Treatment of infectious-dependent bronchial asthma

The curative program includes the following main areas.

Etiological treatment (in the phase of exacerbation) - elimination of acute or exacerbation of chronic inflammatory process in the bronchopulmonary system, sanation of other foci of infection.

In case of bronchial asthma caused by Candida fungi, it is necessary to stop contact with mold fungi at work and at home, use disinfectant fungicidal solutions; Limit the use of products containing yeast mushrooms (cheeses, beer, wine, yeast dough); to sanitize foci of infection with antimycotic drugs.

1. Drug treatment: antibiotics (taking into account flora sensitivity and individual tolerance); sulfonamides of prolonged action; with intolerance to antibiotics and sulfonamides - nitrofurans, metronidazole (trichopolum), antiseptics (dioxidin), phytoncides (chlorophyllipt); antiviral means.

When Carrying Candida fungi, sanitation with levorin, nystatin for 2 weeks is carried out. In severe clinical manifestations of candidomycosis, antimycotic agents of systemic action are treated with amphotericin B, diflucane, nisoral, ancotyl. The drug of choice is diflucane (fluconazole), which does not possess allergic and toxic properties.

2. Bronchopulmonary sanation - endotracheal sanation, therapeutic fibrobronchoscopy (especially with purulent bronchitis, bronchiectasis).
3. Conservative or operative treatment of foci of infection in the ENT organs, oral cavity.

Desensitization (in the phase of remission).

1. Specific desensitization by bacterial allergens.
2. Treatment with autologysed sputum. The sputum of a patient with bronchial asthma is very heterogeneous in antigenic composition, acquires the properties of an autoantigen and plays an important role in the pathogenesis of the disease. Sputum contains various antigens, including bacterial cells, as well as secretion cells of the trachea and bronchi. Treatment with autologysed sputum is a kind of method of specific hyposensitization, most effective in infectious-dependent bronchial asthma. Depending on the severity of the disease and the time elapsed since the last exacerbation, autolyzate dilutions from 1: 40,000-1: 50,000 to 1: 200,000-1: 500,000 are made. Autologysed sputum is injected subcutaneously into the outer surface of the shoulder. There are 3 cycles of 10-13 injections each with intervals of 2 weeks. The full course of treatment includes 30-50 injections. Begin treatment with a dose of 0.1 ml, then in the first cycle of 0.2-0.3 ml, in the second cycle - 0.3-0.4 ml, in the third - 0.3 ml. The entire course of treatment takes 3.5-4.5 months, breaks between courses - 3-6 months. Positive results of treatment are noted in 80-90% of patients (AV Bykova, 1996).

Contraindications to treatment with sputum autolyzed:

• marked exacerbation of bronchial asthma; age over 60 years;
• glucocorticoid dependence.

3. Nonspecific hypo-sensitization and use of intal and ketotifen.

Immunomodulating agents and methods of extracorporeal therapy (hemosorption, plasmapheresis, UFO or laser irradiation of blood).

Effects on the pathophysiological stage.

1. Restoration of the drainage function of the bronchi: bronchodilators, expectorants, postural drainage, chest massage.
2. Physiotherapy.
3. Barotherapy.
4. Sauna therapy. 2-3 visits to sauna are recommended per week. After the hygienic shower and subsequent wiping with a dry towel, the patient is placed twice in the sauna cabin for 6-10 minutes with an interval of 5 minutes at a temperature of 85-95 ° C and a relative humidity of 15%. When leaving, patients take a warm shower and rest for 30 minutes.

The mechanism of action of the sauna: relaxation of the bronchial muscles, increased blood supply to the mucosa of the upper respiratory tract, a decrease in the elastic resistance of lung tissue.

Contraindications: a pronounced active inflammatory process in the broncho-pulmonary system, high arterial hypertension, arrhythmias and pathological changes in the ECG, asthma attack and severe exacerbation.

