Treatment of bronchial asthma in children

Treatment of bronchial asthma is:

• Carrying out elimination activities aimed at reducing or eliminating the effects of causative allergens.
• Pharmacotherapy.
• Allergen-specific immunotherapy.
• Training of patients and their families.

Indications for hospitalization for bronchial asthma

• Severe exacerbation:
  • difficulty breathing at rest, compulsion, refusal to eat in infants, agitation, drowsiness or confused consciousness, bradycardia or shortness of breath (more than 30 per minute);
  • loud wheezing or their absence;
  • heart rate (heart rate) more than 120 per minute (in infants more than 160 per minute);
  • PSV is less than 60% of the proper or best individual value, even after initial treatment;
  • exhaustion of the child.
• Absence of an obvious reaction to the bronchodilator that is fast and preserved for at least 3 hours.
• Lack of improvement after starting treatment with glucocorticosteroids for 2-6 hours.
• Further deterioration of the condition.
• Life-threatening exacerbations of bronchial asthma in the anamnesis or hospitalization in the intensive care unit, intubation for exacerbation of bronchial asthma.
• Social ill-being.

Pharmacotherapy for bronchial asthma

There are two large groups of drugs used to treat asthma in children:

• means of basic (supporting, anti-inflammatory) treatment;
• symptomatic.

The preparations of the basic treatment of bronchial asthma include:

• Preparations with anti-inflammatory and / or prophylactic effect (glucocorticosteroids, antileukotriene drugs, cromones, anti-IgE-napropaty);
• long-acting bronchodilators (long-acting beta2-adrenomimetics, theophylline preparations with slow release).

The greatest clinical and pathogenetic efficacy is currently shown when using IGKS. All preparations of basic anti-inflammatory treatment are taken daily and for a long time. This principle of using anti-inflammatory drugs (basic) allows you to achieve control of the disease and maintain it at the proper level. It should be noted that on the territory of the Russian Federation for the basic treatment of asthma in children using combined drugs containing IGCC (salmeterol + fluticasone (serotide) and budesonide + formoterol (symbicort)) with a 12-hour break. Only the stable dosing regimen is registered. Other schemes in children are not allowed.

Means that relieve the symptoms of bronchial asthma:

• inhalation short-acting beta2-adrenomimetics (the most effective bronchodilators);
• anticholinergic drugs;
• immediate-release theophylline preparations;
• oral short-acting beta2-adrenomimetics.

These drugs are also called "first aid"; use them is necessary to eliminate bronchial obstruction and concomitant acute symptoms (wheezing, chest tightness, coughing). This mode of drug use (ie only when there is a need to eliminate the emerging symptoms of asthma) is called "on-demand mode".

Preparations for the treatment of bronchial asthma are administered in various ways: by mouth, parenterally and by inhalation. The latter is preferable. When choosing a device for inhalation, the effectiveness of drug delivery, cost / effectiveness, ease of use, and patient age are taken into account. Children use three types of devices for inhalation: nebulizers, metered aerosol inhalers and powder inhalers.

Delivery means for bronchial asthma (age priorities)

Means	Recommended age group	Comments
Dosing aerosol inhaler (DAD)	> 5 years	It is difficult to coordinate the moment of inspiration and pressure on the balloon valve, especially for children. About 80% of the dose settles in the oropharynx, it is necessary to rinse the mouth after each inhalation
DAI. Activated by inspiration	> 5 years	The use of this delivery device is indicated for patients who are not able to coordinate the inspiration and pressure on the valve of conventional DAI. Can not be used with any existing spacers other than the optimizer for this type of inhaler
Powder inhaler	> 5 years	With the proper technique of use, the effectiveness of inhalation can be higher than with the use of DAI. It is necessary to rinse the oral cavity after each use to reduce systemic absorption
Spacer	> 4 years <4 years when applied Facial mask	The use of the spacer reduces the settling of the drug in the oropharynx, allows the use of DAI with greater efficiency, in the case of a mask (complete with a strayer), can be used in children under 4 years
Nebulizer	<2 years Patients of any age who can not use a spacer or spacer / face mask	The optimal delivery vehicle for use in specialized departments and intensive care units, as well as in emergency care, since the least effort is required from the patient and the doctor

