Diagnosis of chronic obstructive bronchitis

Vermeirc (1996) proposed the following diagnostic criteria for chronic obstructive bronchitis:

• the actual bronchial obstruction (clinical manifestations and reduction of FEV1 less than 84% and / or a decrease in the Tiffno index below 88% of the expected values);
• irreversibility or partial reversibility of bronchial obstruction, variability (spontaneous variability) of FEV values by less than 12% during the day;
• Stably confirmed bronchial obstruction - at least 3 times during a yearly observation;
• age, as a rule, is more than 50 years;
• detection of the disease usually in smokers or persons exposed to industrial aerosolutions;
• physical and radiological signs of emphysema;
• the steady progression of the disease in the absence of adequate treatment, which is manifested by increasing dyspnea and an annual decrease in OVB1 by more than 50 ml.

Assessment of the severity of chronic obstructive bronchitis

According to the methodological recommendations "Chronic obstructive bronchitis" of the Society of Russian pulmonologists (Moscow, 1997), the severity of chronic obstructive bronchitis is estimated by the value of FEV1. The approach to assessing the severity of patients with chronic obstructive bronchitis is complemented by determining the stage of the disease, based on the overall pattern of the severity of the disease, violations of bronchial patency according to the recommendations of the American Thoracic Society.

• Stage I. FEV1 is more than 50% of the proper value. The disease has a negligible effect on the quality of life. Patients do not need frequent examinations by a general practitioner. The presence of severe dyspnoea in these patients requires additional examinations and consultations of a pulmonologist.
• Stage II FEV1 is 35-49% of the proper value. The disease significantly reduces the quality of life. Frequent visits to a medical institution and supervision by a pulmonary physician are required.
• Stage III. FEV1 is less than 34% of the proper value. The disease dramatically reduces the quality of life. Frequent visits to medical institutions and supervision by a pulmonary physician are required.

[1], [2], [3], [4], [5], [6], [7], [8], [9],

The program of examination for chronic obstructive bronchitis

1. General analysis of blood and urine.
2. LHC: content of total protein and protein fractions, fibrin, haptoglobin, seromucoid, sialic acids, bilirubin, aminotransferases, glucose, creatinine.
3. IAK: blood content and determination of the functional ability of T and B lymphocytes, determination of subpopulations of T-lymphocytes, immunoglobulins, circulating immune complexes.
4. X-ray examination of the lungs.
5. Spirography; peak flowmetry or pneumotachometry.
6. ECG.
7. Echocardiography.
8. General and bacteriological analysis of sputum.

Laboratory and instrumental diagnostics

At the initial stages of the development of the disease, careful scrutiny of the patient, evaluation of anamnestic data and possible risk factors is of great importance. During this period, the results of objective clinical research, as well as data of laboratory and instrumental methods, are of little informative value. Over time, when the first signs of bronchial obstructive syndrome and respiratory failure appear, objective clinical-laboratory and instrumental data become more and more diagnostic. Moreover, an objective assessment of the stage of the development of the disease, the severity of the course of COPD, the effectiveness of the therapy is possible only with the use of modern research methods.

X-ray examination

X-ray examination by the chest organ in two projections is an obligatory method of examination of all patients with COPD. The study reveals the presence of signs of bronchial obstructive syndrome, including emphysema of the lungs, certain complications of COPD (bronchiectasis, pneumonia, pneumothorax, pulmonary arterial hypertension, chronic pulmonary heart, etc.), indirectly assess the phase of the disease.

An important objective of the study is X-ray differential diagnostics of COPD with diseases accompanied by prolonged cough and dyspnea (lung cancer, pulmonary tuberculosis, bronchiectasis, cystic fibrosis, etc.).

In the initial stage of COPD, x-ray changes may be absent. As the disease progresses, clear radiographic signs of pulmonary emphysema begin to appear, reflecting, first of all, an increase in the airiness of the lungs and the reduction of the vascular bed. Such radiographic features include:

• an increase in the total area of pulmonary fields;
• persistent decrease in the transparency of the lungs;
• impoverishment of pulmonary pattern on the periphery of pulmonary fields;
• the appearance of limited areas of ultra-high transparency, corresponding to large emphysematous bullae;
• flattening of the dome of the diaphragm and a significant limitation of its mobility during breathing (less than 3-5 cm);
• decrease in the transverse dimensions of the heart ("droplet" or "hanging" heart);
• increase retrosterspalyogo space and others.

The listed X-ray signs of pulmonary emphysema are the most important confirmation of the patient's bronchial obstructive syndrome.

It is more difficult to detect radiographic signs of bronchial inflammation. In patients with moderate to severe COPD, inflammation of the bronchi may be accompanied by edema, followed by the development of sclerosis of peribronchial and interstitial tissue and the peculiar severity of the pulmonary pattern. In relatively rare cases, as a rule, with a long history of the disease, a mesh deformation of the lung pattern is observed in the form of mesh pneumosclerosis localized mainly in the lower parts of the lungs. Deformation of the pulmonary pattern is a change in the normal course and shape of the elements of the pulmonary pattern, which forms a randomly branching network. These changes are due to sclerosis of peribronchial tissues, as well as interlobular and intersegmental septa.

One of the causes of impoverishment of the pulmonary pattern are severe violations of bronchial patency in COPD patients, often accompanied by the development of micro-teleclactases. In these cases, depletion of the pulmonary pattern is caused simultaneously by the compensatory overgrowth of the pulmonary tissue that occurs in a confined zone located immediately adjacent to the site of the micro-telepaths.

