Pulmonary disease hobl. COPD treatment by stages

Chronic obstructive pulmonary disease (COPD diagnosis formulation) is a pathological process, which is characterized by partial restriction of air flow in respiratory tract. The disease causes irreversible changes in the human body, so there is a great threat to life if the treatment was not prescribed on time.

The reasons

The pathogenesis of COPD is not yet fully understood. But experts identify the main factors that cause the pathological process. Typically, the pathogenesis of the disease involves progressive bronchial obstruction. The main factors influencing the formation of the disease are:

1. Smoking.
2. Unfavorable working conditions.
3. Damp and cold climate.
4. Mixed infection.
5. Acute lingering bronchitis.
6. Diseases of the lungs.
7. genetic predisposition.

What are the manifestations of the disease?

Chronic obstructive pulmonary disease is a pathology that is most often diagnosed in patients aged 40 years. The first symptoms of the disease that the patient begins to notice are cough and shortness of breath. Often this condition occurs in combination with wheezing when breathing and sputum secretions. At first, it comes out in a small volume. Symptoms become more pronounced in the morning.

Cough is the very first symptom that worries patients. In the cold season, respiratory diseases are exacerbated, which play an important role in the formation of COPD. Obstructive pulmonary disease has the following symptoms:

1. Shortness of breath, which bothers when performing physical exertion, and then can affect a person during rest.
2. Under the influence of dust, cold air shortness of breath increases.
3. Symptoms are complemented by an unproductive cough with sputum that is difficult to secrete.
4. Dry wheezing at a high rate during exhalation.
5. Symptoms of emphysema.

stages

The classification of COPD is based on the severity of the course of the disease. In addition, it implies the presence of a clinical picture and functional indicators.

The classification of COPD involves 4 stages:

1. The first stage - the patient does not notice any pathological abnormalities. He may be visited by a chronic cough. Organic changes are uncertain, so it is not possible to make a diagnosis of COPD at this stage.
2. The second stage - the disease is not severe. Patients go to the doctor for advice on shortness of breath during exercise. Another chronic obstructive pulmonary disease is accompanied by an intense cough.
3. The third stage of COPD is accompanied by a severe course. It is characterized by the presence of a limited intake of air into the respiratory tract, so shortness of breath is formed not only during physical exertion, but also at rest.
4. The fourth stage is an extremely difficult course. The resulting symptoms of COPD are life-threatening. Obstruction of the bronchi is observed and cor pulmonale is formed. Patients who are diagnosed with stage 4 COPD receive a disability.

Diagnostic methods

Diagnosis of the presented disease includes the following methods:

1. Spirometry is a method of research, thanks to which it is possible to determine the first manifestations of COPD.
2. Measurement of lung capacity.
3. Cytological examination of sputum. This diagnosis allows you to determine the nature and severity of the inflammatory process in the bronchi.
4. A blood test can detect an increased concentration of red blood cells, hemoglobin and hematocrit in COPD.
5. X-ray of the lungs allows you to determine the presence of compaction and changes in the bronchial walls.
6. ECG provide data on the development of pulmonary hypertension.
7. Bronchoscopy is a method that allows you to establish the diagnosis of COPD, as well as view the bronchi and determine their condition.

Treatment

Chronic obstructive pulmonary disease is a pathological process that cannot be cured. However, the doctor prescribes a certain therapy to his patient, thanks to which it is possible to reduce the frequency of exacerbations and prolong the life of a person. The course of prescribed therapy is greatly influenced by the pathogenesis of the disease, because it is very important to eliminate the cause that contributes to the occurrence of pathology. In this case, the doctor prescribes the following measures:

1. COPD treatment involves the use of medications, the action of which is aimed at increasing the lumen of the bronchi.
2. To liquefy sputum and remove it, mucolytic agents are used in the therapy process.
3. They help to stop the inflammatory process with the help of glucocorticoids. But their prolonged use is not recommended, as serious side effects.
4. If there is an exacerbation, then this indicates the presence of its infectious origin. In this case, the doctor prescribes antibiotics and antibacterial drugs. Their dosage is prescribed taking into account the sensitivity of the microorganism.
5. For those suffering from heart failure, oxygen therapy is necessary. In case of exacerbation, the patient is prescribed sanitary-resort treatment.
6. If the diagnosis confirms the presence of pulmonary hypertension and COPD, accompanied by reporting, then treatment includes diuretics. Glycosides help to eliminate the manifestations of arrhythmia.

COPD is a disease that cannot be treated without a properly formulated diet. The reason is that the loss of muscle mass can lead to death.

A patient may be admitted to hospital if he/she has:

• greater intensity of the increase in the severity of manifestations;
• treatment does not give the desired result;
• new symptoms appear
• the rhythm of the heart is disturbed;
• diagnosis defines diseases such as diabetes, pneumonia, insufficient performance of the kidneys and liver;
• unable to provide medical care on an outpatient basis;
• difficulties in diagnosis.

Preventive actions

Prevention of COPD includes a set of measures, thanks to which each person will be able to warn his body against this pathological process. It consists of the following recommendations:

1. Pneumonia and influenza are the most common causes of COPD. Therefore, it is essential to get flu shots every year.
2. Vaccinate every 5 years against pneumococcal infection, thanks to which it is possible to protect your body from pneumonia. Only the attending physician will be able to prescribe vaccination after an appropriate examination.
3. Taboo on smoking.

Complications of COPD can be very diverse, but, as a rule, they all lead to disability. Therefore, it is important to carry out treatment on time and be under the supervision of a specialist all the time. And it is best to conduct quality preventive actions to prevent the formation of a pathological process in the lungs and warn yourself against this disease.

Is everything correct in the article from a medical point of view?

Answer only if you have proven medical knowledge

Diseases with similar symptoms:

Asthma - chronic illness, which is characterized by short-term attacks of suffocation, caused by spasms in the bronchi and swelling of the mucous membrane. This disease does not have a certain risk group and age restrictions. But, as medical practice shows, women suffer from asthma 2 times more often. According to official figures, there are more than 300 million people with asthma in the world today. The first symptoms of the disease appear most often in childhood. Older people suffer the disease much more difficult.

Chronic obstructive pulmonary disease is a chronic non-allergic inflammatory disease of the respiratory system that occurs due to irritation of the lungs by toxic substances. The abbreviated name of the disease - COPD, is an abbreviation made up of the first letters of the full name. The disease affects the final sections of the respiratory tract - the bronchi, as well as the respiratory tissue - the lung parenchyma.

COPD is the result of exposure to harmful dust and gases on the human respiratory system. The main symptoms of COPD are cough and shortness of breath during exercise. Over time, the disease progresses steadily, and the severity of its symptoms increases.

The main mechanisms of painful changes in the lungs in COPD:

• development of emphysema - swelling of the lungs with rupture of the walls of the respiratory vesicles-alveoli;
• the formation of irreversible bronchial obstruction - difficulties for the passage of air through the bronchi due to the thickening of their walls;
• a steady increase in chronic respiratory failure.

About the causes of COPD and its dangers

Inhalation of tobacco smoke, toxic gases and dust causes inflammation in the airways. it chronic inflammation destroys the respiratory tissue of the lungs, forms emphysema, violates the natural protective and regenerative mechanisms, causes fibrous degeneration of the small bronchi. As a result, the correct functioning of the respiratory system is disrupted, air is retained in the lungs, and the airflow rate in the bronchi progressively decreases. These internal disturbances cause the patient to experience shortness of breath on exertion and other symptoms of COPD.

Smoking is the main causative factor COPD According to statistics, every 3rd resident smokes in Russia. Thus, the total number of smoking Russians is about 55 million people. In absolute terms, the Russian Federation ranks 4th in the world in terms of the number of smokers.

Smoking is both a risk factor for COPD and cardiovascular disease.

Experts predict that by 2020 smoking will kill 20 people per minute. According to WHO estimates, smoking is the cause of 25% of deaths in patients with coronary heart disease and 75% of deaths in patients with chronic bronchitis and COPD.

The combined effect on the lungs of tobacco smoking and harmful industrial aerosols is a particularly deadly combination. People with this combination of risk factors develop the most severe form of the disease, rapidly leading to permanent lung damage and death from respiratory failure.

COPD is one of the leading causes of morbidity and mortality worldwide, which leads to significant, ever-increasing economic and social damage to society.

What signs will help to suspect COPD?

The presence of COPD should be suspected in people with persistent cough, shortness of breath, sputum production, with past or present exposure to risk factors. These symptoms alone are not diagnostic, but the combination of them greatly increases the likelihood of a diagnosis of COPD being made.

Chronic cough is often the 1st symptom of COPD and is underestimated by the patient himself. People consider these coughs to be a natural consequence of smoking or exposure to other harmful air pollutants. At first, the cough may be intermittent, but over time it becomes daily, constant. In COPD, chronic cough may be without sputum (unproductive).

Shortness of breath on exertion main symptom COPD Patients describe shortness of breath as a feeling of heaviness in the chest, suffocation, lack of air, the need to make efforts to breathe.

Typically, people with COPD cough up a small amount of sticky sputum after a coughing episode. The purulent nature of sputum indicates an exacerbation of inflammation in the airways. A persistent cough with phlegm can bother a person for several years before the onset of shortness of breath (before the start of airflow limitation). However, a decrease in airflow rate in COPD can develop without chronic cough and sputum production.

As the disease progresses, complaints of general weakness, constant malaise, bad mood, increased irritability, and weight loss may appear.

What does an examination reveal in a COPD patient?

In the initial period of the disease, the examination does not reveal any abnormalities characteristic of COPD. Over time, with an increase in bloating and an irreversible violation of the patency of the bronchi, a barrel-shaped deformation of the chest appears - its characteristic expansion in the anterior-posterior size. The appearance and severity of deformity depend on the degree of swelling of the lungs.

Widely known are 2 types of COPD patients - "pink puffers" and "blue puffers". In a number of patients, symptoms of pulmonary distention come to the fore, and in others, airway obstruction. But those and others have both signs.

At severe forms disease, there may be a loss of muscle mass, which leads to a lack of weight. In obese patients, despite the increased weight, one can also notice a decrease in muscle mass.

Prolonged intense work of the respiratory muscles leads to its fatigue, which is further aggravated by malnutrition. A sign of fatigue of the main respiratory muscle (diaphragm) is the paradoxical movement of the anterior wall abdominal cavity- its retraction during inspiration.