5. Speleagherapy.

Glucocorticoids in the inhalation or inside (the indications and the procedure of treatment are the same as with atopic asthma). The need for glucocorticoid therapy is observed more often than with atopic bronchial asthma.

Treatment of dyshormonal variant

Correction of glucocorticoid deficiency.

1. Alternative therapy in case of insufficiency of the glucocorticoid function of the adrenal glands is the use of glucocorticoids inside or parenterally with the administration of the drug at the maximum dose in the first half of the day (i.e., taking into account the circadian rhythm of the adrenal glands).
2. Activation of adrenal cortex function - treatment with etazol, glycyrram, application of physiotherapy methods (DKV, ultrasound to the adrenal glands). With absolute glucocorticoid insufficiency, activation is contraindicated.
3. Application of glucocorticoids in inhalations.
4. Treatment of complications of glucocorticoid therapy.

Decreased cortico-dependence

1. Extracorporeal methods of treatment (hemosorption, plasmapheresis).
2. Treatment with drugs that prevent the degranulation of mast cells (intal, ketotifen).
3. Laser irradiation of blood.
4. Unloading and dietary therapy in combination with acupuncture.
5. In cortico-resistant bronchial asthma, some authors recommend adding non-hormonal immunosuppressants (cytostatics) to the ongoing treatment with glycocorticoids: 6-mercaptopurine (the initial daily dose is 150-200 mg, supporting 50-100 mg), matioprin (the initial daily dose is 200-250 mg, supporting - 100-150 mg), cyclophosphamide (initial dose of 200-250 mg, supporting - 75-100 mg). The course of treatment is 3-6 months, it is possible to conduct a second course in 3-6 months.

Correction of diszovarial disorders.

Patients with bronchial asthma with disovarial disorders (insufficient function of the yellow body) are treated with synthetic progestins in the II phase of the menstrual cycle. The most commonly used are turinal, norkolut (they contain the hormone of the yellow body). Treatment with progestins restores the function of beta2-adrenergic receptors, raises their sensitivity to the effects of adrenaline and improves bronchial patency. The effectiveness of treatment with progestins increases with the simultaneous administration of vitamins E, C and folic acid, glutamic acid, taking into account the phases of the menstrual cycle.

Scheme of the use of synthetic progestins, vitamins and glutamic acid in the treatment of patients with bronchial asthma with disovarial disorders

Phases of the menstrual cycle	Menstrual cycle days
Phase I	1-15 days
folic acid	0.002 g 3 times a day orally
gyutamic acid	0.25 g 3 times a day inwards
II phase	16-28 days
norkolut (turinal)	0.005 g daily for 10 days
ascorbic acid	0.3 g 3 times a day orally
a-tocopherol acetate	one capsule daily inside (vitamin E)

Treatment is carried out for 3 months (three menstrual cycles). With a positive effect, treatment courses are repeated at intervals of 2-3 months.

Treatment with synthetic progestins is carried out in the period of calming exacerbation of bronchial asthma on the background of basic therapy or in the phase of remission.

Contraindications to treatment with synthetic progestins:

• tumors of any localization;
• acute diseases of the liver and biliary tract;
• acute thrombophlebitis with thromboembolic complications in the anamnesis;
• diabetes mellitus (relative contraindication);
• chronic thrombophlebitis, varicose veins, chronic liver disease, kidney.

Correction of male sex hormone production disorders.

Treatment is prescribed for men older than 50 years with the development of clinical manifestations of androgen deficiency, male menopause, especially in individuals receiving glucocorticoids. The most expedient is the use of long-acting androgens - sustanona-250 or omodrene 1 ml intramuscularly once in 3-4 weeks.

Bronchodilators, expectorants, massage.

Used to restore bronchial patency (the same methods as for atopic bronchial asthma).

