Bronchial asthma in the elderly

In recent years, the incidence of such a disease as bronchial asthma in the elderly has increased sharply. This can be associated with three main factors. Firstly, allergic reactivity has increased. Secondly, due to the development of the chemical industry, environmental pollution and other circumstances, contact with allergens has increased. Thirdly, chronic respiratory diseases are becoming more frequent, creating prerequisites for the development of bronchial asthma. The age structure of the disease has also changed. Currently, elderly and senile people make up 44% of the total number of patients with this disease.

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What causes bronchial asthma in older people?

In old and senile age, the infectious-allergic form of the disease is predominantly encountered. Bronchial asthma in the elderly often occurs as a result of inflammatory diseases of the respiratory organs (chronic pneumonia, chronic bronchitis, etc.). From this infectious focus, the body is sensitized by the decay products of its own tissues, bacteria and toxins. Bronchial asthma in the elderly can begin simultaneously with an inflammatory process in the lungs, more often with bronchitis, bronchiolitis, pneumonia.

How does bronchial asthma manifest itself in older people?

In most cases, bronchial asthma in the elderly is chronic and is characterized by constant labored wheezing and shortness of breath, which increases with physical exertion (due to the development of obstructive pulmonary emphysema). Periodic exacerbations are manifested by the occurrence of asthma attacks. Cough with the release of a small amount of light, thick, mucous sputum is noted. Most often, infectious and inflammatory processes in the respiratory organs (acute respiratory viral infections, exacerbations of chronic bronchitis) play a dominant role in the occurrence of asthma attacks and exacerbations of the disease.

An attack of bronchial asthma usually begins at night or early in the morning. This is primarily due to the accumulation of secretions in the bronchi during sleep, which irritate the mucous membrane, receptors and lead to an attack. An increase in the tone of the vagus nerve plays a certain role. In addition to bronchospasm, which is the main functional disorder in asthma at any age, in elderly and old people its course is complicated by age-related pulmonary emphysema. As a result, cardiac failure quickly joins pulmonary failure.

Once it occurs at a young age, it can persist in older people. In this case, attacks are less acute. Due to the long history of the disease, pronounced changes in the lungs (obstructive emphysema, chronic bronchitis, pneumosclerosis) and the cardiovascular system (cor pulmonale - pulmonary heart) are observed.

During an acute attack, the patient experiences wheezing, shortness of breath, cough, and cyanosis. The patient sits, leaning forward, resting on his hands. All muscles involved in the act of breathing are tense. Unlike young people, during an attack, rapid breathing is observed due to severe hypoxia. Percussion reveals a box-like sound, a large number of sonorous buzzing, whistling wheezing sounds are heard, and wet wheezing may also be detected. At the beginning of the attack, the cough is dry, often painful. After the end of the attack, a small amount of viscous mucous sputum is released with cough. The response to bronchodilators (for example, theophylline, isadrine) during an attack in older people is slow and incomplete.

Heart sounds are muffled, tachycardia is observed. At the height of the attack, acute heart failure may occur due to reflex spasm of the coronary vessels, increased pressure in the pulmonary artery system, decreased contractility of the myocardium, and also in connection with concomitant diseases of the cardiovascular system (hypertension, atherosclerotic cardiosclerosis).

How is bronchial asthma treated in the elderly?

To relieve bronchospasm both during an attack and in the interictal period, purines (euphyllin, diaphyllin, diprophylpin, etc.) deserve attention; they can be administered not only parenterally, but also in the form of aerosols. The advantage of prescribing these drugs over adrenaline is that their administration is not contraindicated in hypertension, cardiac asthma, ischemic heart disease, and cerebral atherosclerosis. In addition, euphyllin and other drugs from this group improve coronary and renal circulation. All this determines their wide use in geriatric practice.

Despite the fact that adrenaline usually provides rapid relief of bronchospasm and, thus, relief of an attack, it should be prescribed to elderly and old people with caution due to their increased sensitivity to hormonal drugs. Subcutaneous or intramuscular administration of adrenaline is possible only if the attack cannot be relieved by any medications. The dose of the drug should not exceed 0.2-0.3 ml of 0.1% solution. If there is no effect, adrenaline can be repeated in the same dose only after 4 hours. Prescribing ephedrine provides a less rapid but longer lasting effect. It should be noted that ephedrine is contraindicated in prostate adenoma.

