Broncho-obstructive syndrome in children recommendations. Broncho-obstructive syndrome at the prehospital stage

… from 30 to 50% of children in the first three years of life have some form of broncho-obstructive syndrome.

Broncho-obstructive syndromeIs a pathophysiological concept that characterizes the violation of bronchial patency in a very wide range of acute and chronic diseases. Broncho-obstructive syndrome is not synonymous with bronchospasm, although in many cases, bronchospasm plays an important and sometimes leading role in the genesis of the disease.

Usually, broncho-obstructive syndrome is detected in children during the first four years of life, but it can be diagnosed at an older age.

In the genesis of bronchial obstruction are various pathogenetic mechanisms, which can be conditionally divided into:
reversible (functional): bronchospasm, inflammatory infiltration, edema, mucociliary insufficiency, hypersecretion of viscous mucus;
irreversible: congenital stenosis of the bronchi, their obliteration, etc.

In the development of bronchial obstruction, a certain role is played by age characteristics characteristic of children in the first three years of life:
the narrowness of the bronchi and the entire respiratory system, which significantly increases aerodynamic resistance (according to the Poiselle rule, the resistance of the airways is inversely proportional to their radius to the 4th degree);
compliance of the cartilage of the bronchial tract;
insufficient rigidity of the bone structure of the chest, which freely reacts by retraction of compliant places to increase resistance in the airways;
features of the position and structure of the diaphragm;
features of the bronchial wall: a large number of goblet cells that secrete mucus;
the mucous membrane of the trachea and bronchi quickly reacts with edema and hypersecretion of mucus in response to the development of a viral infection;
increased viscosity of bronchial secretions associated with high levels of sialic acid;
imperfection of immunological mechanisms: the formation of interferon in the upper respiratory tract, serum immunoglobulin A, secretory immunoglobulin A is significantly reduced, the functional activity of the T-immune system is also reduced;
the functional disorders of the respiratory system in a small child are also influenced by such factors as longer sleep, frequent crying, and a predominant supine position in the first months of life.

Broncho-obstructive syndrome is most often infectious and allergic in nature. The viruses that most often cause broncho-obstructive syndrome include respiratory syncytial virus, parainfluenza, less often influenza viruses and adenovirus; a large role is played by intracellular pathogens (chlamydial and mycoplasma infections). It has been reported that broncho-obstructive syndrome is associated with some types of pathogenic microflora secreted from sputum or bronchial secretions, for example, with Moraxella catarrhalis, Candida fungi.

Of particular importance among the environmental factors that can lead to the development of obstructive syndrome (especially in children of the first three years of life) is attached to:
passive smoking in the family (tobacco smoke provokes hypertrophy of the bronchial mucous glands, impaired mucociliary clearance, slowing down the movement of mucus, destruction of the bronchial epithelium);
pollution of the surrounding atmosphere with industrial gases, organic and inorganic dust.

There are the following groups of diseases accompanied by broncho-obstructive syndrome:
respiratory diseases: bronchitis, bronchiolitis, pneumonia, obstructive bronchitis, bronchial asthma, bronchopulmonary dysplasia, malformations of the bronchopulmonary system, tumors of the trachea and bronchi;
foreign bodies of the trachea, bronchi, esophagus;
diseases of aspiration genesis (or aspiration obstructive bronchitis): gastroesophageal reflux, tracheoesophageal fistula, malformations of the gastrointestinal tract, diaphragmatic hernia;
diseases of the cardiovascular system, congenital and acquired nature: congenital heart disease with hypertension of the pulmonary circulation, vascular anomalies, congenital non-rheumatic carditis, etc.);
diseases of the central and peripheral nervous system: birth trauma, myopathy, etc.;
hereditary metabolic anomalies: cystic fibrosis, 1-antitrypsin deficiency, mucopolysaccharidosis;
congenital and acquired immunodeficiency states;
rare hereditary diseases;
other conditions: injuries and burns, poisoning, exposure to various physical and chemical factors of the external environment; compression of the trachea and bronchi of extrapulmonary origin (tumors, lymphogranulomatosis).

Clinical picturebroncho-obstructive syndrome (BOS) in children is determined primarily by the factors that caused bronchoconstriction. Since in most cases, as noted above, biofeedback is associated with manifestations of an acute respiratory viral infection, therefore, let us consider the clinical picture of biofeedback associated with an acute respiratory viral infection (acute obstructive bronchitis).

At the beginning of the disease, there is a rise in body temperature, catarrhal changes in the upper respiratory tract, a violation of the general condition of the child; their severity and character vary greatly depending on which pathogen caused the disease.

Signs of expiratory breathing difficulties can appear both on the first day of the illness and during the course of a viral infection (on the 3-5th day of illness). Respiration rate and expiration duration gradually increase. Breathing becomes noisy and wheezing, which is due to the fact that as hypersecretion develops, secretion accumulates in the lumen of the bronchi due to shortness of breath and fever, the viscous properties of the secretion change - it "dries up", which leads to the appearance of humming (low) and wheezing (high) dry wheezing.

The defeat of the bronchi is common, and therefore hard breathing with dry whistling and buzzing rales is heard equally over the entire surface of the chest. Wheezing can be heard from a distance. The younger the child, the more often, in addition to dry, wet, medium-bubble wheezing can be heard. If the spastic component plays a leading role in the genesis of bronchial obstruction, then the auscultatory data over the lungs are usually more diverse and labile during the day.

As the severity of shortness of breath increases, the participation of the auxiliary muscles becomes more and more - retraction of the intercostal spaces, epigastrium and supraclavicular fossae, inflation (tension) of the wings of the nose. Perioral cyanosis, pallor of the skin are often detected, the child becomes restless, tries to take a sitting position with support on his hands.

Respiratory failure is the more pronounced, the younger the child, but usually with biofeedback it does not exceed the II degree. On physical examination, in addition to scattered dry wheezing and hard breathing, they show signs of swelling of the lungs: narrowing of the boundaries of relative cardiac dullness, a boxed shade of percussion tone.

Bloating of the lungs is a consequence of the collapse of small bronchial branches on exhalation, which leads to the so-called ventilation emphysema. The lung volume increases. The chest is, as it were, constantly in a state of inspiration, that is, it is enlarged in the anteroposterior size.

