Clinical laboratory and instrumental diagnostic symptoms of COPD. Case History - COPD, Chronic Obstructive Pulmonary Disease

COPD (chronic obstructive pulmonary disease) is a disease that develops as a result of an inflammatory response to the action of certain environmental stimuli, with damage to the distal bronchi and the development of emphysema, and which is manifested by a progressive decrease in the airflow rate in the lungs, an increase, as well as damage to other organs.

COPD is the second most common chronic noncommunicable diseases and the fourth largest cause of death, and this figure is steadily increasing. Due to the fact that this disease is inevitably progressive, it occupies one of the first places among the causes of disability, as it leads to a violation of the main function of our body - the respiratory function.

COPD is a truly global problem. In 1998, an initiative group of scientists created the Global Initiative for Chronic Obstructive Lung Disease (GOLD). The main tasks of GOLD are the wide dissemination of information about this disease, the systematization of experience, the explanation of the causes and the corresponding preventive measures. The main idea that doctors want to convey to humanity: COPD can be prevented and treated this postulate is even included in the modern working definition of COPD.

Causes of COPD

COPD develops with a combination of predisposing factors and provoking environmental agents.

Predisposing factors

1. hereditary predisposition. It has already been proven that congenital deficiency of certain enzymes predisposes to the development of COPD. This explains the family history of this disease, as well as the fact that not all smokers, even with long experience, get sick.
2. Gender and age. Men over the age of 40 suffer more from COPD, but this can be explained both by the aging of the body and the duration of smoking. Data are given that now the incidence rate among men and women is almost equal. The reason for this may be the prevalence of smoking among women, as well as hypersensitivity female body to passive smoking.
3. Any negative impact that affect the development of the respiratory organs of the child in the prenatal period and early childhood increase the risk of future COPD. In itself, physical underdevelopment is also accompanied by a decrease in lung volume.
4. Infections. Frequent respiratory infections in childhood, as well as increased susceptibility to them at an older age.
5. Bronchial hyperreactivity. Although bronchial hyperreactivity is the main mechanism of development, this factor is also considered a risk factor for COPD.

Provoking factors

COPD pathogenesis

Exposure to tobacco smoke and other irritants in susceptible individuals leads to chronic inflammation in the walls of the bronchi. The key is the defeat of their distal departments (that is, those located closer to the lung parenchyma and alveoli).

As a result of inflammation, there is a violation normal discharge and discharge of mucus, blockage of small bronchi, infection easily joins, inflammation spreads to the submucosal and muscle layers, muscle cells die and are replaced by connective tissue (bronchial remodeling process). At the same time, the destruction of the parenchyma of the lung tissue, the bridges between the alveoli occurs - emphysema develops, that is, hyperairiness of the lung tissue. The lungs seem to swell with air, their elasticity decreases.

Small bronchi on exhalation do not expand well - the air hardly comes out of the emphysematous tissue. Normal gas exchange is disturbed, as the volume of inhalation also decreases. As a result, the main symptom of all patients with COPD occurs - shortness of breath, especially aggravated by movement, walking.

Respiratory failure results in chronic hypoxia. The whole body suffers from this. Prolonged hypoxia leads to a narrowing of the lumen of the pulmonary vessels - occurs, which leads to the expansion of the right heart (cor pulmonale) and the addition of heart failure.

Why is COPD singled out as a separate nosology?

The awareness of this term is so low that most of the patients who already suffer from this disease do not know that they have COPD. Even if such a diagnosis is made in medical records, in the everyday life of both patients and doctors, the previously familiar and "emphysema" still prevail.

The main components in the development of COPD are indeed chronic inflammation and emphysema. So why, then, is COPD singled out as a separate diagnosis?

In the name of this nosology, we see the main pathological process - chronic obstruction, that is, narrowing of the airway lumen. But the process of obstruction is also present in other diseases.

The difference between COPD and bronchial asthma is that in COPD, the obstruction is almost or completely irreversible. This is confirmed by spirometric measurements using bronchodilators. In bronchial asthma, after the use of bronchodilators, there is an improvement in FEV1 and PSV by more than 15%. This obstruction is treated as reversible. With COPD, these numbers change slightly.

Chronic bronchitis may precede or accompany COPD, but it is an independent disease with well-defined criteria (prolonged cough and), and the term itself implies damage only to the bronchi. With COPD, all structural elements of the lungs are affected - bronchi, alveoli, blood vessels, pleura. Not always chronic bronchitis is accompanied by obstructive disorders. On the other hand, increased sputum production is not always observed in COPD. So, in other words, there can be chronic bronchitis without COPD, and COPD doesn't quite fit the definition of bronchitis.

Chronic obstructive pulmonary disease

Thus, COPD is now a separate diagnosis, has its own criteria, and in no way replaces other diagnoses.

