All about COPD (chronic obstructive pulmonary disease): symptoms, stages, treatment methods. The first symptoms of COPD Signs of COPD in adults

About 6-10% of people over 40 years of age suffer from chronic obstructive pulmonary disease. There are quite a few reasons for the development of the disease. Most often, the impetus for the development of the disease is smoking, heredity and working in hazardous conditions. To date, it is impossible to completely cure the disease.

All are aimed at reducing and preventing attacks. The disease quite often causes complications, which increases the likelihood of death.

Complications and their danger

Pneumonia

It occurs as a result of stagnation of mucus in the respiratory tract and disruption of mucociliary clearance. The patient begins inflammatory processes with the addition of infection. Pneumonia can also be caused by regular or long-term use of glucocorticosteroids in the form of inhalations. Also, this type of complication is quite often observed in people who suffer from diabetes.

When a secondary one appears, there is a high percentage of deaths. Possible occurrence septic shock. The disease is accompanied severe shortness of breath and the likelihood of kidney failure.

Respiratory failure

This complication always occurs in patients with COPD. This is due to the fact that it is difficult for the lungs to maintain the blood composition that is necessary for quality breathing. This pathological syndrome, which may occur in acute or chronic form. For development acute form A few minutes or a couple of hours is enough. The course of the chronic form is quite rapid. It can develop over a long period of time: from several weeks to several months. This complication has three stages:

1. the first is characterized by the presence of shortness of breath only after more severe physical exertion;
2. in the second degree, shortness of breath occurs even with the slightest exertion;
3. Grade 3 is characterized by severe shortness of breath, difficulty breathing even at rest, as well as a significant decrease in oxygen in the lungs.

Swelling may also appear, morphological changes in the liver and kidneys may occur, and the normal functioning of these organs may be disrupted.

1. Pulmonary hypertension may appear, which leads to high blood pressure;
2. cor pulmonale may occur.

The functions of cardiac activity are impaired, and the patient develops hypertension. The walls of the organ thicken, the section of the right ventricle expands. The disease can be acute, subacute or chronic. There is a possibility of collapse. Possible liver enlargement. The patient also experiences tachycardia, shortness of breath, and coughing up sputum with blood.

Fact! If this type of complication has chronic form, symptoms may be mild and shortness of breath worsens over time. The patient may also experience swelling and decreased urine output.

Acute heart failure

There is a disruption in the proper functioning of the right ventricle, which causes congestion and disruption of the contractile function of the myocardium. This in turn leads to edema, poor circulation, tachycardia, decreased performance, and insomnia. If the disease has taken a severe form, a person experiences severe exhaustion.

Atrial fibrillation

The normal cycle of the heart is disrupted, the muscle fibers of the atrium contract chaotically and are excited. The ventricles contract less frequently than the atrium.

Pneumothorax

Expressed as pain in the chest. If cirrhosis of the lung occurs, it becomes deformed, and the heart and large vessels are also displaced. Appears inflammatory process, and pleurisy begins to develop. This pathology is diagnosed by radiography. Most often, men suffer from this pathology.

Pneumothorax develops very quickly. The first sign is severe pain in the heart with shortness of breath, which the patient experiences even at rest. The patient feels especially severe pain when he inhales or coughs. The patient also appears tachycardia and rapid pulse. High probability of loss of consciousness.

Polycythemia

This type of complication in COLD leads to erythrocytosis. In humans, the production of red blood cells increases, and hemoglobin increases. Polycythemia may occur without symptoms for a long time.

Blockage of blood vessels

The main vessels become clogged with blood clots, which can lead to dire consequences.

Bronchiectasis

This type of complication is characterized by dilatation of the bronchi, which most often occurs in the lower lobes. It is possible to damage not one, but two lungs at once. The patient begins to cough up blood, severe pain in the chest. The secreted sputum has bad smell. The person also becomes irritable, his skin becomes pale and his weight decreases. The phalanges of the fingers thicken.

Pneumosclerosis

Normal tissue is replaced by connective tissue, as a result of which the bronchi are deformed, the pleural tissue becomes denser, and the mediastinal organs are displaced. Gas exchange is disrupted and respiratory failure develops. This complication refers to the last degree of sclerosis and most often causes death. This pathology is characterized by:

• constant shortness of breath;
• blue skin;
• frequent cough with mucus production.

Important! All these complications are life-threatening, so the patient must be observed by a doctor.

Symptoms of exacerbation

In order to begin treatment on time or prevent an attack, the patient needs to know the signs of an approaching exacerbation. Exacerbations of COPD may occur several times a year, therefore, each patient should be able to control their condition and take the necessary measures to prevent them.

The most common signs are:

1. The patient develops sputum mixed with pus.
2. The amount of mucus secreted increases greatly.
3. Shortness of breath becomes severe and can occur even at rest.
4. The intensity of the cough increases.
5. There are wheezing sounds that can be heard from a distance.
6. There may be severe headaches or dizziness.
7. An unpleasant noise appears in the ears.
8. Extremities become cold.
9. Insomnia appears.
10. I feel pain in my heart.

Important! Exacerbations of COLD can increase gradually or rapidly.

Treatment for exacerbations

The doctor selects adequate basic therapy for patients, which includes the following medications:

First-line drugs for adults

• Spiriva;
• Tiotropium-Nativ.

Important! These drugs are prohibited for treating children.

• Foradil;
• Oxis;
• Athymos;
• Serevent;
• Theotard;
• Salmeterol.

These drugs can be used as inhalers for moderate to severe forms of the disease. Well established new drug Spiriva respimat, which is available as a solution for inhalation.

Hormonal drugs

• Flixotide;
• Pulmicort;
• Beclazon-ECO.

Combined preparations of bronchodilators and hormonal agents

• Symbicort;
• Seretide.

A course of antibacterial agents during exacerbation

• Augmenitin;
• Flemoxin;
• Amoxiclav;
• Sumamed;
• Azitrox;
• Klacid;
• Zoflox;
• Sparflo.

Expectorants

• Lazolvana;
• Ambroxol;
• Flavameda.

Antioxidant-mucolytic ACC

If the patient does not have severe respiratory failure, treatment can be carried out at home. If exacerbation of COPD took a severe form, hospitalization is necessary to treat the patient in a hospital.

If a patient experiences severe shortness of breath due to chronic cerebral hypoxia, which can lead to disability, the patient is prescribed a course of oxygen inhalation.

When using inhalations, doctors recommend that patients use a nebulizer, since its use will allow quickly restore functions respiratory tract . If the treatment has no effect or suffocation worsens, calling an ambulance is mandatory.

Useful video

Be sure to watch the video about the new methodology for identifying COPD and how smoking is involved in the disease:

Chronic obstructive pulmonary disease(COPD) - chronic inflammatory disease, which occurs in people over 35 years of age under the influence of various factors of environmental aggression ( risk factors),

the main one of which is tobacco smoking, which occurs with a predominant lesion distal sections respiratory tract and lung parenchyma, the formation of emphysema, characterized by a partially reversible limitation of air flow velocity, induced by an inflammatory response that differs from inflammation during bronchial asthma and exists regardless of the severity of the disease.
The disease develops in predisposed individuals and is manifested by cough, sputum production and increasing shortness of breath, and has a steadily progressive nature with the outcome in chronic respiratory failure and chronic pulmonary heart disease.

ICD-10
J44.0 Chronic obstructive pulmonary disease with acute respiratory infection of the lower respiratory tract
J44.1 Chronic obstructive pulmonary disease with exacerbation, unspecified
J44.8 Other specified chronic obstructive pulmonary disease
J44.9 Chronic obstructive pulmonary disease, unspecified.

EXAMPLE OF FORMULATION OF DIAGNOSIS

EXAMPLE OF FORMULATION OF DIAGNOSIS
■ Nosology - COPD.
■ Severity (stage of disease):
✧mild course (stage I);
✧moderate course (stage II);
✧severe course (stage III);
✧extremely severe course (stage IV).
■ Clinical form (in severe disease): bronchitis, emphysematous, mixed (emphysematous-bronchitis).
■ Progression phase: exacerbation, subsiding exacerbation, stable course. There are two types of flow:
✧with frequent exacerbations (3 or more exacerbations per year);
✧with rare exacerbations.
■ Complications:
✧chronic respiratory failure;
✧acute respiratory failure against the background of chronic;
✧pneumothorax;
✧pneumonia;
✧thromboembolism;
✧if bronchiectasis is present, indicate its location;
✧pulmonary heart;
✧degree of circulatory failure.
■ If there is a possible combination with bronchial asthma, provide its detailed diagnosis.
■ Specify the index of the person who smokes (in units of “pack/years”).
Chronic obstructive pulmonary disease, severe course, bronchitis, exacerbation phase, respiratory failure of the 3rd degree. Chronic pulmonary heart disease, heart failure of the 2nd degree.

