Social significance of the problem of bronchial asthma. Bronchial asthma is an urgent problem in world medicine. The main variants of the course of BA

Bronchial asthma is a chronic disease characterized by repeated attacks of expiratory dyspnea or suffocation caused by allergic reactions occurring in the tissues of the bronchi (mainly small bronchi and bronchioles). The urgency of the problem of bronchial asthma is currently determined by the increase in its prevalence and severity of the course, up to death at the height of an asthmatic attack, the complexity of diagnosis and the appointment of optimal individualized methods of treatment. The immediate cause of bronchial asthma is sensitization to exoallergens (more often) and endoallergens. Exoallergens that enter the body from the environment play a major role in the development of bronchial asthma. According to the classification of A. D. Ado, A. A. Polner (1963), exoallergens are divided into 2 groups: allergens of non-infectious and infectious origin. Accordingly, there are 2 forms of bronchial asthma: non-infectious-allergic (atonic, allergic) and infectious-allergic. The combination of non-infectious and infectious factors in the etiology of bronchial asthma indicates a sour cream form of the disease. Depending on the affiliation of the component, which is an allergen, the following allergens of non-infectious origin are distinguished: household (house dust, library dust, pillow feathers), pollen (timothy, fescue, cocksfoot, ragweed, poplar fluff, etc.), epidermal (fluff, wool, dandruff, animal and human hair), food (strawberries, strawberries, chocolate, citrus fruits, chicken eggs, fish, etc.), medicinal (antibiotics, acetylsalicylic acid, novocaine, iodine preparations, etc.), chemical (preservatives, washing powders, pesticides, varnishes, paints, etc.). Allergens of infectious origin include bacterial (Neisseria, hemolytic streptococcus, hemolytic staphylococcus, Proteus, Escherichia coli, etc.), viral (influenza, parainfluenza, respiratory syncytial virus, adenovirus, rhinovirus, etc.), fungal (candida, etc.). ). Endoallergens are formed in the human body as a result of damaging effects on organs and tissues of various environmental factors, for example, viruses, bacteria, fungi, drugs, chemicals, high and low temperatures, injuries, etc. Participation of endoallergens in the development of bronchial asthma is not noted. in all patients,
Compared with exoallergens, they are less likely to play a role in the formation of the disease. At the heart of an asthmatic attack are allergic reactions that develop in the mucous membrane of the bronchioles and small bronchi upon repeated contact with an etiologically significant allergen. The most studied in bronchial asthma are allergic reactions of immediate and delayed type. Immediate type hypersensitivity is mediated by the B-system of immunity (humoral tyne of hypersensitivity), according to the classification of immunopathological processes proposed by Cell, Coombs (1968), refers to type I reactions (atonic or anaphylactic reactions). Non-infectious-allergic bronchial asthma develops predominantly according to the type of immediate allergy. In the mechanism of immediate allergic reactions, 3 interrelated phases are distinguished (AD Ado): phase - immunological. In response to the initial entry of an allergen (antigen) into the body, specific antibodies, reagins, are formed in the blood, which by their immunological nature belong to class E immunoglobulins. be genetically determined. The essence of sensitization is in the formation and accumulation of specific reagins (IgE antibodies), in this phase of immediate allergic reactions there are no clinical signs of the disease. Subsequently, upon repeated contact with the allergen in the bronchial mucosa, the antigen is combined with IgE fixed on basophilic granulocytes and connective tissue mastocytes. phase - pathochemical. Under the influence of the antigen-antibody immune complex, the enzyme systems of membranes of basophilic granulocytes and mastocytes (proteases, histidine decarboxylase, etc.) are activated, the structural and functional properties of membranes change, the formation and release of biologically active substances (mediators) - histamine, serotonin, bradykinin, acetylcholine, slowly reacting anaphylaxis substances, the activity of which is determined by leukotrieps C4, D4, and E4, prostaglandins, eosinophilic chemotactic factor of anaphylaxis - leukotriene B and 5-HEGE, and other phase - pathophysiological. The influence of mediators of allergic inflammation, the prevalence of cholinergic processes over