Chronic bronchitis: treatment

Chronic bronchitis is a chronic inflammatory process in the bronchi accompanied by a cough with sputum separation for at least 3 months a year for 2 or more years, without any diseases of the bronchopulmonary system and ENT organs that could cause these symptoms.

Treatment of chronic bronchitis is largely determined by the clinical form of the disease, the peculiarities of its course.

[1], [2], [3], [4], [5], [6], [7], [8]

Therapeutic program for chronic bronchitis

1. Elimination of the etiological factors of chronic bronchitis.
2. Inpatient treatment and bed rest for certain indications.
3. Therapeutic nourishment.
4. Antibacterial therapy in the period of exacerbation of purulent chronic bronchitis, including methods of endobronchial administration of drugs.
5. Improved drainage function of the bronchi: expectorants, bronchodilators, positional drainage, chest massage, phytotherapy, heparin therapy, calcitrine treatment.
6. Desintoxication therapy in the period of exacerbation of purulent bronchitis.
7. Correction of respiratory failure: prolonged low-flow oxygen therapy, hyperbaric oxygenation, extracorporeal membrane oxygenation of blood, inhalation of moistened oxygen.
8. Treatment of pulmonary hypertension in patients with chronic obstructive bronchitis.
9. Immunomodulatory therapy and improving the function of the system of local bronchopulmonary protection.
10. Increase nonspecific resistance of the body.
11. Physiotherapy, exercise therapy, breathing exercises, massage.
12. Spa treatment.

Elimination of etiological factors

Elimination of the etiological factors of chronic bronchitis largely slows the progression of the disease, prevents the exacerbation of the disease and the development of complications.

First of all, it is necessary to give up smoking categorically. Great importance is attached to the elimination of occupational hazards (various types of dust, acid vapors, alkalis, etc.), careful sanitation of foci of chronic infection (in ENT organs, etc.). It is very important to create an optimal microclimate in the workplace and at home.

In the case of a pronounced dependence of the onset of the disease and its subsequent exacerbations on unfavorable weather conditions, it is advisable to move to a region with a favorable dry and warm climate.

Patients with the development of local bronchiectasis often show surgical treatment. Elimination of the focus of purulent infection reduces the frequency of exacerbations of chronic bronchitis.

[9], [10], [11], [12], [13], [14], [15]

Inpatient treatment of chronic bronchitis and bed rest

Inpatient treatment and bed rest are shown only to certain groups of patients if the following conditions exist:

• marked exacerbation of chronic bronchitis with an increase in respiratory failure, despite active outpatient treatment;
• development of acute respiratory failure;
• acute pneumonia or spontaneous pneumothorax;
• manifestation or strengthening of right ventricular failure;
• the need for some diagnostic and therapeutic manipulations (in particular, bronchoscopy);
• necessity of surgical intervention;
• significant intoxication and marked worsening of the general condition of patients with purulent bronchitis.

The remaining patients with chronic bronchitis undergo outpatient treatment.

Treatment for chronic bronchitis

Patients with chronic bronchitis are recommended a balanced diet with sufficient vitamins. It is advisable to include in the diet raw vegetables and fruits, juices, yeast drinks.

In chronic bronchitis with the separation of large amounts of sputum, a protein loss occurs, and in decompensated pulmonary heart there is an increased loss of albumin from the vascular bed into the lumen of the intestine. These patients are shown a protein-enriched diet, as well as intravenous drip of albumin and amino acid preparations (polyamine, neframine, alvezin).

In case of decompensated pulmonary heart, diet No. 10 is prescribed with the restriction of energy value, salt and liquid and increased (potassium content.

With severe hypercapnia, carbohydrate load can cause acute respiratory acidosis due to increased formation of carbon dioxide and reduced sensitivity of the respiratory center. In this case, it is proposed to use a hypocaloric diet of 600 kcal with restriction of carbohydrates (30 g of carbohydrates, 35 g of proteins, 35 g of fats) for 2-8 weeks. Positive results were noted in patients with excessive and normal body weight. In the future, a diet of 800 kcal per day is prescribed. Dietary treatment for chronic hypercapnia is quite effective.