Changes in peripheral blood correspond to the nature of the viral infection. The bacterial flora is rarely layered - no more than 5%. Radiographically, in addition to bilateral enhancement of the pulmonary pattern and expansion of the roots of the lungs, they reveal: low standing of the flattened domes of the diaphragm, increased transparency of the pulmonary fields, lengthening of the pulmonary fields, the horizontal arrangement of the ribs on the roentgenogram, that is, signs of swelling of the lungs.

Treatmentbroncho-obstructive syndrome is based on the etiological principle (etiotropic therapy) and is complex in nature. For example, in chronic lung diseases, treatment includes the use of antibacterial drugs (according to indications), mucolytics, bronchodilators and various methods that improve the evacuation of sputum (therapeutic bronchoscopy, positional drainage, vibration massage of the chest), etc.

Sharp corner

Broncho-obstructive syndrome in children

D.Yu. Ovsyannikov

Doctor of Medical Sciences, Head of the Department of Pediatrics, Peoples' Friendship University of Russia

“Bronchial obstructive syndrome” (BOS) is a pathophysiological concept that characterizes the violation of bronchial patency in patients with acute and chronic diseases. The term “broncho-obstructive syndrome” does not mean an independent diagnosis, since BFB is heterogeneous in nature and can be a manifestation of many diseases (Table 1).

The main pathogenetic mechanisms of bronchial obstruction include: 1) thickening of the bronchial mucosa as a result of inflammatory edema and infiltration; 2) hypersecretion and change in the rheological properties of bronchial secretions with the formation of mucous plugs (obturation, the main mechanism of bronchial obstruction in bronchiolitis); 3) spasm of bronchial smooth muscles (the importance of this component increases with the age of the child and with repeated episodes of bronchial obstruction); 4) remodeling (fibrosis) of the submucosal layer (an irreversible component of bronchial obstruction in chronic diseases); 5) bloating of the lungs, increasing obstruction due to compression of the airways. The specified furs

nizmas are expressed to varying degrees in children of different ages and with different diseases.

Common clinical signs of bronchial obstruction include tachypnea, expiratory dyspnea involving accessory muscles, noisy wheezing (in the English literature, this symptom

lex got the name wheezing), chest distension, wet or paroxysmal, spastic cough. With severe bronchial obstruction, cyanosis and other symptoms of respiratory distress (DN) may occur. Scattered moist fine bubbling rales, dry wheezing are determined by auscultation

Table 1. Diseases with biofeedback in children

Acute diseases Chronic diseases

Acute obstructive bronchitis / acute bronchiolitis Aspiration of foreign bodies (acute phase) Helminthiasis (ascariasis, toxocariasis, pulmonary phase) Bronchial asthma Bronchopulmonary dysplasia Bronchiectatic disease Aspiration bronchitis Cystic fibrosis Obliterating bronchiolitis pulmonary artery disease Congenital heart disease Syndrome

Table 2. Classification of DN by severity

DN degree PaO2, mm Hg Art. SaO2,% Oxygen therapy

Norm\u003e 80\u003e 95 -

I 60-79 90-94 Not shown

II 40-59 75-89 Oxygen through nasal cannulas / mask

III<40 <75 ИВЛ

Designations: mechanical ventilation - artificial lung ventilation, Pa02 - oxygen partial pressure.

The information in this section is intended for healthcare professionals only.

Table 3. Differential diagnostic signs of AHB and acute bronchio-litis in children

Sign Acute obstructive bronchitis Acute bronchiolitis

Age More often in children over 1 year of age More often in infants

Broncho-obstructive syndrome From the onset of the disease or on the 2-3rd day of the illness On the 3-4th day from the onset of the illness

Wheezing Severe Not always

Shortness of breath Moderate Severe

Tachycardia No Yes

Auscultatory picture in the lungs Whistling, moist fine bubbling rales Wet fine bubbling rales, crepitus, diffuse weakening of breathing

wheezing, percussion-boxed tone of pulmonary sound, narrowing of the borders of cardiac dullness. A chest x-ray may show signs of pulmonary emphysema. Transcutaneous pulse oximetry, on the basis of which the degree of blood oxygen saturation (saturation, SaO2), is determined (Table 2) allows objectifying the degree of DN and determining indications for oxygen therapy.

Broncho-obstructive syndrome for respiratory infections

In respiratory infections, biofeedback can be a manifestation of acute obstructive bronchitis (AOB) or acute bronchiolitis - infectious and inflammatory diseases of the bronchi, accompanied by clinically severe bronchial obstruction. Acute bronchiolitis is a variant of AR with the defeat of small bronchi and bronchioles in children of the first two years

life. The main etiological factors of AR and acute bronchiolitis are respiratory viruses, more often respiratory syncytial virus.

The onset of the disease is acute, with catarrhal symptoms, body temperature is normal or subfebrile. Clinical signs of biofeedback can appear both on the first day and 2-4 days after the onset of the disease. In infants, especially preterm infants, apnea may occur, usually at the onset of the illness, before symptoms of respiratory distress become apparent. The differences in the clinical picture of AR and bronchiolitis are presented in table. 3.

Broncho-obstructive syndrome in bronchial asthma

Bronchial asthma (BA) is the most common chronic lung disease in children. Currently, BA in children is considered as a chronic allergic (atopic) inflammatory respiratory disease.

pathways, accompanied by increased sensitivity (hyperreactivity) of the bronchi and manifested by bouts of shortness of breath or suffocation as a result of widespread narrowing of the bronchi (bronchial obstruction). BFB in BA is based on bronchospasm, increased mucus secretion, edema of the bronchial mucosa. Bronchial obstruction in BA patients is reversible spontaneously or with treatment.

The following signs increase the likelihood of a child with BA:

Atopic dermatitis in the first year of life;

Development of the first episode of biofeedback at the age of over 1 year;

High level of general / specific immunoglobulins E (^ E) or positive results of skin allergy tests, eosinophilia of peripheral blood;

The presence of atopic diseases in parents and, to a lesser extent, in other relatives;

A history of three or more episodes of bronchial obstruction, especially without an increase in body temperature and after contact with non-infectious triggers;

Night cough, cough after exercise;

Frequent acute respiratory diseases that occur without an increase in body temperature.