Diagnostic Criteria for COPD

You can suspect COPD in the presence of a combination of all or several signs, if they occur in people over 40 years of age:

A reliable confirmation of COPD is the spirometric indicator of the ratio of forced expiratory volume in 1 s to the forced vital capacity of the lungs (FEV1 / FVC), carried out 10-15 minutes after the use of bronchodilators (beta-sympathomimetics, salbutamol, berotek or 35-40 minutes after short-acting anticholinergics -ipratropium bromide). The value of this indicator<0,7 подтверждает ограничение скорости воздушного потока и в сочетании с подтвержденными факторами риска является достоверным критерием диагноза ХОБЛ.

Other spirometry measures, such as peak expiratory flow rate, as well as FEV1 measurement without a bronchodilator test, can be used as a screening examination, but do not confirm the diagnosis of COPD.

Of the other methods prescribed for COPD, in addition to the usual clinical minimum, one can note X-ray of the lungs, pulse oximetry (determination of blood oxygen saturation), blood gases (hypoxemia, hypercapnia), bronchoscopy, CT chest, sputum examination.

COPD classification

There are several classifications of COPD according to stages, severity, clinical options.

Classification by stages takes into account the severity of symptoms and spirometry data:

• Stage 0. Risk group. Impact of adverse factors (smoking). No complaints, lung function is not impaired.
• Stage 1. Mild COPD.
• Stage 2. Moderate course of COPD.
• Stage 3. Severe course.
• Stage 4. Extremely severe course.

The latest GOLD report (2011) proposed to exclude the classification by stages, it remains severity classification based on FEV1:

In patients with FEV1/FVC<0,70:

• GOLD 1: Mild FEV1 ≥80% predicted
• GOLD 2: Moderate 50% ≤ FEV1< 80%.
• GOLD 3: Severe 30% ≤ FEV1< 50%.
• GOLD 4: Extremely severe FEV1<30%.

It should be noted that the severity of symptoms does not always correlate with the degree of bronchial obstruction. Patients with mild obstruction may be bothered by fairly severe dyspnea, and, conversely, patients with GOLD 3 and GOLD 4 may feel quite well for a long time. To assess the severity of dyspnea in patients, special questionnaires are used, the severity of symptoms is determined in points. It is also necessary to focus on the frequency of exacerbations and the risk of complications in assessing the course of the disease.

Therefore, this report proposes, based on the analysis of subjective symptoms, spirometry data and the risk of exacerbations, to divide patients into clinical groups - A, B, C, D.

Practitioners also distinguish clinical forms of COPD:

1. Emphysematous variant of COPD. Of the complaints in such patients, shortness of breath predominates. Cough is observed less often, sputum may not be. Hypoxemia, pulmonary hypertension come late. Such patients tend to have low body weight, color skin pink grey. They are called "pink puffers".
2. bronchitis variant. Such patients complain mainly of cough with phlegm, shortness of breath is less disturbing, they develop cor pulmonale quite quickly with a corresponding picture of heart failure - cyanosis, edema. Such patients are called "blue puffers".

The division into emphysematous and bronchitis variants is rather conditional, mixed forms are more often observed.

During the course of the disease, a phase of a stable course and an exacerbation phase are distinguished.

Exacerbation of COPD

An exacerbation of COPD is an acutely developing condition when the symptoms of the disease go beyond its usual course. There is an increase in shortness of breath, cough and deterioration of the general condition of the patient. Conventional therapy, which he used previously, does not stop these symptoms to the usual state, a change in dose or treatment regimen is required. Usually, hospitalization is required for an exacerbation of COPD.

Diagnosis of exacerbations is based solely on complaints, anamnesis, clinical manifestations, and can also be confirmed by additional studies (spirometry, general analysis blood, microscopy and bacteriological examination of sputum, pulse oximetry).

The causes of exacerbation are most often respiratory viral and bacterial infections, less often - other factors (exposure to harmful factors in the surrounding air). A common event in a patient with COPD is an event that significantly reduces lung function, and return to baseline may take a long time, or stabilization will occur at a more severe stage of the disease.

The more frequent exacerbations occur, the worse the prognosis of the disease and the higher the risk of complications.

Complications of COPD

Due to the fact that patients with COPD exist in a state of constant hypoxia, they often develop the following complications:

COPD treatment

Basic principles of therapeutic and preventive measures for COPD:

1. To give up smoking. At first glance, a simple, but the most difficult to implement moment.
2. Pharmacotherapy. Early initiation of basic drug treatment can significantly improve the patient's quality of life, reduce the risk of exacerbations and increase life expectancy.
3. The drug therapy regimen should be selected individually, taking into account the severity of the course, the patient's adherence to long-term treatment, the availability and cost of drugs for each individual patient.
4. Influenza and pneumococcal vaccinations should be offered to patients with COPD.
5. The positive effect of physical rehabilitation (training) has been proven. This method is under development, while there are no effective therapeutic programs. The easiest way that can be offered to the patient is daily walking for 20 minutes.
6. In the case of a severe course of the disease with severe respiratory failure, long-term oxygen inhalation as a means of palliative care improves the patient's condition and prolongs life.

To give up smoking

Tobacco cessation has been proven to have a significant impact on the course and prognosis of COPD. Despite the fact that the chronic inflammatory process is considered irreversible, smoking cessation slows down its progression, especially in the early stages of the disease.