EPIDEMIOLOGY

EPIDEMIOLOGY
■ The prevalence of COPD symptoms largely depends on smoking, age, occupation, condition environment, country or region and, to a lesser extent, gender and race.
■ COPD is in 6th place among the leading causes of death in the world, in 5th place in developed countries of Europe, in 4th place in the USA. According to WHO forecasts, in 2020 COPD will rank 5th among all causes of death after stroke, myocardial infarction, diabetes and injuries. Mortality over the past 20 years has increased among men from 73.0 to 82.6 per 100 thousand population and among women from 20.1 to 56.7 per 100 thousand population. Global smoking prevalence is expected to continue to rise, causing deaths from COPD to double by 2030.

CLASSIFICATION

CLASSIFICATION
A common feature of all stages of COPD is a post-bronchodilator decrease in the ratio of FEV1 to forced vital capacity of less than 70%, which characterizes the limitation of expiratory air flow. The dividing sign that makes it possible to assess the mild (stage I), moderate (stage II), severe (stage III) and extremely severe (stage IV) course of the disease is the value of the post-bronchodilator FEV1.
The recommended classification of COPD according to the severity of the disease distinguishes 4 stages. All values ​​of FEV1 and forced vital capacity in the COPD classification refer to post-bronchodilation. If dynamic monitoring of the state of external respiration function is unavailable, the stage of the disease can be determined based on analysis clinical symptoms.
■ Stage I - mild COPD. At this stage, the patient may not notice that his lung function is impaired. Obstructive disorders - the ratio of FEV1 to forced vital capacity of the lungs is less than 70%, FEV1 is more than 80% of the required values. Usually, but not always, chronic cough and sputum production.
■ Stage II - moderate COPD. This is the stage at which patients seek medical care due to shortness of breath and exacerbation of the disease. It is characterized by an increase in obstructive disorders (FEV1 is more than 50%, but less than 80% of the expected values, the ratio of FEV1 to the forced vital capacity of the lungs is less than 70%). There is an increase in symptoms with shortness of breath appearing with physical activity.
■ Stage III - severe COPD. It is characterized by a further increase in airflow limitation (the ratio of FEV1 to the forced vital capacity of the lungs is less than 70%, FEV1 is more than 30%, but less than 50% of the required values), an increase in shortness of breath, and frequent exacerbations.
■ Stage IV - extremely severe COPD. At this stage, quality of life deteriorates markedly, and exacerbations can be life-threatening. The disease becomes disabling. It is characterized by extremely severe bronchial obstruction (the ratio of FEV1 to the forced vital capacity of the lungs is less than 70%, FEV1 is less than 30% of the expected values, or FEV1 is less than 50% of the expected values ​​in the presence of respiratory failure). Respiratory failure: paO2 less than 8.0 kPa (60 mm Hg) or oxygen saturation less than 88% in combination (or without) paCO2 more than 6.0 kPa (45 mm Hg). At this stage, the development of cor pulmonale is possible.

PHASES OF COPD

PHASES OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
According to clinical signs, there are two main phases of COPD: stable and exacerbation of the disease.
■ A condition is considered stable when the progression of the disease can be detected only with long-term dynamic observation of the patient, and the severity of symptoms does not change significantly over the course of weeks or even months.
■ Exacerbation - deterioration of the patient’s condition, manifested by an increase in symptoms and functional disorders and lasting at least 5 days. Exacerbations can begin gradually, gradually, or can be characterized by a rapid deterioration of the patient’s condition with the development of acute respiratory and right ventricular failure.
The main symptom of exacerbation of COPD is increased shortness of breath, which is usually accompanied by the appearance or intensification of distant wheezing, a feeling of tightness in the chest, a decrease in exercise tolerance, an increase in the intensity of cough and the amount of sputum, a change in its color and viscosity. At the same time, indicators of the function of external respiration and blood gases significantly deteriorate: speed indicators (FEV1, etc.) decrease, hypoxemia and even hypercapnia may occur.
Two types of exacerbation can be distinguished: exacerbation, characterized by an inflammatory syndrome (increased body temperature, increase in the amount and viscosity of sputum, purulent nature of the latter), and exacerbation, manifested by an increase in shortness of breath, increased extrapulmonary manifestations of COPD (weakness, fatigue, headache, bad dream, depression). The more severe the COPD, the more severe the exacerbation. Depending on the intensity of symptoms and response to treatment, there are 3 degrees of severity of exacerbation.
■ Mild - slight increase in symptoms, relieved by increasing bronchodilator therapy.
■ Moderate - requires medical intervention and can be treated on an outpatient basis.
■ Difficult - definitely demanding inpatient treatment and manifested by an increase in symptoms not only of the underlying disease, but also by the appearance or worsening of complications.
The severity of the exacerbation usually corresponds to the severity clinical manifestations disease during its stable course. Thus, in patients with mild or moderate COPD (grades I–II), an exacerbation is usually characterized by increased shortness of breath, cough and an increase in sputum volume, which allows patients to be managed on an outpatient basis. On the contrary, in patients with severe COPD (grade III), exacerbations are often accompanied by the development of acute respiratory failure, which requires intensive care in a hospital setting.
In some cases, it is necessary to distinguish (in addition to severe) very severe and extremely severe exacerbation of COPD. In these situations, the participation of auxiliary muscles in the act of breathing and paradoxical movements are taken into account chest, the appearance or worsening of central cyanosis and peripheral edema.

CLINICAL FORMS OF COPD

CLINICAL FORMS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
In patients with moderate and severe disease, two clinical forms of COPD can be distinguished: emphysematous (panacinar emphysema, “pink puffers”) and bronchitis (centroacinar emphysema, “blue puffers”). Their main differences are given in table. 2-11.
Table 2-11. Clinical characteristics of COPD in moderate and severe cases
Identification of two forms of COPD has prognostic significance. Thus, in the emphysematous form, decompensation of the cor pulmonale occurs at later stages compared to the bronchitis form of COPD. A combination of these two forms of the disease is often observed.
The sensitivity of physical (objective) methods of examining patients in diagnosing COPD and in determining the degree of its severity is low. They provide guidelines for further direction diagnostic study using instrumental and laboratory methods.

DIAGNOSTICS

DIAGNOSTICS
■ COPD should be suspected in all patients who have cough and sputum production and/or shortness of breath and who have risk factors for developing the disease.
■ Chronic cough and sputum production often long precede airflow limitation leading to shortness of breath.
■ If any of the above symptoms are present, spirometry should be performed.
■ These signs are not diagnostic individually, but the presence of several of them increases the likelihood of having COPD.

COMPLAINTS
The severity of complaints depends on the stage and phase of the disease.
■ Cough (it is necessary to establish the frequency of its occurrence and intensity) - the most early symptom, manifesting itself by 40–50 years of age. The cough is observed daily or is intermittent. Most often observed during the day, rarely at night.
■ Sputum (it is necessary to determine the nature and quantity). Sputum, as a rule, is released in small quantities in the morning (rarely more than 50 ml/day) and is mucous in nature. The purulent nature of sputum and an increase in its quantity are signs of exacerbation of the disease. Special attention deserves the appearance of blood in the sputum, which gives reason to suspect another cause of cough (lung cancer, tuberculosis and bronchiectasis), although streaks of blood in the sputum may appear in a patient with COPD as a result of a persistent hacking cough.
■ Shortness of breath (it is necessary to evaluate its severity and its relationship with physical activity). Dyspnea, a cardinal sign of COPD, is the reason why the majority of patients consult a doctor. Quite often, the diagnosis of COPD is made at this stage of the disease. Shortness of breath, felt during physical activity, occurs on average 10 years later than cough (extremely rarely, the onset of the disease can begin with shortness of breath). As pulmonary function decreases, shortness of breath becomes more severe. Dyspnea in COPD is characterized by: progression (constant increase), persistence (every day), intensification with physical activity, increase with respiratory infections.
In addition to the main complaints, the patient may be bothered by morning headache and drowsiness during the day, insomnia at night (a consequence of hypoxia and hypercapnia), weight loss and weight loss. These signs refer to extrapulmonary manifestations of COPD.