Finally, in severe cases, it is possible to identify X-ray signs of pulmonary arterial hypertension and chronic pulmonary heart with hypertrophy and dilatation of the right ventricle. The development of pulmonary arterial hypertension is indicated by the expansion of all major branches of the pulmonary artery in the roots (more than 1.5-1.6 cm) and a decrease in the caliber of small peripheral arteries of the muscular type (the symptom of a "jump of caliber"). There is also a bulging cone of the pulmonary artery trunk in the form of an increase in the second arc of the left contour of the heart.

The well-known radiographic signs of right ventricular hypertrophy in COPD patients are not always revealed, primarily due to the decrease in the total transverse size of the heart ("hanging" heart) and the presence of pronounced emphysema, which increases the retrosternal space and, as it were, moves the wall of the right ventricle from the anterior chest wall.

X-ray computed tomography (CT) has significant advantages over traditional X-ray examination and allows revealing signs of bronchial inflammatory damage and pulmonary emphysema even at the earliest stages of the development of the disease.

For the diagnosis of pulmonary emphysema, for example, a CT technique with a quantitative measurement of the transparency of the lung on inspiration and expiration is used. However, despite the high information content, the CT technique is rarely used in patients with COPD to confirm the lesions of the bronchi and pulmonary parenchyma. More often CT is used to exclude lung tumors, tuberculosis or other diseases reminiscent of the clinical picture of COPD.

Blood test

Exacerbation of COPD may be accompanied by neutrophilic leukocytosis with a shift of the blood formula to the left and an increase in ESR, although these changes are not mandatory.

With prolonged course of the disease accompanied by chronic respiratory failure and hypoxemia, signs of secondary erythrocytosis (increase in the number of erythrocytes, increase in hemoglobin content, increase in blood viscosity and hematocrit (in women more than 47% and in men over 52%) can be determined in peripheral blood. Against this background, there is often a decrease in ESR to 1-3 mm / h.

There is also an increase in serum levels of acute phase proteins (a1-antitrypsin, a2-glycoprotein, a2-macroglobulin, haptoglobulin, ceruloplasmin, seromucoid, C-reactive protein), as well as a2 and beta globulips, which indicates the activity of the inflammatory process in bronchi.

[10], [11], [12], [13]

Sputum examination

Sputum examination in COPD patients differs little from the corresponding procedure in patients with pneumonia. When microscopy of mucopurulent sputum, corresponding, as a rule, moderate activity of the inflammatory process in the bronchi, neutrophils (up to 75%) and alveolar macrophages predominate in smears. Purulent endobronchitis is characterized by an even higher content of neutrophils (up to 85-95%) and dystrophically altered cells of the bronchial epithelium.

In patients with severe exacerbation of obstructive bronchitis, purulent sputum, or with frequent relapses of bronchial inflammation, it becomes necessary to determine the causative agent of endobronchitis. For this purpose, bacteriological examination of sputum or BALF is carried out.

The most common exacerbations of chronic bronchitis are caused by a hemophilic rod or association of a hemophilic rod with morocell. Especially often this association is found in smokers, including those who do not have chronic obstructive bronchitis. In other cases, the causative agent of endobronchitis are pymmococci and other streptococci.

In elderly, debilitated patients with severe COPD, staphylococci, pseudomonasis and Klebsiella may predominate in sputum.

Finally, in recent years, in patients of relatively young and middle age, intracellular ("atypical") microorganisms, chlamydia, legionella, or mycoplasma, are becoming the causative agent of the inflammatory process in bronchi, in some countries (up to 20-30%).

Bronchoscopy

Bronchoscopy is currently one of the most common and informative methods of airway research. The method allows:

1. visually assess the anatomical features of the respiratory tract, trachea, major, segmental and subsegmental bronchi;
2. conduct a biopsy of the tracheobronchial tree areas of interest and obtain material for histological and cytological examination;
3. with the aspiration of bronchial washing water to obtain material for cytological, immunological and bacterioscopic examination
4. with a therapeutic purpose to hold the lavage of the bronchi.

Bronchoscopy in COPD patients is advisable in the following cases:

• in the presence of clinical and radiological signs, suspicious for the presence of a lung tumor;
• with purulent sputum;
• if there is a suspicion of tracheobronchial dyskinesia;
• when specifying the source of pulmonary hemorrhage;
• if it is necessary to obtain an aspiration material to clarify the etiology of the disease (for example, identification of the causative agent of the infectious process and bronchi and lungs);
• if necessary with the therapeutic purpose of local administration of medications (eg antibiotics) directly into the affected area;
• when performing therapeutic lavage of the bronchi.

The main contraindications for bronchoscopy are:

• acute myocardial infarction or unstable angina;
• severe circulatory failure of stage II6-III and / or hemodynamic instability;
• paroxysmal arrhythmias;
• arterial hypertension with an increase in blood pressure above 200 and 110 mm Hg. Art. Or hypertensive crisis;
• acute disturbance of cerebral circulation;
• rapidly progressive hypercapnia;
• unconsciousness of the patient, complete absence of contact with the patient;
• acute inflammatory diseases or tumors of the upper respiratory tract (acute laryngitis, larynx cancer, etc.);
• insufficient instrumentation and training of medical staff.

It should be emphasized that in patients with arterial hypoxemia and even in patients with disorders of the blood coagulation system and thrombocytopenia, bronchoscopy is quite safe. However, the latter cases do not show a biopsy of bronchial mucosa and pulmonary parenchyma and other invasive procedures.

[14], [15], [16], [17], [18], [19]

Technique of research

Bronchoscopy, which is a fairly complex technical instrumental research method, associated with a certain risk for the patient, should be performed only in specialized pulmonological departments by a hospital with resuscitation service. The study is carried out in special X-ray chest surgery rooms that meet the requirements of a small surgical or surgical dressing, or in an endoscopic room equipped with a mobile X-ray unit, preferably with an electron-optical converter and a TV.