Tobacco addiction is a serious problem that requires a lot of time and effort not only for the patient himself, but also for doctors and relatives. A special long-term study was conducted with a group of smokers, which offered various activities aimed at combating this addiction (conversations, persuasion, practical advice, psychological support, visual agitation). With such an investment of attention and time, it was possible to achieve smoking cessation in 25% of patients. Moreover, the longer and more often the conversations are held, the more likely they are to be effective.

Anti-tobacco programs are becoming national targets. There is a need not only to promote a healthy lifestyle, but also to legislate punishment for smoking in public places. This will help limit the harm from at least passive smoking. Tobacco smoke is especially harmful for pregnant women (both active and passive smoking) and children.

For some patients, tobacco addiction is akin to drug addiction, and in this case, interviews will not be enough.

In addition to agitation, there are also medical ways to combat smoking. These are nicotine replacement tablets, sprays, chewing gums, skin patches. The effectiveness of some antidepressants (bupropion, nortriptyline) in the formation of long-term smoking cessation has also been proven.

Pharmacotherapy for COPD

Drug therapy for COPD is aimed at managing symptoms, preventing exacerbations, and slowing the progression of chronic inflammation. It is impossible to completely stop or cure the destructive processes in the lungs with currently existing drugs.

The main drugs used to treat COPD are:

Bronchodilators

Bronchodilators, used to treat COPD, relax the smooth muscles of the bronchi, thereby expanding their lumen and facilitating the passage of air on exhalation. All bronchodilators have been shown to increase exercise tolerance.

Bronchodilators include:

1. Short-acting beta stimulants ( salbutamol, fenoterol).
2. Long acting beta stimulants ( salmoterol, formoterol).
3. Short acting anticholinergics ipratropium bromide - atrovent).
4. Long acting anticholinergics ( tiotropium bromide - spiriva).
5. Xanthines ( eufillin, theophylline).

Almost all existing bronchodilators are used in inhaled form, which is more preferable than oral administration. There are different types of inhalers (metered dose aerosol, powder inhalers, breath-activated inhalers, liquid forms for nebulizer inhalation). In severely ill patients, as well as in patients with intellectual disabilities, it is better to carry out inhalation through a nebulizer.

This group of drugs is the main one in the treatment of COPD; it is used at all stages of the disease as monotherapy or (more often) in combination with other drugs. For permanent therapy, the use of long-acting bronchodilators is preferable. If it is necessary to prescribe short-acting bronchodilators, combinations are preferred fenoterol and ipratropium bromide (berodual).

Xanthines (eufillin, theophylline) are used in the form of tablets and injections, have many side effects, and are not recommended for long-term treatment.

Glucocorticosteroid hormones (GCS)

GCS are a powerful anti-inflammatory agent. They are used in patients with a severe and extremely severe degree, and are also prescribed in short courses for exacerbations in the moderate stage.

The best form of application is inhaled corticosteroids ( beclomethasone, fluticasone, budesonide). The use of such forms of corticosteroids minimizes the risk of systemic side effects of this group of drugs, which inevitably occur when taken orally.

GCS monotherapy is not recommended for patients with COPD, more often they are prescribed in combination with long-acting beta-agonists. The main combination drugs: formoterol + budesonide (symbicort), salmoterol + fluticasone (seretide).

In severe cases, as well as during an exacerbation, systemic corticosteroids can be prescribed - prednisolone, dexamethasone, kenalog. Long-term therapy with these drugs is fraught with the development of severe side effects (erosive and ulcerative lesions of the gastrointestinal tract, Itsenko-Cushing's syndrome, steroid diabetes, osteoporosis, and others).

Bronchodilators and corticosteroids (and more often a combination of them) are the main most affordable drugs that are prescribed for COPD. The doctor selects the treatment regimen, doses and combinations individually for each patient. In the choice of treatment, not only recommended GOLD schemes for different clinical groups are important, but also the social status of the patient, the cost of drugs and its availability for a particular patient, the ability to learn, and motivation.

Other drugs used in COPD

Mucolytics(sputum thinning agents) are prescribed in the presence of viscous, difficult to expectorate sputum.

Phosphodiesterase-4 inhibitor roflumilast (Daxas) is a relatively new drug. It has a prolonged anti-inflammatory effect, is a kind of alternative to GCS. It is used in tablets of 500 mg 1 time per day in patients with severe and extremely severe COPD. Its high efficiency has been proven, but its use is limited due to the high cost of the drug, as well as a rather high percentage of side effects (nausea, vomiting, diarrhea, headache).

There are studies that the drug fenspiride (Erespal) has an anti-inflammatory effect similar to corticosteroids, and can also be recommended for such patients.

Of the physiotherapeutic methods of treatment, the method of intrapulmonary percussion ventilation of the lungs is gaining popularity: a special device generates small volumes of air that are supplied to the lungs with quick shocks. From such a pneumomassage, the collapsed bronchi are straightened and the ventilation of the lungs is improved.