ANAMNESIS
When talking with a patient, you need to remember that the disease begins to develop long before the appearance of severe symptoms. COPD proceeds for a long time without significant clinical symptoms: at least, patients do not present active complaints for a long time. It is advisable to clarify what the patient himself associates with the development of symptoms of the disease and their increase. When studying the anamnesis, it is advisable to establish the frequency, duration and characteristics of the main manifestations of exacerbations and evaluate the effectiveness of previously carried out treatment measures. Find out if there is a hereditary predisposition to COPD and other pulmonary diseases.
In cases where the patient underestimates his condition, and the doctor, during a conversation with him, cannot determine the nature and severity of the disease, special questionnaires should be used.
As the disease progresses, COPD is characterized by a steadily progressive course.
RISK FACTOR ANALYSIS
When questioning the patient, it is necessary to pay attention to the analysis of risk factors for each individual patient. Ask in detail about the patient’s childhood, clarify the features of climatic and living conditions, and working conditions. The main risk factors are smoking, prolonged exposure to occupational irritants, atmospheric and household air pollution, and genetic predisposition. Often risk factors can be combined.
■ Smoking (both active and passive). COPD develops in about 15% of men and women who smoke and in about 7% of former smokers.
✧If the patient smokes or has smoked, then it is necessary to study the smoking history (experience) and calculate the smoking index, expressed in “pack/years”:
Number of cigarettes smoked (days) Length of smoking (years)/20
The smoking index of more than 10 (pack/years) is a reliable risk factor for COPD.
Smoker index over 25 (pack/years) is a heavy smoker.
✧There is another formula for calculating the IR index: the number of cigarettes smoked during the day is multiplied by the number of months per year during which a person smokes at this intensity. If the result exceeds 120, then the patient must be considered as having a risk factor for COPD, and above 200 - as a heavy smoker.
■ Long-term exposure to occupational irritants (dust, chemical pollutants, vapors of acids and alkalis). On the development of the disease and stage pathological process work experience, the nature of the dust and its concentration in the inhaled air have a direct impact. The maximum permissible concentration for low-toxic dust is 4–6 mg/m3. Professional experience by the time the first symptoms of COPD appear is on average 10–15 years. COPD develops in approximately 4.5–24.5% of people working in hazardous and unfavorable working conditions.
■ Atmospheric and household air pollution. The most common and most dangerous pollutants are diesel fuel combustion products, car exhaust gases (sulfur dioxide, nitrogen and carbon dioxide, lead, carbon monoxide, benzopyrene), industrial waste - black soot, smoke, etc. Soil particles also enter the atmospheric air in large quantities dust (silicon, cadmium, asbestos, coal) during excavation work and multi-component dust during the construction of various objects. The role of outdoor air pollution in the development of COPD is still unclear, but is probably small compared to smoking.
■ Particular importance in the development of COPD is given to disturbances in the ecology of the home: increased levels of nitrogen dioxide, accumulation of combustion products of organic fuel in residential premises without adequate ventilation, etc. Home air pollution by products of combustion of organic fuel in heating devices, fumes from cooking in insufficiently ventilated areas is considered a significant risk factor for the development of COPD.
■ Infectious diseases respiratory tract. Recently, great importance has been given to the development of COPD respiratory infections(especially bronchiolitis obliterans) transferred to childhood. The role of these conditions in the pathogenesis of COPD deserves further study.
■ Genetic predisposition. The development of COPD in non-smokers under 40 years of age is primarily associated with a deficiency of:
✧ 1-antitrypsin - the basis of the body’s antiprotease activity and the main inhibitor of neutrophil elastase. In addition to congenital deficiency of 1-antitrypsin, hereditary defects may be involved in the development and progression of COPD;
✧ 1-antichymotrypsin;
✧ 2-macroglobulin, vitamin D-binding protein, cytochrome P4501A1, etc. This can probably explain the development of COPD not in every smoker.
■ The disease can significantly increase in its manifestations when several risk factors are combined in the same patient.
When collecting information from a patient with COPD, attention should be paid to studying the factors that provoke exacerbation of the disease: bronchopulmonary infection, increased exposure to exogenous damaging factors, inadequate physical activity, etc., and also evaluate the frequency of exacerbations and hospitalizations for COPD. It is necessary to clarify the presence of concomitant diseases (pathology of the cardiovascular system, gastrointestinal tract), which occur in more than 90% of patients with COPD and influence the severity of the disease and the nature of complex drug therapy. It is necessary to find out the effectiveness and tolerability of previously prescribed therapy, and the regularity of its implementation by the patient.

PHYSICAL EXAMINATION

PHYSICAL EXAMINATION
The results obtained from an objective examination of the patient (assessment of objective status) depend on the severity of bronchial obstruction, the severity of emphysema and the manifestation of pulmonary hyperinflation (overdistension of the lungs), the presence of complications such as respiratory failure and chronic pulmonary heart disease, and the presence of concomitant diseases. However, the absence of clinical symptoms does not exclude the patient from having COPD.
■ Examination of the patient:
✧Evaluation appearance the patient, his behavior, the reaction of the respiratory system to a conversation, movement around the office. The lips are pulled together in a “tube”, forced position - signs of severe COPD.
✧Assessment of skin color is determined by a combination of hypoxia, hypercapnia and erythrocytosis. Central gray cyanosis is usually a manifestation of hypoxemia. Acrocyanosis detected at the same time is usually a consequence of heart failure.
✧Inspection of the chest: its shape [deformation, “barrel-shaped”, inactive during breathing, paradoxical retraction (retraction) of the lower intercostal spaces during inspiration (Hoover’s sign)] and participation in the act of breathing of the auxiliary muscles of the chest and abdominal muscles; significant expansion of the chest in the lower sections are signs of severe COPD.
■ Percussion of the chest: a boxy percussion sound and drooping lower borders of the lungs are signs of emphysema.
■ Auscultatory picture
✧Hard or weakened vesicular breathing in combination with a low diaphragm confirms the presence of pulmonary emphysema.
✧Dry wheezing, increasing with forced exhalation, in combination with increased exhalation - obstruction syndrome.

LABORATORY AND INSTRUMENTAL STUDIES

LABORATORY AND INSTRUMENTAL STUDIES
The most important method for diagnosing COPD at the stage of laboratory and instrumental examination is the study of external respiratory function. This method is necessary not only for making a diagnosis, but also for determining the severity of the disease, selecting individual therapy, assessing the effectiveness of its implementation, clarifying the prognosis of the course of the disease and conducting an examination of work capacity.

STUDY OF EXTERNAL RESPIRATORY FUNCTION

STUDY OF EXTERNAL RESPIRATORY FUNCTION
Patients with chronic productive cough should undergo pulmonary function testing primarily to detect airflow limitation, even if they do not have shortness of breath.
■ Spirography. Reducing the lumen bronchial tree, manifested by chronic airflow limitation, is the most important documented factor in the diagnosis of COPD.
The main criterion for saying that a patient has chronic airflow limitation or chronic obstruction is a decrease in the ratio of post-bronchodilator FEV1 to forced vital capacity of the lungs to less than 70% of the proper value, and this change is recorded starting from stage I of the disease (lung course of COPD). Bronchial obstruction is considered chronic if it occurs at least 3 times within one year, despite therapy.
Partially reversible bronchial obstruction, characteristic of COPD, is determined in patients during a bronchodilation test. An increase in FEV1 of less than 12% of the predicted value and less than 200 ml is recognized as a marker of a negative bronchodilation response. If such a result is obtained, bronchial obstruction is documented as poorly reversible and indicates COPD.
■ Peak flowmetry. Determining the volume of peak expiratory flow is the simplest and fastest method for assessing the state of bronchial patency, but has low sensitivity, performed by a general practitioner or general practitioner medical practice. Peak expiratory flow values ​​may remain within normal limits for a long time in patients with COPD. Daily peak flowmetry is indicated to exclude bronchial asthma if the diagnosis remains unclear.
Peak flowmetry can be used to identify a group at risk of developing COPD as a screening method and to establish the negative impact of various pollutants.
In COPD, determination of peak expiratory flow is a necessary method of control during an exacerbation of the disease and especially during the rehabilitation stage. To assess the effectiveness of the therapy, the doctor should recommend that the patient monitor peak expiratory flow using peak flowmetry.