Treatment of an autoimmune pathogenetic variant

The curative program includes the following areas:

1. Limitation (termination) of processes of denaturalization of tissues and autosensibilization, fight against infection, including viral infection.
2. Treatment of atopy (nonspecific hyposensitization, intal, antistiamine drugs).
3. Glucocorticoid therapy.
4. Immunomodulating therapy (thymomimetic drugs - thymalin, T-activin, antilymphocytic globulin with a decrease in T-suppressor pool)

Antilymphocytic globulin contains antibodies against lymphocytes, blocking their interaction with antigens. With the appointment of small doses, the drug stimulates the suppressor function of T-lymphocytes and helps to reduce the synthesis of IgE. Antilymphocytic globulin is injected intravenously at a dose of 0.5-0.7 mg / kg. The positive effect is manifested 3-5 weeks after the administration. Possible development of the following side effects: fever, chills, infectious complications. Contraindications to treatment with antilymphocytic globulin: epidermal sensitization, intolerance to protein and serum preparations.

Immunosuppressants, cytotoxic drugs

In patients with autoimmune variant of bronchial asthma, there is almost always a development of glcocorticoid dependence and corticosteroids, various complications of systemic glucocorticoid therapy. In connection with the above, it is recommended that cytostatics be included in the treatment complex. In this situation, they exhibit the following positive effects:

• immunosuppressive (suppress the formation of anti-pulmonary antibodies, formed as a result of sensitization of patients to pulmonary tissue antigens); autoimmune asthma due to allergic reactions III-IV types;
• anti-inflammatory;
• significantly reduce the dose and the number of side effects of glucocorticides.

The most commonly used are the following immunosuppressants.

Methotrexate, an antagonist of folic acid, necessary for the synthesis of RNA and DNA, suppresses the proliferation of mononuclears and fibroblasts, the formation of autoantibodies to the bronchopulmonary system, and reduces the migration of neutrophils to the inflammatory focus. It is prescribed in a dose of 7.5-15 mg per week for 6-12 months.

The main side effects of methotrexate:

• leukopenia; thrombocytopenia;
• development of infectious complications;
• toxic hepatitis;
• ulcerative stomatitis;
• pulmonary fibrosis;
• alopecia.

Contraindications to treatment with methotrexate:

• leukopenia;
• thrombocytopenia; liver, kidney disease; pregnancy;
• an active inflammatory process of any localization; a peptic ulcer.

Treatment should be carried out under the control of the number of leukocytes and platelets in peripheral blood (1-2 times per week) and liver and kidney function.

Ciclosporin A (sandimmun) is a polypeptide cytostatic produced by the fungus Tolypodadium inflatum.

The mechanism of action of cyclosporine:

• selectively inhibits the function of T-lymphocytes;
• blocks the transcription of genes responsible for the synthesis of interleukins 2, 3, 4 and 5, taking part in inflammation, therefore, cyclosporine has an anti-inflammatory effect;
• suppresses degranulation of mast cells and basophils and, thus, prevents the release of inflammatory mediators and allergies from them.

Ciclosporin A is administered internally at a dose of 5 mg / kg per day for 3-6 months.

The drug may exhibit the following side effects:

• gingival hyperplasia;
• hypertrichosis;
• abnormal liver function;
• paresthesia;
• tremor;
• arterial hypertension;
• thrombocytopenia;
• leukopenia.

Treatment is carried out under the control of blood levels of platelets, leukocytes, liver function and kidney function. Contraindications to cyclosporine are the same as for methotrexate.

As immunosuppressants, monoclonal antibodies against T-lymphocytes and cytokines, antagonists of interleukins are also used.

Efferent therapy (hemosorption, plasmapheresis).

Means that improve microcirculation and prevent thrombogenesis (heparin 10-20 thousand units per day for 4 weeks, curantyl to 300 mg / day).

Bronchodilators, expectorants.

Psychotropic therapy (sedative, psychotropic drugs, rational psychotherapy, auto-training).

Treatment of adrenergic imbalance

With adrenergic imbalance, the ratio between beta and alpha-adrenergic receptors is violated towards the predominance of alpha-adrenergic receptors. The activity of beta-adrenergic receptors in this variant of bronchial asthma is sharply reduced. Often the main reason for the development of adrenergic imbalance is an overdose of adrenomimetics.

