chronic obstructive pulmonary disease (COPD)? We will analyze the causes of occurrence, diagnosis and treatment methods in the article by Dr. Nikitin I.L., an ultrasound doctor with 25 years of experience.

Definition of disease. Causes of the disease

Chronic obstructive pulmonary disease (COPD) - a disease that is gaining momentum, moving forward in the ranking of causes of death for people over 45 years old. Today the disease ranks 6th among the leading causes of death in the world, according to WHO forecasts in 2020, COPD will take 3rd place.

This disease is insidious in that the main symptoms of the disease, in particular, with tobacco smoking, appear only 20 years after the start of smoking. It does not give clinical manifestations for a long time and may be asymptomatic, however, in the absence of treatment, airway obstruction imperceptibly progresses, which becomes irreversible and leads to early disability and a reduction in life expectancy in general. Therefore, the topic of COPD seems to be especially relevant these days.

It is important to know that COPD is a primary chronic disease in which early diagnosis is important in the initial stages, since the disease tends to progress.

If the doctor diagnosed "Chronic obstructive pulmonary disease (COPD)", the patient has a number of questions: what does it mean, how dangerous it is, what to change in the lifestyle, what is the prognosis of the course of the disease?

So, chronic obstructive pulmonary disease or COPD Is a chronic inflammatory disease with damage to the small bronchi (airways), which leads to impaired breathing due to narrowing of the lumen of the bronchi. Over time, emphysema develops in the lungs. This is the name of a condition in which the elasticity of the lungs decreases, that is, their ability to contract and expand during breathing. At the same time, the lungs are constantly, as if in a state of inhalation, there is always a lot of air in them, even during exhalation, which disrupts normal gas exchange and leads to the development of respiratory failure.

Causes of COPD are:

• exposure to harmful environmental factors;
• smoking;
• occupational hazards (dust containing cadmium, silicon);
• general environmental pollution (car exhaust gases, SO 2, NO 2);
• frequent respiratory tract infections;
• heredity;
• deficiency of α 1 -antitrypsin.

If you find similar symptoms, consult your doctor. Do not self-medicate - it is dangerous for your health!

Symptoms of chronic obstructive pulmonary disease

COPD - a disease of the second half of life, often develops after 40 years. The development of the disease is a gradual long process, often invisible to the patient.

Appearing to see a doctor dyspnea and cough- the most common symptoms of the disease (shortness of breath is almost constant; frequent and daily cough, with expectoration in the morning).

A typical patient with COPD is a 45-50 year old smoker who complains of frequent shortness of breath during exercise.

Cough- one of the earliest symptoms of the disease. It is often underestimated by patients. In the initial stages of the disease, coughing is episodic, but later becomes daily.

Sputum also a relatively early symptom of the disease. In the early stages, it is excreted in small amounts, mainly in the morning. The character is slimy. Purulent profuse sputum appears during an exacerbation of the disease.

Dyspnea occurs in the later stages of the disease and is noted at first only with significant and intense physical activity, and intensifies with respiratory diseases. In the future, shortness of breath is modified: the feeling of lack of oxygen during normal physical exertion is replaced by severe respiratory failure and increases over time. It is shortness of breath that becomes a common reason to see a doctor.

When is COPD suspected?

Here are some questions about the early diagnosis of COPD algorithm:

• Do you cough several times every day? Does it bother you?
• Does coughing up sputum or mucus (often / daily)?
• Do you experience shortness of breath faster / more often than your peers?
• Are you over 40?
• Do you smoke and have you had to smoke before?

If more than 2 questions are answered positively, spirometry with a bronchodilation test is necessary. With an FEV test score of 1 / FVC ≤ 70, a suspicion of COPD is determined.

Pathogenesis of chronic obstructive pulmonary disease

With COPD, both the airways and the tissue of the lung itself - the pulmonary parenchyma - are affected.

The disease begins in the small airways with their clogging with mucus, accompanied by inflammation with the formation of peribronchial fibrosis (thickening of the connective tissue) and obliteration (overgrowth of the cavity).

With the formed pathology, the bronchitic component includes:

The emphysematous component leads to the destruction of the terminal sections of the airways - the alveolar walls and supporting structures with the formation of significantly expanded air spaces. The lack of a tissue frame of the airways leads to their narrowing due to the tendency to dynamic collapse during exhalation, which causes expiratory collapse of the bronchi.

In addition, the destruction of the alveolar-capillary membrane affects the gas exchange processes in the lungs, reducing their diffuse capacity. As a result, there is a decrease in oxygenation (oxygen saturation of the blood) and alveolar ventilation. Excessive ventilation of insufficiently perfused zones occurs, leading to an increase in ventilation of the dead space and a violation of the removal of carbon dioxide CO 2. The area of \u200b\u200bthe alveolar-capillary surface is reduced, but may be sufficient for gas exchange at rest, when these abnormalities may not appear. However, during physical exertion, when the demand for oxygen increases, if there are no additional reserves of gas exchange units, then hypoxemia occurs - a lack of oxygen in the blood.