Antibiotics for chronic bronchitis

Antibacterial therapy is performed in the period of exacerbation of purulent chronic bronchitis within 7-10 days (sometimes with a pronounced and prolonged exacerbation within 14 days). In addition, antibiotic therapy is prescribed in the development of acute pneumonia in the background of chronic bronchitis.

When choosing an antibacterial agent, the effectiveness of the previous therapy is taken into account. Criteria for the effectiveness of antibiotic therapy in the period of exacerbation:

• positive clinical dynamics;
• slimy sputum character;

Decrease and disappearance of indicators of active infectious-inflammatory process (normalization of ESR, leukocyte blood formula, biochemical indices of inflammation).

In chronic bronchitis, the following groups of antibacterial agents can be used: antibiotics, sulfonamides, nitrofurans, trichopolum (metronidazole), antiseptics (dioxidin), phytoncides.

Antibacterial drugs can be administered in the form of aerosols, orally, parenterally, endotracheally and endobronchially. The last two methods of using antibacterial drugs are the most effective, since they allow the antibacterial substance to penetrate directly into the inflammatory focus.

Antibiotics are prescribed taking into account the sensitivity of the sputum flora to them (sputum should be examined by the method of Mulder or examined for flora and susceptibility to antibiotics sputum obtained from bronchoscopy). To prescribe antibiotic therapy before obtaining the results of a bacteriological study, sputum microscopy with Gram staining is useful. Usually the exacerbation of the infectious inflammatory process in the bronchi is caused not by one infectious agent, but by the association of microbes, often resistant to most drugs. Often among pathogens there is a gram-negative flora, mycoplasmal infection.

The correct choice of an antibiotic for chronic bronchitis is determined by the following factors:

• microbial spectrum of infection;
• the sensitivity of the infectious agent to infection;
• distribution and penetration of antibiotic into sputum, bronchial mucosa, bronchial glands, lung parenchyma;
• cytokinetics, i.e. The ability of the drug to accumulate inside the cell (this is important for the treatment of infection caused by "intracellular infectious agents" - chlamydia, legionella).

Yu. B. Belousov et al. (1996) give the following data on the etiology of acute and exacerbation of chronic bronchitis:

• Haemophilus influenzae 50%
• Streptococcus pneumoniae 14%
• Pseudomonas aeruginosas 14%
• Moraxella (Neiseria or Branhamella) catarrhalis 17%
• Staphylococcus aureus 2%
• Other 3%

According to Yu Novikov (1995), the main pathogens for exacerbation of chronic bronchitis are:

• Streptococcus pneumoniae 30.7%
• Haemophilus influenzae 21%
• Str. Haemolitjcus 11%
• Staphylococcus aureus 13.4%
• Pseudomonas aeruginosae 5%
• Mycoplazma 4.9%
• Not detected pathogen 14%

Quite often in chronic bronchitis a mixed infection is detected: Moraxella catairhalis + Haemophilus influenzae.

According to 3. V. Bulatova (1980), the specific weight of mixed infection in exacerbation of chronic bronchitis is as follows:

• microbes and mycoplasma - in 31% of cases;
• microbes and viruses - in 21% of cases;
• microbes, viruses of imicoplasm - in 11% of cases.

Infectious agents release toxins (eg H. Influenzae - peptidoglycans, lipo-oligosaccharides, Str. Pneumoniae - pneumolysin, P. Aeruginosae - piocyanin, rhamnolipids) that damage the ciliated epithelium, slow ciliary fluctuations and even cause the death of the bronchial epithelium.

When prescribing antibacterial therapy after determining the type of pathogen, the following circumstances are taken into account.

H. Influenzae is resistant to beta-lactam antibiotics (penicillin and ampicillin), which is due to the production of the TEM-1 enzyme that destroys these antibiotics. Inactive against H. Influenzae and erythromycin.

Recently, a significant spread of Str. Pneumoniae, resistant to penicillin and many other beta-lactam antibiotics, macrolides, tetracycline.