Cyanosis (cyanosis) of the skin of a gray-ashy shade indicates a pronounced lack of oxygen in the blood and a severe degree of respiratory failure. It is important to determine the level of consciousness. Lethargy, drowsiness, despite severe shortness of breath, or, conversely, the excitement accompanying it, indicate oxygen starvation, life threatening which requires urgent care.

Symptoms of COPD on external examination

An external examination of the lungs in the initial period of the disease carries scarce information. When percussion of the chest, a box sound may appear. When listening to the patient's lungs during an exacerbation, dry whistling or buzzing rales appear.

In the clinically significant stage of COPD, external examination data reflect severe pulmonary emphysema and severe bronchial obstruction. The doctor finds during the study: boxed sound when percussion, limitation of diaphragm mobility, chest rigidity, weakening of breathing, wheezing or buzzing scattered wheezing. The predominance of one or another sound phenomenon depends on the type of disease.

Instrumental and laboratory diagnostics

The diagnosis of COPD must be confirmed with spirometry, a lung function test. Spirometry in COPD detects bronchial airflow limitation. A characteristic feature of the disease is the irreversibility of bronchial obstruction, that is, the bronchi practically do not expand when inhaled with a standard dose of a bronchodilator drug (400 μg of salbutamol).

Radiation diagnostic methods (X-ray, CT) are used to exclude other severe lung diseases that have similar symptoms.

With clinical signs of severe respiratory failure, an assessment of the levels of oxygen and carbon dioxide in the arterial blood is necessary. If this analysis is not possible, a pulse oximeter that measures saturation can help assess the lack of oxygen. When blood saturation is less than 90%, immediate administration of oxygen inhalation is indicated.

Principles of COPD treatment

Key points in the treatment of patients with COPD:

• smoking patients need to stop smoking, otherwise taking medication loses its meaning;
• smoking cessation is facilitated by nicotine replacement drugs (chewing gum, inhaler, nasal spray, skin patch, sublingual tablets, lozenges);
• to reduce shortness of breath and swelling of the lungs, drugs are used that expand the bronchi for 12-24 hours (long-acting bronchodilators) in inhalations;
• to reduce the severity of inflammation with frequent exacerbations, roflumilast is prescribed - new drug for the treatment of COPD;
• patients with decreased oxygen saturation in the blood<90%, показана длительная кислородотерапия >15 hours a day;
• for patients with a low inhalation rate, inhalation of drugs can be carried out using a nebulizer - a special compressor inhaler;
• exacerbation of the disease with expectoration of purulent sputum is treated with antibiotics and expectorants;
• all patients with COPD are shown classes in the pulmonary rehabilitation program, including smoking cessation, education, feasible physical training, nutritional counseling and social support;
• to prevent infectious exacerbations, COPD patients are recommended annual influenza vaccination, as well as vaccination against pneumococcus.

COPD prevention

most effective prevention COPD would be a worldwide ban on the production, sale and smoking of tobacco and tobacco products. But while the world is ruled by capital and greed, this can only be dreamed of.

The drowning will have to take their salvation into their own hands:

• to prevent the development of COPD in a smoker, you need to part with cigarettes (cigarettes, tobacco, etc.);
• to prevent the development of COPD in a non-smoker, he does not need to start smoking;
• to prevent the development of COPD in workers in hazardous industries, it is necessary to strictly observe safety precautions and the maximum allowable periods of continuous work in this industry.

To prevent COPD in your children and grandchildren, set an example of a healthy lifestyle and zero tolerance for smoking.

Chronic obstructive pulmonary disease (COPD)- symptoms and treatment

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

Definition of illness. Causes of the disease

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

This disease is insidious in that the main symptoms of the disease, in particular, with smoking, appear only 20 years after the start of smoking. It does not give for a long time clinical manifestations 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 today.

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 has diagnosed Chronic Obstructive Pulmonary Disease (COPD), the patient has a number of questions: what does this mean, how dangerous is it, what to change in lifestyle, what is the prognosis for 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 respiratory failure due to narrowing of the bronchial lumen. 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 factors environment;
• smoking;
• occupational hazard factors (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 experience 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 imperceptible to the patient.

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

The typical COPD patient is a 45-50 year old smoker who complains of frequent shortness of breath on exertion.

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

Sputum also relatively early symptom diseases. In the first stages, it is released in small quantities, mainly in the morning. Slimy character. Purulent copious 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 exertion, increases 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 intensifies over time. It is shortness of breath that becomes common cause in order to see a doctor.

When can COPD be suspected?

Here are a few questions of the COPD early diagnosis algorithm:

• Do you cough several times a day? Does it bother you?
• Does coughing produce phlegm or mucus (often/daily)?
• Do you get short of breath faster/more often than your peers?
• Are you over 40?
• Do you smoke or have you ever smoked before?

If more than 2 questions are answered positively, spirometry with a bronchodilator test is necessary. When the test indicator FEV 1 / FVC ≤ 70, COPD is suspected.

Pathogenesis of chronic obstructive pulmonary disease

In COPD, both the airways and the tissue of the lung itself, the lung parenchyma, are affected.

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

With the formed pathology, the bronchitis component includes:

The emphysematous component leads to the destruction of the final sections of the respiratory tract - the alveolar walls and supporting structures with the formation of significantly expanded air spaces. The absence of a tissue framework of the airways leads to their narrowing due to the tendency to dynamically collapse during expiration, which causes expiratory bronchial collapse.

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 the ventilation of the dead space and a violation of the removal of carbon dioxide CO 2 . The area of ​​the alveolar-capillary surface is reduced, but may be sufficient for gas exchange at rest, when these anomalies may not appear. However, during exercise, when the need for oxygen increases, if there are no additional reserves of gas exchange units, then hypoxemia occurs - a lack of oxygen in the blood.

The hypoxemia that appeared during long-term existence in patients with COPD includes a number of adaptive reactions. Damage to the alveolar-capillary units causes a rise in pressure in pulmonary artery. Since the right ventricle of the heart under 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 exacerbates 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. Also in patients with COPD, bronchogenic carcinoma (lung cancer) is more common, although it is not a direct complication of the disease.

Respiratory failure- device status external respiration, in which either the maintenance of the voltage of O 2 and CO 2 in arterial blood is not ensured at 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 cor pulmonale- an increase and expansion of the right parts of the heart, which occurs with an increase in blood pressure in the pulmonary circulation, which, in turn, has developed as a result of pulmonary diseases. The main complaint of patients is also shortness of breath.

Diagnosis of chronic obstructive pulmonary disease

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

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

Physical examination may reveal symptoms characteristic of long-term bronchitis: "watch glasses" and / or "drumsticks" (deformity of the fingers), tachypnea (rapid breathing) and shortness of breath, a change in the shape of the chest (a barrel-shaped form is characteristic of emphysema), small its mobility during breathing, the retraction of the intercostal spaces with the development of respiratory failure, the descent of the boundaries of the lungs, the change in percussion sound to a box sound, weakened vesicular breathing or dry wheezing, which increase with forced expiration (that is, a quick exhalation after a deep breath). Heart sounds can be heard with difficulty. In the later stages, diffuse cyanosis, severe shortness of breath, and peripheral edema may occur. For convenience, the disease is divided into two clinical forms: emphysematous and bronchitis. Although in practical medicine cases of the mixed form of a disease meet more often.

The most important step in diagnosing COPD is analysis of respiratory function (RF). 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. Decrease in forced expiratory volume in the first second to the forced vital capacity of the lungs FEV 1 / FVC up to 70% - initial sign airflow restrictions even with a saved FEV 1 > 80% of the proper value. A low peak expiratory airflow rate that does not change significantly with bronchodilators also favors COPD. With newly diagnosed complaints and changes in indicators FVD spirometry repeats throughout the year. Obstruction is defined as chronic if it occurs at least 3 times per year (regardless of treatment), and COPD is diagnosed.

FEV monitoring 1 is an important method for confirming the diagnosis. Spireometric measurement of FEV 1 is carried out repeatedly over several years. The norm of the annual fall 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, which determines maximum rate FEV 1, the stage and severity of COPD are established, and bronchial asthma is excluded (with a positive result), the tactics and volume of treatment are chosen, the effectiveness of therapy is evaluated and the course of the disease is predicted. It is 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 found that people with a diagnosis of CO BL after taking a bronchodilator, the percentage increase in FEV 1 - less than 12% of the original (or ≤200 ml), and in patients with bronchial asthma, it usually exceeds 15%.

Chest x-rayhas an auxiliary value chenie, since changes appear only in the later stages of the disease.

ECG can detect changes that are characteristic of cor pulmonale.

echocardiography necessary to detect symptoms of pulmonary hypertension and changes in the right heart.

General blood analysis- it can be used to evaluate hemoglobin and hematocrit (may be increased due to erythrocytosis).

Determining the level of oxygen in the blood(SpO 2) - pulse oximetry, a non-invasive study to clarify the severity of respiratory failure, as a rule, 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

Treatment for COPD helps:

• reduction of clinical manifestations;
• increasing tolerance to physical activity;
• prevention of disease progression;
• prevention and treatment of complications and exacerbations;
• improving the quality of life;
• reduction in mortality.

The main areas of treatment include:

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

Weakening the degree of influence of risk factors

Smoking cessation is required. This is the most effective way to reduce the risk of developing COPD.

Occupational hazards should also be controlled and reduced using adequate ventilation and air cleaners.

Educational programs

Educational programs for COPD include:

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

Patient education plays an important role in patient management and influences subsequent prognosis (Evidence A).

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

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

Medical 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, and concomitant diseases. Drugs that fight COPD are divided into drugs to relieve an attack and to prevent the development of an attack. Preference is given to inhaled forms of drugs.

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

Preparations for the prevention of seizures:

• formoterol;
• tiotropium bromide;
• combined preparations (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 SR 1000 mg 1 time per day, clarithromycin 500 mg 2 times a day, amoxicillin + clavulanic acid 625 mg 2 times a day, cefuroxime 750 mg twice 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 positive effect in patients with COPD.

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

Forecast. Prevention

The prognosis of the disease is affected by the stage of COPD and the number of recurrent exacerbations. At the same time, any exacerbation negatively affects the general course of the process, therefore, the earliest possible diagnosis of COPD is highly desirable. Treatment of any exacerbation of COPD should begin as early as possible. It is also important to fully treat the exacerbation, in no case is it permissible to carry it “on the legs”.

Often people decide to see a doctor for medical help, starting from the II moderate stage. 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 cor pulmonale is not excluded.

The prognosis of the disease is affected by patient compliance with medical recommendations, adherence to treatment and a healthy lifestyle. Continued smoking contributes to the progression of the disease. Smoking cessation leads to slower progression of the disease and slower decline in FEV 1 . Due to the fact that the disease has a progressive course, many patients are forced to take drugs for life, many require gradually increasing doses and additional funds during periods of exacerbation.

