Bronchial asthma (AD)
is a chronic disease, the basis of which is an inflammatory process in the airways involving a variety of cellular elements, especially mast cells, eosinophils and T-lymphocytes.
Modern concepts of bronchial asthma A
fundamentally important point of the modern concept of asthma is the recognition of chronic persistent inflammatory inflammation of the respiratory tract as the leading link in the pathogenesis of the disease (it dictates the need for early detection of these changes and anti-inflammatory treatment).
The peculiarity of inflammation in AD is a combination of immunological and non-immunological mechanisms of its occurrence.
According to most researchers, a hereditary predisposition is a fundamental factor in the formation of AD. This pathology should be attributed to diseases with an additive-polygenic type of inheritance with a threshold effect. In other words, multiple hereditary disorders form the disease under the influence of negative environmental factors.
Multifactorial diseases are characterized by the existence of clinical symptom polymorphism. Moreover, the population has a certain number of clinically healthy individuals with subthreshold level of disorders. This position is fully consistent with the concept put forward by us about “biological defects” as the first stage in the formation and development of AD.
A significant place in the etiology of the disease belongs to external factors:
professional aggressive influences,
increased contact with allergens (“allergenic life”),
smoking (including passive) and others.
Extrapulmonary diseases play a significant role in the formation of AD: lesions of the upper respiratory tract (chronic rhinosinusopathies, polyposis) and skin integuments (urticaria, eczema, atonic dermatitis), which have some common mechanisms of pathogenesis with AD. A significant part of patients with this pathology have an altered sensitivity and reactivity of the bronchi, often among relatives there are AD patients.
Lesions of the extrapulmonary sphere in their isolated form can be considered as a stage of preastma.
Currently, the question of the causes of AD heterogeneity at the stage of an already formed disease remains a difficult one.
The course and treatment of AD The
nature of the course of AD and its long-term prognosis are largely determined by the age at which the disease arose.
In the vast majority of children with an allergic form of the disease, it proceeds relatively easily. However, in children receiving continuous hormonal therapy in patients with bleeding (with insufficient volume), severe forms of asthma, severe asthmatic statuses, and even deaths may occur.
The long-term prognosis of AD that began in childhood is favorable. As a rule, by the puberty, children “grow up” from asthma. Nevertheless, they retain (sometimes asymptomatically) a number of violations of pulmonary function, bronchial hyperreactivity, and deviations in the immune status. In the literature, there are indications of an adverse course of AD, which debuted in adolescence.
The nature of the development and prognosis of AD, which debuted in adulthood and old age, are more predictable. The severity of the course of the disease is determined, first of all, by its form. Allergic BA is easier and more prognostic. “Pollen” asthma has a milder course than “dust”. Patients in old age have an initially severe course, especially in patients with “aspirin” BA.
As noted in the International Consensus, the adequacy of treatment is certainly an important factor affecting the course of AD and its long-term prognosis. Currently, the so-called “stepwise” approach is used in the treatment of AD. Its goal is to achieve maximum control of the symptoms of the disease by selecting the optimal drugs for this patient and their doses, which give a minimum of side effects. Schematically, this approach can be described as follows:
1 STEP – a mild episodic course. In patients belonging to this group, the disease is characterized by the appearance of rare, as a rule, short-term, minimally expressed asthmatic symptoms without significant functional impairment, which usually occurs in certain provocative situations.
Mild episodic asthma should be treated by actively identifying triggering factors and eliminating them. This approach, which is also significant for other groups of patients, in patients with mild episodic asthma is effective in some cases without the use of any additional therapeutic measures.
If its effectiveness is insufficient, short-acting beta2-agonists can be used to relieve symptoms, “on demand”. These same drugs or sodium cromoglycate are used prophylactically before exercise or contact with an allergen.
2 STEP – easy persistent current. Asthma is characterized by mild, but more distinct, clinically and functionally pronounced persistent symptoms, which require active treatment of inflammation in the airways. For this group of patients, inhalation anti-inflammatory drugs (mast cell stabilizers) should be the drugs of choice. They are prescribed for a long time and are practically devoid of significant side effects.
Currently, an increasingly important place among anti-inflammatory drugs is given to leukotriene receptor blockers (acolate).
Short-term impairments – asthma attacks or shortness of breath – are stopped by short-acting beta2-agonists, which are prescribed no more often 3-4 times a day. The increased need for beta2-agonists means the need for increased anti-inflammatory therapy.
STAGE 3 – a moderate course. Asthmatic symptoms vary in frequency and severity: from relatively mild to significantly pronounced. Functional indicators are very labile (FEV1 (forced expiratory volume in the first second) and POSvid. (Peak expiratory flow rate) account for 60-80% of the proper values, daily spread of 20-30%).
Therapy of patients in this group should be individualized, using, in various combinations, almost the entire arsenal of anti-asthma drugs.
The main role is given to anti-inflammatory drugs – including glucocorticosteroids (GCS), prescribed, as a rule, daily, for a long time, followed by the selection of individual maintenance doses.
To control symptoms, especially at night, the use of bronchodilating drugs (b2-agonists, methylxanthines, anticholinergics), mainly a prolonged action, is indicated. The choice depends on the effectiveness of the drug and its tolerability.
4 STAGE – severe course. Severe AD is characterized by a continuous relapse of the symptoms of the disease, leading to impaired physical activity and, often, patient disability. Given the significant severity of inflammatory changes, the leading place in the treatment of patients of this group belongs to inhaled GCS in combination with the minimum, individually selected doses of systemic GCS administered orally.
The main objective in the treatment of patients with severe AD is to reduce the consumption of corticosteroids, especially systemic ones. This is achieved by a reasonable combination of them with various groups of bronchodilators, mainly prolonged action.
In some cases, it is possible to reduce the dose of corticosteroids by using them with sodium nedocromil, which has a high anti-inflammatory activity.
In accordance with a stepwise approach to the treatment of AD, when achieving and maintaining stable results (within a few weeks or months), the intensity of drug therapy can be reduced to the level necessary to maintain control of the disease (“step down”).
The transition to the “step up” (increased drug treatment) is necessary if it is impossible to control the disease at the previous stage, provided that the patient’s doctor’s prescriptions are correctly followed.
According to the provisions of the International Consensus, the recommendations for the medical treatment of AD patients presented are a scheme reflecting the modern, most general and effective approaches to the basic treatment of the vast majority of patients.
The inclusion in the arsenal of therapeutic measures of other drugs and non-drug methods is carried out in accordance with individual indications and contraindications.
Patients with asthma should be registered with a local doctor, who, if necessary, consults with a pulmonologist and other specialists (allergist, dermatologist, rhinotolaryngologist, etc.), solves issues of disability, hospitalization, and employment.
Regular exchange of information between the doctor, the patient and his family allows you to:
create adequate ideas about the nature of the disease,
help the patient in the implementation of an individual treatment plan,
teach him to navigate the changes in his condition and correctly respond to them.
Patients should be introduced to the popular medical literature available to them, to conduct training in the system of “asthma schools” and “asthma clubs.”