M. Catarrhal is a normal saprophyte flora, but quite often it can cause exacerbation of chronic bronchitis. A special feature of moraxella is the high ability of adhesion to oropharyngeal cells, and this is especially true for people over the age of 65 with chronic obstructive bronchitis. Most often, morocell is the cause of exacerbation of chronic bronchitis in areas with high air pollution (centers of the metallurgical and coal industry). Approximately 80% of the strains of moraxella produce beta-lactamases. Combined preparations of ampicillin and amoxicillin with clavulanic acid and sulbactam are not always active against beta-lactamase-producing strains of moraxella. This exciter is sensitive to septrim, bactrim, biseptol, and also highly sensitive to 4-fluoroquinolones, to erythromycin (however, 15% of Moraçella strains are not sensitive to it).

In case of mixed infection (moraxella + haemophilic rod), producing β-lactamase, ampicillin, amoxicillin, cephalosporins (ceftriaxone, cefuroxime, cefaclor) may not be effective.

When choosing an antibiotic in patients with exacerbation of chronic bronchitis can use the recommendations of P. Wilson (1992). He suggests the following groups of patients and, accordingly, a group of antibiotics.

• Group 1 - Healthy before the face with postvirus bronchitis. In these patients, as a rule, viscous purulent sputum is observed, antibiotics penetrate poorly into the mucous membrane of the bronchi. This group of patients should be recommended plentiful drink, expectorants, plant collections that have bactericidal properties. However, in the absence of effect, antibiotics amoxicillin, ampicillin, erythromycin and other macrolides, tetracyclines (doxycycline) are used.
• Group 2 - Patients with chronic bronchitis, smokers. These include the same recommendations as for individuals in Group 1.
• Group 3 - Patients with chronic bronchitis with concomitant severe somatic diseases and a high probability of the presence of resistant forms of pathogens (morocell, hemophilic rod). This group is recommended beta-lactamase-stable cephalosporins (cefaclor, cefixime), fluoroquinolones (ciprofloxacin, ofloxacin, etc.), amoxicillin with clavulanic acid.
• Group 4 - Patients with chronic bronchitis with bronchiectasis or chronic pneumonia, secreting purulent sputum. Use the same drugs that were recommended for patients of the 3rd group, as well as ampicillin in combination with sulbactam. In addition, active drainage therapy, physical therapy is recommended. With bronchiectasis, the most common pathogen found in the bronchi is Haemophylus influenzae.

In many patients with chronic bronchitis, the exacerbation of the disease is caused by chlamydia, legionella, mycoplasmas.

In these cases, macrolides are highly active and to a lesser extent doxycycline. Special attention should be paid to high-efficiency macrolides ozithromycin (sumamed) and roxithromycin (rulid), rovamycin (spiramycin). These drugs, after ingestion, penetrate the bronchial system well, persist in the tissues for a long time in sufficient concentration, accumulate in polymorphonuclear neutrophils and alveolar macrophages. Phagocytes deliver these drugs to the site of the infectious-inflammatory process. Roxithromycin (rulid) is prescribed 150 mg twice a day, azithromycin (sumamed) - 250 mg once a day, rovamycin (spiramycin) - 3 million ME 3 times a day inside. The duration of the course of treatment is 5-7 days.

When prescribing antibiotics, individual tolerability of drugs should be considered, especially for penicillin (it should not be used with a pronounced bronchospastic syndrome).

Antibiotics in aerosols are currently used rarely (aerosol antibiotic can provoke bronchospasm, in addition, the effect of this method is not great). Most often, antibiotics are administered orally and parenterally.

When Gram-positive cocci flora is detected, the most effective use of semi-synthetic penicillins, mostly combined (ampiox on 0.5 g 4 times per day intramuscularly or inward), or cephalosporins (kefzol, cephalexin, cloforan 1 g 2 times a day intramuscularly), with Gram-negative coccal flora - aminoglycosides (gentamicin to 0.08 g 2 times a day intramuscularly or amikacin 0.2 g 2 times a day intramuscularly), carbenicillin (1 g intramuscularly 4 times a day) or cephalosporins of the last generation (fortum 1 g 3 times per day intramuscularly).