Treatment of exacerbation of COPD

The goal of exacerbation treatment is to manage the current exacerbation as much as possible and prevent future exacerbations. Depending on the severity, exacerbations can be treated on an outpatient basis or in a hospital.

Basic principles of treatment of exacerbations:

• It is necessary to correctly assess the severity of the patient's condition, exclude complications that can be disguised as exacerbations of COPD, and promptly send for hospitalization in life-threatening situations.
• With an exacerbation of the disease, the use of short-acting bronchodilators is preferable to long-acting ones. Doses and frequency of administration, as a rule, increase compared to usual. It is advisable to use spacers or nebulizers, especially in critically ill patients.
• With insufficient effect of bronchodilators, it is added intravenous administration eufillina.
• If monotherapy was previously used, a combination of beta-stimulants with anticholinergics (also short-acting) is used.
• In the presence of symptoms of bacterial inflammation (the first sign of which is the appearance of purulent sputum), broad-spectrum antibiotics are prescribed.
• Connection of intravenous or oral administration of glucocorticosteroids. An alternative to the systemic use of corticosteroids is the inhalation of pulmicort through a nebulizer 2 mg twice a day after berodual inhalations.
• Dosed oxygen therapy in the treatment of patients in a hospital through nasal catheters or a Venturi mask. The oxygen content in the inhaled mixture is 24-28%.
• Other activities - maintaining water balance, anticoagulants, treatment of concomitant diseases.

Caring for patients with severe COPD

As already mentioned, COPD is a disease that is steadily progressing and inevitably leads to the development of respiratory failure. The speed of this process depends on many things: the patient's refusal to smoke, adherence to treatment, the patient's financial capabilities, his memory abilities, and the availability of medical care. Starting with a moderate degree of COPD, patients are referred to MSEC to receive a disability group.

With an extremely severe degree of respiratory failure, the patient cannot even perform normal household activities, sometimes he cannot even take a few steps. These patients require constant care. Inhalations for seriously ill patients are carried out only with the help of a nebulizer. Significantly facilitates the condition of many hours of low-flow oxygen therapy (more than 15 hours a day).

For these purposes, special portable oxygen concentrators have been developed. They do not require filling with pure oxygen, but concentrate oxygen directly from the air. Oxygen therapy increases the life expectancy of such patients.

COPD prevention

COPD is a preventable disease. It is important that the level of COPD prevention depends very little on physicians. The main measures should be taken either by the person himself (quitting smoking) or by the state (anti-smoking laws, improving the environment, promoting and stimulating a healthy lifestyle). It has been proven that COPD prevention is economically beneficial by reducing the incidence and reducing the disability of the working population.

Video: COPD in the program “Live healthy”

Video: what is COPD and how to detect it in time

Chronic obstructive pulmonary disease (COPD definition) is a pathological process characterized by partial restriction of airflow in the airways. 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 air supply in Airways Therefore, 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;
• diagnostics determines diseases such as diabetes mellitus, 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. Once every 5 years, vaccinate 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 is a chronic disease that 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.

Function research external respiration is one of the most important steps in the diagnosis of COPD. It has already been discussed above that the pathophysiological concept of airway obstruction formed the basis for the definition of COPD. For Russian doctors, this provision is of fundamental importance, also because the methods of functional examination of the ventilation, gas exchange and diffusion functions of the lungs remain inaccessible. The study of the function of external respiration is necessary for the diagnosis of COPD, determining the severity of the disease, evaluating the effectiveness of the therapy. Airway obstruction and impaired oxygen transport are important indicators of lung ventilation impairment. Forced expiratory volume in 1 second (FEV, or FEV) is an easily determined and reproducible parameter in dynamics.

Determination of peak expiratory flow is the simplest, cheapest and fastest method. Patients with bronchial asthma are advised to resort to daily measurement of peak expiratory flow to monitor the adequacy of the treatment. Patients with chronic obstructive bronchitis and pulmonary emphysema do not need to measure peak expiratory flow as often. Peak flowmetry is effective as a screening method for detecting a risk group for developing obstructive pulmonary disease, for determining the negative impact of various pollutants, and is also necessary during an exacerbation of COPD, especially at the stage of rehabilitation.

However, none of the screening tests is able to answer the question whether the airway obstruction in a particular patient is a consequence of emphysema or chronic obstructive bronchitis. In patients with COPD, there is an increase in the total lung capacity (total lung capacity), functional residual volume (functional residual capacity) and residual volume (residua! volume). More sensitive in the diagnosis of emphysema is the study of CO diffusion. The test result in patients with emphysema decreases in proportion to the reduction of the capillary bed. It should be emphasized that the diffusion test is not able to detect emphysema in the early stages of its development. Diagnostic significance has a comparison of the data f-tion of external respiration and saturation of the blood with gases. Mild hypoxemia with normal CO2 tension is recorded with sufficiently pronounced obstructive disorders. Hypercapnia usually appears when FEV1 drops to the level of 1 liter, i.e. are indicators of end-stage respiratory failure. The gas composition of the blood worsens with an exacerbation of COPD. during exercise and during sleep.