The best means of preventing COPD are: a healthy lifestyle, including good nutrition, hardening of the body, reasonable physical activity, and the exclusion of exposure to harmful factors. Smoking cessation is an absolute condition for the prevention of exacerbations of COPD. Existing occupational hazards, when diagnosing COPD, are a sufficient reason to change jobs. Preventive measures are also avoiding hypothermia and limiting contact with those with SARS.

In order to prevent exacerbations, patients with COPD are shown annual influenza vaccination. People with COPD aged 65 years or older and patients with an FEV1< 40% показана вакцинация поливалентной пневмококковой вакциной.

Version: Directory of Diseases MedElement

Other chronic obstructive pulmonary disease (J44)

Pulmonology

general information

Short description

(COPD) is a chronic inflammatory disease that occurs under the influence of various factors of environmental aggression, the main of which is smoking. Occurs with a predominant lesion of the distal respiratory tract and parenchyma Parenchyma - a set of basic functioning elements internal organ, limited by the connective tissue stroma and capsule.
lungs, emphysema Emphysema - stretching (swelling) of an organ or tissue by air that has entered from the outside, or by gas formed in the tissues
.

COPD is characterized by partially reversible and irreversible airflow limitation. The disease is caused by an inflammatory response that is different from inflammation in bronchial asthma and exists regardless of the severity of the disease.

COPD develops in predisposed individuals and is manifested by cough, sputum production and increasing shortness of breath. The disease has a steadily progressive character with an outcome in chronic respiratory failure and cor pulmonale.

Currently, the concept of "COPD" has ceased to be collective. Partially reversible airflow limitation associated with the presence of bronchiectasis is excluded from the definition of "COPD" Bronchiectasis - expansion of limited areas of the bronchi due to inflammatory-dystrophic changes in their walls or anomalies in the development of the bronchial tree
, cystic fibrosis Cystic fibrosis - hereditary disease, characterized by cystic degeneration of the pancreas, intestinal glands and respiratory tract due to blockage of their excretory ducts with a viscous secret.
, post-tuberculous fibrosis, bronchial asthma.

Note. Specific approaches to the treatment of COPD in this subheading are presented in accordance with the views of leading pulmonologists of the Russian Federation and may not coincide in detail with the recommendations of GOLD - 2011 (- J44.9).

Classification

Severity classification of airflow limitation in COPD(based on post-bronchodilatory FEV1) in patients with FEV1/FVC<0,70 (GOLD - 2011)

Clinical classification of COPD by severity(used in case of impossibility of dynamic control over the state of FEV1 / FVC, when the stage of the disease can be approximately determined based on the analysis clinical symptoms).

Stage I Mild COPD: the patient may not notice that he has impaired lung function; there is usually (but not always) a chronic cough and sputum production.

Stage II. Moderate course of COPD: at this stage, patients seek medical help due to shortness of breath and exacerbation of the disease. There is an increase in symptoms with shortness of breath that occurs during exercise. The presence of repeated exacerbations affects the quality of life of patients and requires appropriate treatment tactics.

Stage III. Severe COPD: characterized by a further increase in airflow limitation, an increase in dyspnea, the frequency of exacerbations of the disease, which affects the quality of life of patients.

Stage IV Extremely severe COPD: at this stage, the quality of life of patients deteriorates markedly, and exacerbations can be life-threatening. The disease acquires a disabling course. Extremely severe bronchial obstruction in the presence of respiratory failure is characteristic. Typically, arterial oxygen partial pressure (PaO 2 ) is less than 8.0 kPa (60 mm Hg) with or without an increase in PaCO 2 greater than 6.7 kPa (50 mm Hg). Cor pulmonale may develop.

Note. Severity stage "0": Increased risk of developing COPD: chronic cough and sputum production; exposure to risk factors, lung function is not changed. This stage is considered as a predisease, which does not always turn into COPD. Allows you to identify patients at risk and prevent further development of the disease. In current recommendations, stage "0" is excluded.

The severity of the condition without spirometry can also be determined and assessed over time according to some tests and scales. A very high correlation between spirometric indicators and some scales was noted.

Etiology and pathogenesis

COPD develops as a result of the interaction of genetic and environmental factors.

Etiology

Environmental factors:

Smoking (active and passive) is the main etiological factor in the development of the disease;

Smoke from biofuel combustion for home cooking is an important etiological factor in underdeveloped countries;

Occupational hazards: organic and inorganic dust, chemical agents.

Genetic factors:

Deficiency of alpha1-antitrypsin;

Polymorphisms in the genes for microsomal epoxide hydrolase, vitamin D-binding protein, MMP12, and other possible genetic factors are currently being investigated.

Pathogenesis

Airway inflammation in COPD patients is a pathologically enhanced normal airway inflammatory response to long-term irritants (eg, cigarette smoke). The mechanism by which the enhanced response occurs is currently not well understood; It is noted that it may be genetically determined. In some cases, the development of COPD in non-smokers is observed, but the nature of the inflammatory response in such patients is unknown. Due to oxidative stress and an excess of proteinases in the lung tissue, the inflammatory process further intensifies. Together, this leads to pathomorphological changes characteristic of COPD. The inflammatory process in the lungs continues after smoking cessation. The role of autoimmune processes and persistent infection in the continuation of the inflammatory process is discussed.

Pathophysiology

1. Airflow limitation and "air traps". inflammation, fibrosis Fibrosis is the growth of fibrous connective tissue, which occurs, for example, as a result of inflammation.
and overproduction of exudate Exudate is a protein-rich fluid that exits small veins and capillaries into surrounding tissues and body cavities during inflammation.
in the lumen of small bronchi cause obstruction. As a result of this, "air traps" appear - an obstacle to the exit of air from the lungs in the exhalation phase, and then hyperinflation develops. Hyperinflation - increased airiness detected on x-rays
. Emphysema also contributes to the formation of "air traps" on exhalation, although it is more associated with impaired gas exchange than with a decrease in FEV1. Due to hyperinflation, which leads to a decrease in inspiratory volume (especially during exercise), shortness of breath and limitation of exercise tolerance appear. These factors cause a violation of the contractility of the respiratory muscles, which leads to an increase in the synthesis of pro-inflammatory cytokines.
Currently, it is believed that hyperinflation has been developing for early stages diseases and serves as the main mechanism for the occurrence of shortness of breath during exercise.

2.Gas exchange disorders lead to hypoxemia Hypoxemia - reduced oxygen in the blood
and hypercapnia Hypercapnia - increased levels of carbon dioxide in the blood and (or) other tissues
and in COPD are due to several mechanisms. Transport of oxygen and carbon dioxide generally becomes worse as the disease progresses. Severe obstruction and hyperinflation, combined with impaired contractility of the respiratory muscles, lead to an increase in the load on the respiratory muscles. This increase in load, combined with reduced ventilation, can lead to carbon dioxide buildup. Violation of alveolar ventilation and a decrease in pulmonary blood flow cause further progression of the violation of the ventilation-perfusion ratio (VA/Q).

3. Mucus hypersecretion, which leads to a chronic productive cough, is a characteristic feature of chronic bronchitis and is not necessarily associated with airflow limitation. Symptoms of mucus hypersecretion are not detected in all patients with COPD. If there is hypersecretion, it is due to metaplasia Metaplasia is a persistent replacement of differentiated cells of one type with differentiated cells of another type while maintaining the main type of tissue.
mucosa with an increase in the number of goblet cells and the size of the submucosal glands, which occurs in response to the chronic irritant effect on the respiratory tract of cigarette smoke and other harmful agents. Mucus hypersecretion is stimulated by various mediators and proteinases.

4. Pulmonary hypertension may develop in the later stages of COPD. Its appearance is associated with hypoxia-induced spasm of the small arteries of the lungs, which ultimately leads to structural changes: hyperplasia Hyperplasia - an increase in the number of cells, intracellular structures, intercellular fibrous formations due to enhanced organ function or as a result of a pathological tissue neoplasm.
intima and later hypertrophy/hyperplasia of the smooth muscle layer.
Endothelial dysfunction and an inflammatory response similar to those in the airways are observed in the vessels.
An increase in pressure in the pulmonary circle can also contribute to the depletion of pulmonary capillary blood flow in emphysema. Progressive pulmonary hypertension can lead to right ventricular hypertrophy and eventually right ventricular failure (cor pulmonale).

5. Exacerbations with increased respiratory symptoms in patients with COPD may be triggered by bacterial or viral infection (or a combination of both), environmental pollution and unidentified factors. With a bacterial or viral infection, patients experience a characteristic increase in the inflammatory response. During an exacerbation, there is an increase in the severity of hyperinflation and "air traps" in combination with a reduced expiratory flow, which causes increased dyspnea. In addition, an aggravation of the imbalance in the ventilation-perfusion ratio (VA/Q) is revealed, which leads to severe hypoxemia.
Diseases such as pneumonia, thromboembolism and acute heart failure can simulate an exacerbation of COPD or aggravate its picture.

6. Systemic manifestations. Airflow limitation and especially hyperinflation adversely affect the work of the heart and gas exchange. Circulating inflammatory mediators in the blood may contribute to muscle loss and cachexia Cachexia is an extreme degree of depletion of the body, characterized by a sharp emaciation, physical weakness, a decrease in physiological functions, asthenic, and later apathetic syndrome.
, and can also provoke the development or aggravate the course of concomitant diseases (ischemic heart disease, heart failure, normocytic anemia, osteoporosis, diabetes, metabolic syndrome, depression).

Pathomorphology

In the proximal airways, peripheral airways, lung parenchyma and pulmonary vessels in COPD, characteristic pathological changes are found:
- signs of chronic inflammation with an increase in the number of specific types of inflammatory cells in different parts of the lungs;
- Structural changes caused by the alternation of damage and restoration processes.
As the severity of COPD increases, inflammatory and structural changes increase and persist even after smoking cessation.

Epidemiology

Existing data on the prevalence of COPD have significant discrepancies (from 8 to 19%) due to differences in research methods, diagnostic criteria and approaches to data analysis. On average, the prevalence is estimated at about 10% in the population.