The emerging hypoxemia with long-term existence in patients with COPD includes a number of adaptive reactions. Damage to the alveolar-capillary units causes an increase in pressure in the pulmonary artery. Since the right ventricle of the heart in such conditions must develop more pressure to overcome the increased pressure in the pulmonary artery, it hypertrophies and expands (with the development of right ventricular heart failure). In addition, chronic hypoxemia can cause an increase in erythropoiesis, which subsequently increases blood viscosity and increases right ventricular failure.

Classification and stages of development of chronic obstructive pulmonary disease

Complications of chronic obstructive pulmonary disease

Complications of COPD are infections, respiratory failure, and chronic cor pulmonale. Bronchogenic carcinoma (lung cancer) is also more common in patients with COPD, although it is not a direct complication of the disease.

Respiratory failure - the state of the external respiration apparatus, in which either the O 2 and CO 2 voltage in the arterial blood is not maintained at a normal level, or it is achieved due to the increased work of the external respiration system. It manifests itself mainly as shortness of breath.

Chronic pulmonary heart - an increase and expansion of the right heart, which occurs with an increase in blood pressure in the pulmonary circulation, which developed, in turn, as a result of pulmonary diseases. Shortness of breath is also the main complaint of patients.

Diagnosis of chronic obstructive pulmonary disease

If patients have cough, sputum production, shortness of breath, and risk factors for the development of chronic obstructive pulmonary disease have been identified, then all of them should be presumed to have a diagnosis of COPD.

In order to establish a diagnosis, data are taken into account clinical examination (complaints, history, physical examination).

Physical examination may reveal symptoms characteristic of long-term bronchitis: "watch glasses" and / or "drumsticks" (deformation of the fingers), tachypnea (rapid breathing) and shortness of breath, a change in the shape of the chest (emphysema is characterized by a barrel-shaped form), small its mobility during breathing, the retraction of the intercostal spaces during the development of respiratory failure, the lowering of the borders of the lungs, a change in percussion sound to a boxed one, weakened vesicular breathing or dry wheezing rales, which intensify with forced exhalation (that is, rapid exhalation after a deep breath). Heart sounds can be difficult to listen to. In the later stages, diffuse cyanosis, severe shortness of breath, and peripheral edema may appear. For convenience, the disease is divided into two clinical forms: emphysematous and bronchitis. Although in practical medicine, cases of a mixed form of the disease are more common.

The most important step in diagnosing COPD is respiratory function analysis (FVD)... It is necessary not only to determine the diagnosis, but also to establish the severity of the disease, draw up an individual treatment plan, determine the effectiveness of therapy, clarify the prognosis of the course of the disease and assess the ability to work. Establishing the percentage of FEV 1 / FVC is most often used in medical practice. A decrease in the forced expiratory volume in the first second to the forced vital capacity of the lungs FEV 1 / FVC up to 70% is an initial sign of airflow limitation even with the preserved FEV 1\u003e 80% of the proper value. A low peak expiratory flow rate, which does not change significantly with bronchodilators, also favors COPD. With newly diagnosed complaints and changes in the parameters of the FVD, spirometry is repeated throughout the year. Obstruction is defined as chronic if it is fixed at least 3 times a year (regardless of the treatment), and COPD is diagnosed.

FEV monitoring 1 is an important method of confirming the diagnosis. Spireometric measurement of the FEV 1 index is carried out repeatedly over several years. The rate of the annual decline in FEV 1 for people of mature age is within 30 ml per year. For patients with COPD, a typical indicator of such a drop is 50 ml per year or more.

Bronchodilator test - initial examination, in which the maximum FEV 1 is determined, the stage and severity of COPD are established, and bronchial asthma is excluded (with a positive result), the tactics and scope of treatment are selected, the effectiveness of therapy is assessed and the course of the disease is predicted. It is very important to distinguish COPD from bronchial asthma, since these common diseases have the same clinical manifestation - broncho-obstructive syndrome. However, the approach to treating one disease is different from another. The main distinguishing feature in the diagnosis is the reversibility of bronchial obstruction, which is a characteristic feature of bronchial asthma. It has been established that in people diagnosed with CO BL after taking a bronchodilator percentage increase in FEV 1 - less than 12% of the initial (or ≤200 ml), and in patients with bronchial asthma, it usually exceeds 15%.

Chest x-ray has an auxiliary signstudy, since changes appear only in the later stages of the disease.

ECG can reveal changes that are characteristic of cor pulmonale.

Echocardiographyis necessary to identify the symptoms of pulmonary hypertension and changes in the right heart.