In addition, it is necessary to assess the effect of the elimination and use of P2-agonists - a rapid positive dynamics of clinical symptoms of bronchial obstruction after termination of contact with a causal

The information in this section is intended for healthcare professionals only.

allergen (for example, during hospitalization) and after inhalation.

A great achievement in the development of diagnostic criteria for BA in children was the international recommendations of the working group, including 44 experts from 20 countries, PRACTALL (Practical Allergology Pediatric Asthma Group). According to this document, persistent asthma is diagnosed when bronchial obstruction is combined with the following factors: clinical manifestations of atopy (eczema, allergic rhinitis, conjunctivitis, food allergy); eosinophilia and / or an increased level of total IgE in the blood (in this regard, it should be noted that the experts of GINA (The Global Initiative for Asthma - Global Strategy for the Treatment and Prevention of Bronchial Asthma) do not consider an increase in the level of total IgE to be a marker of atopy due to the high variability of this indicator ); specific IgE-mediated sensitization to food allergens in infancy and early childhood and to inhalation allergens in the future; sensitization to inhalation allergens under the age of 3 years, especially with sensitization and a high level of exposure to household allergens at home; the presence of BA in parents.

A number of clinical-anamnestic and laboratory-instrumental signs increase the likelihood of the diagnostic hypothesis that BFB in this patient is not BA, but is a manifestation of other diseases (see Table 1).

These signs include the following:

Onset of symptoms at birth;

Artificial ventilation of the lungs, respiratory distress syndrome in the neonatal period;

Neurological dysfunction;

Lack of effect from glucocorticosteroid therapy;

Wheezing associated with feeding or vomiting, difficulty swallowing and / or vomiting;

Poor weight gain;

Long-term oxygen therapy;

Deformation of the fingers (“drum sticks”, “watch glasses”);

Heart murmurs;

Stridor;

Local changes in the lungs;

Irreversible airway obstruction;

Persistent radiological changes.

In case of recurrence of broncho-obstructive syndrome, the child needs an in-depth examination to clarify the diagnosis and exclude bronchial asthma.

Thus, in case of recurrence of biofeedback, the child needs an in-depth examination to clarify the diagnosis. Until recently, in Russia, along with the term “acute obstructive bronchitis”, the term “recurrent obstructive bronchitis” was used (in accordance with the 1995 classification of bronchopulmonary diseases in children). In revising this

classification of 2009, this diagnosis was excluded due to the fact that asthma and other chronic diseases that require timely diagnosis often occur under the guise of recurrent obstructive bronchitis.

Treatment of biofeedback in children

The first-line drugs for biofeedback are inhaled bronchodilators. The response to these drugs, taking into account the heterogeneity of the etiology and pathogenesis of biofeedback, is variable and depends on the patient's disease. Thus, there is no evidence of the effectiveness of bronchodilators in patients with acute bronchiolitis (both inhalation and oral, including clenbuterol and salbutamol as part of complex preparations).

For the treatment of AD in children, the same classes of drugs are used as in adults. However, the use of existing drugs in children is associated with certain characteristics. To a large extent, these features relate to the means of delivery of inhaled drugs into the respiratory tract. In children, the use of metered-dose aerosol inhalers (MDIs) with bronchodilators is often difficult due to the lack of inhalation technique due to age characteristics and / or the severity of the condition, which affects the dose of the drug entering the lungs and, consequently, the response ... The use of AIM requires precise technique, which is not always able to master not only children,

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Ipratropium bromide:

Fenoterol *

M-anticholinergic selective P2-agonist

Features of the pharmacological action of the components of Berodual (ipratropium bromide 21 mcg + fenoterol 50 mcg). * Acts primarily in the proximal respiratory tract. ** Effects mainly in the distal respiratory tract.

but also adults. The larger the aerosol particles and the higher their initial velocity, the more of them will remain in the oropharynx, colliding with its mucous membrane. To enhance the efficiency of the use of AIM, it is necessary to reduce the speed of the aerosol jet, which is achieved by using a spacer. In addition, during the period of BA exacerbation, when using a spacer, less coordination of inspiration is required. The spacer is an additional device to the MDI in the form of a tube (less often of another shape) and is intended to improve the delivery of a drug into the respiratory tract. The spacer has two holes - one is for the inhaler, through the other the aerosol with the medicine enters the oral cavity, and then into the respiratory tract.

To relieve acute bronchial obstruction in BA patients, P2-agonists (formo-terol, salbutamol, fenoterol), anticholinergic drugs (ipratropium bromide), methylxanthines are used. The main mechanisms

reversible bronchial obstruction in children with asthma is spasm of bronchial smooth muscles, mucus hypersecretion, and mucosal edema. Edema of the mucous membrane of the bronchi and hypersecretion of mucus are the leading mechanisms of the development of bronchial obstruction in young children, which in the clinical picture is manifested by the predominance of moist wheezing. Together

The use of ipratropium bromide in combination with P2-agonists in the treatment of children with exacerbation of bronchial asthma improves respiratory function, reduces the duration and number of inhalations, and reduces the frequency of subsequent visits.

however, the effect of bronchodilators on these developmental mechanisms of biofeedback is different. So, P2-agonists and aminophylline have a predominant effect on bronchospasm, and M-anticholinergics - on edema of the mucous membrane. Such heterogeneity of action of different bronchodilators is associated with the distribution

by the reduction of adrenergic receptors and M-cholinergic receptors in the respiratory tract. In small-caliber bronchi, in which bronchospasm dominates, P2-adrenergic receptors are predominantly represented, in medium and large bronchi with a predominant development of mucosal edema - cholinoreceptors (figure). These circumstances explain the necessity, effectiveness and advantages of combined (P2-agonist / M-anticholinergic) bronchodilator therapy in children.