Factors and risk groups

- smoking (active and passive) - the main and main risk factor; smoking during pregnancy may put the fetus at risk through adverse effects on fetal growth and lung development and possibly through primary antigenic effects on the immune system;
- genetic congenital deficiencies of some enzymes and proteins (most often - antitrypsin deficiency);
- occupational hazards (organic and inorganic dust, chemical agents and smoke);
- male gender;
- age over 40 (35) years;
- socio-economic status (poverty);
- low body weight;
- low birth weight, as well as any factor that adversely affects lung growth during fetal development and in childhood;
- bronchial hyperreactivity;
- chronic bronchitis (especially in young smokers);
- severe respiratory infections in childhood.

Clinical picture

Symptoms, course

If cough, sputum production, and/or dyspnoea are present, COPD should be considered in all patients with risk factors for the disease. It should be kept in mind that chronic cough and sputum production can often occur long before the development of airflow limitation leading to dyspnoea.
If the patient has any of these symptoms, spirometry should be performed. Each sign alone is not diagnostic, but the presence of several of them increases the likelihood of having COPD.

Diagnosis of COPD consists of the following steps:
- information gleaned from a conversation with the patient (verbal portrait of the patient);
- data of an objective (physical) examination;
- results of instrumental and laboratory studies.

The study of the verbal portrait of the patient

Complaints(their severity depends on the stage and phase of the disease):

1. Cough is the earliest symptom and usually appears at the age of 40-50 years. During the cold seasons, such patients experience episodes of respiratory infection, which at first are not associated by the patient and doctor in one disease. The cough may be daily or intermittent; more often observed during the day.
In a conversation with the patient, it is necessary to establish the frequency of occurrence of cough and its intensity.

2. Sputum, as a rule, is secreted in a small amount in the morning (rarely > 50 ml / day), has a mucous character. An increase in the amount of sputum and its purulent nature are signs of an exacerbation of the disease. If blood appears in the sputum, another cause of cough should be suspected (lung cancer, tuberculosis, bronchiectasis). In a COPD patient, streaks of blood in the sputum may appear as a result of a persistent hacking cough.
In a conversation with the patient, it is necessary to find out the nature of sputum and its quantity.

3. Shortness of breath is the main symptom of COPD and for most patients it is a reason to visit a doctor. The diagnosis of COPD is often made at this stage of the disease.
As the disease progresses, dyspnea can vary widely, from feeling short of breath with normal physical exertion to severe respiratory failure. Shortness of breath during physical exertion appears on average 10 years later than cough (very rarely, the disease debuts with shortness of breath). The severity of dyspnea increases as lung function decreases.
In COPD, the characteristic features of shortness of breath are:
- progression (constant increase);
- constancy (every day);
- strengthening during physical activity;
- increased in respiratory infections.
Patients describe shortness of breath as "increasing effort in breathing", "heaviness", "air starvation", "difficulty breathing".
In a conversation with the patient, it is necessary to assess the severity of dyspnea and its relationship with physical activity. There are several special scales for assessing shortness of breath and other symptoms of COPD - BORG, mMRC Dyspnea Scale, CAT.

Along with the main complaints, patients may be concerned about the following extrapulmonary manifestations of COPD:

morning headache;
- drowsiness during the day and insomnia at night (a consequence of hypoxia and hypercapnia);
- weight loss and weight loss.

Anamnesis

When talking with a patient, it should be borne in mind that COPD begins to develop long before the onset of severe symptoms and long time proceeds without clear clinical symptoms. It is desirable for the patient to clarify with what he himself associates the development of the symptoms of the disease and their increase.
When studying the anamnesis, it is necessary to establish the frequency, duration and characteristics of the main manifestations of exacerbations and evaluate the effectiveness of previous therapeutic measures. It is required to find out the presence of a hereditary predisposition to COPD and other pulmonary diseases.
If the patient underestimates his condition and the doctor has difficulty in determining the nature and severity of the disease, special questionnaires are used.

A typical "portrait" of a patient with COPD:

Smoker;

Middle or old age;

Suffering from shortness of breath;

Having a chronic cough with phlegm, especially in the morning;

Complaining of regular exacerbations of bronchitis;

Having a partially (weakly) reversible obstruction.

Physical examination

The results of an objective examination depend on the following factors:
- severity of bronchial obstruction;
- severity of emphysema;
- the presence of manifestations of pulmonary hyperinflation (extension of the lungs);
- the presence of complications (respiratory failure, chronic cor pulmonale);
- the presence of concomitant diseases.

It should be borne in mind that the absence of clinical symptoms does not exclude the presence of COPD in a patient.

Examination of the patient

1. Grade appearance the patient, his behavior, the reaction of the respiratory system to a conversation, movement around the office. Signs of a severe course of COPD - lips collected by a "tube" and a forced position.

2. Assessment of skin color, which is determined by a combination of hypoxia, hypercapnia and erythrocytosis. Central gray cyanosis is usually a manifestation of hypoxemia; if it is combined with acrocyanosis, then this, as a rule, indicates the presence of heart failure.

3. Chest examination. Signs of severe COPD:
- deformity of the chest, "barrel-shaped" shape;
- inactive when breathing;
- paradoxical retraction (retraction) of the lower intercostal spaces on inspiration (Hoover's sign);
- participation in the act of breathing of the auxiliary muscles of the chest, abdominal press;
- significant expansion of the chest in the lower sections.

4. Percussion chest. Signs of emphysema are boxed percussion sound and lowered lower borders of the lungs.

5.auscultatory picture:

Signs of emphysema: hard or weakened vesicular breathing in combination with a low standing diaphragm;

Obstruction Syndrome: Dry wheezes that are exacerbated by forced expiration, combined with increased exhalation.

Clinical forms of COPD

In patients with moderate and severe disease, two clinical forms are distinguished:
- emphysematous (panacinar emphysema, "pink puffers");
- bronchitis (centroacinar emphysema, "blue edema").

Isolation of two forms of COPD has prognostic value. In the emphysematous form, cor pulmonale decompensation occurs at later stages compared to the bronchitis form. Often there is a combination of these two forms of the disease.

Based on clinical signs, they are two main phases of COPD: stable and exacerbation of the disease.

stable state - the progression of the disease can be detected only with long-term dynamic monitoring of the patient, and the severity of symptoms does not change significantly over weeks and even months.

Aggravation- deterioration of the patient's condition, which is accompanied by an increase in symptoms and functional disorders and lasts at least 5 days. Exacerbations may have a gradual onset or be manifested by a rapid deterioration of the patient's condition with the development of acute respiratory and right ventricular failure.

Main symptom of exacerbation of COPD- increased shortness of breath. Usually, this symptom accompanied by a decrease in exercise tolerance, a feeling of pressure in the chest, the occurrence or intensification of remote wheezing, an increase in the intensity of cough and sputum amount, a change in its color and viscosity. In patients, indicators of the function of external respiration and blood gases deteriorate significantly: speed indicators (FEV1, etc.) decrease, hypoxemia and hypercapnia may occur.

There are two types of exacerbation:
- exacerbation characterized by inflammatory syndrome(increase in body temperature, increase in the amount and viscosity of sputum, purulent nature of sputum);
- exacerbation, manifested by an increase in shortness of breath, an increase in extrapulmonary manifestations of COPD (weakness, headache, bad dream, depression).

Allocate 3 severity of exacerbation depending on the intensity of symptoms and response to treatment:

1. Mild - the symptoms increase slightly, the exacerbation is stopped with the help of bronchodilator therapy.

2. Moderate - exacerbation requires medical intervention and can be stopped on an outpatient basis.

3. Severe - exacerbation requires inpatient treatment, is characterized by an increase in COPD symptoms and the appearance or aggravation of complications.

In patients with mild or moderate COPD (stages I-II), exacerbation is usually manifested by increased dyspnea, cough and an increase in sputum volume, which allows patients to be managed on an outpatient basis.
In patients with severe COPD (stage III), exacerbations are often accompanied by the development of acute respiratory failure, which requires intensive care measures in a hospital setting.

In some cases, in addition to severe, there are very severe and extremely severe exacerbations of COPD. In these situations, participation in the act of breathing of auxiliary muscles, paradoxical movements of the chest, the occurrence or aggravation of central cyanosis are taken into account. Cyanosis is a bluish hue of the skin and mucous membranes due to insufficient oxygenation of the blood.
and peripheral edema.

Diagnostics

Instrumental Research

1. Examination of the function of external respiration- the main and most important method for diagnosing COPD. Performed to detect airflow limitation in patients with chronic productive cough, even in the absence of dyspnea.

The main functional syndromes in COPD:

Violation of bronchial patency;

Changes in the structure of static volumes, violation of the elastic properties and diffusion capacity of the lungs;

Decreased physical performance.

Spirometry
Spirometry or pneumotachometry are generally accepted methods for recording bronchial obstruction. When conducting research, forced exhalation in the first second (FEV1) and forced vital capacity (FVC) are evaluated.

The presence of chronic airflow limitation or chronic obstruction is indicated by a post-bronchodilatory decrease in the FEV1/FVC ratio of less than 70% of the proper value. This change is recorded starting from stage I of the disease (mild COPD).
The post-bronchodilation FEV1 index is highly reproducible if the maneuver is performed correctly and allows monitoring the state of bronchial patency and its variability.
Bronchial obstruction is considered chronic if it occurs at least 3 times within one year, despite ongoing therapy.

Bronchodilatory test carry out:
- with short-acting β2-agonists (inhalation of 400 µg salbutamol or 400 µg fenoterol), evaluation is carried out after 30 minutes;
- with M-anticholinergics (inhalation of ipratropium bromide 80 mcg), evaluation is carried out after 45 minutes;
- it is possible to conduct a test with a combination of bronchodilators (fenoterol 50 mcg + ipratropium bromide 20 mcg - 4 doses).

For correct execution bronchodilation test and avoiding distortion of the results, it is necessary to cancel the therapy in accordance with the pharmacokinetic properties of the drug taken:
- short-acting β2-agonists - 6 hours before the start of the test;
- long-acting β2-agonists - for 12 hours;
- prolonged theophyllines - for 24 hours.

Calculation of the increase in FEV1

by absolute increase in FEV1 in ml (the easiest way):

Disadvantage: this method does not allow to judge the degree of relative improvement in bronchial patency, since neither the initial nor the achieved indicator is taken into account in relation to the due one.

according to the ratio of the absolute increase in the FEV1 indicator, expressed as a percentage, to the initial FEV1:

Disadvantage: A small absolute increase will result in a high percentage increase if the patient initially had low rate OFV1.

- Method for measuring the degree of bronchodilatory response as a percentage of the due FEV1 [ΔOFE1 due. (%)]:

Method for measuring the degree of bronchodilatory response as a percentage of the maximum possible reversibility [ΔOEF1 possible. (%)]:

Where FEV1 ref. - initial parameter, FEV1 dilat. - indicator after bronchodilatory test, FEV1 should. - proper parameter.