X-RAY STUDIES

X-RAY STUDIES
■ Chest X-ray. Primary X-ray examination to exclude other diseases (lung cancer, tuberculosis, etc.) accompanied by similar symptoms COPD clinical symptoms, is carried out on an outpatient basis with the direction of a therapist or general practitioner. With mild COPD, significant radiological changes are usually not detected.
If a diagnosis of COPD is established during an exacerbation, an X-ray examination is performed to exclude pneumonia, spontaneous pneumothorax, pleural effusion, etc.
X-ray of the chest organs makes it possible to detect emphysema (an increase in lung volume is indicated by a flat diaphragm and a narrow shadow of the heart on a direct radiograph, flattening of the diaphragmatic contour and an increase in the retrosternal space on a lateral radiograph). Confirmation of the presence of emphysema can be the presence of bullae on a radiograph, defined as radiolucent spaces more than 1 cm in diameter with a very thin arcuate border.
■ Chest CT is required when presenting symptoms are disproportionate to spirometric findings; to clarify changes detected during chest x-ray; to evaluate indications for surgical treatment. CT, especially high-resolution CT (1 to 2 mm pitch), has higher sensitivity and specificity for diagnosing emphysema than standard chest radiography.

BLOOD STUDIES

BLOOD STUDIES
■ Study of blood gas composition. Blood gas tests are not performed on outpatient patients.
In a clinic setting, digital and ear oximetry may be the means of choice for examining patients to determine blood saturation. Pulse oximetry is used to measure and monitor oxygen saturation, but it only records oxygenation levels and does not monitor changes in paCO2. If oxygen saturation is less than 92%, then a blood gas test is indicated.
Pulse oximetry is indicated to determine the need for oxygen therapy (if there is cyanosis, or cor pulmonale, or FEV1 is less than 50% of normal values).
■ Clinical analysis blood. Neutrophilic leukocytosis with band shift are signs of exacerbation of the disease. With the development of hypoxemia in patients with a predominant bronchitis type of COPD, polycythaemic syndrome is formed (increased number of red blood cells, high level hemoglobin, low ESR, increased hematocrit more than 47% in women and more than 52% in men, increased blood viscosity). Identified anemia may be the cause of shortness of breath or an aggravating factor.
Sputum examination is not performed on an outpatient basis.

OTHER STUDIES

OTHER STUDIES
■ ECG. Detects signs of hypertrophy of the right heart, it is possible to detect heart rhythm disturbances. Allows you to exclude the cardiac origin of respiratory symptoms.
■ EchoCG. EchoCG allows you to evaluate and identify signs pulmonary hypertension, dysfunction of the right and left parts of the heart and determine the severity of pulmonary hypertension.

SUMMARY
So, a COPD patient - who is he?
■ Smoker
■ middle-aged or elderly
■ short of breath
■ having a chronic cough with sputum, especially in the morning
■ complaining of regular exacerbations of bronchitis
■ having partially reversible obstruction.
When formulating the diagnosis of COPD, the severity of the disease is indicated: mild (stage I), moderate (stage II), severe (stage III) and extremely severe (stage IV), exacerbation or stable course of the disease; the presence of complications (cor pulmonale, respiratory failure, circulatory failure). Indicates risk factors and the smoking index. In case of severe disease, it is recommended to indicate the clinical form of COPD (emphysematous, bronchitis, mixed).
If there is difficulty in diagnosing COPD, determining the clinical form in patients with severe disease, interpreting additional examination data, incl. spirography, consultation with a pulmonologist is recommended.

DIFFERENTIAL DIAGNOSTICS

DIFFERENTIAL DIAGNOSTICS
BRONCHIAL ASTHMA
■ The main disease with which COPD must be differentiated is bronchial asthma. The main differential diagnostic criteria for COPD and bronchial asthma are given in Table. 2-12. Approximately 10% of COPD patients also have bronchial asthma. If it is difficult to carry out differential diagnosis with bronchial asthma, the patient is referred for consultation to a pulmonologist.
Table 2-12. Main criteria for differential diagnosis of COPD and bronchial asthma

* Bronchial asthma can begin in middle and old age.
** Allergic rhinitis, conjunctivitis, atopic dermatitis, urticaria.
*** The type of inflammation of the respiratory tract is most often determined by cytological examination sputum and fluid obtained from bronchoalveolar lavage.
Approximately 10% of COPD patients also have bronchial asthma.
OTHER DISEASES
In a number of clinical situations, it is necessary to make a differential diagnosis of COPD with the following diseases.
■ Heart failure. Wheezing in the lower parts of the lungs on auscultation. Significant decrease in left ventricular ejection fraction. Dilation of the heart. The x-ray shows expansion of the contours of the heart, congestion (up to pulmonary edema). When studying pulmonary function, disorders of the restrictive type are determined without restriction of air flow. Consultation with a cardiologist.
■ Bronchiectasis. Large volumes of purulent sputum. Frequently associated with bacterial infection. Rough moist rales of various sizes on auscultation. "Drumsticks". An X-ray or CT scan shows dilation of the bronchi and thickening of their walls. If suspected, consult a pulmonologist
■ Tuberculosis. Starts at any age. X-ray shows pulmonary infiltration or focal lesions. If suspected, consult a phthisiatrician.
■ Bronchiolitis obliterans. Development at a young age. No connection with smoking has been established. Contact with vapors, smoke. CT scan reveals areas of low density during exhalation. Often rheumatoid arthritis. If suspected, consult a pulmonologist.
Consultation with an otorhinolaryngologist to exclude pathology of the upper respiratory tract.

TREATMENT
TREATMENT GOALS
■ Prevention of disease progression.
■ Relief of symptoms.
■ Increased tolerance to physical activity.
■ Improving quality of life.
■ Prevention and treatment of complications.
■ Prevention of exacerbations.
■ Reduced mortality.

INDICATIONS FOR HOSPITALIZATION

INDICATIONS FOR HOSPITALIZATION
See the subsection “Indications for hospitalization of patients with exacerbation of COPD” in the “Drug treatment” section.

MAIN AREAS OF TREATMENT

MAIN AREAS OF TREATMENT
■ Reducing the influence of risk factors.
■ Educational programs.
■ Treatment of COPD when the condition is stable.
■ Treatment of exacerbation of the disease.

REDUCING THE INFLUENCE OF RISK FACTORS

REDUCING THE INFLUENCE OF RISK FACTORS
SMOKING
Quitting smoking is the first mandatory step in the COPD treatment program.
The patient must be clearly aware of the harmful effects of tobacco smoke on respiratory system. Quitting smoking is the single most effective and cost-effective way to reduce the risk of developing COPD and prevent progression of the disease.
Only two methods have proven effectiveness - nicotine replacement therapy and conversations with doctors and medical staff. The Tobacco Addiction Treatment Guide contains 3 programs.
Short courses of tobacco addiction treatment are more effective. Even a three-minute conversation with a smoker can encourage him to quit smoking, and such a conversation should be held with every smoker at every medical appointment. More intensive strategies increase the likelihood of quitting smoking.
To date, there is no drug therapy that can slow down the deterioration of lung function if the patient continues to smoke. In these patients, drugs cause only subjective improvement and alleviate symptoms during severe exacerbations.
INDUSTRIAL HAZARDS, ATMOSPHERIC AND HOME POLLUTANTS
Reducing the risk of the adverse effects of atmospheric and household pollutants requires both individual preventive measures and public and hygienic measures. Primary preventive measures consist of eliminating or reducing the influence of various pathogenic substances in the workplace. Secondary prevention is no less important - epidemiological control and early detection of COPD.
It is necessary to monitor and take into account the susceptibility and individual characteristics of each patient in the family history, the influence of industrial and household pollutants. Patients with COPD and those at high risk should avoid vigorous exercise during episodes of increased air pollution. When using solid fuels, adequate ventilation is necessary. The use of air purifiers and air filters aimed at protecting against pollutants from household sources or incoming atmospheric air has not been proven positive influence on health status.

