Chronic bronchitis - Treatment

Chronic bronchitis is a chronic inflammatory process in the bronchi, accompanied by a cough with sputum production for at least 3 months a year for 2 or more years, while there are no 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 and the characteristics of its course.

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Treatment program for chronic bronchitis

1. Elimination of etiological factors of chronic bronchitis.
2. Inpatient treatment and bed rest for certain indications.
3. Therapeutic nutrition.
4. Antibacterial therapy during the period of exacerbation of purulent chronic bronchitis, including methods of endobronchial administration of drugs.
5. Improving the drainage function of the bronchi: expectorants, bronchodilators, positional drainage, chest massage, herbal medicine, heparin therapy, treatment with calcitrin.
6. Detoxification therapy during exacerbation of purulent bronchitis.
7. Correction of respiratory failure: long-term low-flow oxygen therapy, hyperbaric oxygenation, extracorporeal membrane oxygenation of blood, inhalation of humidified oxygen.
8. Treatment of pulmonary hypertension in patients with chronic obstructive bronchitis.
9. Immunomodulatory therapy and improvement of the function of the local bronchopulmonary defense system.
10. Increased non-specific resistance of the body.
11. Physiotherapy, exercise therapy, breathing exercises, massage.
12. Sanatorium and resort treatment.

Elimination of etiological factors

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

First of all, it is necessary to categorically give up smoking. Great importance is attached to the elimination of occupational hazards (various types of dust, acid vapors, alkalis, etc.), thorough 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 are often shown surgical treatment. Elimination of the source of purulent infection reduces the frequency of exacerbations of chronic bronchitis.

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Inpatient treatment of chronic bronchitis and bed rest

Inpatient treatment and bed rest are indicated only for certain groups of patients in the presence of the following conditions:

• severe exacerbation of chronic bronchitis with increasing respiratory failure, despite active outpatient treatment;
• development of acute respiratory failure;
• acute pneumonia or spontaneous pneumothorax;
• manifestation or worsening of right ventricular failure;
• the need to carry out certain diagnostic and therapeutic procedures (in particular, bronchoscopy);
• the need for surgical intervention;
• significant intoxication and marked deterioration of the general condition of patients with purulent bronchitis.

The remaining patients with chronic bronchitis undergo outpatient treatment.

Therapeutic nutrition for chronic bronchitis

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

In chronic bronchitis with the separation of a large amount of sputum, protein loss occurs, and in decompensated pulmonary heart disease, an increased loss of albumin from the vascular bed into the intestinal lumen is noted. These patients are shown a protein-rich diet, as well as intravenous drip transfusion of albumin and amino acid preparations (polyamine, neframin, alvezin).

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

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

Antibiotics for chronic bronchitis

Antibacterial therapy is carried out during the period of exacerbation of purulent chronic bronchitis for 7-10 days (sometimes with severe and prolonged exacerbation for 14 days). In addition, antibacterial therapy is prescribed in the development of acute pneumonia against the background of chronic bronchitis.

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

• positive clinical dynamics;
• mucous character of sputum;

Reduction and disappearance of indicators of an active infectious and inflammatory process (normalization of ESR, leukocyte count, biochemical indicators of inflammation).

For chronic bronchitis, the following groups of antibacterial agents can be used: antibiotics, sulfonamides, nitrofurans, trichopolum (metronidazole), antiseptics (dioxidine), 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, as they allow the antibacterial substance to penetrate directly into the inflammation site.

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

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

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

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

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

According to Yu. Novikov (1995), the main pathogens in exacerbations of chronic bronchitis are:

• Streptococcus pneumoniae 30.7%
• Haemophilus influenzae 21%
• Str. haemolyticus 11%
• Staphylococcus aureus 13.4%
• Pseudomonas aeruginosa 5%
• Mycoplasma 4.9%
• Unidentified pathogen 14%

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

According to Z. V. Bulatova (1980), the proportion 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, mycoplasma viruses - in 11% of cases.

Infectious agents release toxins (for example, H. influenzae - peptideglycans, lipooligosaccharides; Str. pneumoniae - pneumolysin; P. aeruginosae - pyocyanin, rhamnolipids), which damage the ciliated epithelium, slow down ciliary oscillations and even cause the death of the bronchial epithelium.

When prescribing antibacterial therapy after establishing 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 enzyme TEM-1, which destroys these antibiotics. Erythromycin is also inactive against H. influenzae.