The choice of method for calculating the reversibility index depends on the clinical situation and the specific reason for which the study is being conducted. The use of the reversibility indicator, which is less dependent on the initial parameters, allows for a more correct comparative analysis.

Marker of a positive bronchodilatory response the increase in FEV1 is considered to be ≥15% of the predicted value and ≥ 200 ml. Upon receipt of such an increase, bronchial obstruction is documented as reversible.

Bronchial obstruction can lead to a change in the structure of static volumes in the direction of hyperairiness of the lungs, a manifestation of which, in particular, is an increase in the total lung capacity.
To detect changes in the ratios of static volumes that make up the structure of the total lung capacity in hyperair and emphysema, body plethysmography and measurement of lung volumes by the method of diluting inert gases are used.

Bodyplethysmography
With emphysema, anatomical changes in the lung parenchyma (expansion of air spaces, destructive changes in the alveolar walls) are functionally manifested by an increase in the static extensibility of the lung tissue. A change in the shape and angle of the "pressure-volume" loop is noted.

Measurement of lung diffusion capacity is used to detect damage to the lung parenchyma due to emphysema and is performed after forced spirometry or pneumotachometry and determination of the structure of static volumes.

In emphysema, the diffusing capacity of the lungs (DLCO) and its relationship to the alveolar volume DLCO/Va are reduced (mainly as a result of the destruction of the alveolar-capillary membrane, which reduces the effective area of ​​gas exchange).
It should be borne in mind that a decrease in the diffusion capacity of the lungs per unit volume can be compensated by an increase in the total lung capacity.

Peakflowmetry
Determining the volume of peak expiratory flow (PSV) is the simplest quick method for assessing the condition of bronchial patency. However, he has low sensitivity, since PSV values ​​can remain within the normal range for a long time in COPD, and low specificity, since a decrease in PSV values ​​can also occur with other respiratory diseases.
Peak flowmetry is used in the differential diagnosis of COPD and bronchial asthma, and can also be used as effective method screening to identify a risk group for developing COPD and to establish the negative impact of various pollutants A pollutant (pollutant) is one of the types of pollutants, any chemical substance or compound that is present in an environmental object in quantities exceeding the background values ​​and thereby causing chemical pollution.
.

Determination of PSV is a necessary control method during the period of exacerbation of COPD and especially at the stage of rehabilitation.

2. Radiography chest organs.

Primary x-ray examination is carried out to exclude other diseases (lung cancer, tuberculosis, etc.), accompanied by clinical symptoms similar to those of COPD.
In mild COPD, significant x-ray changes are usually not detected.
In exacerbation of COPD, an x-ray examination is performed to exclude the development of complications (pneumonia, spontaneous pneumothorax, pleural effusion).

Chest X-ray reveals emphysema. An increase in lung volume is indicated by:
- on a direct roentgenogram - a flat diaphragm and a narrow shadow of the heart;
- on the lateral radiograph - flattening of the diaphragmatic contour and an increase in the retrosternal space.
Confirmation of the presence of emphysema can be the presence of bullae on the radiograph. Bulla - an area of ​​swollen, overstretched lung tissue
- are defined as radiolucent spaces greater than 1 cm in diameter with a very thin arcuate border.

3. CT scan chest organs is required in the following situations:
- when the symptoms present are disproportionate to the spirometry data;
- to clarify the changes identified by radiography of the chest;
- to assess the indications for surgical treatment.

CT, especially high-resolution CT (HRCT) with 1 to 2 mm increments, has higher sensitivity and specificity for diagnosing emphysema than radiography. With the help of CT in the early stages of development, it is also possible to identify a specific anatomical type of emphysema (panacinar, centroacinar, paraseptal).

CT scan of many patients with COPD reveals pathognomonic saber deformity of the trachea, which is pathognomonic for this disease.

Since a standard CT examination is performed at the height of inspiration, when excess airiness of the lung tissue is not noticeable, if COPD is suspected, CT tomography should be supplemented with exhalation.

HRCT allows you to assess the fine structure of the lung tissue and the condition of the small bronchi. The state of the lung tissue in violation of ventilation in patients with obstructive changes is studied under the conditions of expiratory CT. Using this technique, HRCT is performed at the height of the delayed expiratory flow.
In areas of impaired bronchial patency, areas of increased airiness - "air traps" - are revealed, which lead to hyperinflation. This phenomenon occurs as a result of an increase in the compliance of the lungs and a decrease in their elastic recoil. During exhalation, airway obstruction causes air to be retained in the lungs due to the inability of the patient to fully exhale.
Air traps (such as IC - inspiratory capacity, inspiratory capacity) are more closely correlated with the state of the airways of a patient with COPD than FEV1.

Other studies

1.Electrocardiography in most cases, it allows to exclude the cardiac genesis of respiratory symptoms. In some cases, ECG reveals signs of hypertrophy of the right heart during the development of cor pulmonale as a complication of COPD.

2.echocardiography allows you to assess and identify signs of pulmonary hypertension, dysfunction of the right (and in the presence of changes - and left) parts of the heart and determine the severity of pulmonary hypertension.

3.Exercising study(step test). In the initial stages of the disease, disturbances in the diffusion capacity and gas composition of the blood may be absent at rest and appear only during exercise. Conducting a test with physical activity is recommended to objectify and document the degree of decrease in exercise tolerance.

An exercise test is performed in the following cases:
- when the severity of shortness of breath does not correspond to a decrease in FEV1 values;
- to monitor the effectiveness of the therapy;
- for the selection of patients for rehabilitation programs.

Most often used as a step test 6 minute walk test which can be performed on an outpatient basis and is the simplest means for individual observation and monitoring of the course of the disease.

The standard protocol for the 6-minute walk test involves instructing patients about the goals of the test, then instructing them to walk along the measured corridor at their own pace, trying to walk the maximum distance within 6 minutes. Patients are allowed to stop and rest during the test, resuming walking after rest.

Before and at the end of the test, shortness of breath is assessed on the Borg scale (0-10 points: 0 - no shortness of breath, 10 - maximum shortness of breath), according to SatO 2 and pulse. Patients stop walking if they experience severe shortness of breath, dizziness, pain in chest or in the legs, with a decrease in SatO 2 to 86%. The distance traveled within 6 minutes is measured in meters (6MWD) and compared with the due indicator 6MWD(i).
The 6-minute walk test is a component of the BODE scale (see section "Forecast"), which allows you to compare FEV1 values ​​​​with the results of the mMRC scale and body mass index.

4. Bronchoscopy used in the differential diagnosis of COPD with other diseases (cancer, tuberculosis, etc.), manifested by similar respiratory symptoms. The study includes examination of the bronchial mucosa and assessment of its condition, taking bronchial contents for subsequent studies (microbiological, mycological, cytological).
If necessary, it is possible to conduct a biopsy of the bronchial mucosa and perform the technique of bronchoalveolar lavage with the determination of the cellular and microbial composition in order to clarify the nature of inflammation.

5. Studying the quality of life. Quality of life is an integral indicator that determines the patient's adaptation to COPD. To determine the quality of life, special questionnaires are used (non-specific questionnaire SF-36). The most famous questionnaire of St. George's Hospital - The St. George's Hospital Respiratory Questionnaire - SGRQ.

6. Pulse oximetry used to measure and monitor SatO 2 . It allows you to register only the level of oxygenation and does not make it possible to monitor changes in PaCO 2 . If SatO 2 is less than 94%, then a blood gas test is indicated.

Pulse oximetry is indicated to determine the need for oxygen therapy (if cyanosis or cor pulmonale or FEV1< 50% от должных величин).

When formulating the diagnosis of COPD indicate:
- severity of the course of the disease: mild course (stage I), moderate course (stage II), severe course (stage III) and extremely severe course (stage IV), exacerbation or stable course of the disease;
- the presence of complications (cor pulmonale, respiratory failure, circulatory failure);
- risk factors and smoker index;
- in case of severe disease, it is recommended to indicate clinical form COPD (emphysematous, bronchitis, mixed).

Laboratory diagnostics

1. Study of the gas composition of the blood carried out in patients with an increase in shortness of breath, a decrease in FEV1 values ​​\u200b\u200bless than 50% of the due value, in patients with clinical signs respiratory failure or right heart failure.

Respiratory failure criterion(when breathing air at sea level) - PaO 2 less than 8.0 kPa (less than 60 mm Hg) regardless of the increase in PaCO 2. It is preferable to take samples for analysis by arterial puncture.

2. Clinical blood test:
- during exacerbation: neutrophilic leukocytosis with a stab shift and an increase in ESR;
- with a stable course of COPD, there are no significant changes in the content of leukocytes;
- with the development of hypoxemia, a polycythemic syndrome is observed (an increase in the number of red blood cells, a high level of Hb, low ESR, an increase in hematocrit > 47% in women and > 52% in men, increased blood viscosity);
- Identified anemia can cause or increase shortness of breath.

3. Immunogram carried out to detect signs of immune deficiency in the steady progression of COPD.

4. Coagulogram is carried out with polycythemia for the selection of adequate deaggregating therapy.

5. Sputum cytology is carried out to identify the inflammatory process and its severity, as well as to identify atypical cells (given the advanced age of most COPD patients, there is always oncological alertness).
If sputum is absent, the method of studying induced sputum is used, i.e. collected after inhalation of hypertonic sodium chloride solution. The study of sputum smears during Gram staining allows for an approximate identification of the group affiliation (gram-positive, gram-negative) of the pathogen.

6. Culture of sputum is carried out to identify microorganisms and select rational antibiotic therapy in the presence of persistent or purulent sputum.

Differential Diagnosis

The main disease with which it is necessary to differentiate COPD is bronchial asthma.

Main criteria differential diagnosis COPD and bronchial asthma

1 Bronchial asthma can begin in middle and old age
2 Allergic rhinitis, conjunctivitis, atopic dermatitis, urticaria
3 The type of airway inflammation is most often determined by cytological examination sputum and fluid obtained from bronchoalveolar lavage.

Help in doubtful cases of diagnosis of COPD and bronchial asthma can be provided by the following signs identifying bronchial asthma:

1. An increase in FEV1 of more than 400 ml in response to inhalation with a short-acting bronchodilator or an increase in FEV1 of more than 400 ml after 2 weeks of treatment with prednisolone 30 mg / day for 2 weeks (in patients with COPD, FEV1 and FEV1 / FVC as a result of treatments do not reach normal values).