Anti-inflammatory (basic) drugs for the treatment of bronchial asthma

[1], [2], [3], [4], [5],

Inhaled glucocorticoids and combined agents containing them

Currently, inhaled glucocorticosteroids are the most effective drugs for controlling bronchial asthma, therefore they are recommended for the treatment of persistent asthma of any severity. In children of school age, maintenance therapy IGKS allows you to control the symptoms of bronchial asthma, reduces the frequency of exacerbations and the number of hospitalizations, improves the quality of life, improves the function of external respiration, reduces the hyperreactivity of the bronchi and reduces bronchoconstriction in exercise. IGKS in children of preschool age. Suffering from bronchial asthma, leads to a clinically significant improvement in the condition. Including scores of day and night cough, wheezing and wheezing, physical activity, use of emergency drugs and use of health system resources. Beclomethasone is used in children. Fluticasone. Budesonide. The use of these drugs in low doses is safe: when appointing higher doses, it is necessary to remember the possibility of developing side effects. Distinguish between low, medium and high doses of drugs used for basic treatment.

Calculated equipotent daily doses of inhaled glucocorticoids

A drug

Low daily doses, μg

Average daily doses, μg

High daily doses, μg

Doses for children under 12 years

Beclomethasone dipropionate 1 '	100-200	> 200-400	> 400
Budesonide '	100-200	> 200-400	> 400
Fluticasone	100-200	> 200-500	> 500

Doses for children over 12 years

Beclomethasone dipropionate	200 500	> 500-1000	> 1000-2000
Budesonide	200-400	> 400-800	> 800-1600
Fluticasone	100-250	> 250-500	> 500-1000

IGKS are included in the combined preparations for the treatment of asthma [salmeterol + fluticasone (serotide) and formoterol + budesonide (symbicort)]. A large number of clinical studies have shown that a combination of long-acting beta2-adrenomimetics and low-dose inhaled glucocorticosteroids is more effective than increasing the dose of the latter. Combined treatment with salmeterol and fluticasone (in one inhaler) promotes better control of bronchial asthma than long-acting beta2-adrenomimetic and IGKS in separate inhalers. Against the backdrop of prolonged therapy with salmeterol and fluticasone, almost every second patient can achieve complete control of bronchial asthma (according to a study that included patients aged 12 years and older). There is a significant improvement in the effectiveness of treatment: PSV, FEV1, frequency of exacerbations, quality of life. In the event that the use of low doses of IHKS in children does not allow to achieve control over bronchial asthma. Recommended the transition to use a combination drug, which can be a good alternative to increasing the dose of IGKS. This was shown in a new prospective, multicenter, double-blind, randomized trial in parallel groups of 12 weeks. Where the efficacy of a combination of salmeterol and fluticasone at a dose of 50/100 μg twice a day and a 2-fold higher dose of fluticasone propionate (200 μg twice a day in 303 children aged 4-11 years with persistent symptoms of bronchial asthma, despite previous treatment low doses of IGKS). It turned out that regular use of a combination of fluticasone / salmeterol (sertide) prevents symptoms and provides control of asthma as effectively as a double dose of IGKS. Treatment with serotide is accompanied by a more pronounced improvement in lung function and a decrease in the need for medications to alleviate asthma symptoms with good tolerability: in the Sertifera group, the morning PSV increase is 46% higher, and the number of children with a total lack of "rescue therapy" is 53% in the group of fluticasone propionate. The use of a combination of formoterol / budesonide in one inhaler provides better control of asthma symptoms compared to one budesonide in patients who previously did not provide IHKS with symptom control.