In a number of cases, antibiotics of a wide spectrum of action of macrolides (erythromycin 0.5 g 4 times a day inwards, oleandomycin 0.5 g 4 times per day orally or intramuscularly, ericyclin - a combination of erythromycin and tetracycline - in capsules of 0.25 g, 2 capsules 4 once a day inside), tetracyclines, especially prolonged action (metacyclin or rondomycin 0.3 g 2 times a day inwards, doxycycline or vibramycin in capsules of 0.1 g 2 times a day inwards).

Thus, according to modern ideas, 1-series drugs in the treatment of exacerbation of chronic bronchitis are ampicillin (amoxicillin), including in combination with beta-lactamase inhibitors (clavulanic acid augmentin, amoxiclav or sulbactam unasin, sulacillin), oral cephalosporins of the second or third generation , fluoroquinolone preparations. If suspicion of the role of mycoplasmas, chlamydia, legionella in exacerbation of chronic bronchitis, it is advisable to use macrolide antibiotics (especially azithromycin-sumamed, roxithromycin-rulid) or tetracyclines (doxycycline, etc.). It is also possible the combined use of macrolides and tetracyclines.

[16], [17], [18], [19]

Sulfanilamide preparations for chronic bronchitis

Sulfonamide drugs are widely used in exacerbation of chronic bronchitis. They have chemotherapeutic activity with gram-positive and non-negative flora. Usually prescribed drugs of prolonged action.

Biseptol in tablets of 0.48 g. Assign inside 2 tablets 2 times a day.

Sulfaton in tablets of 0.35 g. On the first day, 2 tablets are prescribed in the morning and in the evening, in the following days 1 tablet in the morning and in the evening.

Sulfamonometoksin in tablets of 0.5 g. On the first day, appoint 1 g in the morning and evening, in the following days, 0.5 g in the morning and in the evening.

Sulfadimethoxin is administered in the same way as sulfamonomethoxin.

Recently, a negative effect of sulfonamides on the function of the ciliated epithelium has been established.

Nitrofuran preparations

Nitrofuran preparations have a wide spectrum of action. It is prescribed predominantly furazolidone according to 0.15 g 4 times a day after meals. Metronidazole (trichopolum), a broad-spectrum preparation, can also be used, in tablets 0.25 g four times a day.

Antiseptics

Among the antiseptics of a wide spectrum of action, most attention should be paid to dioxygen and furacilin.

Dioxydin (0.5% solution for 10 and 20 ml for intravenous administration, 1% solution in 10 ml ampoules for cavitary and endobronchial administration) is a preparation of broad antibacterial action. Slowly intravenously injected 10 ml of 0.5% solution in 10-20 ml of isotonic sodium chloride solution. Dioxydin is also widely used in the form of aerosol inhalations - 10 ml of 1% solution per inhalation.

[20], [21], [22]

Phytoncidal preparations

Phytoncides include chlorophyllipt, a preparation made from eucalyptus leaves, which has a pronounced antistaphylococcal effect. Is used inside 1% alcohol solution for 25 drops 3 times a day. It is possible to administer intravenously slowly 2 ml 0.25% solution in 38 ml sterile isotonic sodium chloride solution.

The phytoncides also include garlic (in inhalations) or for ingestion.

Endobronchial sanitation

Endobronchial sanation is performed by endotracheal infusions and fibrobronchoscopy. Endotracheal infusions with a laryngeal syringe or a rubber catheter are the simplest method of endobronchial sanitation. The number of injections is determined by the effectiveness of the procedure, the amount of sputum and the severity of its suppuration. Usually, initially 30-50 ml of isotonic sodium chloride solution, heated to 37 ° C, is poured into the trachea. After coughing up phlegm, antiseptics are administered:

• solution furatsilina 1: 5000 - small portions of 3-5 ml during inspiration (total 50-150 ml);
• solution 0.5% solution;
• juice Kalanchoe in the 1: 2 dilution;
• in the presence of bronchoeukases, 3-5 ml of the antibiotic solution can be administered.

Fibrobronchoscopy under local anesthesia is also effective. For sanitation of a bronchial tree are applied: a solution furatsilina 1: 5000; 0.1% solution of furagin; 1% rivanol solution; 1% solution of chlorophyllipt in the dilution 1: 1; dimexide solution.