2. Reversibility of bronchial obstruction is the most important differential diagnostic feature. It is known that in patients with COPD after taking a bronchodilator, the increase in FEV1 is less than 12% (and ≤200 ml) of the baseline, and in patients with bronchial asthma, FEV1, as a rule, exceeds 15% (and > 200 ml).

3. Approximately 10% of patients with COPD also have signs of bronchial hyperreactivity.

Other diseases

1. Heart failure. Signs:
- wheezing in the lower parts of the lungs - during auscultation;
- a significant decrease in the ejection fraction of the left ventricle;
- dilatation of the heart;
- expansion of the contours of the heart, congestion (up to pulmonary edema) - on the x-ray;
- violations of the restrictive type without airflow limitation - in the study of lung function.

2. Bronchiectasis. Signs:
- large volumes of purulent sputum;
- frequent association with bacterial infection;
- rough wet rales of various sizes - during auscultation;
- a symptom of "drumsticks" (flask-shaped thickening of the terminal phalanges of the fingers and toes);

Expansion of the bronchi and thickening of their walls - on x-ray or CT.

3. Tuberculosis. Signs:
- starts at any age;
- infiltrate in the lungs or focal lesions - with x-ray;
- high incidence in the region.

If you suspect pulmonary tuberculosis, you need:
- tomography and / or CT of the lungs;
- microscopy and culture of sputum Mycobacterium tuberculosis, including the flotation method;
- study of pleural exudate;
- diagnostic bronchoscopy with biopsy for suspected bronchus tuberculosis;
- Mantoux test.

4. Obliterating bronchiolitis. Signs:
- development at a young age;
- no connection with smoking has been established;
- contact with vapors, smoke;
- foci of low density during expiration - at CT;
rheumatoid arthritis is often present.

Complications

- acute or chronic respiratory failure;
- secondary polycythemia;
- chronic cor pulmonale;
- pneumonia;
- spontaneous pneumothorax Pneumothorax is the presence of air or gas in the pleural cavity.
;
- pneumomediastinum Pneumomediastinum - the presence of air or gas in the tissue of the mediastinum.
.

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Treatment

Treatment goals:
- prevention of disease progression;
- relief of symptoms;
- increasing tolerance to physical activity;
- improving the quality of life;
- prevention and treatment of complications;
- prevention of exacerbations;
- Decreased mortality.

The main directions of treatment:
- reducing the influence of risk factors;
- educational programs;
- treatment of COPD in stable condition;
- treatment of exacerbation of the disease.

Reducing the influence of risk factors

Smoking
Smoking cessation is the first mandatory step in a COPD treatment program and the single most effective way to reduce the risk of developing COPD and prevent progression of the disease.

The Tobacco Dependence Treatment Guidelines contain 3 programs:
1. Long-term treatment program for the purpose of complete smoking cessation - designed for patients with a strong desire to quit smoking.

2. A short treatment program to reduce smoking and increase motivation to quit smoking.
3. A smoking reduction program designed for patients who do not want to quit smoking but are willing to reduce their intensity.

Industrial hazards, atmospheric and household pollutants
Primary preventive measures are to eliminate or reduce the impact of various pathogenic substances in the workplace. Equally important is secondary prevention - epidemiological control and early detection of COPD.

Educational programs
Education plays an important role in the management of COPD, especially educating patients to quit smoking.
Highlights of educational programs for COPD:
1. Patients should understand the nature of the disease, be aware of the risk factors leading to its progression.
2. Education must be adapted to the needs and environment of the individual patient, as well as to the intellectual and social level of the patient and those who care for him.
3. It is recommended to include the following information in the training programs: smoking cessation; basic information about COPD; general approaches to therapy, specific treatment issues; self-management skills and decision-making during an exacerbation.

Treatment of patients with stable COPD

Medical therapy

Bronchodilators are the mainstay of symptomatic treatment of COPD. All categories of bronchodilators increase exercise tolerance even in the absence of changes in FEV1. Inhalation therapy is preferred.
All stages of COPD require exclusion of risk factors, yearly influenza vaccine, and use of short-acting bronchodilators as needed.

Short acting bronchodilators used in patients with COPD as empirical therapy to reduce the severity of symptoms and limit physical activity. Usually they are used every 4-6 hours. In COPD, the regular use of short-acting β2-agonists as monotherapy is not recommended.

Long acting bronchodilators or their combination with short-acting β2-agonists and short-acting anticholinergics are given to patients who remain symptomatic despite monotherapy with short-acting bronchodilators.

General principles of pharmacotherapy

1. With mild (stage I) COPD and the absence of clinical manifestations of the disease, regular drug therapy not required.

2. In patients with intermittent symptoms of the disease, inhaled β2-agonists or short-acting M-anticholinergics are indicated, which are used on demand.

3. If inhaled bronchodilators are not available, long-acting theophyllines may be recommended.

4. Anticholinergics are considered first choice for moderate, severe, and very severe COPD.

5. Short-acting M-anticholinergic (ipratropium bromide) has a longer bronchodilator effect compared to short-acting β2-agonists.

6. According to studies, the use of tiotropium bromide is effective and safe in the treatment of patients with COPD. It has been shown that taking tiotropium bromide once a day (compared with salmeterol 2 times a day) leads to a more pronounced improvement in lung function and a decrease in dyspnea.
Tiotropium bromide reduces the frequency of exacerbations of COPD at 1 year of use compared with placebo and ipratropium bromide and at 6 months of use compared with salmeterol.
Thus, once-daily tiotropium bromide seems to be the best basis for the combined treatment of stage II-IV COPD.

7. Xanthines are effective in COPD, but are second-line drugs due to their potential toxicity. For more severe disease, xanthines may be added to regular inhaled bronchodilator therapy.

8. With a stable course of COPD, the use of a combination of anticholinergic drugs with short-acting β2-agonists or long-acting β2-agonists is more effective.
Nebulizer therapy with bronchodilators is indicated for patients with stage III and IV COPD. To clarify the indications for nebulizer therapy, PSV is monitored for 2 weeks of treatment; therapy continues even if the peak expiratory flow rate improves.

9. If bronchial asthma is suspected, a trial treatment with inhaled corticosteroids is carried out.
The effectiveness of corticosteroids in COPD is lower than in bronchial asthma, and therefore their use is limited. Long-term treatment with inhaled corticosteroids in patients with COPD is prescribed in addition to bronchodilator therapy in the following cases:

If the patient has a significant increase in FEV1 in response to this treatment;
- in severe / extremely severe COPD and frequent exacerbations (3 times or more in the last 3 years);
- regular (permanent) treatment with inhaled corticosteroids is indicated for patients with stage III and IV COPD with repeated exacerbations of the disease requiring antibiotics or oral corticosteroids at least once a year.
When the use of inhaled corticosteroids is limited for economic reasons, it is possible to prescribe a course of systemic corticosteroids (no longer than 2 weeks) to identify patients with a pronounced spirometric response.

Systemic corticosteroids with a stable course of COPD are not recommended.

The scheme of treatment with bronchodilators at various stages of COPD without exacerbation

1. On mild stage(I): Treatment with bronchodilators is not indicated.

2. At moderate (II), severe (III) and extremely severe (IV) stages:
- regular intake of short-acting M-anticholinergics or
- regular intake of long-acting M-anticholinergics or
- regular use of long-acting β2-agonists or
Regular intake of short-acting or long-acting M-anticholinergics + short-acting or long-acting inhaled β2-agonists, or
Regular intake of long-acting M-anticholinergics + long-acting theophyllines or
- inhaled long-acting β2-agonists + long-acting theophyllines or
- regular intake of short-acting or long-acting M-anticholinergics + short-acting or long-acting inhaled β2-agonists + theophyllines
long-acting

Examples of treatment regimens for various stages of COPD without exacerbation

All stages(I, II, III, IV)
1. Exclusion of risk factors.
2. Annual vaccination with influenza vaccine.
3. If necessary, inhalation of one of the following drugs:

Salbutamol (200-400 mcg);
- fenoterol (200-400 mcg);
- ipratropium bromide (40 mcg);

Fixed combination of fenoterol and ipratropium bromide (2 doses).

Stage II, III, IV
Regular inhalations:
- ipratropium bromide 40 mcg 4 rubles / day. or
- tiotropium bromide 18 mcg 1 rub/day. or
- salmeterol 50 mcg 2 r./day. or
- formoterol "Turbuhaler" 4.5-9.0 mcg or
- formoterol "Autohaler" 12-24 mcg 2 r./day. or
- fixed combination of fenoterol + ipratropium bromide 2 doses 4 rubles / day. or
- ipratropium bromide 40 mcg 4 rubles / day. or tiotropium bromide 18 mcg 1 p./day. + salmeterol 50 mcg 2 r. / day. (or formoterol "Turbuhaler" 4.5-9.0 mcg or formoterol "Autohaler" 12-24 mcg 2 r./day or ipratropium bromide 40 mcg 4 r./day) or
- tiotropium bromide 18 mcg 1 rub/day + inside theophylline 0.2-0.3 g 2 rub/day. or (salmeterol 50 mcg 2 r./day or formoterol "Turbuhaler" 4.5-9.0 mcg) or
- ormoterol "Autohaler" 12-24 mcg 2 rubles / day. + inside theophylline 0.2-0.3 g 2 rubles / day. or ipratropium bromide 40 mcg 4 times a day. or
- tiotropium bromide 18 mcg 1 rub/day. + salmeterol 50 mcg 2 r. / day. or formoterol "Turbuhaler" 4.5-9.0 mcg or
- formoterol "Autohaler" 12-24 mcg 2 rubles / day + inside theophylline 0.2-0.3 g 2 rubles / day.

Stages III and IV:

Beclomethasone 1000-1500 mcg / day. or budesonide 800-1200 mcg / day. or
- fluticasone propionate 500-1000 mcg / day. - with repeated exacerbations of the disease, requiring at least once a year antibiotics or oral corticosteroids, or

Fixed combination of salmeterol 25-50 mcg + fluticasone propionate 250 mcg (1-2 doses 2 times a day) or formoterol 4.5 mcg + budesonide 160 mcg (2-4 doses 2 times a day) indications are the same, as for inhaled corticosteroids.

Oxygen therapy

The main cause of death in COPD patients is acute respiratory failure. In this regard, the correction of hypoxemia with oxygen is the most reasonable treatment for severe respiratory failure.
In patients with chronic hypoxemia, long-term oxygen therapy (VCT) is used, which helps to reduce mortality.