General blood analysis - with its help, you can assess the indicators of hemoglobin and hematocrit (can be increased due to erythrocytosis).

Determination of blood oxygen level (SpO2) - pulse oximetry, a non-invasive study to clarify the severity of respiratory failure, usually in patients with severe bronchial obstruction. Blood oxygen saturation of less than 88%, determined at rest, indicates severe hypoxemia and the need for oxygen therapy.

Treatment of chronic obstructive pulmonary disease

COPD treatment promotes:

• decrease in clinical manifestations;
• increasing exercise tolerance;
• prevention of disease progression;
• prevention and treatment of complications and exacerbations;
• improving the quality of life;
• decrease in mortality.

The main areas of treatment include:

• weakening the degree of influence of risk factors;
• educational programs;
• drug treatment.

Reducing the influence of risk factors

Quitting smoking is a must. This is the most effective way to reduce the risk of developing COPD.

Industrial hazards should also be controlled and mitigated by using adequate ventilation and air purifiers.

Educational programs

COPD education programs include:

• basic knowledge of the disease and general treatment approaches to encourage patients to quit smoking;
• training in how to properly use individual inhalers, spacers, nebulizers;
• practice of self-control using peak flow meters, the study of emergency self-help measures.

Patient education plays a significant role in patient care and affects future prognosis (level of evidence A).

The peak flowmetry method enables the patient to independently monitor the peak forced expiratory volume on a daily basis - an indicator that closely correlates with the FEV 1 value.

Patients with COPD are shown physical training programs at each stage to increase exercise tolerance.

Drug treatment

Pharmacotherapy for COPD depends on the stage of the disease, the severity of symptoms, the severity of bronchial obstruction, the presence of respiratory or right ventricular failure, concomitant diseases. Drugs that fight COPD are divided into drugs for relieving an attack and for preventing the development of an attack. Preference is given to inhaled forms of drugs.

To relieve rare attacks of bronchospasm, inhalations of short-acting β-adrenostimulants are prescribed: salbutamol, fenoterol.

Preparations for the prevention of seizures:

• formoterol;
• tiotropium bromide;
• combined drugs (berotek, berovent).

If the use of inhalation is not possible or their effectiveness is insufficient, then theophylline may be necessary.

With a bacterial exacerbation of COPD, antibiotics are required. Can be used: amoxicillin 0.5-1 g 3 times a day, azithromycin 500 mg for three days, clarithromycin CP 1000 mg once a day, clarithromycin 500 mg 2 times a day, amoxicillin + clavulanic acid 625 mg 2 times a day, cefuroxime 750 mg 2 times a day.

Glucocorticosteroids, which are also administered by inhalation (beclomethasone dipropionate, fluticasone propionate), also help relieve symptoms of COPD. If COPD is stable, then the appointment of systemic glucocorticosteroids is not indicated.

Traditional expectorants and mucolytics have little benefit in patients with COPD.

In severe patients with a partial pressure of oxygen (pO 2) 55 mm Hg. Art. and less oxygen therapy is indicated at rest.

Forecast. Prevention

The prognosis of the disease is influenced by the stage of COPD and the number of recurrent exacerbations. At the same time, any exacerbation negatively affects the overall course of the process, therefore, the earliest possible diagnosis of COPD is highly desirable. Treatment for any exacerbation of COPD should be started as early as possible. It is also important to have a full-fledged exacerbation therapy, in no case should it be tolerated "on the legs".

Often people decide to see a doctor for medical help, starting with stage II of moderate severity. At stage III, the disease begins to have a rather strong effect on the patient, the symptoms become more pronounced (increased shortness of breath and frequent exacerbations). At stage IV, there is a noticeable deterioration in the quality of life, each exacerbation becomes a threat to life. The course of the disease becomes disabling. This stage is accompanied by respiratory failure, the development of a pulmonary heart is not excluded.

The prognosis of the disease is influenced by patient compliance with medical recommendations, adherence to treatment and a healthy lifestyle. Continued smoking contributes to the progression of the disease. Smoking cessation slows the progression of the disease and slows down the decline in FEV 1. Due to the fact that the disease has a progressive course, many patients have to take medicines for life, many require gradually increasing doses and additional funds during exacerbations.

The best means of preventing COPD are: a healthy lifestyle that includes good nutrition, hardening of the body, reasonable physical activity, and the elimination of exposure to harmful factors. Quitting smoking is an absolute condition for preventing COPD exacerbation. The existing occupational hazards, when diagnosed with COPD, are a sufficient reason to change jobs. Preventive measures also include avoiding hypothermia and limiting contact with people with SARS.

In order to prevent exacerbations, patients with COPD are shown annual influenza vaccination. People with COPD aged 65 and older and patients with FEV 1< 40% показана вакцинация поливалентной пневмококковой вакциной.