The curative program includes the following areas:

1. Complete elimination of adrenomimetic until the recovery of beta-adrenergic receptor sensitivity.
2. Increase in activity of beta2-adrenergic receptors, restoration of their sensitivity:
   • glucocorticoids (mainly parenterally at doses corresponding to those for asthmatic status, for example, hydrocortisone hemisuccinate at the beginning at a dose of 7 mg / kg body weight, then 7 mg / kg every 8 hours for 2 days, then gradually reduce the dose by 25-30% per day to the minimum supporting);
   • unloading-dietary therapy;
   • barotherapy;
   • correction of hypoxemia (inhalation of an oxygen-air mixture with an oxygen content of 35-40%;
   • relief of metabolic acidosis by intravenous drip of sodium bicarbonate under the control of the pH of the plasma (usually about 150-200 ml of 4% sodium bicarbonate solution);
3. Intravenous administration of euphyllin against the background of glucocorticides (initial dose of 5-6 mg / kg drip for 20 minutes, and then to an improvement in the dose of 0.6-0.9 mg / kg / h, but not more than 2 feet).
4. Treatment with membrane stabilizing drugs (intal, sodium nedocromil), they reduce the need for inhalation of beta2-adrenostimulyatorov and glucocorticoids.
5. Decrease in the activity of alpha-adrenergic receptors: the use of pyrroxane (0.015 g 3 times a day for 2 weeks, it is possible to use droperidol 1-2 times a day by intramuscular injection of 1 ml 0.25% solution.) Treatment with alpha-adrenergics is carried out under careful control of blood pressure and it is contraindicated in arterial hypotension, severe organic lesions of the heart and blood vessels.
6. Decreased activity of cholinergic receptors: treatment with atrovent, trentol, platyphin, atropine, preparations of belladonna.
7. Treatment with antioxidants (vitamin E, autotransfusion of blood irradiated with ultraviolet, helium-neon laser).
8. The use of agents that optimize the microviscosity of the lipid matrix of membranes (inhalation of a liposome preparation of lily made from natural phosphatevdicholine, treatment with lipostable).
9. The use of beta2-adrenostimulants after restoration of sensitivity to them porphyrenorceptors.

Treatment of the neuro-pathogenetic variant

1. Medication effect on the central nervous system (carried out in different ways, taking into account the nature of the disorders of the functional state of the central nervous system):
   • sedatives (elenium - 0.005 g 3 times a day, seduksen - 0.005 g 2-3 times a day, etc.);
   • Neuroleptics (aminazine - 0.0125-0.025 g 1-2 times a day); sleeping pills (radedorm 1 tablet before bedtime); antidepressants (amitriptyline - 0.0125 g 2-3 times a day).
2. Non-pharmacological effects on the central nervous system: psychotherapy (rational, pathogenetic, suggestion in wakeful and hypnotic states), autogenic training, neurolinguistic programming.
3. Effects on the autonomic nervous system:
   • acupuncture;
   • electroacupuncture;
   • Novocain blockades (intradermal paravertebral, vagosympathetic);
   • acupressure.
4. General strengthening therapy (multivitamin therapy, adaptogen, physiotherapy, sanatorium-and-spa treatment).

Treatment of asthma physical effort

Asthma of physical effort develops during or after exercise. As an independent variant of the disease is observed in 3-5% of patients with bronchial asthma, in which only submaximal physical load causes obstruction of the bronchi, in the absence of signs of allergy, infection, disruption of endocrine and nervous systems.