The use of ipratropium bromide in combination with P2-agonists in the treatment of children with exacerbation of asthma in the emergency department helps to improve respiratory function, reduce the duration and number of inhalations, and reduce the frequency of subsequent visits. In an observational study in children under 2 years of age, a significant effect of the use of an aerosol of an anticholinergic drug was not proven, but the effect of using a combination of ipratropium bromide and a P2-agonist was noted. In a systematic review of 13 randomized controlled trials involving children with asthma aged 18 months to 17 years, it was found that in severe attacks of the disease, the use of several inhalations of ipratropium bromide in combination with a P2-agonist (for example, fenoterol) improves the forced expiratory volume in 1 second and reduces the frequency of hospitalizations to a greater extent than P2-agonist monotherapy. In children with mild to moderate

The information in this section is intended for healthcare professionals only.

in small attacks, this therapy also improved respiratory function. In this regard, inhalation of ipratropium bromide is recommended in children with exacerbation of asthma, especially in the absence of a positive effect after the initial use of inhaled P2-agonists.

According to the recommendations of GINA (2014) and the Russian National Program “Bronchial asthma in children. Treatment strategy and prevention ”(2012), a fixed combination of fenoterol and ipratropium bromide (Berodual) is the drug of choice in the treatment of exacerbations, well-proven in children from an early age. With the simultaneous use of two active substances, the expansion of the bronchi occurs through the implementation of two different pharmacological mechanisms, such as a combined antispasmodic effect on the bronchial muscles and a decrease in edema of the mucous membrane.

For an effective bronchodilator effect when using this combination, a lower dose of β-adrenergic drug is required, which allows you to minimize the number of side effects and

The use of Berodual allows you to reduce the dose of b2-adreno-mimetic, which reduces the likelihood of side effects and allows you to select the dosage regimen individually for each child.

select a dosage regimen individually for each child. A small dose of fenoterol and a combination with an anticholinergic drug (1 dose of Berodual N - 50 μg of fenoterol and 20 μg of ipratropium bromide) determine the high efficacy and low frequency of side effects of Berodual. The bronchodilator effect of Berodual is higher than that of the original drugs separately, different

grows quickly (after 3-5 minutes) and is characterized by a duration of up to 8 hours.

At the moment, there are two pharmaceutical forms of this drug - MDI and solution for inhalation. The presence of various forms of delivery of Berodual, both in the form of a MDI and in the form of a solution for a nebulizer, allows the drug to be used in various age groups starting from the first year of life.

- a complex of symptoms characterized by impaired patency of the bronchial tree of functional or organic origin. Clinically, it is manifested by prolonged and noisy exhalation, attacks of suffocation, activation of the auxiliary respiratory muscles, dry or unproductive cough. The main diagnosis of broncho-obstructive syndrome in children includes the collection of anamnestic data, physical examination, radiography, bronchoscopy and spirometry. Treatment - bronchodilator pharmacotherapy with β2-adrenomimetics, elimination of the leading etiological factor.

Broncho-obstructive syndrome (BOS) is a clinical symptom complex characterized by narrowing or occlusion of the bronchi of various calibers due to the accumulation of bronchial secretions, wall thickening, spasm of smooth muscle muscles, decreased lung mobility or compression by surrounding structures. BFB is a common pathological condition in pediatrics, especially among children under the age of 3 years. According to various statistics, against the background of acute diseases of the respiratory system, biofeedback occurs in 5-45% of cases. In the presence of a burdened anamnesis, this figure is 35-55%. The prognosis for biofeedback varies and directly depends on the etiology. In some cases, there is a complete disappearance of clinical manifestations against the background of adequate etiotropic treatment, in others there is a chronization of the process, disability or even death.

Causes of broncho-obstructive syndrome in children

The main reason for the development of broncho-obstructive syndrome in children is infectious diseases and allergic reactions. Among acute respiratory viral infections, bronchial obstruction is most often provoked by parainfluenza viruses (type III) and MS infection. Other probable causes: congenital heart and bronchopulmonary system defects, RDS, genetic diseases, immunodeficiency states, bronchopulmonary dysplasia, aspiration of foreign bodies, GERH, round worms, regional lymph node hyperplasia, neoplasms of the bronchi and adjacent tissues, side effects of medications.

In addition to the main causes of broncho-obstructive syndrome in children, contributing factors are distinguished that significantly increase the risk of developing the disease and worsen its course. In pediatrics, these include a genetic tendency to atopic reactions, passive smoking, increased reactivity of the bronchial tree and its anatomical and physiological characteristics in infancy, thymus hyperplasia, vitamin D deficiency, feeding with artificial mixtures, body weight deficiency, and intrauterine diseases. All of them are capable of strengthening each other's influence on the child's body and aggravating the course of broncho-obstructive syndrome in children.

Pathogenetically, broncho-obstructive syndrome in children can be caused by an inflammatory reaction of the bronchial wall, spasm of smooth muscle muscles, occlusion or compression of the bronchus. The above mechanisms can cause narrowing of the bronchial lumen, impaired mucociliary clearance and thickening of secretions, edema of the mucous membrane, destruction of the epithelium in large bronchi and its hyperplasia in small ones. As a result, deterioration of patency, lung dysfunction and respiratory failure develop.

Classification of broncho-obstructive syndrome in children

Depending on the pathogenesis of broncho-obstructive syndrome in children, the following forms of pathology are distinguished:

1. BFB of allergic genesis... It occurs against the background of bronchial asthma, hypersensitivity reactions, hay fever and allergic bronchitis, Leffler's syndrome.

2. Biofeedback caused by infectious diseases... The main reasons: acute and chronic viral bronchitis, acute respiratory viral infections, pneumonia, bronchiolitis, bronchiectasis.

3. Biofeedback developed against the background of hereditary or congenital diseases... Most often it is cystic fibrosis, α-antitrypsin deficiency, Kartagener and Williams-Campbell syndromes, GERH, immunodeficiency states, hemosiderosis, myopathy, emphysema and bronchial malformations.

4. Biofeedback caused by neonatal pathologies. It often forms against the background of SDR, aspiration syndrome, stridor, hernia of the diaphragm, tracheoesophageal fistula, etc.

5. BFB as a manifestation of other nosologies. Broncho-obstructive syndrome in children can also be triggered by foreign bodies in the bronchial tree, thymomegaly, hyperplasia of regional lymph nodes, benign or malignant neoplasms of the bronchi or adjacent tissues.