VCT is indicated for patients with severe COPD if the possibilities of drug therapy have been exhausted and the maximum possible therapy does not lead to an increase in O 2 above the borderline values.
The purpose of VCT is to increase PaO 2 to at least 60 mm Hg. at rest and/or SatO 2 - not less than 90%. VCT is not indicated for patients with moderate hypoxemia (PaO 2 > 60 mm Hg). Indications for VCT should be based on gas exchange parameters, which were assessed only during the stable state of patients (3-4 weeks after the exacerbation of COPD).

Indications for continuous oxygen therapy:
- RaO 2< 55 мм рт.ст. или SatO 2 < 88% в покое;
- PaO 2 - 56-59 mm Hg. or SatO 2 - 89% in the presence of chronic cor pulmonale and/or erythrocytosis (hematocrit > 55%).

Indications for "situational" oxygen therapy:
- decrease in PaO 2< 55 мм рт.ст. или SatO 2 < 88% при физической нагрузке;
- decrease in PaO 2< 55 мм рт.ст. или SatO 2 < 88% во время сна.

Assignment Modes:
- flow O 2 1-2 l/min. - for the majority of patients;
- up to 4-5 l/min. - for the most severe patients.
At night, during physical activity and during air travel, patients should increase the flow of oxygen by an average of 1 l / min. compared to the optimal daily flow.
According to international studies MRC and NOTT (from nocturnal oxygen therapy), VCT is recommended for at least 15 hours a day. with breaks not exceeding 2 hours in a row.

Possible side effects of oxygen therapy:
- violation of mucociliary clearance;
- decrease in cardiac output;
- decrease in minute ventilation, carbon dioxide retention;
- systemic vasoconstriction;
- pulmonary fibrosis.

Non-invasive ventilation of the lungs is carried out using a mask. It helps to improve the gas composition of arterial blood, reduce the days of hospitalization and improve the quality of life of patients.
Indications for long-term mechanical ventilation in patients with COPD:
- PaCO 2 > 55 mm Hg;
- PaCO 2 within 50-54 mm Hg. in combination with nocturnal desaturation and frequent episodes of hospitalization of the patient;
- shortness of breath at rest (respiratory rate> 25 per minute);
- participation in breathing of auxiliary muscles (abdominal paradox, alternating rhythm - alternation of chest and abdominal types of breathing.

Absolute readings:
- stop breathing;
- pronounced disturbances of consciousness (stupor, coma);
- unstable hemodynamic disorders (systolic blood pressure< 70 мм рт.ст., ЧСС < 50/мин или >160/min);
- fatigue of the respiratory muscles.

Relative readings:
- respiratory rate > 35/min;
- severe acidosis (pH of arterial blood< 7,25) и/или гиперкапния (РаСО 2 > 60 mmHg);
- RaO 2 < 45 мм рт.ст., несмотря на проведение кислородотерапии.
- inefficiency of non-invasive ventilation of the lungs.

Protocol for the management of patients with exacerbation of COPD in the intensive care unit.
1. Assessment of the severity of the condition, radiography of the respiratory organs, blood gases.
2. Oxygen therapy 2-5 l / min., at least 18 hours / day. and/or noninvasive ventilation.
3. Repeated control of the gas composition after 30 minutes.
4. Bronchodilator therapy:

4.1 Increasing the dosage and frequency of administration. A solution of ipratropium bromide 0.5 mg (2.0 ml) via an oxygen nebulizer in combination with solutions of short-acting β2-agonists: salbutamol 5 mg or fenoterol 1.0 mg (1.0 ml) every 2-4 hours.
4.2 Combination of fenoterol and ipratropium bromide (berodual). Berodual solution 2 ml through an oxygen nebulizer every 2-4 hours.
4.3 Intravenous administration of methylxanthines (if ineffective). Eufillin 240 mg/h. up to 960 mg / day. in / in with an injection rate of 0.5 mg / kg / h. under ECG control. The daily dose of aminophylline should not exceed 10 mg/kg of the patient's body weight.
5. Systemic corticosteroids intravenously or orally. Inside - 0.5 mg / kg / day. (40 mg / day for 10 days), if oral administration is not possible - parenterally up to 3 mg / kg / day. A combined method of prescribing intravenous and oral administration is possible.
6. Antibacterial therapy (for signs of a bacterial infection orally or intravenously).
7. Subcutaneous anticoagulants for polycythemia.
8. Treatment of concomitant diseases (heart failure, cardiac arrhythmias).
9. Non-invasive ventilation of the lungs.
10. Invasive lung ventilation (IVL).

Exacerbation of COPD

1. Treatment of COPD exacerbation on an outpatient basis.

With a mild exacerbation, an increase in the dose and / or frequency of taking bronchodilator drugs is indicated:
1.1 Anticholinergic drugs are added (if not previously used). Preference is given to inhaled combined bronchodilators (anticholinergics + short-acting β2-agonists).

1.2 Theophylline - if it is impossible to use inhaled forms of drugs or their effectiveness is insufficient.
1.3 Amoxicillin or macrolides (azithromycin, clarithromycin) - with a bacterial nature of COPD exacerbation.

In moderate exacerbations, along with increased bronchodilator therapy, amoxicillin / clavulanate or second-generation cephalosporins (cefuroxime axetil) or respiratory fluoroquinolones (levofloxacin, moxifloxacin) are prescribed for at least 10 days.
In parallel with bronchodilator therapy, systemic corticosteroids are prescribed at a daily dose of 0.5 mg / kg / day, but not less than 30 mg of prednisolone per day or another systemic corticosteroid in an equivalent dose for 10 days, followed by cancellation.

2. Treatment of COPD exacerbation in stationary conditions.

2.1 Oxygen therapy 2-5 l / min, at least 18 hours / day. with the control of the gas composition of the blood after 30 minutes.

2.2 Bronchodilator therapy:
- increase in dosage and frequency of administration; solutions of ipratropium bromide - 0.5 mg (2 ml: 40 drops) through an oxygen nebulizer in combination with solutions of salbutamol (2.5-5.0 mg) or fenoterol - 0.5-1.0 mg (0.5- 1.0 ml: 10-20 drops) - "on demand" or
- a fixed combination of fenoterol and an anticholinergic agent - 2 ml (40 drops) through an oxygen nebulizer - "on demand".
- intravenous administration methylxanthines (with inefficiency): eufillin 240 mg / h to 960 mg / day. in / in with an injection rate of 0.5 mg / kg / h. under ECG control.

2.3 Systemic corticosteroids intravenously or orally. Inside 0.5 mg / kg / day. (40 mg / day. Prednisolone or other SCS in an equivalent dose for 10 days), if oral administration is not possible - parenterally up to 3 mg / kg / day.

2.4 Antibacterial therapy (for signs of bacterial infection orally or intravenously):

2.4.1 Simple (uncomplicated) exacerbation: drug of choice (one of the following) orally (7-14 days):
- amoxicillin (0.5-1.0 g) 3 rubles / day.
Alternative drugs (one of these) by mouth:
- azithromycin (500 mg) 1 r./day. according to the scheme;
- amoxicillin / clavulanate (625) mg 3 times a day. or (1000 mg) 2 r./day;
- cefuroxime axetil (750 mg) 2 times a day;
- clarithromycin SR (500 mg) 1 rub/day;
- clarithromycin (500 mg) 2 times a day;

- moxifloxacin (400 mg) 1 rub/day.

2.4.2 Complicated exacerbation: drug of choice and alternative drugs (one of the following) IV:
- amoxicillin/clavulanate 1200 mg 3 times a day;
- levofloxacin (500 mg) 1 rub/day;
- moxifloxacin (400 mg) 1 rub/day.
If you suspect the presence of Ps. aeruginosa within 10-14 days:
- ciprofloxacin (500 mg) 3 rubles / day. or
- ceftazidime (2.0 g) 3 times a day

After intravenous antibiotic therapy, one of the following drugs is administered orally for 10-14 days:
- amoxicillin / clavulanate (625 mg) 3 rubles / day;
- levofloxacin (500 mg) 1 rub/day;
- moxifloxacin (400 mg) 1 rub/day;
- ciprofloxacin (400 mg) 2-3 rubles / day.

Forecast

The prognosis for COPD is conditionally unfavorable. The disease slowly, steadily progresses; in process of its development working capacity of patients is steadily lost.
Continued smoking usually contributes to the progression of airway obstruction leading to early disability and reduced life expectancy. After quitting smoking, there is a slowdown in the decline in FEV1 and the progression of the disease. To alleviate the condition, many patients are forced to take drugs in gradually increasing doses until the end of their lives, as well as use additional drugs during exacerbations.
Adequate treatment significantly slows down the development of the disease, up to periods of stable remission for several years, but does not eliminate the cause of the development of the disease and the formed morphological changes.

Among other diseases, COPD is the fourth leading cause of death in the world. Mortality depends on the presence of concomitant diseases, the age of the patient and other factors.

BODE Method(Body mass index, Obstruction, Dyspnea, Exercise - body mass index, obstruction, shortness of breath, exercise stress) gives a combined score that predicts subsequent survival better than either of the above scores taken alone. Currently, research on the properties of the BODE scale as a tool for quantitative assessment of COPD is ongoing.

Chronic obstructive pulmonary disease or COPD refers to chronic lung diseases associated with respiratory failure. Bronchial damage develops with emphysema complications against the background of inflammatory and external stimuli and has a chronic progressive character.

The alternation of latent periods with exacerbations requires a special approach to treatment. Development risk serious complications quite high, which is confirmed by statistical data. Respiratory dysfunction causes disability and even death. Therefore, patients with this diagnosis need to know COPD, what it is and how the disease is treated.

general characteristics

When exposed to the respiratory system of various irritating substances in people with a predisposition to pneumonia, negative processes begin to develop in the bronchi. First of all, the distal sections are affected - located in close proximity to the alveoli and lung parenchyma.

Against the background of inflammatory reactions, the process of natural discharge of mucus is disrupted, and small bronchi are clogged. When an infection is attached, inflammation spreads to the muscle and submucosal layers. As a result, bronchial remodeling occurs with replacement by connective tissues. In addition, lung tissue and bridges are destroyed, which leads to the development of emphysema. With a decrease in the elasticity of the lung tissues, hyperairiness is observed - the air literally inflates the lungs.

Problems arise precisely with the exhalation of air, since the bronchi cannot fully expand. This leads to a violation of gas exchange and a decrease in the volume of inhalation. Change natural process breathing manifests itself in patients as shortness of breath in COPD, which increases significantly with exercise.