Recently, there have been reports of a significant spread of Str. pneumoniae strains resistant to penicillin and many other beta-lactam antibiotics, macrolides, and tetracycline.

M. catarrhal is a normal saprophytic flora, but can often cause exacerbation of chronic bronchitis. A feature of Moraxella is its high ability to adhere to oropharyngeal cells, and this is especially typical for people over 65 years of age with chronic obstructive bronchitis. Moraxella is most often the cause of exacerbation of chronic bronchitis in areas with high air pollution (centers of the metallurgical and coal industries). About 80% of Moraxella strains produce beta-lactamases. Combined preparations of ampicillin and amoxicillin with clavulanic acid and sulbactam are not always active against beta-lactamase-producing Moraxella strains. This pathogen is sensitive to septrim, bactrim, biseptol, and is also highly sensitive to 4-fluoroquinolones and erythromycin (however, 15% of Moraxella strains are not sensitive to it).

In case of mixed infection (Moraxella + Haemophilus influenzae) producing β-lactamases, ampicillin, amoxicillin, cephalosporins (ceftriaxone, cefuroxime, cefaclor) may not be effective.

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

• Group 1 - Previously healthy individuals with post-viral bronchitis. These patients usually have viscous purulent sputum, antibiotics do not penetrate the bronchial mucosa well. This group of patients should be advised to drink plenty of fluids, take expectorants, and herbal infusions with bactericidal properties. However, if there is no effect, antibiotics such as amoxicillin, ampicillin, erythromycin and other macrolides, and tetracyclines (doxycycline) are used.
• Group 2 - Patients with chronic bronchitis, smokers. The same recommendations apply to them as for people 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 (moraxella, hemophilic bacillus). 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. The same drugs are used that were recommended for patients of group 3, as well as ampicillin in combination with sulbactam. In addition, active drainage therapy and physiotherapy are recommended. In bronchiectasis, the most common pathogen found in the bronchi is Haemophylus influenzae.

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

In these cases, macrolides and, to a lesser extent, doxycycline are highly active. Particularly noteworthy are the highly effective macrolides ozythromycin (sumamed) and roxithromycin (rulid), rovamycin (spiramycin). After oral administration, these drugs penetrate well into the bronchial system, remain in tissues for a long time in sufficient concentration, and accumulate in polymorphonuclear neutrophils and alveolar macrophages. Phagocytes deliver these drugs to the site of the infectious and inflammatory process. Roxithromycin (rulid) is prescribed at 150 mg 2 times a day, azithromycin (sumamed) - at 250 mg 1 time per day, rovamycin (spiramycin) - at 3 million IU 3 times a day orally. The duration of the course of treatment is 5-7 days.

When prescribing antibiotics, individual tolerance of the drugs should be taken into account, this is especially true for penicillin (it should not be prescribed for severe bronchospasmodic syndrome).

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

When gram-positive coccal flora is detected, the most effective treatment is with semi-synthetic penicillins, mainly combined (ampiox 0.5 g 4 times a day intramuscularly or orally), or cephalosporins (kefzol, cephalexin, claforan 1 g 2 times a day intramuscularly), with gram-negative coccal flora - aminoglycosides (gentamicin 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 the latest generation cephalosporins (fortum 1 g 3 times a day intramuscularly).

In some cases, broad-spectrum antibiotics, macrolides (erythromycin 0.5 g 4 times a day orally, oleandomycin 0.5 g 4 times a day orally or intramuscularly, erycycline - a combination of erythromycin and tetracycline - in capsules of 0.25 g, 2 capsules 4 times a day orally), tetracyclines, especially extended-release (metacycline or rondomycin 0.3 g 2 times a day orally, doxycycline or vibramycin in capsules of 0.1 g 2 times a day orally) may be effective.

Thus, according to modern concepts, the first-line 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 drugs. If the role of mycoplasmas, chlamydia, legionella in the exacerbation of chronic bronchitis is suspected, it is advisable to use macrolide antibiotics (especially azithromycin - sumamed, roxithromycin - rulid) or tetracyclines (doxycycline, etc.). Combined use of macrolides and tetracyclines is also possible.

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Sulfanilamide drugs for chronic bronchitis

Sulfanilamide drugs are widely used in acute cases of chronic bronchitis. They have chemotherapeutic activity against gram-positive and non-negative flora. Extended-release drugs are usually prescribed.

Biseptol in tablets of 0.48 g. Prescribed orally, 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 evening, on the following days, 1 tablet in the morning and evening.