According to the duration of the course, broncho-obstructive syndrome in children is divided into:

• Acute. The clinical picture is observed for no more than 10 days.
• Protracted. Signs of bronchial obstruction are detected for 10 days or longer.
• Recurrent. Acute BFB occurs 3-6 times a year.
• Continuously relapsing. It is characterized by short remissions between episodes of protracted biofeedback or their complete absence.

Symptoms of broncho-obstructive syndrome in children

The clinical picture of broncho-obstructive syndrome in children largely depends on the underlying disease or the factor that provokes this pathology. The general condition of the child in most cases is moderate, there is general weakness, moodiness, sleep disturbance, loss of appetite, signs of intoxication, etc. Directly biofeedback, regardless of etiology, has characteristic symptoms: noisy loud breathing, wheezing that is heard at a distance, a specific whistle when exhalation.

There is also the participation of auxiliary muscles in the act of breathing, attacks of apnea, shortness of breath of an expiratory (more often) or mixed nature, dry or unproductive cough. With a protracted course of broncho-obstructive syndrome in children, a barrel-shaped chest can form - expansion and protrusion of the intercostal spaces, the horizontal course of the ribs. Depending on the underlying pathology, fever, underweight, mucous or purulent nasal discharge, frequent regurgitation, vomiting, etc. may also be present.

Diagnosis of broncho-obstructive syndrome in children

Diagnosis of broncho-obstructive syndrome in children is based on the collection of anamnestic data, objective research, laboratory and instrumental methods. When a mother is interviewed by a pediatrician or neonatologist, attention is focused on possible etiological factors: chronic diseases, malformations, allergies, episodes of biofeedback in the past, etc. Physical examination of the child is very informative in case of broncho-obstructive syndrome in children. Percussion is determined by the strengthening of the pulmonary sound up to tympanitis. The auscultatory picture is characterized by hard or weakened breathing, dry, wheezing, in infancy - small-caliber moist rales.

Laboratory diagnostics for broncho-obstructive syndrome in children includes general tests and additional tests. In the KLA, as a rule, nonspecific changes are determined, indicating the presence of a focus of inflammation: leukocytosis, shift of the leukocyte formula to the left, increased ESR, in the presence of an allergic component - eosinophilia. If it is impossible to establish the exact etiology, additional tests are shown: ELISA with the determination of IgM and IgG to probable infectious agents, serological tests, a test to determine the level of chlorides in sweat if cystic fibrosis is suspected, etc.

Among the instrumental methods that can be used for broncho-obstructive syndrome in children, the most often used are radiography of the OGC, bronchoscopy, spirometry, less often CT and MRI. Radiography makes it possible to see the dilated roots of the lungs, signs of concomitant damage to the parenchyma, the presence of neoplasms or enlarged lymph nodes. Bronchoscopy allows you to identify and remove a foreign body from the bronchi, assess the patency and condition of the mucous membranes. Spirometry is carried out with a long course of broncho-obstructive syndrome in children in order to assess the function of external respiration, CT and MRI - with low information content of radiography and bronchoscopy.

Treatment, prognosis and prevention of broncho-obstructive syndrome in children

Treatment of broncho-obstructive syndrome in children is aimed at eliminating the factors causing obstruction. Regardless of the etiology, hospitalization of the child and emergency bronchodilator therapy using β2-adrenergic agonists are indicated in all cases. In the future, anticholinergic drugs, inhaled corticosteroids, systemic glucocorticosteroids can be used. Mucolytic and antihistamines, methylxanthines, infusion therapy are used as auxiliary drugs. After determining the origin of broncho-obstructive syndrome in children, etiotropic therapy is prescribed: antibacterial, antiviral, anti-tuberculosis drugs, chemotherapy. In some cases, surgery may be required. In the presence of anamnestic data indicating a possible entry of a foreign body into the respiratory tract, an emergency bronchoscopy is performed.

The prognosis for broncho-obstructive syndrome in children is always serious. The younger the child, the more difficult his condition is. Also, the outcome of biofeedback largely depends on the underlying disease. In acute obstructive bronchitis and bronchiolitis, as a rule, recovery is observed, hyperreactivity of the bronchial tree rarely remains. BFB in bronchopulmonary dysplasia is accompanied by frequent acute respiratory viral infections, but often stabilizes by the age of two. In 15-25% of these children, it is transformed into bronchial asthma. BA itself can have a different course: the mild form goes into remission already at primary school age, the severe one, especially against the background of inadequate therapy, is characterized by a deterioration in the quality of life, regular exacerbations with a fatal outcome in 1-6% of cases. BFB against the background of obliterating bronchiolitis often leads to emphysema and progressive heart failure.

Prevention of broncho-obstructive syndrome in children implies the elimination of all potential etiological factors or minimization of their impact on the child's body. This includes antenatal fetal care, family planning, medical genetic counseling, rational use of medications, early diagnosis and adequate treatment of acute and chronic diseases of the respiratory system, etc.

Every fourth child under the age of 6 undergoes bronchial obstruction, as a rule, against the background of acute respiratory viral infections 50% of children had wheezing and shortness of breath at least once in their life. Recurrent course of bronchial obstruction - in 25% of children Clough J.B., 1999 Scientific and practical program "Bronchial asthma in children ..." 2012 The prevalence of biofeedback in children of the first 6 years of life

Anatomical and physiological features of the respiratory system in young children hyperplasia of glandular tissue secretion of predominantly viscous sputum relative narrowness of the airways smaller volume of smooth muscles low collateral ventilation insufficiency of local immunity structural features of the diaphragm

1. Diseases of the respiratory system Infectious-inflammatory Allergic Bronchopulmonary dysplasia Primary ciliary dyskinesia Respiratory distress syndrome Congenital anomalies of the trachea and bronchi Cystic fibrosis Acute and chronic obliterating bronchiolitis Tuberculosis Tumors ETIOLOGY OF BRONCHOUSTRUCTURAL SYNTHESIS

1. Diseases of the respiratory system 2. Foreign bodies of the respiratory tract 3. Diseases of aspiration genesis 4. Gastroesophageal reflux disease 5. Hereditary diseases 6. Helminthiasis 7. Diseases of the cardiovascular system 8. Diseases of the nervous system 9. Immunodeficiencies 10. Other ETIOLOGY OF BRONCHOOBSTRUCTURE OF Disease Syndrome

The main reasons for the recurrent course of biofeedback in children with acute respiratory viral infections Presence of bronchial hyperactivity, developed as a result of a previous respiratory infection (including - in CWD (Frequently Affected Children) - with persistent infections) Presence of bronchial asthma Latent course of chronic bronchopulmonary disease (cystic fibrosis, Kartagener's syndrome etc.)!