The curative program for asthma physical effort includes the following areas:

1. The use of beta2-adrenomimetics - 1-2 inhalations for 5-10 minutes before exercise.
2. Treatment with stabilizers of mast cells (intal, tayled). Intal is inhaled in a daily dose of 40-166 mg, tayled - 4-6 mg. These drugs can be used as a means of pathogenetic treatment of bronchial hyperreactivity (a course of 2-3 months), and also for preventive purposes for 20-30 minutes before exercise.
3. Treatment with calcium antagonists (nifedipine). This drug can be used for pathogenetic treatment (30-60 mg / day for 2-3 months) or as a prophylactic for 45 minutes before exercise. Tableted forms of calcium antagonists are chewed, kept in the mouth for 2-3 minutes and swallowed.
4. Inhalation of magnesium sulfate (single dose - 0.3-0.4 g, course 10-14 inhalation).
5. Ergotherapy - the use of the training regime of physical loads of increasing power with the help of ergometric devices (veloergometer, tredban, stepper, etc.). A two-month course of ergotherapy with 3-4 sessions per week on a veloergometer completely eliminates after-loading bronchospasm in 43% of patients and reduces its severity in 40% of patients.
6. Willed control of breathing at rest and under physical exertion. Breathing in the controlled hypoventilation mode at a respiration rate of 6-8 per min for 30-60 min 3-4 times a day eliminates or significantly reduces the severity of post-exercise bronchospasm.
7. Inhalation of cholinolitics beroduala, trventola in the form of course and preventive treatment.
8. Course treatment with inhaled heparin.

It has been established that heparin inhalations prevent the development of an asthma attack after physical effort. Heparin acts as a specific blocker of inositol triphosphate receptors and blocks calcium release in obese and other cells.

9. Application of acupressure. It stops obstructive reactions at the level of large bronchi, eliminates hyperventilation in response to physical stress. The braking method is used, the massage time of one point is 1.5-2 minutes, for the procedure no more than 6 points are used.
10. Prevention of bronchospasm induced by cold air and physical exertion:
    • breathing through a special conditioning mask, thus forming a heat and mass exchange zone, equally reducing the loss of heat and moisture by the bronchi;
    • vibration effect on the body as a whole by mechanical oscillations of infra- and low-sound frequencies for 6-8 min before physical exertion.

The mechanism of action is to reduce the stock of mediators in the mast cells.

Treatment of aspirinic asthma

Aspirinovaya asthma is a clinico-pathogenetic variant of bronchial asthma associated with intolerance to acetylsalicylic acid (aspirin) and other non-steroidal anti-inflammatory drugs. It is often combined with a polyposis of the nose and this syndrome is called the asthmatic triad (asthma + intolerance to acetylsalicylic acid + polyposis of the nose).

After taking acetylsalicylic acid and non-steroidal anti-inflammatory drugs from arachidonic acid, cell membranes due to the activation of the 5-lipoxygenase pathway produce leukotrienes, which cause bronchospasm.

The curative program for aspirin bronchial asthma includes the following areas:

1. Exclusion of products containing natural and added salicylates.

Food products containing salicylates

Naturally occurring				Containing added salicylates
Fruit	Berries	Vegetables	Mixed Group
Apples Apricots Grapefruits Grapes Lemons Peaches Melons Oranges Plums Prunes	Black currant Cherry Blackberry Raspberries Strawberries Strawberry Cranberry Gooseberry	Cucumbers Pepper Tomatoes Potatoes Radish Turnip	Almond Walnut Different grades Currants Raisins Winter greens	Beverages from root vegetables Mint candies Sweets with greenery additives Confectionery products with greenery additives