In patients with COPD, the study is performed using a flexible bronchophibroscope under local anesthesia with a 2.4% trimecaine solution, 2-4% lidocaine solution or 1% solution of dicain. First, anesthesia of the upper respiratory tract, the oropharynx and vocal cords, is achieved by irrigation or by lubrication with a local anesthetic. After 5 minutes, the bronchophibroscope is inserted through the lower nasal passageway or oral cavity, and inhaled through the vocal cavity. By installing aseptics through the bronchoscope, anesthesia of the trachea and major bronchi is performed.

The study using the bronchoscope includes several stages:

Visual assessment of the condition of vocal folds, lining space, trachea, main, segmental and subsegmental bronchi.

Aspiration of the contents of the bronchus with a special bronchophobroscope. Aspirate the contents of the bronchus for subsequent bacteriological, cytological and other types of examination. With a small amount of bronchial secretion, at first about 20 ml of isotonic solution is instilled in the bronchus, and then this solution is aspirated together with the contents of the bronchus, resulting in the so-called washing modes of the bronchi, which are subsequently subjected to bacteriological and cytological examination.

Diagnostic subsegmental bronchoalveolar lavage (BAL) for cytological and bacteriological examination of bronchoalveolar contents. For this procedure, the bronchic fibroscope is visually guided to the mouth of the subsegmental bronchus and about 50-60 ml of isotonic sodium chloride solution is injected into the bronchial tube through the aspiration channel of the bronchophoscope, then the liquid coming from the bronchial lumen (BAL) is aspirated into a special polyethylene beaker. The administration of the solution and the aspiration of BALF are repeated 2 ~ 3 times. BALF consists of cellular, protein; and other components of the alveolar and, to a lesser extent, bronchial contents. To reduce the admixture of bronchial secretions, bacteriological and cytological studies use not the first but the second or third portion of the BALF obtained. Bronchial biopsy, which is carried out with the help of special flexible forceps (direct bronchial biopsy) or brushes with a diameter of about 2 mm (brush, or brush-biopsy), brought to the site of interest through the bronchoscopic aspiration channel under visual endoscopic control. After receiving biopsy material from it immediately prepared smears.

If necessary, an intrabronchial (intrapulmonary) biopsy and a puncture biopsy of trachrobronchial lymph nodes can be performed.

Some of these methods are very complex and unsafe for the patient, so the choice of each of them depends on the specific indications and contraindications to the bronchoscopy, the equipment of the bronchoscopy cabinet, in particular the X-ray television equipment and the qualification of the endoscopist. A visual assessment of the trachea and bronchial conditions is performed in all cases of bronchoscopy

Visual assessment of trachea and bronchus

The effectiveness of diagnosing respiratory diseases with bronchoscopy depends not only on the equipment of the endoscopic room and the qualification of the endoscopist, but also on the correct choice of one or another method of investigation and also on the diagnostic skills of the method by the treating physician-therapist

Thorough examination of the vocal folds, lining space, trachea and bronchi allows to assess the anatomical features of the upper and lower respiratory tract, to reveal inflammatory, neoplastic and other changes in the mucosa and also to assess some disorders of the function of the trachea and bronchi.

Hypotonic tracheobronchial dyskinesia. For patients with COPD, a very characteristic violation is the elastic-elastic properties of the bronchial walls with the appearance in some cases of a clinical picture of hypotonic tracheobronchial dyskinesia, the diagnosis of which can only be confirmed endoscopically.

Tracheobronchial dyskinesia is a prolapse into the lumen of the trachea or large bronchi of the posterior membrane part of the mucosa of these organs, causing attacks of excruciating coughing accompanied by a gasp, choking breath and even loss of consciousness. It should be remembered that bronchoscopy is the only reliable and at the same time accessible method that allows to reveal tracheobronchial dyskinesia.

The main endoscopic sign of tracheobronchial dyskinesia is a significant increase in comparison with the norm of the amplitude of respiratory motion of the membrane wall of the trachea and the main bronchi and, accordingly, the degree of their expiratory narrowing. Recall that in normal during a quiet exhalation there is a slight noticeable bulging of the membrane part of the mucosa in the lumen of the trachea and bronchi during inspiration, it returns to its original position. When forced breathing or coughing, expiratory swelling of the trachea and major bronchus wall increases, however, in the norm such an expiratory narrowing of the lumen does not exceed 30%.

With dyskinesia of the 1st degree, the expiratory narrowing of the trachea and the main bronchus are observed up to 2/3 of their lumens while maintaining their normal (rounded) configuration or some flattening of the lumen. For dyskinesia of the second degree, complete closure during the exhalation of the posterior and anterior membranous walls and a significant flattening of the lumen of the trachea and bronchi are characteristic.

Tracheobronchial dyskinesia in COPD patients can significantly increase the resistance of the trachea and major bronchi during forced exhalation and aggravate the expiratory airway obstruction.

Inflammation of the mucosa. To endoscopic signs of inflammatory changes in the mucosa of the trachea and bronchi include:

• hyperemia of the mucosa of the trachea and bronchi;
• swelling of the mucosa;
• bleeding of the mucosa with instrumental palpation;
• change in the vascular pattern of the mucosa;
• separate clusters of mucous or mucopurulent secretion (with catarrhal endobronchitis) or abundant purulent contents in the lumen of the bronchi (for example, with purulent endobronchitis), etc.

The last sign has an independent and very important diagnostic value and shows a suppurative process in the lung, although it can not always be caused by purulent bronchitis (pus can enter the lumen of the bronchi from the alveolar tissue, abscess, etc.). Such an endoscopic picture always requires further in-depth examination of patients.