Age aspect of the validity of the diagnosis: “ARI. Obstructive bronchitis. DN ... "Obstructive bronchitis (as an independent nosological form of acute respiratory infections) usually affects children in the first 4 - 5 years of life. Obstructive bronchitis (as an independent nosological form of acute respiratory infections) usually affects children in the first 4 - 5 years of life.

Predisposing factors: intrauterine growth retardation, prematurity SDR + mechanical ventilation (duration, adequacy) immunodiathesis: - atopic - atopic - lymphatic-hypoplastic - lymphatic-hypoplastic exudative-catarrhal diathesis atopic dermatitis passive smoking, etc.

Clinical picture - ARI symptoms - nonspecific: - ARI symptoms - nonspecific: fever, catarrhal phenomena (rhinitis, conjunctivitis - one or two-sided), cough, pain when swallowing, etc.) intoxication (behavior disorder, sleep - inversion is dangerous, decrease appetite, decreased exercise tolerance, vagotonia)

The clinical picture - symptoms of expiratory dyspnea on 3-5 days of illness (with repeated episodes of obstruction, dyspnea may appear on the first day) - symptoms of expiratory dyspnea on 3-5 days of illness (with repeated episodes of obstruction, shortness of breath may appear on the first day) breathing is hard with an abundance of whistling and buzzing wheezes - totally. Wet m / n (and s / n) wheezing is the more often, the younger the child is the signs of DN (the more pronounced, the younger the child is), boxed pulmonary sound due to ventilation emphysema. The rib cage is enlarged in anteroposterior size

Laboratory indicators Laboratory indicators neutropenia + lymphocytosis - ARVI leukocytosis + lymphocytosis + N ESR - whooping cough? neutrophilic leukocytosis - attachment of bacterial flora cytology of nasal secretion - eosinophilia? blood gases do not change abruptly CBS - by the severity of the patient's condition X-ray (required) - emphysema

Differential diagnosis Differential diagnosis of AD - debut? cystic fibrosis - (pilocarpine test-chlorides) obliterating bronchiolitis (zonal rheography of the lungs) foreign body micro aspiration clinical manifestation of malformations of the bronchopulmonary system

Bronchial asthma - pediatric asthma problem is more common among children than among adults. In childhood, BA accounts for more than 90% of all cases of broncho-obstructive syndrome. In 27-33% of cases of asthma begins before 1 year, in 55% of cases - up to 3 years, in 80-85% - up to 6 years. In school and adolescence, BA makes its debut less often. (Delyagin V.M., Rumyantsev A.G., 2004) However, BA is the most common cause of hospitalization in school and adolescence.

Airway inflammation in asthma Allergen / Trigger Inflammation Airway constriction (obstruction) Symptoms Wheezing Shortness of breath Feeling of chest tightness Coughing Symptoms often develop during the night hours Inflammatory mediators Inflammatory cells Inflammatory cells Eosinophils T lymphocytes Dendritic cells Macrophages\u003e 100 Neuthemines leukotrienes Cytokines (eg IL-1β, TNF-α, IL-3, IL-4, IL-5, GM-CSF) Histamine Nitric oxide Prostaglandin D2 Mast cells Adapted from the Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention 100 types including: chemokines Cysteinyl leukotrienes Cytokines (eg IL-1β, TNF-α, IL-3, IL-4, IL-5, GM-CSF) Histamine Nitric oxide Prostaglandin D2 Mast cells Adapted from the Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2007.http: //www.ginasthma.org. 8 "\u003e

Clinical criteria for asthma: the presence of attacks of expiratory dyspnea and / or wheezing difficulty in breathing - upon contact with allergens - upon exposure to nonspecific factors; - more often at night Difficulty exhalation Choking Cough Whistling wheezing on auscultation Various moist wheezing

Why it is difficult to make a diagnosis The widespread prevalence of episodes of wheezing in the chest and cough in children associated with other causes, especially under 2 years of age. Limited ability to examine lung function. Diagnosis is based on complaints, history and examination data. Assessment of clinical manifestations and severity of the disease is usually based on the impression of the 3rd person. Different phenotypes of asthma.

Difficulties in diagnosing biofeedback in young children Anamnesis (the child may be unattended, "family war", etc.) Manifestation of biofeedbacks of various origins against the background of ARVI Atypical BA Lack of highly informative and accessible methods of functional diagnostics

Diagnosis in children under 5 years of age Based on history and clinical, but not functional, examination. In infants who have had 3 or more episodes of wheezing associated with triggers, in the presence of atopic dermatitis and (or) allergic rhinitis, eosinophilia in the blood, BA should be suspected, and an examination and differential diagnosis should be performed.

AD risk groups at an early age Cutaneous manifestations of atopy in the first year of life. High (more than 100 IU per ml) levels of total IG-E or positive skin tests. Parents (other relatives) suffer from BA. Three episodes of obstruction or more. Obstructive episodes often with or after ARVI, occur without fever and are paroxysmal

Anamnesis up to 2 years: noisy breathing, vomiting associated with cough; retraction of the chest while breathing; feeding difficulties (groaning breathing, sluggish sucking); tachypnea. Anamnesis older than 2 years: shortness of breath during the day or at night, fatigue, poor school performance, decreased intensity of physical activity, avoidance of other types of activity, reaction to specific triggers, smoking.