2. The exclusion of medicines containing aspirin, as well as non-steroidal anti-inflammatory drugs: citramone, asphene, ascophene, novotsefalgin, theofedrine, acetylsalicylic acid, in combination with ascorbic acid (various variants), indomethacin (methindol), voltaren, brufen, etc.
3. Exclusion of food substances containing tartrazine. Tartrazine is used as a yellow calorie food additive and is derived from coal tar. In 30% of patients with aspirin intolerance, there is a cross-intolerance to tartrazine. That is why with aspirin asthma, products containing tartrazine are excluded from the patients' diet: yellow cakes, mixtures for. Glazing, yellow ice cream, yellow candies, soda water, biscuits.
4. Exclusion of medicinal substances containing tartrazine: indial, dilantine, elixophylline, dental elixir, multivitamins, etc.
5. Treatment with membrane stabilizing drugs (intal, tayled, ketotifen).
6. Desensitization with acetylsalicylic acid to reduce sensitivity to it. For patients with low sensitivity to aspirin (a threshold dose of 160 mg or more), one of the following desensitization schemes is recommended:
   • aspirin is taken within one day at two-hour intervals in increasing doses of 30, 60, 100, 320 and 650 mg;
   • Aspirin is taken within 2 days at three-hour intervals:
     • on the first day 30, 60, 100 mg;
     • on the second day of 150, 320, 650 mg with the transition to receiving a maintenance dose of 320 mg in the following days.

For patients with low sensitivity to aspirin (a threshold dose of less than 160 mg) EV Evsyukova (1991) developed a desensitization scheme with small doses of aspirin, the initial dose being 2 times lower than the threshold dose. Then, within a day, the dose is slightly increased at intervals of 3 hours under the control of the indices of forced expiration. In the following days, gradually increase the dose of aspirin to the threshold dose and take it 3 times a day. After achieving good results, bronchial passableness is passed to the maintenance of a single dose of aspirin per day, which is taken several months.

Patients with very high susceptibility to aspirin (threshold dose 20-40 mg) before desensitization are given an AOFOK course consisting of 5 sessions, with the interval between the first three sessions being 3-5 days, between the others - 8 days. 20 minutes before and 20 minutes after AOFOK, the function of external respiration was examined. After the course of AOFOK, the threshold of sensitivity to aspirin is increased 2-3 times.

7. With a very severe course of aspirin asthma, glucocorticides are treated.

Treatment of cholinergic (vagotonic) bronchial asthma

A cholinergic variant of bronchial asthma is a variant that proceeds with a high tonus of the vagus nerve.

The curative program includes the following activities.

1. Application of peripheral M-holinolitikov (atropine, platifillina, extract of belladonna, belloid).
2. Inhalational use of M-holinolitikov: iprotropium bromide (atrovent), oxotropium bromide (oxyvent), glycotropium bromide (robinul). These drugs are more preferable in comparison with platifillin, atropine, belladonna, since they do not penetrate the blood-brain barrier, do not adversely affect mucociliary transport. They are applied 2 times 4 times a day.
3. The use of a combined preparation of berodual, consisting of fenoterol beta2-adrenostimulant and cholinolytics ipratropium bromide. It is applied 2 times 4 times a day.
4. Iglor reflexology - reduces the manifestation of vagotonia.

Treatment of food asthma

1. Elimination and hypoallergenic diet.

Products that cause asthma attacks of the patient, as well as products that are more likely to cause asthma (fish, citrus, eggs, nuts, honey, chocolate, strawberries) are excluded. With allergies to cereals exclude rice, wheat, barley, corn. If you are allergic to a chicken egg, chicken should be excluded, since it also has sensitization to it.

2. Unloading and dietary therapy.
3. Enterosorption.
4. Stabilizers of mast cells (ketotifen).
5. Extracorporeal methods of treatment (hemosorption, plasmapheresis).

Treatment of nocturnal bronchial asthma

Night bronchial asthma is the appearance of signs of suffocation solely or with a clear predominance in the night and early morning hours.

About 74% of patients with bronchial asthma wake up between 1-5 h in the morning due to increased bronchospasm, while there are no significant differences between atopic and non-atopic forms of the disease. Often in the initial phase of bronchial asthma, nighttime attacks of suffocation are the only sign of the disease, and therefore bronchial asthma is not diagnosed by a doctor when the patient is examined during the day.