TREATMENT OF COPD IN STABLE CONDITION

TREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN STABLE CONDITION
NON-DRUG TREATMENT
OXYGEN THERAPY
The effectiveness of drug therapy in patients with COPD decreases with increasing severity of the disease, and in extremely severe COPD it is quite low. The main cause of death in patients with COPD is acute respiratory failure. Correction of hypoxemia with oxygen is the most pathophysiologically based method of treating severe respiratory failure. The use of oxygen in patients with chronic hypoxemia must be constant, long-term and, as a rule, carried out at home, therefore this form of therapy is called long-term oxygen therapy. Long-term oxygen therapy is the only treatment that can reduce mortality in patients with COPD.
Long-term oxygen therapy is indicated for patients with severe COPD. Before prescribing long-term oxygen therapy to patients, it is also necessary to ensure that the possibilities of drug therapy have been exhausted and the maximum possible therapy does not lead to an increase in O2 above the limit values.
Unfortunately, long-term oxygen therapy at home for patients with COPD has not yet become a practice in Russian healthcare.
To determine the indications for long-term oxygen therapy, a patient with severe COPD is referred for a consultation with a pulmonologist.

DRUG THERAPY

DRUG THERAPY
Drug therapy is used to prevent and control symptoms of the disease, improve lung function, reduce the frequency and severity of exacerbations, improve general condition and increasing exercise tolerance. None of the available treatments for COPD affect long-term decline in pulmonary function.

MAIN MEDICINES

MAIN MEDICINES
Basis symptomatic treatment COPD are bronchodilators. All categories of bronchodilators increase exercise tolerance even in the absence of changes in FEV1. Inhalation therapy is preferred.
For all stages of COPD it is necessary: ​​exclusion of risk factors, annual vaccination with influenza vaccine and short-acting bronchodilators as needed. Typically, short-acting bronchodilators are used after 4–6 hours. Regular use of short-acting β2-agonists as monotherapy for COPD is not recommended.
Short-acting bronchodilators are used in patients with COPD as empirical therapy to reduce the severity of symptoms and limit physical activity.
Long-acting bronchodilators or their combination with short-acting β2-agonists and short-acting anticholinergics are prescribed to patients who remain symptomatic despite monotherapy with short-acting bronchodilators.
■ With mild (stage I) COPD and the absence of clinical manifestations of the disease, the patient does not need regular drug therapy.
■ For patients with intermittent symptoms of the disease, inhaled β2-agonists or short-acting M-anticholinergics are indicated, which are used as required.
■ If inhaled bronchodilators are not available, long-acting theophylline may be recommended.
■ If bronchial asthma is suspected, trial treatment with inhaled glucocorticoids is carried out.
■ In moderate, severe and extremely severe (stages II–IV) COPD, anticholinergic drugs are considered the first choice.
■ Short-acting M-anticholinergic (ipratropium bromide) has a longer-lasting bronchodilator effect compared to short-acting β2-agonists.
■ Xanthines are effective for COPD, but given their potential toxicity, they are “second-line” drugs. Xanthines may be added to regular inhaled bronchodilator therapy for more severe disease.
■ In stable COPD, a combination of anticholinergic drugs with short-acting β2-agonists or long-acting β2-agonists is more effective than either drug alone. Nebulizer therapy with bronchodilators is carried out for patients with severe and extremely severe COPD (stages III and IV of the disease), especially if they have noted improvement after treatment during exacerbation of the disease. To clarify the indications for nebulizer therapy, it is necessary to monitor the peak expiratory flow rate during 2 weeks of treatment and continue therapy even if the peak expiratory flow rate improves.
■ The therapeutic effect of glucocorticoids in COPD is much less pronounced than in bronchial asthma.
Regular (ongoing) treatment with inhaled glucocorticoids is indicated for patients with stage III (severe) and stage IV (extremely severe) COPD with repeated exacerbations of the disease requiring antibiotics or oral glucocorticoids at least once a year.
■ Systemic glucocorticoids are not recommended for stable COPD.
■ If by economic reasons the use of inhaled glucocorticoids is limited; a course of systemic glucocorticoids can be prescribed (for no longer than 2 weeks) and referred for consultation to a pulmonologist.

OTHER MEDICINES

OTHER MEDICINES
Vaccines
■ In order to prevent exacerbation of COPD during epidemic outbreaks of influenza, it is recommended to use vaccines containing killed or inactivated viruses, administered once in October–the first half of November annually.
■ The influenza vaccine can reduce severity and mortality in patients with COPD by 50%. A pneumococcal vaccine containing 23 virulent serotypes is also used, but there is insufficient data on its effectiveness in COPD. However, according to the Committee of Advisors on Immunization Practices, patients with COPD are considered to be at high risk of developing pneumococcal disease and are included in the target group for vaccination.
Mucolytic agents
■ Mucoactive drugs for COPD are prescribed only to patients with viscous sputum. To reduce the frequency of exacerbations and the severity of exacerbation symptoms in this category of patients, it is recommended to prescribe N-acetylcysteine ​​in daily dose 600–1200 mg for 3 to 6 months.
In table 2-13 shows the treatment scheme for patients depending on the severity of COPD.
Table 2-13. Treatment regimen for various stages of COPD without exacerbation

REHABILITATION

REHABILITATION
For patients with COPD at all stages of the process high efficiency have physical training programs that increase exercise tolerance and reduce shortness of breath and fatigue. Ideal candidates for inclusion in rehabilitation programs are patients with severe and extremely severe COPD, i.e. patients whose disease imposes serious restrictions on the usual level of functional activity.
Proven effects of pulmonary rehabilitation include:
■ improvement of physical performance;
■ reducing the intensity of dyspnea;
■ improving the quality of life;
■ reduction in the number of hospitalizations and days spent in hospital;
■ reducing the severity of depression and anxiety associated with COPD;
■ improvement in the condition of patients after a pulmonary rehabilitation program is prolonged;
■ improving patient survival;
■ training the respiratory muscles brings a positive effect, especially when combined with general training exercises.
Psychosocial interventions have positive effects.

PHYSICAL TRAINING

PHYSICAL TRAINING
The “ideal” duration of training programs has not been precisely established; the optimal training period is considered to be 8 weeks.
The duration of one physical training (depending on the patient’s condition) varies from 10 to 45 minutes, the frequency of training is from 1 to 5 times a week. The load intensity is set taking into account subjective feelings sick. Physical training must include exercises to develop strength and endurance lower limbs(metered walking, bicycle ergometer); in addition, they may include exercises that increase the strength of the muscles of the upper shoulder girdle (lifting dumbbells 0.2–1.4 kg, manual ergometer).

ASSESSMENT AND CORRECTION OF NUTRITIONAL STATUS

ASSESSMENT AND CORRECTION OF NUTRITIONAL STATUS
Weight loss and decreased muscle mass are a common problem in patients with COPD. The loss of muscle mass, as well as a change in the ratio of muscle fiber types, is closely associated with a decrease in the strength and endurance of the skeletal and respiratory muscles of patients. A decrease in body mass index is an independent risk factor for mortality in patients with COPD.
The most rational diet - frequent use small portions of food, since with a limited ventilation reserve, the usual amount of food can lead to a noticeable increase in dyspnea due to displacement of the diaphragm. The optimal way to correct nutritional deficiency is a combination of additional nutrition with physical training, which has a nonspecific anabolic effect.

MANAGEMENT OF PATIENTS WITH COPD COMPLICATED BY THE DEVELOPMENT OF HEART PULMONARY

MANAGEMENT OF PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE COMPLICATED BY THE DEVELOPMENT OF PULMONARY HEART
Chronic cor pulmonale refers to changes in the right ventricle, hypertrophy, dilatation and dysfunction resulting from pulmonary hypertension that developed as a result of a number of pulmonary diseases, and not associated with a primary lesion of the left atrium or congenital defects hearts. The development of pulmonary hypertension and cor pulmonale is a natural outcome of long-term COPD.
Patients with the bronchitis type of COPD are characterized by earlier development of cor pulmonale than patients with the emphysematous type. Clinical manifestations of progressive respiratory failure in patients with the bronchitis type are observed more often in old age.
The goal of treatment of COPD patients with chronic cor pulmonale is to prevent further increase in pulmonary hypertension. The most important tasks to achieve this goal should be considered to improve oxygen transport and reduce hypoxemia.
Complex therapy of chronic pulmonary heart disease includes, first of all, the treatment of COPD itself and the correction of respiratory and heart failure. Treatment and prevention of exacerbations of COPD are the most important components of complex therapy for chronic pulmonary heart disease. Recommendations based on the principles of evidence-based medicine for the treatment of chronic pulmonary heart disease and COPD are still missing.