Criteria for the diagnosis of persistent asthma Broncho-obstructive episodes Clinical manifestations of atopy Eosinophilia and (or) an increase in IH-E Specific sensitization to food allergens in infancy and early age and to inhalation allergens subsequently Sensitization to inhaled allergens of asthma under 3 years of age (household) Presence at parents

Infections: Chlamydial Mycoplasma Cytomegalovirus Herpetic Pneumocystis Helminthiasis Type of examination: Identification of the pathogen (cultural, virological) PCR Serological (Ig M, IgG, Ig A) Examination for the presence of infections provoking bronchial obstruction

1) Atopic diseases in the family Atopic diseases in a child Sensitization to aeroallergens Small signs: (\u003e 2) Whistling xp "title \u003d" (! LANG: Bronchial asthma in young children More than 3 episodes of wheezing in 12 months Large signs: ( \u003e 1) Atopic diseases in the family Atopic diseases in a child Sensitization to aeroallergens Minor signs: (\u003e 2) Whistling chronic" class="link_thumb"> 36 !} Bronchial asthma in young children More than 3 episodes of wheezing in 12 months Large signs: (\u003e 1) Atopic diseases in the family Atopic diseases in a child Sensitization to aeroallergens Small signs: (\u003e 2) Wheezing rales without ARVI Eosinophilia Food sensitization + FDMartines, 1995 1) Atopic diseases in the family Atopic diseases in a child Sensitization to aeroallergens Minor signs: (\u003e 2) Whistling cp "\u003e 1) Atopic diseases in a family Atopic diseases in a child Sensitization to aeroallergens Minor signs: (\u003e 2) Whistling wheezing without ARVI Eosinophilia Sensitization to food + FDMartines, 1995 "\u003e 1) Atopic diseases in the family Atopic diseases in a child Sensitization to aeroallergens Minor signs: (\u003e 2) Whistling xp" title \u003d "(! LANG: Bronchial asthma in young children More than 3 episodes wheezing in 12 months Large signs: (\u003e 1) Atopic diseases in the family Atopic diseases in a child Sensitization to aeroallergens Small signs: (\u003e 2) Wheezing"> title="Bronchial asthma in young children More than 3 episodes of wheezing in 12 months Large signs: (\u003e 1) Atopic diseases in the family Atopic diseases in a child Sensitization to aeroallergens Small signs: (\u003e 2) Wheezing"> !}

Difficulties of inhalation therapy of biofeedback in children The need for special methods of drug delivery: Does not require significant effort when inhaling Simple (without inhalation synchronization) In children over 2 years old - without a mask (the mask reduces the dose of the drug due to deposition in the nasal cavity) Small in size Not causing negative emotions in the child

Inhalation therapy of obstructive respiratory diseases Advantages Creation of a high (sufficient) concentration of the drug in the lungs Lack of biotransformation of the drug (binding by blood proteins, modification in the liver, etc.) before its action Decrease in the severity of the systemic action of the drug Reduction of the total dose of the drug administered to the patient Disadvantages It is necessary to train the patient in the technique of performing inhalations. The effectiveness of treatment depends not only on the mechanism of action of the drug, but also on the completeness of its delivery to the "target" organ. Potential for local irritation High percentage (80%) sedimentation of drugs in the oropharynx Impossibility of delivering large doses Errors made by patients

The frequency of errors made by patients when using the AID Stages of correct use of the inhaler Errors made by patients (in%) Remove the cap 7 Shake the inhaler 43 Exhale 29 Place in the mouth between tightly compressed lips 29 Slow act of inhalation 64 Injection of the drug at the beginning of inhalation (synchronization) 57 Continued inspiration 46 Holding the breath at the end of inspiration 43 Slow expiration 5 (D. Ganderton, 1997)

47

Algorithm for the treatment of the actual obstruction Step 1 2 -agonist or 2 -agonist + ipratropium bromide 2 -agonist or 2-agonist + ipratropium bromide (dosed aerosol - salbutamol, fenoterol, berodual) without a spacer - 1 dose, with a spacer 2-4 doses or solution through a nebulizer (berodual, salbutamol, fenoterol - 0.5 - 1.0 ml) or

Algorithm for the treatment of obstruction itself Step 1 orally: salbutamol, or intramuscularly: orciprenaline Assessment in minutes: effect is present - supportive treatment, no effect - Step 2

Evaluation of the effectiveness of therapy for obstruction; reduction of RR per breath per minute; disappearance of distant noises;

Algorithm for the treatment of the actual obstruction Step 2 repeated dose of 2-agonist or 2-agonist + ipratropium bromide: 2-agonist or 2-agonist + ipratropium bromide: Assessment in minutes: Assessment in minutes: there is an effect - maintenance treatment, no effect - Step 3

Algorithm for the treatment of the obstruction itself Step 3 Systemic glucocorticosteroids IM: Dexamethasone 0.5 - 0.75 mg / kg or Prednisolone 3 - 5 mg / kg Evaluation in minutes: Supportive therapy

Algorithm for the treatment of obstruction itself Supportive therapy: 2-agonist + ipratropium bromide (aerosol Berodual) 2-agonist + ipratropium bromide (aerosol Berodual) or 2-agonist (aerosol, inside) 2-agonist (aerosol, inside) or Euphyllin (inside) 4 - 5 - 6 mg / kg 3 times a day

Pathogenetic treatment of obstruction at the stage of maintenance therapy with ICS (pulmicort through a nebulizer) - usually 2 weeks - indications (for the period when signs of obstruction persist) In children with a family history of allergies and / or skin manifestations of allergy (for the period when signs of obstruction persist)

The main goal of managing a patient with bronchial asthma, uniting the efforts of the doctor and the patient, is to achieve complete control. Asthma cannot be cured, but it is possible and necessary, by controlling one's condition, to live a full life without the use of short-acting β 2 -agonists, without exacerbations of the disease, without nighttime awakenings and without complications. This should be facilitated by timely prescribed control (anti-inflammatory) therapy.

Selection of the basic therapy Basic therapy is aimed at combating the main pathogenetic link of AD - allergic inflammation (synonymous with control or preventive therapy). In the situation with each patient, it is necessary to strive to ensure that the basic therapy provides complete control. A stepwise approach to treatment is used. The duration of basic therapy is at least three months. Mandatory use of age-appropriate delivery vehicles.

Broncho-obstructive syndrome (BOS) - which is often found in medical practice, is severe with the development of respiratory failure. The syndrome occurs in people who often suffer from respiratory ailments, with cardiovascular pathologies, poisoning, diseases of the central nervous system - in general, with more than 100 diseases.