Sulfamonomethoxine in tablets of 0.5 g. On the first day, 1 g is prescribed in the morning and evening, on the following days, 0.5 g in the morning and evening.

Sulfadimethoxine is prescribed in the same way as sulfamonomethoxine.

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

Nitrofuran drugs

Nitrofuran drugs have a broad spectrum of action. Furazolidone is mainly prescribed at 0.15 g 4 times a day after meals. Metronidazole (Trichopolum), a broad-spectrum drug, can also be used in tablets of 0.25 g 4 times a day.

Antiseptics

Among broad-spectrum antiseptics, dioxidine and furacilin deserve the most attention.

Dioxidine (0.5% solution of 10 and 20 ml for intravenous administration, 1% solution in 10 ml ampoules for cavity and endobronchial administration) is a drug with a broad antibacterial action. 10 ml of 0.5% solution in 10-20 ml of isotonic sodium chloride solution is slowly administered intravenously. Dioxidine is also widely used in the form of aerosol inhalations - 10 ml of 1% solution per inhalation.

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Phytoncidal preparations

Phytoncides include chlorophyllipt, a preparation made from eucalyptus leaves that has a pronounced antistaphylococcal effect. A 1% alcohol solution is taken orally, 25 drops 3 times a day. It can be administered intravenously slowly, 2 ml of a 0.25% solution in 38 ml of sterile isotonic sodium chloride solution.

Phytoncides also include garlic (inhaled) or taken orally.

Endobronchial sanitation

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

• furacilin solution 1:5000 - in small portions of 3-5 ml during inhalation (50-150 ml in total);
• dioxidine solution - 0.5% solution;
• Kalanchoe juice diluted 1:2;
• If bronchoecgases are present, 3-5 ml of antibiotic solution can be administered.

Fiber bronchoscopy under local anesthesia is also effective. For sanitization of the bronchial tree the following are used: furacilin solution 1:5000; 0.1% furagin solution; 1% rivanol solution; 1% chlorophyllipt solution in a 1:1 dilution; dimexide solution.

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Aerosoltherapy

Aerosol therapy with phytoncides and antiseptics can be performed using ultrasonic inhalers. They create uniform aerosols with an optimal particle size that penetrate to the peripheral sections 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, you can inhale antiseptics furacilin, rivanol, chlorophyllipt, onion or garlic juice (diluted with 0.25% novocaine solution in a ratio of 1:30), fir infusion, lingonberry leaf condensate, dioxidine. After aerosol therapy, postural drainage and vibration massage are performed.

In recent years, the aerosol preparation bioparoxocobtal has been recommended for the treatment of chronic bronchitis. It contains one active component, fusafungin, a preparation of fungal origin that has antibacterial and anti-inflammatory effects. Fusanfungin is active against predominantly gram-positive cocci (staphylococci, streptococci, pneumococci), as well as intracellular microorganisms (mycoplasma, legionella). In addition, it has antifungal activity. According to White (1983), the anti-inflammatory effect of fusafungin is associated with the suppression of oxygen radical production by macrophages. Bioparox is used in the form of dosed inhalations - 4 breaths every 4 hours for 8-10 days.

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Improving the drainage function of the bronchi

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

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

Expectorants, herbal medicine

According to the definition of B. E. Votchal, expectorants are substances that change the properties of sputum and facilitate its discharge.

There is no generally accepted classification of expectorants. It is advisable to classify them by mechanism of action (V. G. Kukes, 1991).

Classification of expectorants

1. Means that promote expectoration:
   • drugs that act reflexively;
   • resorptive drugs.
2. Mucolytic (or secretolytic) drugs:
   • proteolytic drugs;
   • amino acid derivatives with SH group;
   • mucoregulators.
3. Rehydrators of mucous secretions.

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

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

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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 impairment of pulmonary ventilation and gas exchange of the obstructive type and manifested by cough, shortness of breath and sputum production not associated with damage to other organs and systems (Consensus on chronic obstructive bronchitis of the Russian Congress of Pulmonologists, 1995). As chronic obstructive bronchitis progresses, pulmonary emphysema develops, among the causes of which are exhaustion and impaired production of protease inhibitors.

The main mechanisms of bronchial obstruction:

• bronchospasm;
• inflammatory edema, infiltration of the bronchial wall during exacerbation of the disease;
• hypertrophy of the bronchial muscles;
• hypercrinia (increased amount of sputum) and dyscrinia (change in rheological properties of sputum, it becomes viscous, thick);
• collapse of small bronchi during exhalation due to a decrease in the 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 the discharge of sputum.