[23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35]

Aerosol therapy

Aerosol therapy with phytoncides and antiseptics can be performed with the help of ultrasonic inhalers. They create uniform aerosols with an optimal particle size that penetrate to the peripheral parts of the bronchial tree. The use of drugs in the form of aerosols ensures their high local concentration and uniform distribution of the drug in the bronchial tree. With the help of aerosols, it is possible to inhalate antiseptics of furacilin, rivanol, chlorophyllipt, onion or garlic juice (diluted with 0.25% novocaine solution in the ratio 1:30), fir infusion, cowberry leaf condensate, dioxin. After aerosol therapy, postural drainage, vibration massage is performed.

In recent years, the aerosol preparation bioparoksokobalt is recommended for the treatment of chronic bronchitis). It contains one active component of fusanfungin - a preparation of fungal origin, which has antibacterial and anti-inflammatory effect. Fusanfungin is active against predominantly Gram-positive cocci (staphylococcus, streptococcus, pneumococcus), as well as intracellular microorganisms (mycoplasma, legionella). In addition, it has antifungal activity. According to White (1983), the anti-inflammatory effect of fusanfungin is associated with the suppression of the production of oxygen radicals by macrophages. Bioparox is used in the form of metered-dose inhalations - 4 breaths every 4 hours for 8-10 days.

[36], [37], [38], [39], [40], [41], [42], [43]

Improvement of drainage function of the bronchi

Restoration or improvement of drainage function of the bronchi is of great importance, since it contributes to the onset of clinical remission. In patients with chronic bronchitis in bronchi, the number of mucus-forming cells and sputum increases, its character changes, it becomes more viscous and thick. A large amount of sputum and an increase in its viscosity disrupt the drainage function of the bronchi, ventilation-perfusion relationships, reduces the activity of the local system of bronchopulmonary protection, including local immunological processes.

To improve the drainage function of the bronchi, expectorants, postural drainage, bronchodilators (with bronchospastic syndrome), and massage are used.

Expectorants, phytotherapy

According to the definition of BE Votchal, expectorants are substances that alter the properties of phlegm and facilitate its departure.

There is no generally accepted classification of expectorants. It is expedient to classify them according to the mechanism of action (VG Kukes, 1991).

Classification of expectorants

1. Means that soluble expectoration:
   • drugs acting reflexively;
   • preparations of resorptive action.
2. Mucolytic (or secretolitic) drugs:
   • proteolytic preparations;
   • derivatives of amino acids with SH-group;
   • mucoregulators.
3. Regulators of mucous secretions.

Sputum consists of bronchial secretions and saliva. Normally, bronchial mucus has the following composition:

• water with dissolved in it ions of sodium, chlorine, phosphorus, calcium (89-95%); the content of water depends on the consistency of sputum, liquid sputum is necessary for the normal functioning of mucociliary transport;
• insoluble macromolecular compounds (high- and low-molecular, neutral and acidic glycoproteins-mucins), which cause the viscous character of the secretion to be 2-3%;
• complex plasma proteins - albumins, plasma glycoproteins, immunoglobulins of classes A, G, E;
• antiproteolytic enzymes - 1-antichymotrylsin, 1-a-antitrypsin;
• lipids (0.3-0.5%) - surfactant phospholipids from alveoli and bronchioles, glycerides, cholesterol, free fatty acids.

[44], [45], [46], [47], [48], [49]

Bronchodilators for chronic bronchitis

Bronchodilators are used for chronic obstructive bronchitis.

Chronic obstructive bronchitis is a chronic diffuse non-allergic inflammation of the bronchi leading to progressive disruption of pulmonary ventilation and gas exchange in an obstructive type and manifested by coughing, shortness of breath and sputum excretion unrelated to damage to other organs and systems (Consensus on chronic obstructive bronchitis of the Russian pulmonary congress, 1995) . In the process of progression of chronic obstructive bronchitis, emphysema is formed, including the causes of depletion and impaired production of protease inhibitors.

The main mechanisms of bronchial obstruction:

• bronchospasm;
• inflammatory edema, infiltration of the bronchus wall during exacerbation of the disease;
• hypertrophy of the musculature of the bronchi;
• hypercrinia (increase in the amount of sputum) and discrinia (a change in the rheological properties of sputum, it becomes viscous, dense);
• collapse of small bronchi on exhalation due to decreased elastic properties of the lungs;
• fibrosis of the bronchial wall, obliteration of their lumen.