The fundamental question, which always remains to be decided, is to establish reversibility of bronchial obstruction. In order to determine whether bronchial obstruction is reversible or irreversible (more correctly, partially reversible), a test with inhaled bronchodilator drugs is usually performed. Before inhalation of a bronchodilator, the parameters of the flow-volume curve are examined, mainly fixing attention on the FEV1 indicator. Parameters indicating the level of forced expiratory flows at different levels of exhaled forced vital capacity (FVC) cannot be compared with each other, because the FVC value itself, against which these flows are calculated, is variable during repeated respiratory maneuvers. In this regard, other indicators of the flow-volume curve (with the exception of FEV1), which are mainly derivatives of FVC, are not recommended.

When examining a particular patient with COPD, it is necessary to proceed from the fact that the reversibility of airway obstruction is variable and may depend on a number of factors. Thus, the period of exacerbation of the underlying disease has a great influence; its phase, ongoing therapy, comorbidities and other factors.

The bronchodilatory response depends on the choice of drug, the technique of inhalation (using a nebulizer or a metered-dose pocket inhaler). Factors influencing the bronchodilatory response are also the dose of the drug used; time elapsed after inhalation; bronchial lability during the study period and the state of pulmonary function at that moment; as well as the reproducibility of the compared indicators. There are recommendations of the European Respiratory Society for conducting bronchodilator and bronchoconstrictor tests, which are also followed in our country. The standard for conducting a bronchodilatory test is a re-examination of the function of external respiration 15 minutes after inhalation of two doses of salbutamol 100 mcg. Bronchial obstruction is considered reversible if the increase in FEV1 is 15% or more; this type of obstruction is more typical for patients with bronchial asthma. An increase in FEV1 less than 12% is more typical for patients with COPD. Thus, the study of the functional characteristics of the lungs belongs to the field of the same mandatory diagnostic procedures as measuring blood pressure, recording an electrocardiogram. Determining forced expiratory volume in one second (FEV1) or peak expiratory flow is available to everyone. Without determining these parameters, it is impossible to make a functional diagnosis in a patient with a clinical picture of COPD. For Russian doctors, this provision is very important, since the entire medical community needs to improve the quality of diagnosis of such a representative group of diseases as COPD.

Functional diagnosis also makes it possible to establish the severity of the disease and develop optimal therapy for the treatment of patients with chronic obstructive bronchitis, pulmonary emphysema and severe forms of bronchial asthma; it is guided in the preparation and implementation of rehabilitation programs, the definition of criteria for working capacity and disability.

In patients with increasing degree of dyspnea and the presence of cyanosis, it is necessary to blood gas testing. However, it is necessary to proceed from real possibilities: many medical institutions, primarily polyclinics, do not have expensive gas analyzers, and cannot conduct these studies. The way out is to purchase more affordable devices (pulse oximeters), with the help of which it is possible to determine the rate of oxygen saturation in the blood and identify patients with hypoxemia. This is a special group of patients with COPD, which, as a rule, needs long-term oxygen therapy. Pulse oximetry should be performed in patients with congestive heart failure in order to objectively establish the level of physical tolerance and give the sick person individual recommendations.

So, in patients with obstructive respiratory diseases, it is necessary, when making a functional diagnosis, to at least measure the volume of forced vital capacity in one second (FEV, or FEV1) and determine blood oxygen saturation; a more advanced program includes an inhalation test with bronchodilators and physical activity, study of acid-base balance. It is advisable to adhere to these diagnostic parameters, as they will dramatically improve the diagnosis and treatment of patients with COPD, which, ultimately, will quickly affect the quality of life of a sick person.

So, sputum examinations, radiography of the respiratory organs, and analysis of the ventilation and gas exchange functions of the lungs are among the necessary diagnostic programs for examining patients with COPD.

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 of the 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 is a 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 of 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 course of 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. Generally, the partial pressure of oxygen in arterial blood(PaO 2) less than 8.0 kPa (60 mm Hg) in combination (or without) with an increase in PaCO 2 more 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 develops already in the early stages of the disease and serves as the main mechanism for the occurrence of dyspnea 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 amount.

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 distress. 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 for a long time proceeds without vivid 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. Appearance rating 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. As a rule, this symptom is accompanied by a decrease in exercise tolerance, a feeling of pressure in the chest, the occurrence or intensification of distant 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 an inflammatory syndrome (fever, increase in the amount and viscosity of sputum, purulent nature of sputum);
- exacerbation, manifested by an increase in shortness of breath, increased extrapulmonary manifestations of COPD (weakness, headache, poor sleep, 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-bronchodilatory FEV1 index has a high degree of reproducibility with the correct execution of the maneuver and allows you to monitor 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 the correct performance of the bronchodilation test and avoiding distortion of the results, it is necessary to cancel the ongoing therapy in accordance with the pharmacokinetic properties of the drug being 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 has a low baseline FEV1.