Bronchodilators are prescribed taking into account the daily rhythms of bronchial patency. Sympathomimetic agents (beta-adrenergic receptor stimulants), anticholinergic drugs, purine derivatives (phosphodiesterase inhibitors) - methylxanthines are used as bronchodilators.

Sympathomimetic agents stimulate beta-adrenergic receptors, which leads to increased adenyl cyclase activity, accumulation of cAMP and then a bronchodilatory effect. Use ephedrine (stimulates beta-adrenergic receptors, which provides bronchodilation, as well as alpha-adrenergic receptors, which reduces swelling of the bronchial mucosa) 0.025 g 2-3 times a day, a combination drug theofedrine 1/2 tablet 2-3 times a day, bronholitin (a combination drug, 125 g of which contains glaucine 0.125 g, ephedrine 0.1 g, sage oil and citric acid 0.125 g each) 1 tablespoon 4 times a day. Bronholitin causes a bronchodilatory, antitussive and expectorant effect.

It is especially important to prescribe ephedrine, theophedrine, and broncholitin in the early morning hours, since this is the time when bronchial obstruction peaks.

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

In this regard, the greatest attention is paid to selective beta2-adrenergic stimulants (selectively stimulate beta2-adrenergic receptors and have virtually no effect on beta1-adrenergic receptors). Solbutamol, terbutaline, ventolin, berotek, and also the partially beta2-selective stimulant astmopent are usually used. These drugs are used in the form of metered aerosols, 1-2 inhalations 4 times a day.

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

In recent years, long-acting beta2-adrenergic stimulants (duration of action about 12 hours) have come into use - salmeterol, fortemol in the form of dosed aerosols 1-2 inhalations 2 times a day, spiropent 0.02 mg 2 times a day orally. These drugs are less likely to cause tachyphylaxis.

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

In case of severe bronchial obstruction, euphyllin is prescribed at 10 ml of a 2.4% solution in 10 ml of isotonic sodium chloride solution intravenously very slowly, intravenously by drip to prolong its action - 10 ml of a 2.4% solution of euphyllin in 300 ml of isotonic sodium chloride solution.

In case of chronic bronchial obstruction, it is possible to use euphyllin preparations in tablets of 0.15 g 3-4 times a day orally after meals or in the form of alcohol solutions, which are better absorbed (euphyllin - 5 g, 70% ethyl alcohol - 60 g, distilled water - up to 300 ml, take 1-2 tablespoons 3-4 times a day).

Of particular interest are prolonged theophylline preparations that act for 12 hours (taken twice a day) or 24 hours (taken once a day). Theodur, theolong, theobilong, theotard are prescribed at 0.3 g twice a day. Uniphylline ensures a uniform level of theophylline in the blood throughout the day and is prescribed at 0.4 g once a day.

In addition to the bronchodilatory effect, extended-release theophyllines also cause the following effects in bronchial obstruction:

• reduce pressure in the pulmonary artery;
• stimulate mucociliary clearance;
• improve the contractility 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 the patient has not previously taken theophylline preparations, then treatment should be started with smaller doses, gradually (after 2-3 days) increasing them.

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Anticholinergic agents

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

The arguments in favor of a wider use of anticholinergics in chronic obstructive bronchitis are the following circumstances:

• Anticholinergics cause bronchodilation to the same extent as beta2-adrenergic stimulants, and sometimes even more pronounced;
• the effectiveness of anticholinergics does not decrease even with prolonged use;
• With increasing age of the patient, as well as with the development of pulmonary emphysema, the number of beta2-adrenergic receptors in the bronchi progressively decreases and, consequently, the effectiveness of beta2-adrenergic receptor stimulants decreases, while the sensitivity of the bronchi to the bronchodilating effect of anticholinergics remains.

Ipratropium bromide (Atrovent) is used - in the form of a metered aerosol 1-2 inhalations 3 times a day, oxytropium bromide (Oxyvent, Ventilate) - a long-acting anticholinergic, prescribed in a dose of 1-2 inhalations 2 times a day (usually in the morning and before bedtime), if there is no effect - 3 times a day. The drugs are virtually free of side effects. They exhibit a bronchodilating effect after 30-90 minutes and are not intended to relieve an attack of suffocation.

Anticholinergics can be prescribed (in the absence of a bronchodilating effect) in combination with beta2-adrenergic stimulants. The combination of atrovent with the beta2-adrenergic stimulant fenoterol (berotek) is available in the form of a dosed aerosol berodual, which is used 1-2 doses (1-2 inhalations) 3-4 times a day. The simultaneous use of anticholinergics and beta2-agonists enhances the effectiveness of bronchodilating therapy.

