Tuberculosis and chronic nonspecific lung diseases

In everyday clinical activities, TB doctors, pulmonologists often face the problem of the interrelationship between chronic nonspecific lung diseases (CHDL) and tuberculosis. The frequency of CSNL in patients with pulmonary tuberculosis is from 12-15 to 90% with a tendency to increase in frequency with destructive and chronic forms. In this chapter, two diseases are considered: bronchial asthma and chronic obstructive pulmonary disease - in combination with tuberculosis of the respiratory system.

Tuberculosis often joins XHZL (paratuberculous process), two diseases can occur in one patient at the same time (metatuberculous process). CSNL sometimes develop due to tuberculosis after a residual changes (posttuberculous process). Chronic obstructive pulmonary disease contributes to the development of obstructive disorders or strengthens them, aggravates mucociliary clearance disorders and makes them diffuse. The use of systemic glucocorticoids can lead to the development or exacerbation of tuberculosis.

Chronic obstructive pulmonary disease is a preventable, responding condition, characterized by an incompletely reversible restriction of airway patency. Restriction of airway patency, usually progressing, is associated with an abnormal inflammatory response of the lungs to exposure to harmful particles or gases, primarily tobacco smoke. Although COPD affects the lungs, this disease also causes significant systemic disorders.

The course of tuberculosis in patients with COPD is less favorable. First of all, it is necessary to investigate sputum for the presence of a non-tubercular microflora and its resistance to antibiotics, and also to determine the function of external respiration (spirogram and flow-volume curve) with an assessment of the reversibility of bronchial obstructive syndrome (bronchodilator test-inhalation in the presence of obstruction). In most cases, patients with COPD are smokers. It is known that tobacco smoke affects not only the person, but also the mycobacteria, which, on the one hand, learns the cases of their mutations with the formation of forms resistant to antibiotics, and on the other hand - by activating their metabolism and propensity to multiply, i.e. Increasing the effectiveness of treatment for sensitive strains. With age, the number of patients with pulmonary tuberculosis in combination with COPD is increasing.

The severity of COPD is divided into four stages, based on the clinical manifestations and parameters of the spirogram.

Treatment of chronic nonspecific lung diseases in tuberculosis

The basic therapy of stable COPD of moderate severity and severity is holinoblokatory short (ipratropium bromide) and long-acting (tiotropium bromide); a fixed combination with β ₂ -adrenomimetics (ipratropium bromide with fenoterol, ipratropium bromide with salbutamol) can be used . The form of delivery (metered aerosol inhaler, powder inhaler or nebulizer) is chosen by the doctor based on the availability of the drug, the patient's skills and capabilities, individual tolerability. The effectiveness of these drugs has been demonstrated in patients with respiratory tuberculosis with bronchial obstructive syndrome. Inhaled glucocorticoids (IGKS) should be used only with a positive sample (test therapy IGKS under the control of spirometry before and after treatment). With an increase in FEV ₁ by 12-15% (not less than 200 ml), appropriate use of inhaled corticosteroids or fixed combinations of inhaled corticosteroids and β ₂ -adrenomimetikov long acting (formoterol with budesonide, salmeterol with fluticasone). The slow-release theophylline is the drug of choice, but due to the high likelihood of side effects, preference is given to inhalation drugs. Metabolism of theophylline is disturbed by rifamycins. Systemic glucocorticoids recommended for COPD as a two-week test therapy for tuberculosis are used with caution and only against a full complex etiotropic therapy. Mucolytics and mucoregulators (ambroxol, acetylcysteine) are prescribed only in the presence of difficult-to-separate sputum.

When exacerbating COPD, use short-acting β ₂ -adrenomimetics or combined drugs (a metered aerosol inhaler with a spacer or through a nebulizer). A short course of systemic steroids (for example, prednisolone with 30 mg per day inside 14 days) is performed only in the adherent patients who receive a full-scale complex treatment and who do not have contraindications to corticosteroid therapy. In severe cases, non-invasive mechanical ventilation, transfer of the patient to the intensive care unit, use of low-flow oxygen therapy are recommended.

Antibiotic therapy is prescribed for patients with COPD in the presence of signs of bacterial infection (increased sputum, a change in the color of sputum - yellow or green, the appearance or intensification of fever). The drugs of choice are aminopenicillins with β-lactamase inhibitors, new macrolides (azithromycin, clarithromycin), respiratory fluoroquinolones (levofloxacin, moxifloxacin, hemifloxacin). It should be noted that many fluoroquinolones are effective against mycobacteria tuberculosis and can be included in treatment regimens for resistant forms of tuberculosis.

Bronchial asthma is a chronic inflammatory disease of the respiratory tract, in which many cells and cellular elements participate. Chronic inflammation is associated with bronchial hyperreactivity, which leads to repeated episodes of wheezing, shortness of breath, chest pain and coughing, especially at night or early morning. This is usually associated with diffuse, but variable bronchial obstruction, which is often reversible both spontaneously and under the influence of treatment. Patients with bronchial asthma have a higher probability of developing allergic reactions to medications.

According to federal protocols, bronchial asthma has four degrees of severity.

Stage 1 - preparations "on demand".

Patients with short-term daytime symptoms, arising from time to time (≤2 per week in the afternoon). Nocturnal symptoms are present.

• Rapid-acting inhaled β ₂ -adrenomimetic for symptom relief (<2 per week in the afternoon).
• When the symptoms increase and / or periodically increase their severity - regular constant therapy (step 2 or higher).

Stage 2. One of the drugs of constant therapy + therapy

• Low doses of IGSC as initial constant therapy at any age.
• Alternative constant therapy with leukotriene antagonists if patients are unable / unwilling to use IGKS.

Stage 3. One or two drugs for constant therapy + "on demand" preparations.

• For adults, a combination of low doses of IGKS with long-acting inhaled β ₂ -adrenomimetik in one inhaler (fluticasone + salmeterol or budesonide + formoterol) or in separate inhalers
• Inhaled beta ₂ -adrenomimetik long-acting (salmeterol or formoterol) should not be used as monotherapy.
• For children - increased doses of IGKS to medium.

Additional stage 3 - options for adults.

• Increase doses of IGKS to average.
• Low doses of IGKS in combination with leukotriene antagonists.
• Low doses of theophylline with sustained release.

Stage 4. Two (always) a drug or more for constant therapy + a preparation «on demand».

• Medium or high doses of inhaled corticosteroids in combination with long-acting inhaled β ₂ -adrenomimetics.
• Medium or high doses of IGKS in combination with a leukotriene antagonist.
• Low doses of theophylline with sustained release in addition to medium or high doses of IGCC in combination with long-acting inhaled β ₂ -adrenomimetics.

Stage 5. Additional drugs of constant therapy + therapy "on demand."

• Adding oral glucocorticoids to other constant-therapy drugs can be effective, but significant side effects are possible.
• Adding anti-IgE-therapy to other drugs of constant therapy improves the controllability of atopic bronchial asthma in cases when control has not been achieved.

Treatment of bronchial asthma in patients with tuberculosis is carried out according to the same principles, but taking into account a number of features. The appointment of systemic glucocorticoids and IGKS should be accompanied by a controlled intake of antituberculous drugs. The clearance of theophylline preparations with the use of anti-tuberculosis drugs (especially rifampicins) is lower, the half-life is longer, which requires a lower dose of theophylline drugs, especially in older patients.