Influence of IGCC on growth

Uncontrolled or severe bronchial asthma slows the growth of children and reduces the total growth in adulthood. None of the long-term controlled trials has shown any statistically or clinically significant effect on the growth of treatment with ICSS at a dose of 100-200 μg / day. Deceleration of linear growth is possible with the long-term administration of any IGCC in a high dose. However, children with bronchial asthma who receive IGKS achieve normal growth, although sometimes later than other children.

Effect on bone tissue

None of the studies showed a statistically significant increase in the risk of bone fractures in children receiving IGCC.

[6], [7], [8], [9], [10]

Influence on the hypothalamic-pituitary-adrenal system

Treatment of IGKS in a dose of <200 mcg / day (in terms of budesonide) is not accompanied by any significant depression of the hypothalamic-pituitary-adrenal system. For higher doses, clinically relevant changes are also usually uncharacteristic.

Candidiasis of the mouth

Clinically pronounced thrush is rarely noted, it is probably associated with concomitant antibiotic treatment, high doses of inhaled glucocorticoids and a high incidence of inhalation. The use of spacers and mouthwash reduces the incidence of candidiasis.

[11], [12], [13], [14], [15], [16], [17]

Other side effects

Against the background of regular basic anti-inflammatory treatment, there was no increase in the risk of cataract and tuberculosis.

Leukotriene Receptor Antagonists

Antileukotriene drugs provide partial protection against bronchospasm caused by physical exertion, within a few hours after admission. Addition of antileukotriene drugs to treatment in the case of insufficient effectiveness of low doses of IHKS provides a moderate clinical improvement, including a statistically significant reduction in the frequency of exacerbations. Clinical efficacy of anti-leukotriene drugs has been shown in children over the age of 5 years with all degrees of severity of bronchial asthma, but usually these drugs are inferior to IGKS in low doses. Antileukotriene drugs (zafirlukast, montelukast) can be used to enhance treatment in children with moderate bronchial asthma in those cases when the disease is not adequately controlled by the use of low doses of IGKS. With the use of leukotriene receptor antagonists, moderate improvement in lung function (in children 6 years and older) and bronchial asthma control (in children 2 years and older) is noted as a monotherapy in patients with severe and moderate bronchial asthma. Zafirlukast has moderate effectiveness in relation to the function of external respiration in children 12 years and older with moderate and severe bronchial asthma.

Cromones

Cromons have a weak anti-inflammatory effect and are inferior in effectiveness even to low doses of IGKS. Cromoglycic acid is less effective than IGKS for clinical symptoms, external respiratory function, bronchial asthma physical effort, airway hyperreactivity. Long-term treatment with cromoglycic acid in children with bronchial asthma is not significantly different from placebo in its effectiveness. Nedocromed, prescribed before exercise, can reduce the severity and duration of bronchoconstriction caused by it. Nedocromil, as well as cromoglycic acid, is less effective than IGKS. Cromons are contraindicated in the aggravation of bronchial asthma, when intensive therapy with bronchodilators of rapid action is needed. The role of cromones in the basic treatment of bronchial asthma in children is limited, especially at preschool age, due to the lack of evidence of their effectiveness. The meta-analysis carried out in 2000 did not allow to make an unambiguous conclusion about the effectiveness of cromoglycic acid as a means of basic treatment of bronchial asthma in children. Preparations of this group do not use for starting therapy of moderate and severe asthma. The use of cromones as a basic treatment is possible in patients with complete control of the symptoms of bronchial asthma. Cromons should not be combined with long-acting beta2-adrenomimetics, since the use of these drugs without IGSC increases the risk of death from asthma.

[18], [19], [20], [21],

Anti-IgE preparations

Antibodies to IgE are a fundamentally new class of drugs currently used to improve control of severe persistent atopic bronchial asthma. Omalizumab, the most studied, the first and only recommended drug in this group, is permitted for the treatment of uncontrolled bronchial asthma in adults and children over 12 years in various countries of the world. The high cost of treatment with omalizumab, as well as the need for monthly visits to the doctor for injecting the drug are justified in patients who need repeated hospitalizations, emergency medical care, using high doses of inhaled and / or systemic glucocorticoids.