Bronchodilators improve bronchial patency by eliminating bronchospasm. In addition, methylxanthines and beta2-agonists stimulate the function of the ciliated epithelium and increase spitting.

Bronchodilators are prescribed taking into account the diurnal rhythms of bronchial patency. As bronchodilators use sympathomimetic drugs (beta-adrenoreceptor stimulants), cholinolytic drugs, purine derivatives (phosphodiesterase inhibitors) - methylxanthines.

Sympathomimetic drugs stimulate beta-adrenoreceptors, which leads to an increase in adenylcyclase activity, accumulation of cAMP and then bronchodilating effect. Use ephedrine (stimulates beta-adrenoreceptors, which provides bronchodilation, as well as alpha-adrenergic receptors, which reduces the swelling of the bronchial mucosa) by 0.025 g 2-3 times a day, the combined preparation of the theo- fedrine 1/2 tablet 2-3 times a day, broncholitin (combined preparation, 125 g of which contains glaucin 0.125 g, ephedrine 0.1 g, sage oil and citric acid 0.125 g), 1 tablespoon 4 times a day. Broncholitin causes a bronchodilating, antitussive and expectorant effect.

Ephedrine, theofedrine, broncholitin is especially important to appoint in the early morning hours, since at this time there is a peak of bronchial obstruction.

When treating these drugs, side effects associated with the stimulation of both beta1 (tachycardia, extrasystole) and alpha-adrenergic receptors (arterial hypertension) are possible.

In this regard, most attention is paid to selective beta2-adrenostimulator (selectively stimulate beta2-adrenoreceptors and practically do not affect beta 1-adrenergic receptors). Usually they use solubutamol, terbutaline, ventolin, berotek, and also partially beta2-selective stimulant asthmopent. These drugs are used in the form of metered aerosols for 1-2 inhalations 4 times a day.

With prolonged use of beta-adrenoreceptor stimulants, tachyphylaxis develops-a decrease in the sensitivity of bronchial tubes to them and a decrease in the effect, which is explained by a decrease in the number of beta2-adrenoreceptors on the membranes of the smooth muscles of the bronchi.

In recent years, beta2-adrenostimulants of long-acting (duration of about 12 hours) - salmeterol, metformol as metered aerosols 1-2 inhalations 2 times a day, spiro pent by 0.02 mg 2 times a day inside. These drugs are less likely to cause tachyphylaxis.

Purine derivatives (methylxanthines) inhibit phosphodiesterase (this contributes to the accumulation of cAMP) and adenosine bronchial receptors, which causes bronchodilation.

With severe bronchial obstruction appoint euphyllin 10 ml of 2.4% solution in 10 ml isotonic sodium chloride solution intravenously very slowly, intravenously drip to prolong its action -10 ml of 2.4% euphyllin solution in 300 ml isotonic sodium chloride solution.

With chronic bronchial obstruction, eufillin preparations can be used in tablets 0.15 g 3-4 times per day orally after meals or as alcohol solutions that are better absorbed (euphillin - 5 g, ethyl alcohol 70% - 60 g, distilled water - up to 300 ml, take 1-2 tablespoons 3-4 times a day).

Of particular interest are the preparations of extended theophyllines, which are active for 12 hours (taken 2 times a day) or 24 hours (taken once a day). Teodur, teolong, teobilong, and theotard are prescribed by 0.3 g 2 times a day. Unifilin provides an even level of theophylline in the blood during the day and is prescribed 0.4 g once a day.

In addition to bronchodilator action, theophylline prolonged action with bronchial obstruction also causes the following effects:

• reduce the pressure in the pulmonary artery;
• stimulate mucociliary clearance;
• improve the contractile ability of the diaphragm and other respiratory muscles;
• stimulate the release of glucocorticoids by the adrenal glands;
• have a diuretic effect.

The average daily dose of theophylline for non-smokers is 800 mg, for smokers 1100 mg. If previously the patient did not take theophylline preparations, then treatment should begin with smaller doses, gradually (2-3 days later) increasing them.