TREATMENT OF PATIENTS WITH ACUTE COPD

TREATMENT OF PATIENTS WITH ACHIEVEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Risk factors for exacerbation of COPD:
■ infection: viral (Rhinovirus spp., Influenza); bacterial (Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Enterobacteriaceae spp., Pseudomonas spp.);
■ harmful environmental factors;
■ polluted air;
■ long-term oxygen therapy;
■ ineffective pulmonary resuscitation.
Relapses of exacerbation of COPD occur in 21–40% of cases.
Risk factors for recurrent exacerbations of COPD include:
■ low FEV1 values,
■ increased need for bronchodilators and glucocorticoids,
■ previous exacerbations of COPD (more than three in the last 2 years),
■ previously administered antibacterial therapy (mainly ampicillin),
■ the presence of concomitant diseases (heart failure, coronary insufficiency, renal and/or liver failure).
When treating patients with exacerbation of COPD, the doctor must evaluate the following circumstances: the severity of COPD, the presence of concomitant pathology and the severity of previous exacerbations.
Diagnosis of exacerbation of COPD is based on certain clinical and diagnostic criteria(Table 2-14).
Table 2-14. Clinical signs and the scope of diagnostic examination for exacerbation of COPD in an outpatient setting

* Concomitant diseases that aggravate exacerbation of COPD (coronary artery disease, heart failure, diabetes, renal and/or liver failure).

TREATMENT OF ACUTE COPD IN AN OUTPATIENT SETTING

TREATMENT OF ACHIEVEMENTS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN AN OUTPATIENT CONDITION
With a mild exacerbation of the disease, there is a need to increase the dose and/or frequency of taking bronchodilators.
■ If not used previously, then anticholinergic drugs are added. Preference is given to inhaled combined bronchodilators (anticholinergic drugs + short-acting β2-agonists).
■ If it is impossible (by various reasons) applications inhalation forms Medicines, and also if their effectiveness is insufficient, theophylline can be prescribed.
■ For bacterial exacerbations of COPD (increased cough with purulent sputum, increased body temperature, weakness and malaise), the use of amoxicillin or macrolides (azithromycin, clarithromycin) is indicated.
■ For moderate exacerbation (increased cough, shortness of breath, increased amount of purulent sputum, increased body temperature, weakness and malaise), along with increased bronchodilator therapy, prescribe antibacterial drugs(Table 2-15).
Table 2-15. Antibacterial therapy for exacerbation of COPD in an outpatient setting

■ Systemic glucocorticoids are prescribed in parallel with bronchodilator therapy at a daily dose of 0.5 mg/(kg day), but not less than 30 mg of prednisolone per day or another systemic glucocorticoid in an equivalent dose for 10 days, followed by discontinuation.

INDICATIONS FOR HOSPITALIZATION

INDICATIONS FOR HOSPITALIZATION
■ Increased severity of clinical manifestations (eg, sudden development of dyspnea at rest).
■ Initially severe COPD.
■ The appearance of new symptoms characterizing the severity of respiratory and heart failure (cyanosis, peripheral edema).
■ Lack of positive dynamics from outpatient treatment or deterioration of the patient’s condition during treatment.
■ Severe concomitant diseases.
■ New occurrence of cardiac arrhythmia.
■ The need for differential diagnosis with other diseases.
■ Older age of the patient with a burdened somatic status.
■ Impossibility of treatment at home.

APPROXIMATE DURATION OF TEMPORARY DISABILITY

APPROXIMATE DURATION OF TEMPORARY DISABILITY
9–16 days for exacerbation, depending on severity.

EDUCATION OF THE PATIENT

EDUCATION OF THE PATIENT
Patient education to motivate smoking cessation has the greatest potential impact on the course of COPD.
For patients with COPD, it is necessary to understand the nature of the disease, the risk factors leading to the progression of the disease, and an understanding of one’s own role and the role of the doctor to achieve optimal treatment results. Training should be tailored to the needs and environment of the individual patient, interactive, aimed at improving quality of life, easy to implement, practical and appropriate to the intellectual and social level of the patient and their caregivers.
It is recommended to include the following components in training programs: smoking cessation; information about COPD; basic approaches to therapy, specific treatment issues [in particular, the correct use of inhaled drugs; self-management skills (peak flowmetry) and decision-making during an exacerbation]. Patient education programs should include the distribution of printed materials, educational sessions, and seminars (both providing information about the disease and teaching patients specific skills).

EDUCATIONAL PROGRAMS

EDUCATIONAL PROGRAMS
For COPD patients, education plays an important role. Educating patients to encourage them to quit smoking has the greatest potential impact on the course of COPD. Training should be provided on all aspects of the treatment of the disease and can be in different forms: consultations with a doctor or other medical professional, home programs, outside classes, full-fledged pulmonary rehabilitation programs.
■ Patients need to understand the nature of the disease, risk factors leading to progression, understanding their own role and the role of the doctor in achieving optimal treatment results.
■ Education should be tailored to the needs and environment of the individual patient, interactive, easy to implement, practical and appropriate to the intellectual and social level of the patient and those caring for him, and aimed at improving quality of life.
■ It is recommended to include the following components in training programs: smoking cessation; basic information about COPD; general approaches to therapy, specific treatment issues; self-management skills and decision-making during an exacerbation.
■ There are different types of education programs, ranging from simple distribution of printed materials to educational classes and seminars aimed at providing information about the disease and teaching patients specific skills.
■ Training is most effective when conducted in small groups.
■ The cost-effectiveness of COPD education programs depends largely on local factors that determine the cost of care.

FORECAST
Continued smoking usually contributes to the progression of airway obstruction, leading to early disability and shortened life expectancy. After quitting smoking, the decline in FEV1 and disease progression slow down. To alleviate the condition, many patients are forced to take drugs in gradually increasing doses for the rest of their lives, and also use additional drugs during exacerbations.

According to the international GOLD program (2003), in patients with COPD it is necessary to indicate the phase of the disease and the severity of the disease. There are four degrees of severity (stages) of COPD.

Table 1

The main signs of various types COPD (severe)

Rice. 2. Patient with COPD: “cyanotic swelling.” “Cyanotic edema” is cyanotic due to severe hypoxemia and has peripheral edema as a manifestation of heart failure. When examining them, signs of chronic bronchitis and “ pulmonary heart" Shortness of breath is insignificant, the main manifestations of exacerbation of the disease are cough with purulent sputum, cyanosis and signs of hypercapnia (headache, anxiety, tremor, confusion of speech, etc.). It should be remembered that uncontrolled administration of oxygen to this group of patients can significantly aggravate (!) their existing respiratory failure.

.

Rice. 3. Patient with COPD: “pink puffer.” “Pink puffers” are not cyanotic in appearance and have low nutrition. When examined, signs of pulmonary emphysema predominate. The cough is minor, and the main complaint is shortness of breath on exertion. The work of the respiratory muscles is significantly increased. Changes in the gas composition of arterial blood are minimal. The patient usually breathes shallowly. Exhalation is carried out through half-closed lips (“puffing” breathing). Patients with COPD often sit with their torso bent forward, resting their hands on their knees, on the skin of which trophic changes form (Dahl sign).

table 2

Classification of COPD severity

The classification of COPD severity proposed by WHO experts is based on the severity of bronchial obstruction, assessed using spirometry (Table 2).

The main phases of the course of COPD are distinguished: stable and exacerbation (deterioration of the patient’s condition, manifested by an increase in symptoms and functional disorders, occurring suddenly or gradually and lasting at least 5 days).

Complications: acute or chronic respiratory failure, pulmonary hypertension, cor pulmonale, secondary polycythemia, heart failure, pneumonia, spontaneous pneumothorax, pneumomediastinum.

Formulationdiagnosis(based on the recommendations of the All-Russian Scientific Society of Pulmonologists):

1. COPD, predominantly bronchitis type, stage IV, extremely severe, exacerbation, chronic purulent bronchitis, exacerbation. Chronic decompensated pulmonary heart, N III, DN III.