[22], [23], [24], [25]

Long-acting methylxanthines

Theophylline is significantly more effective than placebo in controlling the symptoms of bronchial asthma and improving lung function even at doses below the usually recommended therapeutic range. However, the use of theophyllines for the treatment of bronchial asthma in children is problematic because of the possibility of severe rapid onset (cardiac arrhythmia, death) and delayed (behavioral disorders, learning problems, etc.) side effects. In this regard, the use of theophyllines is possible only under strict pharmacodynamic control. (In most of the clinical guidelines that exist for the treatment of bronchial asthma, in the different US states theophyllines are not generally permitted for use in children.)

Long- acting beta ₂ -adrenomimetics

Classification of beta ₂ -adrenomimetics:

• short-acting, fast-acting (salbutamol);
• long-acting:
• high-speed (formoterol);
• with a slower onset of action (salmeterol).

Salbutamol is the "gold standard" for the relief of asthma symptoms in "as needed" mode.

Inhaled beta2-adrenomimetics of long-acting

Preparations of this group are effective for maintaining control of bronchial asthma. On a permanent basis, they are used only in combination with IGKS and are prescribed when the standard initial doses of the IGCC used do not allow the control of the disease to be achieved. The effect of these drugs persists for 12 hours. Formoterol in the form of inhalations has its therapeutic effect (relaxation of smooth muscles of the bronchi) after 3 minutes, the maximum effect occurs 30-60 minutes after inhalation. Salmeterol begins to act relatively slowly, a significant effect is noted 10-20 minutes after inhalation of a single dose of 50 mcg, and an effect comparable to that of salbutamol occurs 30 minutes later. Because of the slow onset of action, salmeterol should not be prescribed for relief of acute symptoms of bronchial asthma. Since the action of formoterol develops faster than salmeterol, it allows us to use formoterol not only for prevention, but also for relief of symptoms. However, according to the recommendations of GIN A (2006), long-acting beta2-adrenomimetics are used only in patients already receiving regular maintenance treatment of IHKS.

Children tolerate long-acting inhaled beta2-adrenomimetics even with prolonged use, and their side effects are comparable to those of short-acting beta2-adrenomimetics (if they are applied on demand). Preparations of this group are prescribed only in conjunction with the basic treatment of IHKS, since monotherapy with long-acting beta2-adrenomimetics without IGKS increases the probability of death of patients! Due to contradictory data on the effect on exacerbations of bronchial asthma, these remedies are not the drugs of choice for patients requiring the appointment of two means of maintenance treatment and more.

Oral beta2-adrenomimetics of long-acting

Drugs of this group include long-acting salbutamol dosage forms. These drugs can help in controlling the nocturnal symptoms of bronchial asthma. They can be used in addition to IGSC if the latter do not provide adequate control of nocturnal symptoms in standard doses. Possible side effects include cardiovascular stimulation, anxiety and tremor. In pediatric clinical practice, these drugs are rarely used.

Anticholinergic drugs

Inhalation anticholinergics are not recommended for long-term use (basic treatment) in children with bronchial asthma.

[26], [27], [28], [29], [30], [31]

Systemic glucocorticoids

Despite the fact that systemic GCS is effective against bronchial asthma, it is necessary to take into account undesirable phenomena with long-term treatment, such as oppression of the hypothalamic-pituitary-adrenal system, weight gain, steroid diabetes, cataracts, hypertension, growth retardation, immunosuppression, osteoporosis, mental disorders. Given the risk of side effects with prolonged use, oral glucocorticoids are used in children with asthma only in the case of severe exacerbations, both against the background of a viral infection, and in its absence.

Allergen-specific immunotherapy

Allergen-specific immunotherapy reduces the severity of symptoms and the need for medicines, reduces allergen-specific and nonspecific bronchial hyperreactivity. Is conducted by an allergist.