[50], [51], [52], [53], [54], [55]

Holinolytic means

Peripheral M-cholinolytics are used, they block acetylcholine receptors and thus contribute to bronchodilation. Preference is given to inhalation forms of anticholinergics.

Arguments in favor of wider use of anticholinergics in chronic bronchitis are the following:

• anticholinergic drugs cause bronchodilation in the same way as stimulants of beta2-adrenergic receptors, and sometimes even more pronounced;
• the efficacy of cholinolytics does not decrease even after prolonged use;
• with increasing age of the patient, and also with the development of emphysema, the number of beta2-adrenoceptors in the bronchi progressively decreases and, consequently, the effectiveness of beta2-adrenoreceptor stimulants decreases, and the bronchodilator sensitivity to the bronchodilating effect of cholinolytics remains.

Applied ipratropium bromide (atrovent) - in the form of a metered aerosol 1-2 inhalations 3 times a day, oxytropium bromide (oxyvene, ventilate) - anticholinergic long-acting, prescribed at a dose of 1-2 inhalations 2 times a day (usually in the morning and at bedtime) , in the absence of effect - 3 times a day. The drugs are virtually devoid of side effects. They show bronchodilator effect in 30-90 minutes and are not designed to stop the attack of suffocation.

Cholinolytics can be prescribed (in the absence of bronchodilator effect) in combination with beta2-adrenostimulyatorami. The combination of atrovent with beta2-adrenostimulyatorom fenoterolom (berotekom) is issued in the form of metered aerosol beroduala, which is used for 1-2 doses (1-2 breaths) 3-4 times a day. The simultaneous use of anticholinergics and beta2-agonists enhances the effectiveness of bronchodilator therapy.

In chronic obstructive bronchitis, it is necessary to individually select basic therapy with bronchodilator drugs in accordance with the following principles:

• achievement of maximum bronchodilation in the course of the whole day, the basic therapy is selected taking into account the circadian rhythms of bronchial obstruction;
• when selecting basic therapy, they are guided both by subjective and objective criteria for the effectiveness of bronchodilators: volume of forced expiration in 1 s or peak expiratory flow in l / min (measured using an individual peak flow meter);

With moderately pronounced bronchial obstruction, it is possible to improve bronchial permeability with the combined preparation theophedrine (which together with the other components includes theophylline, belladonna, ephedrine) in 1/2, 1 tablet 3 times a day, or with powders of the following composition: ephedrine 0.025 g, platifimin 0.003 g, eufillin 0.15 g, papaverine 0.04 g (1 powder 3-4 times a day).

The following tactics are recommended for the treatment of chronic obstructive bronchitis.

Preparations of the first series are ipratrotum bromide (atrovent) or oxotropium bromide, in the absence of the effect of treatment with inhaled anticholinergics, beta2-adrenoreceptor stimulants (fenoterol, salbutamol, etc.) are added or a combined preparation of berodual is used. In the future, in the absence of effect, sequential addition to the previous stages of prolonged theophyllines, then inhalation forms of glucocorticides (the most effective and safe inhacorte (hemihydrate flunisolide) is recommended, in its absence, becotide is used and, finally, in the ineffectiveness of previous stages of treatment, short courses of glucocorticoid ingestion. OV Alexandrov and ZV Vorobyeva (1996) consider the following scheme effective: prednisolone is prescribed with a gradual increase in the dose to 10-15 mg for 3 days, then 5 days, the dose is applied, then it gradually decreases in 3-5 days.It is advisable to connect anti-inflammatory drugs (intal, tileed) to bronchodilator funds reducing the swelling of the bronchial wall and bronchial obstruction before the glucocorticoids are administered.

Appointment of glucocorticoids inside, of course, is undesirable, but in cases of severe bronchial obstruction, in the absence of the effect of the above bronchodilator therapy, there may be a need for their application.

In these cases, it is preferable to use short-acting drugs, i.e. Prednisolone, urbazone, try to use small daily doses (3-4 tablets per day) not for a long time (7-10 days), with subsequent transfer to maintenance doses, which it is advisable to prescribe in the morning on an intermittent method (twice the supporting dose every other day). Part of the maintenance dose can be replaced by inhalation of becotide, inhacorta.