According to the most common classification, J. Lemoine (1965) distinguishes three main forms of bronchial inflammatory disease that can be detected by visual examination:

1. Diffuse endobronchitis, characterized by the spread of inflammation to all visible bronchi and the absence of a distal boundary of mucosal inflammation.
2. Partially diffuse endobronchitis, in which signs of inflammation persist in all visible bronchi, with the exception of the upper lobe bronchi.
3. Limited (local) endobronchitis with clearly defined boundaries of inflammatory changes that are localized in the main and lobar bronchi and absent in segmental and subsegmental bronchi.

When studying the visual endoscopic picture, as well as histological and cytological changes within the described forms of endobronchitis, it is possible to distinguish various morphological types of bronchitis:

• simple (catarrhal) endobronchitis;
• purulent endobronchitis;
• atrophic endobronchitis.

Catarrhal (simple) endobronchitis is most common in COPD patients. At the same time, endoscopy reveals hyperemia, swelling and increased bleeding of bronchial mucosa. Purulent endobronchitis differs, first of all, by the presence in the lumen of the bronchi of purulent sputum. Finally, atrophic endobronchitis is characterized by thinning and dryness of the mucous membrane, strengthening of the vascular pattern, the appearance of a characteristic fine folding of the mucous membrane, the desolation and widening of the mouths of the bronchial glands, and a tendency to bleeding.

Estimating the results of endoscopy, it should be remembered that a visual examination of the mucosa can be carried out only to the level of 5-7 gradation of segmental bronchi. To obtain information about the lesion of smaller bronchi, characteristic for patients with COPD, you can use the results of a study of bronchial flushes or BALF.

The study of BALF obtained from bronchoscopy includes:

1. study of the cellular composition of bronchoalveolar contents;
2. detection of pathogenic microorganisms, and, if possible, identification of the causative agent of an infectious inflammatory process and, if necessary,
3. biochemical analysis of BALF (determination of protein, lipids, enzymes, immunoglobulins, etc.).

The scope of the BALF study is determined each time by the specific diagnostic tasks facing the physician.

Cytological analysis of BALF. To study the cellular composition of bronchoalveolar contents, BALF is centrifuged at + 4 ° C and swabs are prepared from the sediment, which are stained by Romanovsky-Giemsa or other dyes and subjected to microscopy. The total number of cells in 1 ml of BALF is counted on a hemocytometer or in an automatic hemo-analyzer.

Normally, the number of cells in 1 ml of BALF is 0.5-10.5 x 10 ⁵. Of these, alveolar macrophages account for more than 90% of all cell elements, about 7% for lymphocytes and less than 1% for neutrophils. Other cellular elements are extremely rare.

Diagnosis of lung diseases based on the results of the cytological study of BALF is based on a change in the ratio of the main cellular elements (alveolar macrophages, lymphocytes and neutrophils), the detection of additional inclusions in these cells and the violation of their morphology and histochemical properties, as well as the detection of new pathological cells. In patients with COPD in BALF, an increase in the content of neutrophils as well as lymphocytes is found.

Microbiological examination of BALF

An important practical value is the detection in bronchial and bronchoalveolar contents of pathogens of the inflammatory process in the lungs. The diagnostic significance of the microbiological study of tracheobronchial flushes (bronchial washings) and BALF is somewhat higher than the corresponding sputum examination, since the material for the study can be obtained directly from the lesion. Especially high diagnostic value, the microbiological study of BALF is associated with respiratory infections caused by Pneumocystis carini, mycobacteria tuberculosis, cytomegalovirus, fungi and other pathogens.

At the same time, the complexity of the procedure of bronchoscopy with aspiration of bronchial or bronchoalveolar contents does not yet make it possible to widely use this method to identify the causative agent of the inflammatory process and to determine the sensitivity of microflora to antibiotics. Therefore, in most cases, microbiological examination of sputum remains the most preferable.

The bronchoscopic method of obtaining BAL for the determination of the causative agent of the infectious process seems to be justified only in cases when there is no sputum for various reasons or the results of its microbiological investigation are questionable, and the rapid progression of the inflammatory process and the absence of the effect from the prescribed therapy are clinically revealed. In clinical practice, the method of microbiological examination of BALF obtained with bronchoscopy is usually used if there are other indications for bronchoscopy.

The biochemical study of BALF with the determination of protein, sialic acid, haptoglobin, lipid peroxidation products, antioxidants and other substances is a very promising direction for assessing the activity and the degree of the inflammatory process in the lungs and bronchi and the differential diagnosis of certain forms of bronchial involvement. However, they have not yet found wide application in clinical practice.

Investigation of material obtained by biopsy

Cytological examination. The material for cytologic examination is obtained during bronchoscopy smears, scrapings brush on the lesion site, aspirates of bronchial contents, BAL, punctate, as well as prints of a biopsy piece of tissue. Cytological examination of the material obtained by biopsy makes it possible to diagnose, with a high degree of probability, the morphological changes in cells characteristic of large groups of lung lesions (eg, acute or chronic inflammatory diseases) or even signs pathognomonic to individual diseases.

Thus, for acute inflammatory changes in the lungs and bronchi (bronchitis, pneumonia, abscess) is characterized by the presence of amorphous necrotic masses, a large number of polymorphonuclear leukocytes, reactive structural changes in the cells of the epithelium until the development of their atypia.

In chronic inflammatory diseases, inflammatory infiltrate cells (polymorphonuclear leukocytes, lymphocytes, monocytes, plasmocytes, macrophages, etc.) are detected in the biopsy material, reactive changes in bronchial epithelial cells, and gipheral cell hyperplasia.

Histological examination of biopsy specimens. For histological examination, micropreparations prepared from a piece of tissue obtained with direct biopsy of the mucosa of the trachea and bronchi, transbronchial, transbronchial and other types of tracheobronchial tree biopsy, pulmonary tissue, lymph nodes and pleura are used for histological examination.