The main causes of night attacks of bronchial asthma:

• the presence of circadian rhythms of changes in bronchial patency (even in healthy individuals the maximum bronchial patency is observed from 13 to 17 hours, the minimum - from 3 to 5 am). In patients with nocturnal bronchial asthma, the presence of circadian rhythm of bronchial patency is clearly marked, with deterioration at night;
• daily fluctuations in barometric pressure, relative humidity and air temperature. The respiratory ways of patients with bronchial asthma are hypersensitive to a decrease in ambient air temperature at night;
• increased contact of the patient with bronchial asthma with aggressive allergens in the evening and at night (high concentration of spore fungi in the air on warm summer nights, contact with bedding containing allergens - cushion feather, mites, dermatophagoes in mattresses, etc.);
• the effect of the horizontal position (in the horizontal position the mucociliary clearance worsens, the cough reflex decreases, the tone of the vagus nerve increases);
• the influence of gastroesophageal reflux, especially when taking food before bedtime (bronchospasm is reflexively provoked, especially in people with increased bronchial reactivity, and also the irritating effect of aspirated acidic contents on the respiratory tract at night). Such patients do not recommend taking teofedrine in the second half of the day (it lowers the tone of the lower esophageal sphincter);
• the effect of diaphragmatic hernia (this is the case in some patients), similar to the influence of gastroesophageal reflux;
• increased vagal nerve activity, especially with a cholinergic variant of bronchial asthma and an increase in bronchial sensitivity to acetylcholine at night;
• the highest concentration in the blood of histamine at night;
• increase in the inclination of mast cells and basophils to degranulation at night;
• decrease in blood concentrations of catecholamines and cAMP at night;
• circadian rhythm of cortisol secretion with a decrease in its level in the blood at night;
• circadian rhythms of the change in the number of adrenoreceptors on lymphocytes of patients with bronchial asthma (lymphocytes carry the beta-adrenoreceptors of the same type as the smooth muscles of the bronchi), the minimum density of beta-adrenoreceptors was noted in the early morning hours.

Prevention and treatment of nocturnal seizures of bronchial asthma

1. Maintenance of constantly comfortable conditions in the bedroom (this is especially important for patients with increased meteotropism).
2. When allergic to domestic mites - thorough destruction (radical treatment of apartments with the latest acaricidal preparations, replacement of bedding - foam mattresses, pillows, etc.).
3. Combating the dustiness of premises, the use of filtration systems, allowing to remove from the air almost 100% of the spores of fungi, pollen, house dust and other particles. The systems include an aerosol generator, fans, ionization devices, electrostatically charged filters.
4. Patients with gasroesophageal reflux are advised not to eat before bed, take a lofty position in bed, prescribe antacids, enveloping agents. In some cases (especially in the presence of diaphragmatic hernia), surgical treatment is possible.
5. To improve mucociliary clearance, prescribe, especially before bedtime, bromhexine, 0.008 g 3 times a day and 0.008 g per day or ambroxol (lasolvan) - a metabolite of bromhexine 30 mg 2 times a day and overnight.
6. Patients with severe hypoxemia are recommended breathing oxygen during sleep (this helps to increase the saturation of hemoglobin with oxygen and reduces the number of asthma attacks at night.) To reduce hypoxemia, long-term administration of the vector (almitrine) is also recommended for 0.05 g 2 times a day.
7. Using the principle of chronotherapy. Preliminary for three days at different hours measured bronchial patency. Further, the use of bronchodilators is recommended during periods of expected impairment of respiratory function. So, inhalations of beta-adrenomimetics are prescribed for 30-45 minutes before this time, intala - for 15-30 minutes, beclometha - for 30 minutes, intake of euphyllin inside - for 45-60 minutes. In most patients, chronotherapy reliably prevents night attacks of bronchial asthma.

Programs of "self-management" for patients with bronchial asthma have been developed abroad. Patients control bronchial patency during the day using portable spirometers and peak flowmeters; Correctly corrected the reception of beta-adrenomimetics and thereby reduce the number of attacks of bronchial asthma.