[32], [33]

Means of emergency treatment (preparations of "first aid")

Inhaled beta2-adrenomimetics of fast action (short-acting) are the most effective of existing bronchodilators, they serve as the drugs of choice for the treatment of acute bronchospasm. To this group of drugs include salbutamol, fenoterol and terbutaline.

Anticholinergics play a limited role in the treatment of bronchial asthma in children. In a meta-analysis of ipratropium bromide studies in combination with beta2-adrenomimetics in exacerbation of bronchial asthma, it has been shown that the use of an anticholinergic drug is accompanied by statistically significant, albeit moderate, improvements in lung function and reduced risk of hospitalization.

Preparations of emergency aid for bronchial asthma

A drug	Dose	Side effects	Comments
Beta2-adrenomimetics
Salbutamol (DPI)	1 dose - 100 mcg; 1-2 inhalations up to 4 times a day	Tachycardia, tremor, headache, irritability	Recommended only in "on-demand mode"
Salbutamol (nebulizer)	2.5 mg / 2.5 mL
Fenoterol (DPI)	1 dose - 100 mcg; 1-2 inhalations up to 4 times a day
Fenoterol (solution for nebulizer treatment)	1 mg / ml
Anticholinergic drugs
Ipratropium bromide (DPI) from age 4	1 dose - 20 mcg; 2-3 inhalations up to 4 times a day	Slight dryness and unpleasant taste in the mouth	Primarily used in children under 2 years
Ipratropium bromide (solution for nebulization) since birth	250 μg / ml
Combined preparations
Fenoterol + ipratropium bromide (DAI)	2 inhalations up to 4 times a day	Tachycardia, tremor of skeletal muscles, headache, irritability, slight dryness and unpleasant taste in the mouth	Characterized by the side effects indicated for each of the combination of drugs
Fenoterol + ipratropium bromide (solution for nebulization treatment)	1-2 ml
Theophylline short-acting
Aminophylline (euphyllin) in any dosage form	150 mg; > 3 years at 12-24 mg / kg per day	Nausea, vomiting, headache, tachycardia, heart rhythm disturbances	At present, the use of aminophylline for the relief of asthma symptoms in children is not justified

Assessment of the level of bronchial asthma control

The assessment of the condition of each patient includes determining the amount of current treatment, the degree of implementation of the doctor's recommendations and the level of control of bronchial asthma.

Control of bronchial asthma is a complex concept, including, according to the recommendations of GINA, a set of the following indicators:

• minimum number or absence (less than 2 episodes per week) of daily symptoms of bronchial asthma;
• absence of restrictions in daily activity and physical exertion;
• absence of nocturnal symptoms and awakenings due to bronchial asthma;
• minimum need or lack of need (less than 2 episodes per week) in short-acting bronchodilators;
• normal or almost normal lung function;
• absence of exacerbations of bronchial asthma.

According to GINA (2006) three levels are distinguished - controlled, partially controlled and uncontrolled bronchial asthma.

Currently, several tools for integrated assessment have been developed. One of them is the Childhood Asthma Control Test, a validated questionnaire that allows the doctor and patient (parent) to quickly assess the severity of asthma symptoms and the need to increase the amount of treatment.

The existing literature data on the treatment of bronchial asthma in children aged 5 years and under do not allow detailed recommendations. IGKS - drugs with the most well-proven effects in this age group; low doses of IHRS are recommended in the second stage as a means of initial maintenance treatment.

[34], [35], [36], [37], [38], [39], [40], [41]

Treatment of bronchial asthma, aimed at maintaining control

The choice of medication depends on the current level of asthma control and current therapy. So, if the treatment does not provide control over bronchial asthma, it is necessary to increase the amount of therapy (go to a higher stage) until control is achieved. If it persists for 3 months or more, a reduction in the volume of maintenance treatment is possible in order to achieve the minimum volume and lowest doses of drugs sufficient to maintain control. If partial control over bronchial asthma is achieved, the possibility of increasing the volume of treatment should be considered, taking into account more effective approaches to therapy (ie, the possibility of increasing doses or adding other drugs), their safety, cost and patient satisfaction with the level of control achieved.