In patients with COPD with the help of this method, the characteristic morphological signs of chronic inflammation of bronchial mucosa may be revealed - changes in bronchial epithelium, edema and leukocyte infiltration of bronchial walls, hyperplasia of bronchial glands, etc. In patients with atrophic endobronchitis, a decrease in the number of secreting goblet cells and basal layer cells , a significant increase in the content of degenerated cells of bronchial epithelium, histological signs of atrophy and metaplasia of bronchial epithelium.

Evaluation of the function of external respiration

The most important method for quantifying the degree of ventilation disorders in COPD patients, the severity of the course of the disease and the nature of bronchial obstruction, is the definition of the function of external respiration (FVD).

The most complete picture of these disorders can be obtained by analyzing the structure of the total lung capacity, which is determined by the method of general plethysmography of the body. Nevertheless, the wide clinical practice of using this complex and expensive method of research is limited. Therefore, the evaluation of HPD in patients with COPD is usually carried out using the method of computer spirography and quantitative analysis of the flow-volume loop. In patients with COPD, this method gives quite acceptable results for assessing the severity of bronchial obstructive syndrome.

According to modern ideas, the main spirographic sign of obstructive syndrome is the slowing of forced exhalation due to an increase in airway resistance. The main indicators of the spirogram reflecting these disorders are:

• FEV1 - volume of forced expiration in 1 second;
• FEV1 / FVC (Tiffno index);
• The average volumetric rate of forced expiration is 25-75% of FVC (25% -75% COC).
• The maximum volume rate of forced expiration at the level of 25%, 50% and 75% of FVC (MOS25%, MOC50%, MOS75%).

In a wide clinical practice, the FEV1 indicator, which is considered a marker of bronchial obstructive syndrome, is used. It is believed that a decrease in this indicator below 80% of the expected values is a sign of bronchial obstructive syndrome.

At the same time, it should be remembered that the absolute values of FEV1 may decrease not only with bronchial obstruction, but also with severe restrictive disorders due to a proportional decrease in all pulmonary volumes and capacities, including FVC and FEV1. Therefore, a more reliable indicator of bronchial obstructive syndrome is the Tiffio index - the ratio of FEV1 to FVC (FEV1 / FVC). Reduction of this indicator less than 70% in most cases indicates the presence of bronchial obstruction syndrome.

An even more informative indicator of obstruction of small airways is probably the SOS value of 25-75%, i.e. The average space velocity of the air flow during the forced exhalation, measured at the level of relatively small pulmonary volumes. It is shown, for example, that the COC25-75% index is an earlier and sensitive spirographic marker for increasing the resistance of small airways. In this case, the shape of the flow-volume loop changes: the end region of the expiratory part of the loop becomes concave. This indicates that part of the FVC at the level of small lung volumes is exhaled at relatively low volumetric rates, which is typical for obstruction of the small airways.

At the same time, it should be remembered that this interpretation of the changes in the parameters of the COC25-75% and the shape of the final part of the flow-volume loop is not yet generally accepted.

[20], [21], [22], [23], [24], [25], [26]

Assessment of the degree of bronchial obstruction

According to the recommendations of the European Respiratory Society (ERS) in 1995 to assess the degree of bronchial obstruction in COPD patients and therefore the severity of COPD, the value of FEV1 is currently used in clinical practice, since, despite all the limitations, this indicator is characterized by an extreme simplicity of measurement and sufficient reproducibility. There are three degrees of decrease in the relative values of FEV1%

• light degree - FEV1> 70% of the proper values;
• the average degree is FEV1 in the range from 50 to 69%;
• severe degree - FEV1 <50%.

The degree of decrease in the absolute values of FEV1 correlates well with the prognosis of the disease. Thus, in patients with moderately severe signs of airway obstruction and FEV1 greater than 1 liter, the 10-year mortality rate is slightly higher than that in non-COPD patients. If, in COPD patients, the absolute value of FEV1 is less than 0.75 L, mortality only within the first year from the beginning of the observation is about 30%, and in 10 years of observation it reaches 90-95%.

The criteria for classifying patients with COPD by stages of the disease, recommended by the American Thoracic Society and widely represented in the modern national medical literature, are also based, mainly, on assessing the degree of decline in FEV1. However, they differ slightly from the above recommendations of the EPO. According to the proposal of the American Thoracic Society, three stages of the COPD course should be distinguished:

• 1st stage - FEV1 more than 50% of the proper value. The disease slightly reduces the quality of life and requires a periodic visit to a general practitioner (therapist). A more in-depth examination of patients, including the study of the gas composition of arterial blood and pulmonary volumes, is not required.
• The 2 nd stage - FEV1 from 35% to 49% of the proper value. There is a significant decrease in the quality of life. Frequent visits to medical institutions, observation by a pulmonologist and determination of the gas composition of the blood, the structure of the total lung capacity, diffusive capacity of the lungs and other parameters are necessary.
• 3rd stage - FEV1 less than 35% of the proper value. The disease dramatically reduces the quality of life. Frequent visits to medical institutions, observation by a pulmonologist, in-depth examination of patients, including determination of the gas composition of the blood, the structure of the total lung capacity, diffusive capacity of the lungs, bronchial resistance, etc. Are necessary. When arterial hypoxemia is detected (PaO2 is less than 55 mm Hg), patients are candidates for oxygen therapy.

Thus, according to this classification, a decrease in FEV1 of less than 50% can be regarded as a sign of the second stage of the disease (and the average severity of the course of COPD), whereas the criteria for the degree of bronchial obstruction recommended by ERS, the same decrease of this index corresponds to severe violations of bronchial patency.