2. COPD, predominantly emphysematous type, stage III, chronic purulent bronchitis, remission. DN III, N II.

We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"

Pulmonary obstruction is a progressive disease of the bronchopulmonary system, in which the air in the respiratory tract flows incorrectly. This is due to abnormal inflammation of the lung tissue in response to external stimuli.

This is a non-infectious disease, it is not associated with the activity of pneumococci. The disease is common; according to WHO, 600 million people worldwide suffer from pulmonary obstruction. Mortality statistics indicate that 3 million people die from the disease every year. With the development of megacities, this figure is constantly growing. Scientists believe that in 15-20 years the mortality rate will double.

The problem of the prevalence and incurability of the disease lies in the lack of early diagnosis. A person does not attach importance to the first signs of obstruction - cough in the morning and shortness of breath, which appears faster than in peers when performing the same physical activity. Therefore, patients seek medical help at a stage when it is impossible to stop the pathological destructive process.

Risk factors and mechanism of disease development

Who is at risk for pulmonary obstruction and what are the risk factors for the disease? Smoking comes first. Nicotine several times increases the likelihood of pulmonary obstruction.

Occupational risk factors play a major role in the development of the disease. Professions in which a person is constantly in contact with industrial dust (ore, cement, chemicals):

• miners;
• builders;
• pulp processing industry workers;
• railway workers;
• metallurgists;
• grain and cotton processing workers.

Atmospheric particles that can serve as a trigger for the development of the disease are exhaust gases, industrial emissions, and industrial waste.

Hereditary predisposition also plays a role in the occurrence of pulmonary obstruction. Internal risk factors include hypersensitivity of respiratory tract tissues and lung growth.

The lungs produce special enzymes - protease and antiprotease. They regulate the physiological balance of metabolic processes and maintain the tone of the respiratory organs. When there is systematic and prolonged exposure to air pollutants (harmful air particles), this balance is disrupted.

As a result, the skeletal function of the lungs is impaired. This means that the alveoli (cells of the lung) collapse and lose their anatomical structure. Numerous bullae (vesicle-like formations) form in the lungs. Thus, the number of alveoli gradually decreases and the rate of gas exchange in the organ decreases. People begin to feel severe shortness of breath.

The inflammatory process in the lungs is a response to pathogenic aerosol particles and progressive airflow limitation.

Stages of development of pulmonary obstruction:

• tissue inflammation;
• pathology of small bronchi;
• destruction of parenchyma (lung tissue);
• limitation of air flow speed.

Symptoms of pulmonary obstruction

Obstructive airway diseases are characterized by three main symptoms: shortness of breath, cough, and sputum production.

The first symptoms of the disease are associated with breathing problems. The person is short of air. It is difficult for him to climb several floors. Going to the store takes longer, a person constantly stops to catch his breath. It becomes difficult to leave the house.

System of development of progressive dyspnea:

• initial signs of shortness of breath;
• difficulty breathing during moderate physical activity;
• gradual limitation of loads;
• significant reduction in physical activity;
• shortness of breath when walking slowly;
• refusal of physical activity;
• constant shortness of breath.

Patients with pulmonary obstruction develop a chronic cough. It is associated with partial obstruction of the bronchi. The cough can be constant, daily, or intermittent, with ups and downs. Typically, the symptom is worse in the morning and may occur throughout the day. At night, coughing does not bother a person.

The shortness of breath is progressive and persistent (daily) in nature and only gets worse over time. It also increases with physical activity and respiratory diseases.

With pulmonary obstruction, patients experience sputum discharge. Depending on the stage and advanced stage of the disease, the mucus can be scanty, transparent or abundant, purulent.

The disease leads to chronic respiratory failure - the inability of the pulmonary system to provide high-quality gas exchange. Saturation (oxygen saturation of arterial blood) does not exceed 88%, while the norm is 95-100%. This is a life-threatening condition. In the last stages of the disease, a person may experience apnea at night - suffocation, stopping pulmonary ventilation for more than 10 seconds, on average it lasts half a minute. In extremely severe cases, respiratory arrest lasts 2-3 minutes.

During the daytime, a person feels very tired, drowsiness, and instability of the heart.

Pulmonary obstruction leads to early loss of ability to work and a reduction in life expectancy; a person acquires disability status.

Obstructive changes in the lungs in children

Obstruction of the lungs in children develops as a result of respiratory diseases, malformations of the pulmonary system, chronic pathologies of the respiratory system. The hereditary factor is of no small importance. The risk of developing pathology increases in a family where parents constantly smoke.

Obstruction in children is fundamentally different from obstruction in adults. Blockage and destruction of the respiratory tract are a consequence of one of the nosological forms (a specific independent disease):

1. Chronical bronchitis. The child has a wet cough, wheezing of various sizes, and exacerbations up to 3 times a year. The disease is a consequence of an inflammatory process in the lungs. Initial obstruction occurs due to excess mucus and phlegm.
2. Bronchial asthma. Despite the fact that bronchial asthma and chronic pulmonary obstruction are different diseases, in children they are interrelated. Asthmatics are at risk of developing obstruction.
3. Bronchopulmonary dysplasia. This is a chronic pathology in children during the first two years of life. The risk group includes premature and low birth weight babies who have had acute respiratory viral infection immediately after birth. In such infants, the bronchioles and alveoli are affected, and the functionality of the lungs is impaired. Respiratory failure and oxygen dependence gradually appear. Gross tissue changes occur (fibrosis, cysts), and the bronchi become deformed.
4. Interstitial lung diseases. This is a chronic hypersensitivity of lung tissue to allergenic agents. Develops from inhalation of organic dust. It is expressed by diffuse damage to the parenchyma and alveoli. Symptoms: cough, wheezing, shortness of breath, poor ventilation.
5. Obliterating bronchiolitis. This is a disease of the small bronchi, which is characterized by narrowing or complete blockage of the bronchioles. Such obstruction in a child mainly manifests itself in the first year of life.. The cause is ARVI, adenoviral infection. Signs: non-productive, severe, recurrent cough, shortness of breath, weak breathing.

Diagnosis of pulmonary obstruction

When a person consults a doctor, an anamnesis (subjective data) is collected. Differential symptoms and markers of pulmonary obstruction:

• chronic weakness, decreased quality of life;
• unstable breathing during sleep, loud snoring;
• weight gain;
• increase in the circumference of the collar zone (neck);
• blood pressure is higher than normal;
• pulmonary hypertension (increased pulmonary vascular resistance).

The mandatory examination includes a general blood test to exclude a tumor, purulent bronchitis, pneumonia, and anemia.

A general urine test helps to exclude purulent bronchitis, which reveals amyloidosis, a disorder of protein metabolism.

A general sputum analysis is rarely done, as it is not informative.

Patients undergo peak flowmetry, a functional diagnostic method that evaluates expiratory flow. This is how the degree of airway obstruction is determined.

All patients undergo spirometry - a functional study of external respiration. Assess the speed and volume of breathing. Diagnosis is carried out using a special device - a spirometer.

During the examination, it is important to exclude bronchial asthma, tuberculosis, bronchiolitis obliterans, and bronchiectasis.

Treatment of the disease

The goals of treating pulmonary obstruction are multifaceted and include the following steps:

• improvement of respiratory function of the lungs;
• constant monitoring of symptoms;
• increasing resistance to physical activity;
• prevention and treatment of exacerbations and complications;
• stopping the progression of the disease;
• minimizing side effects of therapy;
• improving quality of life;

The only way to stop the rapid destruction of your lungs is to completely stop smoking.

In medical practice, special programs have been developed to combat nicotine addiction in smokers. If a person smokes more than 10 cigarettes a day, then he is prescribed a course of drug therapy - short - up to 3 months, long - up to a year.

Nicotine replacement treatment is contraindicated in the following internal pathologies:

• severe arrhythmia, angina pectoris, myocardial infarction;
• circulatory disorders in the brain, stroke;
• ulcers and erosions of the gastrointestinal tract.

Patients are prescribed bronchodilator therapy. Basic treatment includes bronchodilators to open up the airways. The drugs are prescribed both intravenously and inhalation. When inhaled, the medicine instantly penetrates the affected lung, has a rapid effect, and reduces the risk of developing negative consequences and side effects.

During inhalation you need to breathe calmly, the duration of the procedure is on average 20 minutes. When taking deep breaths, there is a risk of developing severe coughing and choking.

Effective bronchodilators:

• methylxanthines – Theophylline, Caffeine;
• anticholinergics - Atrovent, Berodual, Spiriva;
• b2-agonists – Fenoterol, Salbutamol, Formoterol.