8. The use of prolonged theophylline preparations is the main way of preventing nighttime attacks of bronchial asthma. Traditional reception of these drugs in an equal dose 2 times a day (morning and evening) leads to the fact that the concentration of theophylline in the blood at night is lower than in the daytime, due to the deterioration of its absorption during the night. Therefore, with the prevalence of nocturnal attacks of suffocation, it is optimal to take one third of the daily dose in the morning or at lunch time and two-thirds of the dose in the evening.

Increasingly, the drugs of extended theophylline II generation (they work 24 hours and are taken once a day).

When the morning dose of prolonged theophylline of the second generation is taken, the greatest concentration of theophylline in the serum is observed during the day, and the night concentration is 30% lower than the average for 24 hours; therefore, for nighttime bronchial asthma, dyurant theophylline daily therapy should be taken in the evening.

The drug unifil with a dose of 400 mg at 20 hours more than 3,000 patients with nocturnal or morning attacks of suffocation reliably prevented these attacks in 95.5% of patients (Dethlefsen, 1987). Domestic drug teopek (prolonged theophylline of the first generation, valid for 12 hours) with night attacks of choking take at night in a dose of 0.2-0.3 g.

9. Reception of prolonged β-adrenomimetics. These drugs accumulate in the lung tissue due to high solubility in lipids and thus have an extended effect. This is formoterol (prescribed 12 μg 2 times a day in the form of a dosed aerosol), salmeterol, terbutaline retard in tablets (take 5 mg in 8 hours and 10 mg in 20 hours), salto in tablets (take 6 mg 3 times a day day.

It was found that the optimal reception is 1/2 a day in the morning and 2/3 in the evening.

10. Anticholinergics.

Ipratropium bromide (atrovent) - in inhalations of 10-80 μg, provides the effect within 6-8 hours.

Oxytropium bromide in inhalations of 400-600 μg provides a bronchodilator effect up to 10 hours.

Treatment with these drugs, inhaled at bedtime, prevents night attacks of bronchial asthma. These drugs are most effective for cholinergic bronchial asthma, with an infectious-dependent bronchial asthma their effect is more pronounced than with atonic.

11. Regular treatment with mast cell stabilizers helps prevent nighttime attacks of suffocation. Used intal, ketotifen, as well as azelastine - a drug of prolonged action. It delays the release of mediators from mast cells and neutrophils, counteracts the effects of C4 and D4 leukotrienes of histamine and serotonin. Azelastine is taken on 4.4 mg 2 times a day or at a dose of 8.8 mg once a day.
12. The question of the effectiveness of evening inhalations of glucocorticoids in the prevention of nocturnal bronchial asthma has not been finally resolved.

Clinical examination

Bronchial asthma is mild with moderate severity

Visit the therapist 2-3 times a year, pulmonologist, ENT doctor, dentist, gynecologist - once a year. General analysis of blood, sputum, spirography 2-3 times a year, ECG - 1 time per year.

Allergological examination - according to the indications.

Medical and recreational activities: dosed fasting - 1 time per 7-10 days; acupuncture, nonspecific desensitization 2 times a year; therapeutic microclimate; psychotherapy; Spa treatment; avoid contact with the allergen; specific disinfection according to indications; breathing exercises.

Severe bronchial asthma

Visit the therapist once every 1-2 months, pulmonologist, allergist - once a year; The examinations are the same as for bronchial asthma of mild and moderate severity, but cortically dependent patients undergo urine and blood glucose analysis twice a year.

Medical and recreational activities: dosed fasting - 1 time per 7-10 days; non-allergic diet, hyposensitizing therapy, respiratory gymnastics, physiotherapy, psychotherapy, halo- and speleotherapy, massage, phytotherapy, bronchodilators.

In terms of dispensary observation in any form and severity of bronchial asthma, it is necessary to provide training for the patient. The patient should know the essence of bronchial asthma, the ways of independent relief of the asthma attack, the situation when it is necessary to call a doctor, individual triggers of asthma to be avoided, signs of deterioration and bronchial patency, an individual daily dose of preventive medications for asthma control.