The criteria for the degree of bronchial obstruction recommended by the European Respiratory Society are more in line with the objectives of domestic medical practice, since they orient the physician to earlier involvement of specialists (pulmonologists) in the management of COPD. In addition, it would be more correct to indicate in the diagnosis, not the stage of the course of COPD, which, by the way, depends not only on the values of OBB1, and the objective functional and morphological characteristics of the disease: the degree of bronchial obstruction and respiratory failure, the presence of emphysema, the degree and nature of the disturbance of gas exchange , the presence of signs of pulmonary arterial hypertension, as well as compensated and decompensated chronic pulmonary heart, etc.

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

Determination of the reversibility of bronchial obstruction

To determine the reversibility of bronchial obstruction in patients with COPD, it is advisable to use bronchodilation tests. Most often for the test use inhalation administration of beta ₂ -adrenergic receptor agonists of short action:

• salbutamol (2.5-5 mg);
• fenoterol (0.5-1.5 mg); .
• tebutamine (5-10 mg).

In this case, the bronchodilator effect is estimated after 15 minutes.

It is also possible to use anticholinergic drugs, for example, ipratropium bromide at a dose of 0.5 mg (inhalation) with measurement of the bronchodilator effect 30 minutes after inhalation.

An increase in FEV1 values by 15% or more indicates the presence of a reversible component of bronchial obstruction, particularly bronchoconstriction, which certainly makes it expedient to designate appropriate bronchodilators for the treatment of patient data. At the same time, it should be borne in mind that the lack of response to bronchodilator inhalation during a single test is not at all a cause of an ooplasm from the appointment of bronchodilator therapy.

[32], [33], [34]

Monitoring of FEV1

The repeated determination of FEV1 (monitoring) allows to finally confirm the diagnosis of COPD, since for this disease the annual decrease in FEV1 is more than 50 ml. Normally, in mature and advanced age, starting from 35-40 years, the physiological decrease of this indicator usually does not exceed 25-30 ml per year. The annual decrease in FEV1 in COPD patients is the strongest prognostic indicator, indicating the rate of progression of bronchial obstructive syndrome. And the rate of decline in FEV1 in COPD patients depends on the age of patients, the duration of smoking, the number of cigarettes smoked daily at present, the frequency and severity of the annual exacerbations of the inflammatory process in the bronchi. It is shown that clinically significant exacerbations of chronic obstructive bronchitis lead to a sharp decrease in FEV1, which persists up to 3 months after the inflammation has been relieved.

Determination of the structure of total lung capacity (OEL)

In most cases, the definition of FEV1, FEV1 / FVC, and COC25-75% is sufficient to characterize the degree of bronchial obstruction in COPD patients. However, with a significant decrease in FEV1 (less than 50% of the proper value), as a rule, there is a need for a more detailed study of the mechanisms for reducing pulmonary ventilation. Recall that the inflammatory and structural changes in large and small bronchi, expiratory tracheobronchial dyskinesia, the expiratory collapse of small bronchi, emphysema of the lungs, etc., can contribute to the occurrence of these disorders. A more detailed description of the participation of these mechanisms in reducing pulmonary ventilation is possible only when studying the structure of total lung capacity (OEL).

In general, COPD patients have an increase in total lung capacity (OEL), functional residual capacity (FOE), residual volume (OOL) and the ratio of OOL / OEL. Nevertheless, far from all patients there is a proportional increase in OOL and OEL, since the last parameter can remain normal. This is due, first of all, to differences in the level of bronchial obstruction. So, if the obstruction of the major airways predominates, an increase in the OOL is observed, whereas OEL usually does not increase. Conversely, with the obstruction of the smaller peripheral bronchi, both indicators are simultaneously increasing.

In patients with emphysematous type of COPD, a significant increase in OOL and OEL is observed, which reflects a pronounced overdistension of the lung parenchyma. In these patients, a significant decrease in FEV1 is found, while the total bronchial inspiratory resistance remains normal.

In patients with bronchial COPD, there is a significant increase in residual lung volume (OOL), although the total lung capacity (OEL) may remain normal or only slightly increase. FEV1 decreases in parallel with an increase in bronchial resistance on inspiration.

With prevalence of restrictive disorders, the OOL and OEL remain normal or decrease together with FDE. In obstructive syndrome, I increase »OOL / OEL (more than 35%) and FOE / OEL (more than 50%). With mixed ventilation disorders, a decrease in the OEL value and a simultaneous increase in the ratio of OOL / OEL and FOE / OEL are observed.

It should nevertheless be remembered that the definition of the structure of total lung capacity still remains the prerogative of large specialized medical centers.

[35], [36], [37], [38], [39],

Investigation of lung diffusivity

Disturbance of the diffusivity of the lungs is also one of the most important rhythms of arterial hypoxemia in COPD patients with pulmonary emphysema. Reduction of the diffusivity of the lungs is associated with a decrease in the effective area of the alveolar-capillary membrane, which is very typical for patients with primary pulmonary emphysema. With the bronchial type of COPD, the diffusion capacity of the lungs suffers less.

Gas composition of blood

Determination of the gas composition (PaO2, PaCO2) and blood pH is one of the most important characteristics of respiratory failure developing in patients with severe COPD. Recall that the cause of arterial hypoxemia (decrease of PaO2) in patients with COPD is a violation of ventilation-perfusion ratios in the lungs caused by severe unevenness of alveolar ventilation, as well as a violation of the diffusive capacity of the lungs during the development of emphysema. Hypercapnia (an increase in PaCO2> 45 mm Hg), which occurs in later stages of the disease, is associated with ventilation respiratory failure due to an increase in the functional dead space and a decrease in the function of the respiratory muscles of the diaphragm).

Respiratory acidosis (a decrease in blood pH less than 7.35), characteristic of patients with chronic respiratory failure, is compensated for a long time by increasing the production of sodium bicarbonate by the kidneys, which is the reason for maintaining a normal pH level.