The stage of treatment aimed at achieving control of bronchial asthma (based on the GINA guidelines, 2006)

Most of the drugs used in bronchial asthma are characterized by a rather favorable benefit / risk relationship compared to the means for treating other chronic diseases. Each stage includes treatment options that can serve as alternatives in choosing supportive treatment for bronchial asthma, although they are not the same in effectiveness. The volume of treatment increases from stage 2 to stage 5; although at stage 5, the choice of treatment also depends on the availability and safety of drugs. Most patients with symptoms of persistent asthma who have not received supportive treatment should start with stage 2. If the clinical manifestations of bronchial asthma are very pronounced during the initial examination and indicate lack of control, treatment begins at stage 3.

Correspondence of stages of treatment to clinical characteristics of bronchial asthma

Stages of treatment	Clinical Characteristics of Patients
Step 1	Short-term (up to several hours) symptoms of bronchial asthma during the day (cough, wheezing, shortness of breath occurring <2 times a week) or its more rare nocturnal symptoms. In the interictal period there are no manifestations of asthma and nocturnal awakenings, the function of the lungs is within the normal range. PSV <80% of the proper values
Step 2	Symptoms of bronchial asthma more often 1 time per week, but less often 1 time 8 days. Exacerbations can disrupt patient activity and nighttime sleep. Nocturnal symptoms are more often than 2 times a month. Functional parameters of external respiration within the limits of age norm. In the interictal period there are no symptoms of bronchial asthma and nocturnal awakenings, tolerability of physical activity is not reduced. PSV> 80% of the proper values
Step 3	Symptoms of bronchial asthma are noted daily. Exacerbations disrupt the child's physical activity and night sleep. Nocturnal symptoms occur more than once a week. In the interictal period, episodic symptoms are noted, changes in the function of external respiration persist. The tolerability of physical activity can be reduced. PSV 60-80% of the proper values
Step 4	Frequent (several times a week or daily, several times a day) the appearance of symptoms of bronchial asthma, frequent night attacks of suffocation. Frequent exacerbations of the disease (1 every 1-2 months). Restriction of physical activity and pronounced impairment of the function of external respiration. In the period of remission, clinical and functional manifestations of bronchial obstruction persist. PSV <60% of the required values
Step 5	Daily daily and nighttime symptoms, several times a day. Severe restriction of physical activity. Pronounced violations of the lung function. Frequent exacerbations (1 time per month and more often). In the period of remission, marked clinical and functional manifestations of bronchial obstruction persist. PSV <60% of the required values

At each stage of treatment, patients should use drugs to quickly relieve the symptoms of bronchial asthma (rapid bronchodilators).

However, their regular use is one of the signs of uncontrolled bronchial asthma, indicating the need to increase the amount of maintenance treatment. That is why the reduction or absence of the need for emergency therapy is an important goal and criterion of the effectiveness of treatment.

Step 1 - use of drugs to relieve symptoms as needed, is only for patients who have not received maintenance treatment. In the case of more frequent onset of symptoms or occasional worsening, patients are shown regular maintenance therapy (see step 2 or higher) in addition to drugs to relieve symptoms as needed.

Steps 2-5 include a combination of the drug for symptom relief (as needed) with regular maintenance treatment. As initial supportive therapy for bronchial asthma in patients of any age in stage 2, IGHS is recommended in a low dose. Alternatives are inhaled anticholinergic drugs, short-acting oral beta2-adrenergics, or short-acting theophylline. However, these drugs are characterized by a slower onset of action and a higher incidence of side effects.