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

Method for measuring the degree of bronchodilator 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, it 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 an effective screening method 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 those similar to COPD. clinical symptoms.
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 scan is performed at the height of inhalation, 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 purpose 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, chest or leg pain, and SatO 2 drops 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 course of the disease, it is recommended to indicate the clinical form of 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 of respiratory failure or insufficiency of the right heart.

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.

The main criteria for the differential diagnosis of 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 of sputum and bronchoalveolar lavage fluid.

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;
- COPD treatment at a stable state;
- 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. No less important is secondary prevention - epidemiological control and early detection 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 (I stage) COPD and the absence clinical manifestations 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 appears to be the best basis for combined treatment COPD II-IV stage.

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 inhaled GCS patients with COPD are 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 (frequency respiratory movements> 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 if they are insufficiently effective.
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 of methylxanthines (with ineffectiveness): 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 medicines in gradually increasing doses for the rest of their lives, and also use additional funds during periods of exacerbation.
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, dyspnea, exercise) gives a combined score that predicts subsequent survival better than any of the above indicators taken separately. Currently, research on the properties of the BODE scale as a tool for quantitative assessment of COPD is ongoing.

COPD (chronic obstructive pulmonary disease) is a pathology that is accompanied by inflammation in the organs of the respiratory system. The reasons may be environmental factors and a number of others, including smoking. The disease is characterized by regular progress, leading to a decrease in the functionality of the respiratory system. Over time, this leads to respiratory failure.

Mostly the disease is observed at the age of 40 years and older. In some cases, patients with COPD are admitted to the hospital at a younger age. As a rule, this is due to a genetic predisposition. There is also a high risk of getting sick in those who smoke for a very long time.

Risk group

The diagnosis of COPD in adult men in Russia is observed in every third person who has crossed the line of 70 years. Statistics allow us to confidently say that this is directly related to tobacco smoking. There is also a clear connection with the way of life, namely the place of work: the likelihood of developing pathology is higher when a person works in harmful conditions and with high dustiness. Living in industrial cities has an effect: here the percentage of cases is higher than in places with a clean environment.

COPD develops more often in older people, but with a genetic predisposition, you can get sick at a young age. This is due to the specifics of the generation of connective lung tissue by the body. There are also medical studies that make it possible to assert the connection of the disease with the prematurity of the child, since in this case there is not enough surfactant in the body, which is why the tissues of the organs cannot be corrected at birth.

What do the scientists say?

COPD, the causes of the development of the disease, the method of treatment - all this has long attracted the attention of doctors. In order to have sufficient materials for research, data collection was carried out, during which cases of the disease were studied in rural areas and urban residents. The information was collected by Russian doctors.

It was possible to reveal that if we are talking about those who live in a village, then here, with COPD, a severe course often becomes inconclusive, and in general, pathology torments a person much more. Often, the villagers observed endobronchitis with purulent secretions or tissue atrophy. Complications of other somatic diseases occur.

It has been suggested that the main reason is the low quality of medical care in rural areas. In addition, in the villages it is impossible to do spirometry, which is required by smoking men aged 40 and over.

How many people know COPD - what is it? How is it treated? What happens with this? Largely due to ignorance, lack of awareness, fear of death, patients become depressed. This is equally characteristic of urban residents and rural residents. Depression is additionally associated with hypoxia, which affects nervous system sick.

Where does disease come from?

Diagnosis of COPD is still difficult today, since it is not known exactly for what reasons the pathology develops. However, it was possible to identify a number of factors provoking the disease. Key aspects:

• smoking;
• unfavorable working conditions;
• climate;
• infection;
• prolonged bronchitis;
• lung diseases;
• genetics.

More about the reasons

Effective prevention of COPD is still under development, but people who want to maintain their health should understand how certain causes affect human body causing this pathology. By realizing their danger and eliminating harmful factors, you can reduce the likelihood of developing the disease.

The first thing that deserves mention in connection with COPD is, of course, smoking. Both active and passive influence equally negatively. Now medicine says with confidence that smoking is the most main factor development of pathology. The disease provokes both nicotine and other components contained in tobacco smoke.

In many ways, the mechanism of the onset of the disease when smoking is associated with the one that provokes pathology when working in harmful conditions, since here a person also breathes air filled with microscopic particles. When working in dusty conditions, in alkali and steam, constantly breathing chemical particles, it is impossible to keep the lungs healthy. Statistics show that the diagnosis of COPD is more often made in miners and people working with metal: grinders, polishers, metallurgists. Welders and employees of pulp mills, agricultural workers are also susceptible to this disease. All these working conditions are associated with aggressive dust factors.

An additional risk is associated with insufficient medical care: some do not have qualified doctors nearby, others try to avoid regular medical examinations.

Symptoms

COPD disease - what is it? How is it treated? How can you suspect it? This abbreviation (as well as its decoding - chronic obstructive pulmonary disease) to this day says nothing to many. Despite the widespread prevalence of pathology, people do not even know what risk their lives are at risk. What to look for if you suspect a lung disease and suspect that it could be COPD? Remember that the following symptoms are common at first:

• cough, mucous sputum (usually in the morning);
• dyspnea, initially on exertion, which eventually accompanies rest.