Persistent respiratory failure causes hypoxia - oxygen deficiency. From oxygen starvation all organs are affected. With prolonged hypoxia, the pulmonary vessels narrow even more, which leads to hypertension. As a result, irreversible changes in the heart occur - the right section increases, which causes heart failure.

Why is COPD classified as a separate group of diseases?

Unfortunately, not only patients, but also medical workers little is known about the term chronic obstructive pulmonary disease. Doctors habitually diagnose emphysema or chronic bronchitis. Therefore, the patient does not even realize that his condition is associated with irreversible processes.

Indeed, in COPD, the nature of symptoms and treatment in remission are not much different from the signs and methods of therapy for pulmonary pathologies associated with respiratory failure. What then made physicians single out COPD as a separate group.

Medicine has determined the basis of such a disease - chronic obstruction. But the narrowing of the gaps in the airways are also found in the course of other pulmonary diseases.

COPD, unlike other diseases such as asthma and bronchitis, cannot be permanently cured. Negative processes in the lungs are irreversible.

So, in asthma, spirometry shows improvement after bronchodilators are used. Moreover, the indicators of PSV, FEV may increase by more than 15%. While COPD does not provide significant improvements.

Bronchitis and COPD are two different diseases. But chronic obstructive pulmonary disease can develop against the background of bronchitis or occur as an independent pathology, just like bronchitis can not always provoke COPD.

Bronchitis is characterized by a prolonged cough with sputum hypersecretion and the lesion extends exclusively to the bronchi, while obstructive disorders are not always observed. Whereas sputum separation in COPD is not increased in all cases, and the lesion extends to structural elements, although bronchial rales are auscultated in both cases.

Why does COPD develop?

Not so few adults and children suffer from bronchitis, pneumonia. Why, then, chronic obstructive pulmonary disease develops only in a few. In addition to provoking factors, predisposing factors also affect the etiology of the disease. That is, the impetus for the development of COPD can be certain conditions in which people who are prone to pulmonary pathologies find themselves.

Predisposing factors include:

1. hereditary predisposition. It is not uncommon to have a family history of certain enzyme deficiencies. This condition has a genetic origin, which explains why the lungs do not mutate in a heavy smoker, and COPD in children develops for no particular reason.
2. Age and gender. For a long time it was believed that the pathology affects men over 40. And the rationale is more related not to age, but to smoking experience. But today the number of women who smoke with experience is no less than that of men. Therefore, the prevalence of COPD among the fair sex is no less. In addition, women who are forced to breathe cigarette smoke also suffer. Passive smoking negatively affects not only the female, but also the children's body.
3. Problems with the development of the respiratory system. Moreover, we are talking about both the negative impact on the lungs during intrauterine development, and the birth of premature babies whose lungs did not have time to develop for full disclosure. In addition, in early childhood, the lag in physical development negatively affects the state of the respiratory system.
4. Infectious diseases. With frequent respiratory diseases of an infectious origin, both in childhood and at an older age, the risk of developing COL increases significantly.
5. Hyperreactivity of the lungs. Initially, this condition is the cause of bronchial asthma. But in the future, the addition of COPD is not ruled out.

But this does not mean that all patients at risk will inevitably develop COPD.

Obstruction develops under certain conditions, which can be:

1. Smoking. Smokers are the main patients diagnosed with COPD. According to statistics, this category of patients is 90%. Therefore, it is smoking that is called the main cause of COPD. And the prevention of COPD is based primarily on smoking cessation.
2. Harmful working conditions. People who, by the nature of their work, are forced to regularly inhale dust of various origins, air saturated with chemicals, and smoke suffer from COPD quite often. Work in mines, construction sites, in the collection and processing of cotton, in metallurgical, pulp, chemical production, in granaries, as well as in enterprises producing cement, other building mixtures leads to the development of respiratory problems to the same extent in smokers and non-smokers .
3. Inhalation of combustion products. We are talking about biofuels: coal, wood, manure, straw. Residents who heat their homes with such fuel, as well as people who are forced to be present during natural fires, inhale combustion products that are carcinogens and irritate the respiratory tract.

In fact, any external effect on the lungs of an irritating nature can provoke obstructive processes.

Main complaints and symptoms

Primary signs of COPD associated with cough. Moreover, cough, to a greater extent, worries patients in the daytime. At the same time, sputum separation is insignificant, wheezing may be absent. The pain practically does not bother, sputum leaves in the form of mucus.

Sputum with the presence of pus or a cough that provokes hemoptysis and pain, wheezing - the appearance of a later stage.

The main symptoms of COPD are associated with the presence of shortness of breath, the intensity of which depends on the stage of the disease:

• With mild shortness of breath, breathing is forced against the background of fast walking, as well as when climbing a hill;
• Moderate shortness of breath is indicated by the need to slow down the pace of walking on a flat surface due to breathing problems;
• Severe shortness of breath occurs after several minutes of walking at a free pace or walking a distance of 100 m;
• For shortness of breath of the 4th degree, the appearance of breathing problems during dressing, performing simple actions, immediately after going outside is characteristic.

The occurrence of such syndromes in COPD may accompany not only the stage of exacerbation. Moreover, with the progress of the disease, the symptoms of COPD in the form of shortness of breath, cough become stronger. On auscultation, wheezing is heard.

Breathing problems inevitably provoke systemic changes in the human body:

• The muscles involved in the breathing process, including the intercostal ones, atrophy, which causes muscle pain and neuralgia.
• In the vessels, changes in the lining, atherosclerotic lesions are observed. Increased tendency to form blood clots.
• A person is faced with heart problems in the form of arterial hypertension, coronary disease and even a heart attack. For COPD, the pattern of cardiac changes is associated with left ventricular hypertrophy and dysfunction.
• Osteoporosis develops, manifested by spontaneous fractures of the tubular bones, as well as the spine. Constant joint pain, bone pain cause a sedentary lifestyle.

The immune defense is also reduced, so any infections are not rebuffed. Frequent colds, in which there is heat, headache, and other signs of infection are not uncommon in COPD.

There are also mental and emotional disorders. Working capacity is significantly reduced, a depressive state, unexplained anxiety develops.

It is problematic to correct emotional disorders that have arisen against the background of COPD. Patients complain of apnea, stable insomnia.

In the later stages, cognitive disorders also appear, manifested by problems with memory, thinking, and the ability to analyze information.

Clinical forms of COPD

In addition to the stages of development of COPD, which are most often used in medical classification,

There are also forms of the disease according to the clinical manifestation:

1. bronchial type. Patients are more likely to cough, wheezing with sputum discharge. In this case, shortness of breath is less common, but heart failure develops more rapidly. Therefore, there are symptoms in the form of swelling and cyanosis of the skin, which gave the name to the patients "blue edema".
2. emphysematous type. The clinical picture is dominated by shortness of breath. The presence of cough and sputum is rare. The development of hypoxemia and pulmonary hypertension is observed only in the later stages. Patients experience significant weight loss and skin acquire a pink-gray hue, which gave the name - "pink puffers".

However, it is impossible to speak of a clear division, since in practice COPD of a mixed type is more common.

Exacerbation of COPD

The disease can be aggravated unpredictably under the influence of various factors, including external, irritating, physiological and even emotional. Even after eating in a hurry, choking may occur. At the same time, the condition of a person is deteriorating rapidly. Increasing cough, shortness of breath. The use of the usual basic COPD therapy in such periods does not give results. During the period of exacerbation, it is necessary to adjust not only the methods of COPD treatment, but also the doses of the drugs used.

Usually treatment is carried out in a hospital, where it is possible to provide emergency assistance sick and spend necessary examinations. If exacerbations of COPD occur frequently, the risk of complications increases.

Urgent care

Exacerbations with sudden attacks suffocation and severe shortness of breath must be stopped immediately. Therefore, emergency assistance comes to the fore.

It is best to use a nebulizer or spacer and provide fresh air. Therefore, a person predisposed to such attacks should always have inhalers with them.

If first aid does not work and suffocation does not stop, it is urgent to call an ambulance.

Video

Chronic obstructive pulmonary disease

Principles of treatment for exacerbations

• Short bronchodilators are used with an increase in the usual dosages and frequency of administration.
• If bronchodilators do not have the desired effect, Eufilin is administered intravenously.
• It can also be prescribed for exacerbation of COPD treatment with beta-stimulants in combination with anticholinergic drugs.
• If pus is present in the sputum, antibiotics are used. Moreover, it is advisable to use antibiotics with a wide spectrum of action. It makes no sense to use narrowly targeted antibiotics without bakposev.
• The attending physician may decide to prescribe glucocorticoids. Moreover, Prednisolone and other drugs can be prescribed in tablets, injections or used as inhaled glucocorticosteroids (IGCS).
• If oxygen saturation is significantly reduced, oxygen therapy is prescribed. Oxygen therapy is performed using a mask or nasal catheters to ensure proper oxygen saturation.

In addition, drugs can be used to treat diseases that frolic against the background of COPD.

Basic treatment

To prevent seizures and improve the general condition of the patient, a set of measures is taken, among which behavioral and drug treatment, dispensary observation is not the last.

The main drugs used at this stage are bronchodilators and corticosteroid hormones. Moreover, it is possible to use long-acting bronchodilator drugs.

Together with taking medications, it is necessary to pay attention to the development of pulmonary endurance, for which breathing exercises are used.

As for nutrition, the emphasis is on getting rid of excess weight and saturation with the necessary vitamins.

The treatment of COPD in the elderly, as well as in severely ill patients, is associated with a number of difficulties due to the presence of concomitant diseases, complications and reduced immune protection. Often such patients require constant care. Oxygen therapy in such cases is used at home and, at times, is the main way to prevent hypoxia and related complications.

When the damage to the lung tissue is significant, cardinal measures are necessary with resection of a part of the lung.

To modern methods cardinal treatment includes radiofrequency ablation (ablation). It makes sense to do RFA when detecting tumors, when for some reason the operation is not possible.

Prevention

Basic Methods primary prevention directly depend on the habits and lifestyle of a person. Smoking cessation, the use of personal protective equipment significantly reduces the risk of developing lung obstruction.

Secondary prevention is aimed at preventing exacerbations. Therefore, the patient must strictly follow the recommendations of doctors for treatment, as well as exclude provoking factors from their lives.

But even cured, operated patients are not fully protected from exacerbations. Therefore, tertiary prevention is also relevant. Regular medical examination allows you to prevent the disease and detect changes in the lungs in the early stages.

Periodic treatment in specialized sanatoriums is recommended for both patients, regardless of the stage of COPD, and cured patients. With such a diagnosis in the anamnesis, vouchers to the sanatorium are provided on a preferential basis.