In step 3, a combination of low-dose inhaled glucocorticosteroids with long-acting inhaled beta2-adrenomimetic is prescribed as a fixed combination. Due to the additive effect of combined treatment, patients usually have low doses of IGKS; an increase in the dose of IHKS is necessary only for patients who have not had control of bronchial asthma after 3-4 months of treatment. It has been shown that formoterol, beta2-adrenomimetic long-acting, characterized by a rapid onset of action when applied as monotherapy or as part of a fixed combination with budesonide, is no less effective for the relief of acute manifestations of bronchial asthma than for short-acting beta2-adrenergics. However, formoterol monotherapy for symptom relief is not recommended, and this drug is always used only with IGKS. In all children, especially at the age of 5 years and younger, combined treatment is studied to a lesser extent than in adults. However, a recent study showed that the addition of long-acting beta2-adrenomimetics is more effective than increasing the dose of IGKS. The second option is to increase the dose of IGKS to averages. Patients of any age receiving medium or high doses of IGKS using a metered aerosol inhaler are recommended to use a spacer to improve delivery of the drug to the respiratory tract, reduce the risk of oropharyngeal side effects and systemic absorption of the drug. Another alternative treatment option in stage 3 is the combination of low-dose inhaled corticosteroids with an anti-leukotriene drug, which may be followed by a small dose of delayed-release theophylline. These treatment options were not investigated in children aged 5 years and under.

The choice of drugs in step 4 depends on the previous appointments in steps 2 and 3. However, the order of adding additional funds should be based on evidence of their comparative effectiveness obtained in clinical studies. If possible, patients who did not achieve bronchial asthma control in stage 3 should be referred to a specialist for the purpose of excluding alternative diagnoses and / or bronchial asthma that is difficult to treat. The preferred approach to treatment in step 4 is the use of a combination of glucocorticoids in a medium or high dose with long-acting inhaled beta2-adrenomimetics. Long-term use of IGSC in high doses accompanies an increased risk of side effects.

Treatment of stage 5 is necessary for patients who do not achieve the effect when using high doses of IGKS in combination with long-acting beta2-adrenomimetics and other drugs for maintenance therapy. Adding an oral glucocorticoid to other drugs for maintenance treatment can increase the effect, but it is accompanied by severe undesirable effects. The patient should be warned about the risk of side effects; also it is necessary to consider the possibility of all other alternatives to the treatment of bronchial asthma.

If control over bronchial asthma is achieved against a background of basic treatment with a combination of IGKS and beta2-adrenomimetic of long-term action and is maintained for at least 3 months, a gradual decrease in its volume is possible. It should begin with a reduction in the dose of IHCS by no more than 50% within 3 months with continued treatment with long-acting beta2-adrenomimetic. While maintaining full control against the background of the use of low doses of IGKS and long-acting beta2-agonists 2 times a day, it is necessary to cancel the last and continue the use of IGKS. Achievement of control on kromonah does not require reduction of their dose.

Another scheme of decreasing the volume of basic treatment in patients receiving long-acting beta2-agonists and IGKS involves the abolition of the first in the first stage with the continuation of glucocorticoid monotherapy in a dose that was in a fixed combination. Subsequently, the amount of IGKS is gradually reduced by no more than 50% within 3 months, provided that full control over bronchial asthma remains.

Monotherapy with long acting beta2-agonists without IGCC is unacceptable. Since it is possible to increase the risk of death of patients with bronchial asthma. Supportive treatment is discontinued if full control over bronchial asthma persists with a minimal dose of anti-inflammatory drug and no relapse of symptoms within 1 year.

With a decrease in the volume of anti-inflammatory treatment, it is necessary to take into account the sensitivity spectrum of patients to allergens. For example, before the season of flowering in patients with bronchial asthma and pollen sensitization, it is strictly forbidden to reduce the doses of the basic drugs used, on the contrary, the volume of treatment for this period should be increased.