If COPD has an exacerbation, then usually the cause is an infection, which affects:

• shortness of breath (increases);
• sputum (becomes purulent, excreted in a larger volume).

With the development of the disease, if chronic obstructive pulmonary disease has been diagnosed, the symptoms are as follows:

• heart failure;
• heartache;
• fingers and lips become bluish;
• bones ache;
• muscles weaken;
• fingers thicken;
• nails change shape, become convex.

COPD Diagnosis: Stages

It is customary to distinguish several stages.

The beginning of the pathology is zero. It is characterized by the production of sputum in a large volume, a person regularly coughs. Lung function at this stage of the development of the disease is preserved.

The first stage is the period of development of the disease, in which the patient chronically coughs. The lungs regularly produce large volumes of sputum. Examination reveals a slight obstruction.

If a moderate form of the disease is diagnosed, it is distinguished by clinical symptoms (described earlier) that manifest themselves during exercise.

The diagnosis of COPD, the third stage, means that it becomes life-threatening. With this form of the disease, the so-called "cor pulmonale" appears. Obvious manifestations of the disease: restriction of air flow during exhalation, shortness of breath is frequent and severe. In some cases, bronchial obstructions are observed, which is typical for an extremely severe form of the pathology. It is dangerous for human life.

Not easy to identify

In fact, the diagnosis of COPD is made when initial form disease is much less common than it actually is. This is due to the fact that the symptoms are not pronounced. At the very beginning, pathology often flows secretly. The clinical picture can be seen as the condition progresses to moderate, and the person goes to the doctor, complaining of sputum and cough.

On the early stage episodic cases are not uncommon when a person coughs up a large amount of sputum. Because it doesn't happen often, people rarely worry and don't see a doctor in a timely manner. The doctor comes later, when the progress of the disease leads to a chronic cough.

The situation gets more complicated

If the disease has been diagnosed and treatment measures taken, not always, for example, folk treatment COPD shows good results. Often the complication occurs due to a third-party infection.

With the appearance of additional infection, even at rest, the person suffers from shortness of breath. There is a change in the nature of the departments: sputum turns into purulent. There are two possible paths for the development of the disease:

• bronchial;
• emphysematous.

In the first case, sputum is secreted in very large volumes and regularly coughs. There are frequent cases of intoxication, the bronchi suffer from purulent inflammation, cyanosis of the skin is possible. Obstruction develops strongly. Pulmonary emphysema for this type of disease is characterized by weak.

With the emphysematous type, shortness of breath is fixed respiratory, that is, it is difficult to exhale. Pulmonary emphysema predominates. The skin takes on a pinkish shade of grey. The shape of the chest changes: it resembles a barrel. If the disease has gone down this path, and if the correct drugs have been chosen for COPD, the patient is more likely to live to an advanced age.

Disease progress

With the development of COPD, complications appear as:

• pneumonia;
• respiratory failure, usually in an acute form.

Less commonly seen:

• pneumothorax;
• heart failure;
• pneumosclerosis.

In severe cases, pulmonary are possible:

• heart;
• hypertension.

Stability and instability in COPD

The disease can be in one of two forms: stable or acute. With a stable variant of development, no changes in the body can be found when observing the dynamics of changes over weeks, months. You can see a certain clinical picture if the patient is regularly examined for at least a year.

But with an exacerbation of just a day or two, they already show a sharp deterioration in the condition. If such exacerbations occur twice a year or more often, then they are considered clinically significant and may lead to hospitalization of the patient. The number of exacerbations directly affects the quality of life and its duration.

In special cases, smokers who previously suffered from bronchial asthma are isolated. In this case, they say about the "cross syndrome". The tissues of the body of such a patient are not able to consume the amount of oxygen necessary for normal functioning, which sharply reduces the body's ability to adapt. In 2011, this type of disease was no longer officially classified as a separate class, but in practice, some doctors still use the old system today.

How can a doctor detect a disease?

When visiting a doctor, the patient will have to undergo a series of studies to determine COPD or find another cause of health problems. Diagnostic activities include:

• general inspection;
• spirometry;
• a test through a bronchodilator, which includes inhalations for COPD, before and after which a special study of the respiratory system is carried out, observing changes in indicators;
• radiography, additionally - tomography, if the case is unclear (this allows you to assess how large the structural changes are).

Be sure to collect sputum samples for analysis of secretions. This allows you to draw conclusions about how strong the inflammation is and what its nature is. If we are talking about an exacerbation of COPD, then sputum can be used to draw conclusions about which microorganism provoked the infection, as well as which antibiotics can be used against it.

A body plethysmography is performed, during which it is evaluated. This allows you to clarify the volume of the lungs, capacity, as well as a number of parameters that cannot be assessed with spirography.

Be sure to take blood for a general analysis. This makes it possible to identify hemoglobin, red blood cells, against which conclusions are drawn about oxygen deficiency. If we are talking about an exacerbation, then a general analysis provides information about the inflammatory process. Analyze the number of leukocytes and ESR.