It is advisable to carry out differentiated treatment of chronic obstructive bronchitis depending on the degree of disturbance of the function of external respiration.

There are three degrees of severity of chronic obstructive bronchitis, depending on the volume of forced expiratory volume in the first second (FEV1):

• easy - FEV1 is equal to or less than 70%;
• Average - FEV1 within the limits of 50-69%;
• heavy - FEV1 less than 50%.

Positional drainage

Positional (postural) drainage is the use of a specific position of the body for better sputum discharge. Positional drainage is performed in patients with chronic bronchitis (especially with purulent forms) with a decrease in cough reflex or too viscous sputum. It is also recommended after endotracheal infusions or the introduction of expectorants in the form of an aerosol.

It is performed 2 times a day (in the morning and in the evening, but more often) after preliminary intake of bronchodilators and expectorants (usually infusion of thermopsis, coltsfoot, rosemary, plantain), as well as hot lime tea. 20-30 minutes later, the patient alternately takes positions that promote maximum emptying from sputum of certain segments of the lungs due to gravity and "drainage" to cough reflexogenic areas. In each position, the patient first performs 4-5 deep slow respiratory movements, inhaling air through the nose, and exhaling through the compressed lips; then after a slow deep inspiration produces a 3-4-fold shallow cough 4-5 times. A good result is achieved by combining the drainage positions with different methods of chest vibration over the draining segments or by compressing it with your hands on exhalation, with a massage done quite vigorously.

Postural drainage is contraindicated in hemoptysis, pneumothorax and the occurrence during the procedure of significant dyspnea or bronchospasm.

Massage for chronic bronchitis

Massage is included in the complex therapy of chronic bronchitis. It promotes sputum discharge, has bronhorasslablivayuschim action. A classic, segmental, acupressure massage is used. The latter type of massage can cause a significant bronchodilator effect.

Heparinotherapy

Heparin prevents degranulation of mast cells, increases the activity of alveolar macrophages, has anti-inflammatory action, antitoxic and diuretic effect, reduces pulmonary hypertension, and facilitates sputum discharge.

The main indications for heparin for chronic bronchitis are:

• presence of reversible bronchial obstruction;
• pulmonary hypertension;
• respiratory insufficiency;
• an active inflammatory process in the bronchi;
• DVS-sivdrom;
• significant increase in sputum viscosity.

Heparin is prescribed for 5000-10,000 ED 3-4 times a day under the skin of the abdomen. The drug is contraindicated in cases of hemorrhagic syndrome, hemoptysis, peptic ulcer.

The duration of treatment with heparin is usually 3-4 weeks, followed by a gradual cancellation by reducing the single dose.

The use of calcitonin

In 1987, V. V. Namestnikova proposed treatment of chronic bronchitis with colcitrin (calcitrine - injectable dosage form of calcitonin). It has an anti-inflammatory effect, inhibits the release of mediators from mast cells, improves bronchial patency. It is used for obstructive chronic bronchitis in the form of aerosol inhalations (1-2 units in 1-2 ml of water for 1 inhalation). The course of treatment - 8-10 inhalations.

Detoxification therapy

With the detoxification goal in the period of exacerbation of purulent bronchitis, intravenous drip infusion of 400 ml of hemodepression is used (contraindicated in severe allergization, bronchospastic syndrome), isotonic sodium chloride solution, Ringer's solution, 5% glucose solution. In addition, a generous drink is recommended (cranberry juice, broth of dogrose, lime tea, fruit juices).

[56], [57], [58]

Correction of respiratory failure

Progression of chronic obstructive bronchitis, emphysema leads to the development of chronic respiratory failure, which is the main cause of deterioration in the quality of life and disability of the patient.

Chronic respiratory insufficiency is a state of the body in which, due to damage to the external respiration system, either maintenance of the normal gas composition of the blood is not ensured, or it is achieved primarily by incorporating the compensatory mechanisms of the system of external respiration, the cardiovascular system, the transport system of blood and metabolic processes in tissues.

[59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69]