The need to determine the gas composition of blood and the acid-base state occurs, as a rule, in COPD patients who are in critical condition for example in patients with acute respiratory failure. These measurements are carried out in intensive care units (resuscitation). Since it is necessary to obtain an arterial blood sample by puncture of the femoral or brachial artery to determine the gas composition, the procedure can not be considered routine and completely safe. Therefore, in practice, a fairly simple method, pulse oximetry, is often used to assess the ability of the lungs to saturate the blood with oxygen (oxy-irradiation).

Pulse oximetry is a method for determining the saturation (saturation) of oxygen in hemoglobin (SaO2) in pulsating arterial vessels.

The method does not allow to assess the level of PaCO2, which significantly limits its diagnostic capabilities. In addition, it should be remembered that the O2 index is influenced by many factors, for example, body temperature, hemoglobin concentration in the blood, blood pH and some technical characteristics of the device.

It is considered that when the SaO2 index is lower than 94%, it is advisable to invasively determine the gas composition of the arterial blood, if the greater condition requires a more accurate assessment of oxygenation and ventilation of the lungs.

Patient examination

The examination data depend on the severity and duration of chronic obstructive bronchitis. In the early stages of the disease there are no specific features. As the chronic obstructive bronchitis progresses due to the development of emphysema, the shape of the chest changes, it becomes barrel-shaped, the neck short, the ribs horizontal, the anterior-posterior size of the chest increases, the kyphosis of the thoracic spine becomes pronounced, the supraclavicular spaces swell. Excursion of the chest with breathing is limited, more pronounced retraction of intercostal spaces.

In severe course of chronic obstructive bronchitis cervical veins swell, especially when exhaled; during inspiration, the swelling of the cervical veins decreases.

With the development of respiratory failure and arterial hypoxemia, a diffuse warm cyanosis of the skin and visible mucous membranes appears. With the development of pulmonary heart failure, acrocyanosis develops, edema of the lower limbs, epigastric pulsation, and the position of orthopnea becomes characteristic.

A typical sign of chronic obstructive bronchitis is a slowing of forced exhalation. To identify this symptom, the patient is offered to take a deep breath and then exhale as quickly and fully as possible. Normally, the full forced exhalation lasts less than 4 s, with chronic obstructive bronchitis - much longer.

Lung examination

Percutary sound in the development of emphysema has a boxed tint, the lower borders of the lungs are omitted, the mobility of the lower pulmonary margin is significantly reduced.

With auscultation of the lung, prolonged exhalation and a hard character of vesicular breathing are noted. A classic auscultative sign of chronic obstructive bronchitis is wheezing dry wheezes during normal breathing or when forced exhalation. It should be noted that with mild bronchial obstruction, it is possible to detect whistling or buzzing rales only in the horizontal position, especially when forced exhalation ("hidden bronchial obstruction"). With severe bronchial obstruction, wheezing dry wheezing is audible even at a distance.

To diagnose bronchial obstruction, it is possible to apply the proposed palpation of exhalation and a test with a match proposed by BE Votchal.

Palpation of exhalation is as follows. In standing position the patient inhales deeply, then exhales with maximum force into the palm of the doctor, located at a distance of 12 cm from the patient's mouth. The doctor determines the strength of the jet of exhaled air (strong, weak, moderate), comparing with the strength of his exhalation. Simultaneously, the duration of exhalation is determined (long - more than 6 s, short - from 3 to 6 s, very short - up to 2 s). With violation of bronchial patency, the exhalation force is reduced, its duration is prolonged.

The sample with the match is performed as follows. At a distance of 8 cm from the patient's mouth there is a burning match and the patient is asked to blow it out. If the patient can not extinguish it, this indicates a marked violation of bronchial patency.

Cardiovascular system examination

In the study of the cardiovascular system, tachycardia is often detected, and blood pressure can be increased. These changes are explained by hypercapnia with peripheral vasodilation and increased cardiac output.

In many patients, epigastric pulsation is determined by the right ventricle. This ripple may be due to right ventricular hypertrophy (in a chronic pulmonary heart) or positional changes in the heart due to pulmonary emphysema.

Heart tones are muffled due to emphysema, often the emphasis of the second tone on the pulmonary artery is due to pulmonary hypertension.

[40], [41], [42], [43], [44],

Research of the digestive system

With severe chronic obstructive bronchitis, chronic gastritis with a decreased secretory function is quite often detected, possibly the development of a stomach ulcer or duodenal ulcer. With severe emphysema, the liver is lowered, its diameter is normal; in contrast to the stagnant liver, it is painless and its size does not change after the use of diuretics.

Clinical manifestations of hypercapnia

With steady progressing of bronchial obstruction, the development of chronic hypercapnia is possible. Early clinical signs of hypercapnia are:

• sleep disturbance - insomnia, which can be accompanied by a slight confusion;
• headache, intensifying mainly at night (at this time of day, hypercapnia is increased due to poor ventilation);
• increased sweating;
• a sharp decrease in appetite;
• muscle twitching;
• a large muscle tremor.

When studying the gas composition of the blood, an increase in the partial tension of carbon dioxide is determined.

As the hypercapnia grows further, the confusion of consciousness increases. The extreme manifestation of severe hypercapnia is hypercapnic hypoxemic coma, accompanied by convulsions.

[45], [46], [47], [48], [49], [50]

Spirography

The violation of bronchial patency is indicated by a decrease in the forced vital capacity of the lungs (FVC) and the volume of forced expiration in the first second (FEV1).

FVC is the amount of air that can be exhaled with the fastest, forced expiration. In healthy people, FVC is greater than 75% LEL. At a bronchial obstruction FVC significantly decreases.

In the absence of violations of bronchial patency, at least 70% of the air leaves the lungs in the first second of forced exhalation.