The blood is also examined for the content of gases. This makes it possible to detect not only the concentration of oxygen, but also carbon dioxide. It is possible to correctly assess whether the blood is sufficiently saturated with oxygen.

ECG, ECHO-KG, ultrasound, during which the doctor receives correct information about the state of the heart, and also finds out the pressure in the pulmonary artery, become indispensable studies.

Finally, fiberoptic bronchoscopy is performed. This is a type of study, during which the condition of the mucous membrane inside the bronchi is clarified. Doctors, using special preparations, receive tissue samples that allow them to examine cellular composition mucous. If the diagnosis is unclear, this technology is indispensable for its clarification, as it allows you to exclude other diseases with similar symptoms.

Depending on the specifics of the case, an additional visit to the pulmonologist may be prescribed to clarify the condition of the body.

We treat without medication

Treatment of COPD is a complex process that requires an integrated approach. First of all, we will consider non-drug measures that are mandatory for the disease.

• completely stop smoking;
• balance nutrition, include protein-rich foods;
• adjust physical activity, do not overstrain;
• reduce weight to the standard, if there are extra pounds;
• walk regularly;
• go swimming;
• practice breathing exercises.

What if drugs?

Of course, without drug therapy for COPD is also indispensable. First of all, pay attention to vaccines against influenza and pneumococcus. It is best to get vaccinated in October-mid-November, since then the effectiveness decreases, the likelihood increases that there have already been contacts with bacteria, viruses, and the injection will not provide an immune response.

They also practice therapy, the main goal of which is to expand the bronchi and keep them in a normal state. To do this, they fight spasms and apply measures that reduce sputum production. The following medicines are useful here:

• theophyllines;
• beta-2 agonists;
• M-cholinolytics.

These drugs are divided into two subgroups:

• long action;
• short action.

The first support the bronchi in a normal state up to 24 hours, the second group acts 4-6 hours.

Short-acting drugs are relevant at the first stage, as well as in the future, if there is a short-term need for this, that is, symptoms suddenly appear that need to be urgently eliminated. But if such medicines do not give a sufficient result, they resort to long-acting medicines.

Also, anti-inflammatory drugs should not be neglected, as they prevent negative processes in the bronchial tree. But it is also impossible to use them outside the recommendations of doctors. It is very important that the doctor supervise drug therapy.

Serious Therapy Is Not a Cause for Fear

COPD is treated with glucocorticosteroids hormonal preparations. As a rule, in the form of inhalations. But in the form of tablets, such drugs are good during an exacerbation. They are taken in courses if the disease is severe, has developed to a late stage. Practice shows that patients are afraid to use such drugs when the doctor recommends them. This comes with concerns about side effects.

Keep in mind that more often adverse reactions caused by hormones taken in the form of tablets or injections. In this case, it is not uncommon:

• osteoporosis;
• hypertension;
• diabetes.

If the drugs are prescribed in the form of inhalations, their effect will be milder due to the small dose. active substance entering the body. This form is applied topically, acting primarily on what and helps to avoid most side effects.

It should also be taken into account that the disease is associated with chronic inflammatory processes, which means that only long courses of medications will be effective. To understand whether there is a result from the selected drug, you will have to take it for at least three months, and then compare the results.

Inhalation forms may cause the following side effects:

• candidiasis;
• hoarse voice.

To avoid this, you need to rinse your mouth every time after taking the remedy.

What else will help?

In COPD, antioxidant preparations containing a complex of vitamins A, C, E are actively used. Mucolytic agents have proven themselves well, as they dilute the mucosal sputum produced and help to cough it up. Useful and in case of severe development of the situation - artificial ventilation pulmonary system. With an exacerbation of the disease, you can take antibiotics, but under the supervision of a doctor.

Selective phosphodiesterase inhibitors - 4 have brought considerable benefit. These are rather specific drugs that can be combined with some drugs used in the treatment of COPD.

If the disease is provoked by a genetic defect, then it is customary to resort to replacement therapy. For this, alpha-1-antitrypsin is used, which, due to a congenital defect, is not produced by the body to a sufficient extent.

Surgery

Preventive measures

What is the prevention of COPD? Whether there is a effective ways prevent the development of the disease? modern medicine says that it is possible to prevent the disease, but for this a person must take care of his health and treat himself responsibly.

First of all, you need to stop smoking, as well as about the possibility of eliminating being in harmful conditions.

If the disease is already detected, its progression can be slowed down by applying secondary preventive measures. The most successful have been:

• vaccination to prevent influenza, pneumococcus;
• regular intake of medicines prescribed by a doctor. Remember that the disease is chronic, so temporary therapy will not bring real benefit;
• control over physical activity. It helps to train the muscles of the respiratory system. You should walk and swim more, use the methodologies of breathing exercises;
• inhalers. They need to be able to use them correctly, since incorrect operation leads to the absence of the result of such therapy. As a rule, the doctor is able to explain to the patient how to use the medication so that it is effective.