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

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

In case of moderate bronchial obstruction, bronchial patency can be improved with the combination drug theophedrine (which, along with other components, includes theophylline, belladonna, ephedrine) 1/2, 1 tablet 3 times a day or by taking powders of the following composition: ephedrine 0.025 g, platyfimin 0.003 g, euphyllin 0.15 g, papaverine 0.04 g (1 powder 3-4 times a day).

The following treatment tactics for chronic obstructive bronchitis are recommended.

The first-line drugs are ipratrotum bromide (atrovent) or oxitropium bromide; if there is no effect from treatment with inhaled anticholinergics, beta2-adrenergic receptor stimulants (fenoterol, salbutamol, etc.) are added or the combination drug berodual is used. In the future, if there is no effect, it is recommended to sequentially add prolonged theophyllines to the previous stages, then inhaled forms of glucocorticoids (Ingacort (flunisolide hemihydrate) is the most effective and safe; if it is not available, Becotide is used, and finally, if the previous stages of treatment are ineffective, short courses of oral glucocorticoids are used. O. V. Aleksandrov and Z. V. Vorobyova (1996) consider the following scheme to be effective: prednisolone is prescribed with a gradual increase in the dose to 10-15 mg over 3 days, then the achieved dose is used for 5 days, then it is gradually reduced over 3-5 days. Before the stage of prescribing glucocorticoids, it is advisable to add anti-inflammatory drugs (Intal, Tayled) to bronchodilators, which reduce swelling of the bronchial wall and bronchial obstruction.

The administration of glucocorticoids orally is, of course, undesirable, but in cases of severe bronchial obstruction in the absence of the effect of the above bronchodilator therapy, it may be necessary to use them.

In these cases, it is preferable to use short-acting drugs, i.e. prednisolone, urbazon, try to use small daily doses (3-4 tablets per day) for a short time (7-10 days), with a subsequent transition to maintenance doses, which are advisable to prescribe in the morning in an intermittent manner (double maintenance dose every other day). Part of the maintenance dose can be replaced by inhalation of becotide, ingacort.

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

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

• mild - FEV1 equal to or less than 70%;
• average - FEV1 within 50-69%;
• severe - FEV1 less than 50%.

Positional drainage

Positional (postural) drainage is the use of a certain body position for better expectoration. Positional drainage is performed in patients with chronic bronchitis (especially in purulent forms) with a decreased 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 twice a day (morning and evening, but can be done more often) after preliminary intake of bronchodilators and expectorants (usually infusion of thermopsis, coltsfoot, wild rosemary, plantain), as well as hot linden tea. After 20-30 minutes, the patient alternately takes positions that promote maximum emptying of sputum from certain segments of the lungs under the action of gravity and "flowing" to the cough reflexogenic zones. In each position, the patient first performs 4-5 deep slow breathing movements, inhaling air through the nose and exhaling through pursed lips; then, after a slow deep breath, he or she coughs 3-4 times, 4-5 times. A good result is achieved by combining drainage positions with various methods of vibration of the chest over the drained segments or its compression with hands on exhalation, massage, done vigorously enough.

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

Massage for chronic bronchitis

Massage is part of the complex therapy of chronic bronchitis. It promotes expectoration and has a bronchial relaxing effect. Classic, segmental, and point massage are used. The latter type of massage can cause a significant bronchial relaxing effect.

Heparin therapy

Heparin prevents mast cell degranulation, increases the activity of alveolar macrophages, has an anti-inflammatory effect, antitoxic and diuretic effect, reduces pulmonary hypertension, and promotes expectoration.

The main indications for heparin in chronic bronchitis are:

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

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

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

Use of calcitonin

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

Detoxification therapy

For detoxification purposes during the period of exacerbation of purulent bronchitis, intravenous drip infusion of 400 ml of hemodez (contraindicated in case of severe allergization, bronchospastic syndrome), isotonic sodium chloride solution, Ringer's solution, 5% glucose solution is used. In addition, drinking plenty of fluids (cranberry juice, rosehip decoction, linden tea, fruit juices) is recommended.

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Correction of respiratory failure

The progression of chronic obstructive bronchitis and pulmonary emphysema leads to the development of chronic respiratory failure, which is the main reason for the deterioration of the quality of life and disability of the patient.

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

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