Usually FEV1 is calculated as a percentage of the ZHEL - the Tiffno index. He is in the norm of 75-83%. In chronic obstructive bronchitis, the Tiffno index is significantly reduced. The prognosis for chronic obstructive bronchitis correlates with the FEV1 indices. With a FEV1 of more than 1.25 liters, the ten-year survival rate is about 50%; With FEV1 equal to 1 liter, the average life expectancy is 5 years; with FEV1 0.5 liters, patients rarely live more than 2 years. According to the recommendations of the European Respiratory Society (1995), the severity of chronic obstructive bronchitis is estimated taking into account the value of FEV1. Re-determination of FEV1 is used to determine the progression of the disease. A decrease in FEV1 by more than 50ml per year indicates a progression of the disease.

For bronchial obstruction, a decrease in the maximum volumetric expiratory flow rate in the range of 25-75% FVC (MOC25%) is typical, as determined by the volume-flow curve analysis.

MOC25-75 is less dependent on effort than FEV1, and therefore serves as a more sensitive indicator of bronchial obstruction in the early stages of the disease.

In chronic obstructive bronchitis, the maximum ventilation of the lungs (MVL) is significantly reduced - the maximum amount of air ventilated by the lungs during 1 minute with deep and frequent breathing.

Normal MVL values:

• men under 50 years of age - 80-100 liters per minute;
• men over 50 years - 50-80l / min;
• women under 50 years - 50-80l / min;
• women over 50 years - 45-70 l / min;

The proper maximum ventilation of the lungs (DMVL) is calculated by the formula:

DMVL = ZHEL x 35

In normal, MVL is 80-120% of DMVL. With COB, MBL is significantly reduced.

Pneumotachometry

With the help of pneumotachometry, the volume velocity of the air jet is determined by inhalation and exhalation.

In men, the maximum exhalation rate is about 5-8 l / s, in women - 4-6 l / s. These indicators also depend on the age of the patient. It is proposed to determine the proper maximum expiratory flow rate (BMD).

DMV = actual LIVES χ 1.2

When there is a violation of bronchial patency, the speed of the air stream on exhalation is significantly reduced.

Peakflowmetry

In recent years, the determination of the state of bronchial patency with the help of peak flowmetry - measurement of the maximum volumetric expiratory flow rate (l / min) has become widespread.

In fact, peakflowmetry allows us to determine the peak expiratory flow rate (PSV), i.e. The maximum rate at which air can escape from the airways during forced exhalation after the maximum inhalation.

The PSV of the patient is compared with the normal values, which are calculated depending on the height, sex and age of the patient.

When the bronchial patency of PSV is significantly lower than normal. The PSV value closely correlates with the values of the forced expiratory volume in the first second.

It is recommended to conduct peak flowmetry not only in the hospital, but also at home for monitoring the bronchial patency (PEF is determined at different times of the day before and after taking bronchodilators).

For a more detailed characterization of the state of bronchial patency and the establishment of a reversible component of bronchial obstruction, samples with bronchodilators (anticholinergics and beta2-adrenostimulants) are used.

The test with berodual (combined aerosol preparation containing anticholinergic ipratropium bromide and beta2-adrenostimulator fenoterol) allows an objective evaluation of both adrenergic and cholinergic components of reversibility of bronchial obstruction. In most patients after inhalation of anticholinergics or beta2-adrenostimulators, FVC increases. Bronchial obstruction is considered reversible when FVC increases by 15% or more after inhalation of these drugs. Before the appointment of bronchodilators, it is recommended that these pharmacological tests be performed. The result of the inhalation test is evaluated after 15 minutes.

Formulation of diagnosis

When formulating the diagnosis of chronic bronchitis, the following characteristics of the disease should be most fully reflected:

• form of chronic bronchitis (obstructive, non-obstructive);
• Clinico-laboratory and morphological characteristics of the inflammatory process in the bronchi (catarrhal, mucopurulent, purulent);
• phase of the disease (exacerbation, clinical remission);
• degree of severity (according to the classification of ERS);
• the presence of complications (emphysema, respiratory failure, bronchiectasis, pulmonary arterial hypertension, chronic pulmonary heart, heart failure).

In addition, if possible, decipher the infectious nature of the disease, indicating a possible causative agent of the inflammatory process in the bronchi. In those cases, when you can clearly identify the nosological affiliation of the disease (bronchitis), the term "COPD" can not be used. For example:

• Chronic catarrhal simple (non-obstructive) bronchitis, an exacerbation phase caused by pneumococcus.
• Chronic perobstuctivny purulent bronchitis, the phase of exacerbation.
• Chronic obstructive catarrhal bronchitis, emphysema of the lungs. Light degree of severity. The phase of exacerbation. Respiratory failure of the I degree.

The term "COPD" is usually used in the formulation of the diagnosis in more severe cases (medium and severe severity), when the isolation of the nosological affiliation of the disease causes certain difficulties, but there are clinical manifestations of bronchial obstructive syndrome and lung respiratory structures. The term "COPD" is, as far as possible, deciphered indicating the diseases that led to its development. For example:

• COPD: chronic obstructive catarrhal bronchitis, emphysema of the lungs. The average severity. The phase of exacerbation. Respiratory failure grade II. Chronic pulmonary heart, compensated.
• COPD: chronic obstructive purulent bronchitis, obstructive lung emphysema. Heavy current. Phase of clinical remission. Respiratory deficiency of the 2nd degree. Polycythemia. Chronic pulmonary heart, decompensated. Chronic heart failure II FC.
• COPD: bronchial asthma, chronic obstructive purulent bronchitis, amphysema of the lungs. Heavy current. The phase of exacerbation caused by the association of the hemophilic rod and moraxella. Respiratory failure grade II. Chronic pulmonary heart, decompensated. Chronic heart failure II FC.