An increase in the volume of treatment in response to the loss of control over bronchial asthma

The volume of treatment with loss of control of bronchial asthma (increased frequency and severity of symptoms of bronchial asthma, the need for inhalation of beta2-adrenomimetics for 1-2 days, a decrease in peak flowmetry or worsening of exercise tolerance) should be increased. The volume of treatment of bronchial asthma is regulated for 1 year in accordance with the spectrum of sensitization by causative allergens. To stop acute bronchial asthma in patients with bronchial asthma, a combination of bronchodilator beta2-adrenomimetics, anticholinergic drugs, methylxanthine) and glucocorticoid drugs is used. Preference is given to inhalation delivery forms, allowing to achieve a quick effect with minimal total impact on the baby's body.

Existing recommendations for reducing the doses of various drugs of basic treatment may have a sufficiently high level of evidence (mainly B), but they are based on data from studies that evaluated only clinical indicators (symptoms, FEV1) without determining the effect of reduced treatment volume on inflammation activity and structural changes in asthma. Thus, recommendations for reducing the amount of therapy require further research aimed at assessing the processes underlying the disease, and not just clinical manifestations.

The necessity of prolonged maintenance of combined treatment of bronchial asthma was confirmed in a study on the effectiveness of various pharmacological regimens. During the first year, a randomized double-blind study was conducted, and then the next 2 years - open, as close to normal clinical practice. In patients treated with salmeterol + fluticasone (serotide, 50/250 μg 2 times a day) there was a 3-fold decrease in the need for an increase in the volume of treatment than in the groups of patients using the regimens of fluticasone propionate (250 μg twice a day) and salmeterol (50 mcg 2 times a day). The use of combined therapy in comparison led to a significant reduction in the frequency of exacerbations of asthma, improvement of bronchial patency and a decrease in bronchial hyperreactivity compared to patients who received each of the drugs separately. After 3 years, complete control of asthma was achieved in 71% of patients treated with serotide and 46% who received fluticasone propionate. In all the observations, good tolerability of the studied drugs was established. In this study, for the first time in adult patients, it has been shown for the first time that the achievement of bronchial asthma control in most patients with long-term treatment with serotide is possible.

[42], [43], [44], [45], [46], [47],

Management of patients, aimed at achieving control of bronchial asthma

The purpose of treating bronchial asthma is to achieve and maintain control over the clinical manifestations of the disease. With the help of medical treatment developed by a doctor in collaboration with the patient and his family members, this goal can be achieved in most patients. Depending on the current level of control, each patient is assigned treatment corresponding to one of the five "stages of therapy"; in the process it is constantly evaluated and corrected on the basis of changes in the level of control of asthma.

The entire treatment cycle includes:

• assessment of the level of control of bronchial asthma;
• treatment aimed at achieving it;
• treatment to maintain control.

Patient education

Education is an essential and important component of an integrated program for the treatment of children with bronchial asthma, this implies establishing a partnership between the patient, his family and a health worker. Good mutual understanding is very important as a basis for further exposure to treatment (compliance).

Tasks of educational programs:

• information about the need for elimination activities;
• training in the use of medicines;
• informing about the basics of therapy;
• training in monitoring the symptoms of the disease, pyclofometry (in children older than 5 years), maintaining a diary of self-control;
• compilation of an individual plan of action for exacerbation.

Prognosis for bronchial asthma

In children with recurring episodes of wheezing in the presence of an acute viral infection that does not show signs of atopy and atopic diseases in a family history, symptoms usually disappear at preschool age, and bronchial asthma does not appear later, although minimal changes in the function of lung and bronchial hyperreactivity are possible. When wheezing occurs at an early age (up to 2 years), in the absence of other symptoms of family atopy, the likelihood that they will persist even later is small. In young children with frequent episodes of wheezing, bronchial asthma in a family history and manifestations of atopy, the risk of developing bronchial asthma at the age of 6 years is significantly increased. Male gender is a risk factor for the onset of bronchial asthma in the prepubertal period, but there is a high probability that bronchial asthma will disappear upon reaching adulthood. Female sex is a risk factor for the persistence of bronchial asthma in adulthood.