In order to increase survival, patients with respiratory failure are prescribed oxygen therapy (at least 15 hours per day).

To thin the mucus, enhance its removal from the walls of the respiratory tract and dilate the bronchi, a complex of drugs is prescribed:

• Guaifenesin;
• Bromhexine;
• Salbutamol.

To consolidate treatment, obstructive pneumonia requires rehabilitation measures. The patient must do physical training every day to increase strength and endurance. Recommended sports are walking from 10 to 45 minutes daily, exercise bike, lifting dumbbells. Nutrition plays an important role. It should be rational, high-calorie, and contain a lot of protein. An integral part of the rehabilitation of patients is psychotherapy.

Chronic obstructive pulmonary disease (COPD) is a progressive disease of the bronchi and lungs associated with an increased inflammatory response of these organs to the action of harmful factors (dust and gases). It is accompanied by impaired ventilation of the lungs due to deterioration of bronchial patency.

Doctors also include emphysema in the concept of COPD. Chronic bronchitis is diagnosed by symptoms: the presence of cough with sputum for at least 3 months (not necessarily consecutive) over the past 2 years. Pulmonary emphysema is a morphological concept. This is an expansion of the airways beyond the terminal sections of the bronchi, associated with the destruction of the walls of the respiratory vesicles and alveoli. In patients with COPD, these two conditions are often combined, which determines the characteristics of the symptoms and treatment of the disease.

Prevalence of the disease and its socio-economic significance

COPD is recognized as a global medical problem. In some countries, such as Chile, it affects one in five adults. In the world, the average prevalence of the disease among people over 40 years of age is about 10%, with men getting sick more often than women.

In Russia, morbidity data largely depend on the region, but in general they are close to global indicators. The prevalence of the disease increases with age. In addition, it is almost twice as high among people living in rural areas. Thus, in Russia, every second person living in a village suffers from COPD.

In the world, this disease is the fourth leading cause of death. Mortality from COPD is increasing very quickly, especially among women. Factors that increase the risk of dying from this disease are increased weight, severe bronchospasm, low endurance, severe shortness of breath, frequent exacerbations of the disease and pulmonary hypertension.

The costs of treating the disease are also high. Most of them occur during inpatient treatment of exacerbations. COPD therapy costs the state more than treatment. The frequent incapacity for work of such patients, both temporary and permanent (disability), is also important.

Causes and mechanism of development

The main cause of COPD is smoking, active and passive. Tobacco smoke damages the bronchi and the lung tissue itself, causing inflammation. Only 10% of cases of the disease are associated with the influence of occupational hazards and constant air pollution. Genetic factors may also be involved in the development of the disease, causing a deficiency of certain lung-protecting substances.

Predisposing factors to the development of the disease in the future are low birth weight of the child, as well as frequent respiratory diseases suffered in childhood.

At the onset of the disease, mucociliary transport of sputum is disrupted, which ceases to be cleared from the respiratory tract in a timely manner. Mucus stagnates in the lumen of the bronchi, creating conditions for the proliferation of pathogenic microorganisms. The body reacts with a protective reaction - inflammation, which becomes chronic. The walls of the bronchi are saturated with immunocompetent cells.

Immune cells release a variety of inflammatory mediators that damage the lungs and trigger a “vicious cycle” of disease. Oxidation and the formation of free oxygen radicals, which damage the walls of lung cells, increase. As a result, they are destroyed.

Impaired bronchial patency is associated with reversible and irreversible mechanisms. Reversible include spasm of the bronchial muscles, swelling of the mucous membrane, and increased mucus secretion. Irreversible are caused by chronic inflammation and are accompanied by the development of connective tissue in the walls of the bronchi, the formation of emphysema (bloating of the lungs, in which they lose the ability to ventilate normally).

The development of emphysema is accompanied by a decrease in blood vessels through the walls of which gas exchange occurs. As a result, the pressure in the pulmonary vasculature increases - pulmonary hypertension occurs. The increased pressure puts strain on the right ventricle, which pumps blood into the lungs. Develops with the formation of the pulmonary heart.

Symptoms

COPD develops gradually and lasts for a long time without external manifestations. The first symptoms of the disease are a cough with light sputum or, especially in the morning, and frequent colds.

The cough gets worse during the cold season. Shortness of breath increases gradually, appearing first with exertion, then with normal activity, and then at rest. It occurs approximately 10 years later than cough.

Periodic exacerbations occur, lasting several days. They are accompanied by increased coughing, shortness of breath, wheezing, and pressing pain in the chest. Physical exercise tolerance decreases.

The amount of sputum increases or decreases sharply, its color and viscosity change, it becomes purulent. The frequency of exacerbations is directly related to life expectancy. Exacerbations of the disease occur more often in women and worsen their quality of life.

Sometimes you can find a division of patients according to the predominant characteristic. If inflammation of the bronchi is important in the clinic, in such patients cough and lack of oxygen in the blood predominate, causing a blue tint to the hands, lips, and then the entire skin (cyanosis). Heart failure develops rapidly with the formation of edema.

If emphysema, manifested by severe shortness of breath, is of greater importance, then cyanosis and cough are usually absent or they appear in the later stages of the disease. Such patients are characterized by progressive weight loss.

In some cases, there is a combination of COPD and bronchial asthma. In this case, the clinical picture takes on the features of both of these diseases.

In COPD, a variety of extrapulmonary symptoms associated with a chronic inflammatory process are recorded:

• weight loss;
• neuropsychiatric disorders, sleep disturbances.

Diagnostics

The diagnosis of COPD is based on the following principles:

• confirmation of smoking, active or passive;
• objective examination (examination);
• instrumental confirmation.

The problem is that many smokers deny they have the disease, considering cough or shortness of breath to be a consequence of a bad habit. Often they seek help in advanced cases when they become unable to work. It is no longer possible to cure the disease or slow its progression at this time.

In the early stages of the disease, external examination does not reveal changes. Subsequently, exhalation through closed lips, a barrel-shaped chest, the participation of additional muscles in breathing, retraction of the abdomen and lower intercostal spaces during inhalation are determined.

Auscultation reveals dry whistling rales, and percussion reveals a boxy sound.

Among the laboratory methods, a general blood test is required. It may show signs of inflammation, anemia, or blood thickening.

Cytological examination of sputum can exclude malignancy and also evaluate inflammation. To select antibiotics, you can use sputum culture (microbiological examination) or analyze bronchial contents, which are obtained during bronchoscopy.
A chest x-ray is taken to rule out other diseases (pneumonia, lung cancer). For the same purpose, bronchoscopy is prescribed. Electrocardiography is used to assess pulmonary hypertension.

The main method for diagnosing COPD and assessing the effectiveness of treatment is spirometry. It is performed at rest and then after inhalation of bronchodilators, for example, salbutamol. Such a study helps to identify bronchial obstruction (reduced airway patency) and its reversibility, that is, the ability of the bronchi to return to normal after using medications. In COPD, irreversible bronchial obstruction is often observed.

If the diagnosis of COPD has already been confirmed, peak flowmetry with determination of peak expiratory flow can be used to monitor the course of the disease.

Treatment

The only way to reduce the risk of the disease or slow its progression is to stop smoking. You can't smoke in front of children!

Attention should also be paid to the cleanliness of the surrounding air and respiratory protection when working in hazardous conditions.

Drug treatment is based on the use of drugs that dilate the bronchi - bronchodilators. They are mainly used. Combination agents are the most effective.

The doctor may prescribe the following groups of medications depending on the severity of the disease:

• Short-acting M-anticholinergics (ipratropium bromide);
• Long-acting M-anticholinergics (tiotropium bromide);
• long-acting beta-agonists (salmeterol, formoterol);
• short-acting beta-agonists (salbutamol, fenoterol);
• long-acting theophyllines (theotard).

For moderate and severe forms of inhalation can be carried out with. In addition, spacers are often useful in older people.

Additionally, in severe cases of the disease, inhaled glucocorticosteroids (budesonide, fluticasone) are prescribed, usually in combination with long-acting beta-agonists.

(sputum thinners) are indicated only for some patients with thick, difficult to cough up mucus. For long-term use and prevention of exacerbations, only acetylcysteine ​​is recommended. Antibiotics are prescribed only during exacerbation of the disease.