It is especially difficult in young children. Why this syndrome develops, how to recognize it and start treatment on time - we will consider later in the article.

Brief characteristics and classification of biofeedback

Broncho-obstructive syndrome (BOS) is not an independent medical diagnosis or disease, BFB is a manifestation of certain nosological forms. For example, in babies under three years of age, half of the cases of bronchial obstruction syndrome are caused by asthma.

Also, in babies, cases of biofeedback can occur due to congenital anomalies of the nasopharynx, swallowing disorders, gastroesophageal reflux, and others.

Did you know? Anatomically, the bronchi resemble an inverted tree, for which they got their name - the bronchial tree. At its base, the lumen width is up to 2.5 cm, and the lumen of the smallest bronchioles is 1 mm. The bronchial tree branches into several thousand small bronchioles, which are responsible for gas exchange between the lungs and the blood.

Bronchial obstruction is a clinical manifestation of impaired bronchial patency with further resistance to air flow. When obstruction occurs, a generalized narrowing of the bronchial lumen of small and large bronchi occurs, which causes their vibration and whistling "sounds".

Especially often, the syndrome develops in children under 3 years of age who have a burdened family history, are prone to allergic reactions and often suffer from respiratory diseases. The origin of biofeedback is the following mechanism: inflammation of various etiologies occurs, which entails spasm and further narrowing of the lumen (occlusion). As a result, the bronchi are compressed.

Bronchial obstruction syndrome is classified according to the form, duration and severity of the syndrome.

The form of biofeedback is:

1. Infectious (viral and bacterial).
2. Hemodynamic (occurs with cardiac pathologies)
3. Obstructive.
4. Allergic.

Depending on the duration of the course, there are:

1. Acute biofeedback. It is accompanied by a pronounced clinical picture, symptoms appear for more than 7 days.
2. Protracted.Clinical manifestations are less pronounced, the course is long.
3. Recurrent. Acute periods are abruptly replaced by periods of remission.
4. Constantly recurrent. Periods of incomplete remission are followed by exacerbations of the syndrome.

The bronchial obstruction syndrome can occur in mild, moderate and severe forms, which differ in the number of clinical manifestations and indicators of the analysis of the composition of gases in the blood. By the way, in practice, syndromes of an allergic and infectious nature are most often encountered.

Development reasons

Among the diseases that can be accompanied by the occurrence of biofeedback, there are:

Functional changes respond well to conservative treatment, while the elimination of organic changes is carried out only in some cases by surgical intervention and due to the adaptive capabilities of the child.

Among the functional changes are bronchospasm, high sputum production in bronchitis, edema of the bronchial mucosa, inflammation and aspiration. Organic changes include congenital malformations of the bronchi and lungs, stenoses, etc.

BFB in babies is due to physiological features at such a young age - the fact is that the child's bronchi are significantly narrower, and their additional narrowing as a result of edema, even by one millimeter, will already have a tangible negative effect.

The normal functioning of the bronchial tree can be disrupted in the first months of life due to frequent crying, being on the back, and prolonged sleep.
Also, an important role is played by prematurity, toxicosis and medication during gestation, complications during the birth process, in the mother, and so on.

In addition, in a baby under one year old, the processes of immune defense have not yet stabilized, which also plays a role in the occurrence of bronchial obstruction.

Signs and symptoms

The clinical manifestations of broncho-obstructive syndrome include the following:

• prolonged inhalation;
• the appearance of whistling and wheezing during breathing;
• lingering unproductive;
• an increase in respiratory movements, the participation of auxiliary muscles in the breathing process;
• hypoxemia;
• shortness of breath, lack of air;
• an increase in the chest;
• breathing becomes loud, weak, or hard.

The listed symptoms indicate precisely the occurrence of narrowing of the bronchial lumen. However, general symptoms are largely determined by the underlying pathology that caused biofeedback.
In case of illness, the child shows moodiness, sleep and appetite disturbances, weakness, symptoms of intoxication, the temperature may rise and body weight decrease.

When contacting a therapist or neonatologist, the doctor will interview the baby's mother for allergies, recent illnesses, identified developmental abnormalities, and a family history.

In addition to the presence of clinical signs, specific physical and functional examinations are required to diagnose biofeedback.

The most important test for confirming the diagnosis is spirometry. - in this case, the volume of inhaled and exhaled air, lung capacity (vital and forced), the amount of air during forced inhalation, and patency of the respiratory tract are examined.

Therapeutic procedures may include:

1. Special breathing exercises.
2. Using breathing machines.
3. Drainage.
4. Vibration massage of the chest.
5. Speleotherapy.
6. Balneological procedures.
7. Physiotherapy.

In the child's room, it is necessary to maintain the temperature at around + 18-19 ° С, the air humidity should be at least 65%. Regular airing of the room will not be superfluous.

If the child feels satisfactory, do not force him to comply with bed rest - physical activity contributes to a better discharge of mucus from the bronchi.

Also provide your baby with enough drinks per day: it can be herbal teas, infusions, fruit juices and fruit drinks, unsweetened compotes.

Forecast

The prognosis for the development of biofeedback depends on the primary pathology and its timely treatment. Also, the consequences and severity of the course of the disease are determined by the age of the child: the younger the age, the more expressive the manifestations of the disease and the more complex the course of the underlying disease.

With bronchitis, the prognosis is positive, however, with pulmonary dysplasia, there are risks of BFB degeneration into asthma (in 20% of cases). Against the background of bronchiolitis, heart failure, emphysema may occur.

Cases of frequent, unproductive, debilitating coughs can lead to nausea, coughing up blood due to damage to the airways. Therefore, it is important to seek qualified help as soon as possible and begin adequate therapy in order to prevent unwanted consequences.

Did you know? During the day, we make up to 23 thousand respiratory movements: inhalation and exhalation.

The basic rules of prevention include the following points:

In 80% of cases, biofeedback occurs from birth to three years. The syndrome causes a lot of trouble for both the child and the parents. However, if the pathology is detected in time and the therapeutic actions are started, serious consequences for the child's health can be avoided.