Isopropylnorepinephrine preparations (isadrine, orciprenaline sulfate, novodrine, etc.) have bronchodilatory properties.

When using trypsin, chymotrypsin and other agents in aerosols to improve expectoration, allergic reactions are possible, mainly related to the absorption of proteolysis products. Antihistamines should be prescribed before their introduction and during therapy. Bronchodilators are used to improve bronchial patency.

The drugs of choice are anticholinergics. In case of intolerance to adrenomimetics (isadrine, ephedrine), abundant sputum secretion and combination with ischemic heart disease, occurring with bradycardia, atrioventricular conduction disorder, anticholinergics are prescribed (atrovent, troventol, truvent, berodual).

Antihistamines (diphenhydramine, suprastin, diprazine, diazolin, tavegil, etc.) are included in complex therapy for bronchial asthma.

In some patients, novocaine has a beneficial effect: intravenously 5-10 ml of a 0.25-0.5% solution or intramuscularly 5 ml of a 2% solution. To stop an attack, a unilateral novocaine vagosympathetic block according to A.V. Vishnevsky can be successfully used. Bilateral block is not recommended, since it often causes side effects in such patients (impaired cerebral circulation, breathing, etc.).

Ganglionic blockers are not recommended for elderly people due to the occurrence of a hypotensive reaction.

If bronchial asthma in elderly people is combined with angina pectoris, inhalation of nitrous oxide (70-75%) with oxygen (25-30%) is indicated - at an administration rate of 8-12 l/min.

Along with bronchodilators, it is always necessary to use cardiovascular drugs during an attack, since an attack can quickly take the cardiovascular system of an elderly person out of a state of relative compensation.

Hormonal therapy (cortisone, hydrocortisone and their derivatives) gives a good effect, stopping an acute attack and preventing it. However, glucocorticosteroids should be administered to the elderly and old in doses 2-3 times smaller than those used for young people. When treating, it is important to establish the minimum effective dose. Hormonal therapy longer than 3 weeks is undesirable due to the possibility of side effects. The use of glucocorticosteroids does not exclude the simultaneous administration of bronchodilators, which, in some cases, allow you to reduce the dose of hormonal drugs. In secondary infections, antibiotics are indicated along with corticosteroids. Even when treating with small doses of corticosteroids in the elderly, side effects are often observed. In this regard, glucocorticosteroids are used only in the following conditions:

1. severe course of the disease that does not respond to treatment with other means;
2. asthmatic condition;
3. a sharp deterioration in the patient's condition against the background of an intercurrent illness.

The introduction of glucocorticosteroids in the form of aerosols is very promising, since a lower dose of the drug achieves a clinical effect and thereby reduces the frequency of side effects. After stopping an acute attack, hormonal drugs can also be administered intravenously.

Cromolyn sodium (Intal) has found wide application in bronchial asthma. It inhibits degranulation of labrocytes (mast cells) and delays the release of mediator substances (bradykinin, histamine, and so-called slow-reacting substances) from them, which promote bronchospasm and inflammation. The drug has a preventive effect before the development of an asthma attack. Intal is used in inhalations of 0.02 g 4 times a day. After the condition improves, the number of inhalations is reduced, selecting a maintenance dose. The effect occurs in 2-4 weeks. Treatment should be long-term.

In bronchial asthma, if the allergen responsible for the disease is identified, it must be excluded if possible and specific desensitization to this substance must be carried out. Elderly patients are less sensitive to allergens, so their correct identification is very difficult. In addition, they are polyvalently sensitized.

In the development of heart failure, cardiac glycosides and diuretics are prescribed.

For very restless patients, it is possible to use tranquilizers (trioxazine), benzodiazepine derivatives (chlordiazepoxide, diazepam, oxazepam), carbamine esters of propanediol (meprobamate, isoprotan), and diphenylmethane derivatives (aminil, metamizil).

Bromhexine, acetylcysteine and physiotherapy are most often used as expectorants and secretolytics.

The use of mustard plasters and hot foot baths brings a certain effect in acute attacks. Bronchial asthma in the elderly should also be treated with therapeutic exercise and breathing exercises. The type and volume of physical exercises are determined individually.