adrenergic ones (normally they are balanced) occurs due to an increase in the synthesis of cyclic guanosine monophosphate (c-GMP, due to an increase in the content of prostaglandins p2 of a delayed type, they are mediated by the T-immunity system (cellular type of hypersensitivity), belong to type IV allergic reactions are of primary importance in the development of an infectious-allergic form of bronchial asthma. At the same time, in the first phase (immunological), during the primary exposure to the allergen, sensitized T-lymphocytes are formed and accumulate in the body (the process of sensitization). Upon repeated contact with the allergen, T-lymphocytes interact with it through receptors located on the cells, which are immunoglobulins of various classes. In phase II (pathochemical), T-lymphocytes secrete biologically active substances, lymphokines (mediators of delayed hypersensitivity) - transfer factors, chemotaxis, lympholysis, a factor that inhibits macrophage migration, blocking blast formation and mitosis, lymphotoxin, etc. In phase III (pathophysiological) under the action of lymphokines, bronchospasm occurs (the leading mechanism is a decrease in c-AMP activity), edema and infiltration of the mucous membrane, hypersecretion of viscous mucus, which is clinically manifested by an asthmatic attack. Much less frequently observed, in particular in some forms of bronchial asthma (for example, fungal etiology), type III allergic reactions, immunocomplex, such as the Arthus phenomenon, occurring with the participation of IgG (precipitating antibodies) and complement (C3 and C5). In this case, immune complexes (IgQ allergen) are fixed on the cell membranes of small blood vessels, leuko- and platelet conglomerates, microthrombosis are formed, which leads to the formation of tissue damage. Complement fractions Q and Cs contribute to the release of mediators of the allergic reaction, causing the development of the pathophysiological phase. Even less frequently, with bronchial asthma, allergic reactions of type II are noted - cytotoxic or cytolytic, carried out by immunoglobulins G, A, M with the participation of complement, in some cases - lymphocytes. In the mechanism of development of bronchial asthma, a combination of several types of allergic reactions in one patient is possible, for example, I and IV, I to III, etc., the ratio of their participation determines the characteristics of the clinical course of the disease. In the development of allergic processes in children with bronchial asthma, congenital or acquired disorders of the barrier function of the bronchial mucosa play an important role - a decrease in the level of serum and especially secretory IgA, which prevents the penetration of allergens into the body, inhibition of nonspecific defense factors (phagocytosis, chemotaxis, lysozyme, etc.) , leading to disruption of the processes of destruction and elimination of allergens. Features of antigenic irritation have a certain value. For hypersensitivity to occur, a sufficient amount of antigen and its high allergenic activity are required. A number of allergens (for example, the pollen of some plants) contain the so-called permeability factor, which ensures the active penetration of the antigen through the intact mucous membrane into the deeper tissues. Contribute to the formation of the disease and viral-bacterial inflammatory diseases of the respiratory tract (ARVI, bronchitis, pneumonia), especially repeated ones. In this case, the high frequency of contact with viral and bacterial allergens, the possibility of the formation of the persistence of a viral infection, the increase in the permeability of the mucous membrane for allergens due to desquamation of the epithelium, vasosecretory disorders, the property of viruses to cause some inhibition of E2-adrenergic receptors and increase the release of histamine in mastocytes are important. In addition to the above immunological, allergological mechanisms underlying the development of bronchial asthma, which are the main ones, neurogenic and endocrine factors play an important role, which in some cases can push allergic manifestations into the background. Among the neurogenic factors, the formation of conditioned reflexes is important (asthmatic attacks due to negative emotions, a reflex to the appearance of an allergen or a memory of it, etc.), the creation of a focus of congestive excitation in the cerebral cortex, which can cause long-lasting bronchospasm. A special role is played by increasing the sensitivity of the receptor apparatus of the bronchi to non-allergic, non-specific irritants - meteorological factors (a sharp change in air temperature, humidity, air velocity), inhalation of dust, smoke, various pungent odors, physical activity. These factors can independently cause the release of mediators of an allergic reaction, followed by the development of a pathophysiological phase and an asthmatic attack - this is a non-immune mechanism for the development of bronchial asthma. Of the endocrine factors, one should be aware of a compensatory increase in the function of the adrenal cortex at the initial stages of the disease (in connection with which the first asthmatic attacks can stop on their own) and inhibition of the synthesis of norepinephrine and glucocorticosteroids in the future, as the frequency and severity of exacerbation increase. Hereditary predisposition to allergic diseases, multifactorial (polygenic) type of inheritance are essential in the development of bronchial asthma. It is manifested by the ability to enhance the synthesis of IgE, a decrease in the barrier function of the mucous membranes, features of the receptor apparatus of the bronchi (congenital block of β2-adrenergic receptors), a decrease in blood histamine pexia (the ability of blood plasma to bind histamine). Participation in the development of bronchial asthma of the system of HLA antigens L7, B8, L1 has been proven. Thus, the pathogenesis of bronchial asthma is extremely complex, multifaceted and has been intensively studied to date. The classification of bronchial asthma in children is given in Table. 40. An attack of bronchial asthma in children can occur against the background of complete health or in connection with SARS (at the beginning or at the end of it). style="background-color:#ffffff;"> Harbingers are typical - a change in behavior, the appearance of transparent watery discharge from the nose, sneezing attacks, itching of the tip of the nose. During an attack, the child takes a forced position - sitting with an emphasis on his hands (with the exception of children of the first years of life), there is severe shortness of breath with difficulty

The form	Type	severity	Flow
allergic	Asthma	Determined by frequency and	With frequent
(atonic)	cue bronchitis	the nature of the attacks, the state during remission, the presence of complications	relapses
Infectious-	Bronchial		With rare
allergic mixed	naya asthma		relapses

Note. In the diagnosis, it is necessary to indicate the period of the disease, exacerbation, remission. with a slow exhalation, breathing becomes noisy, wheezing, a persistent painful cough occurs (unlike adults, often not at the end, but from the first minutes of an attack), cyanosis of the lips, nasolabial triangle, face, limbs gradually increases, whistling, buzzing rales are heard at a distance. The sputum is viscous, poorly coughed up, often swallowed by children, which leads to vomiting with a lot of mucus and sputum. Sometimes there is pain in the abdomen, which is associated with tension in the muscles of the diaphragm and paroxysms of coughing. Objectively, attention is drawn to an emphysematous swollen chest, raised shoulders, a tympanic or box shade of percussion sound is determined, auscultatory - weakened breathing, an abundance of various dry rales that disappear after coughing. Heart sounds are often weakened. Body temperature is usually normal, rarely subfebrile. After the attack of suffocation is relieved, the cough gradually subsides, shortness of breath, cyanosis, and a sharp swelling of the lungs decrease, distant wheezing disappears, a moderate cough, signs of emphysema, catarrhal phenomena in the lungs can persist for several days, which gradually pass, then a period of remission begins. Of the three pathophysiological mechanisms that cause the development of an asthma attack - bronchospasm, mucosal edema, mucus hypersecretion - in older children, as in adults, the leading role belongs to spasm of bronchial muscles (Fig. 12). In children of the first years of life, due to the anatomical and physiological characteristics of the respiratory organs (narrowness of the lumen of the bronchi, insufficient development of muscle elements, abundant lymph and blood supply), exudative, vasosecretory phenomena come to the fore - swelling, swelling of the mucous membrane and increased activity of the bronchial glands. Therefore, during auscultation of the lungs, 12. The mechanism of contraction of the smooth muscles of the bronchi (I. I. Balabolkin, 1985) not only dry, but also many different-sized moist rales are sewn. The disease often proceeds not in the form of typical delineated attacks, but in the form of asthmatic bronchitis. In this case, the attack unfolds slowly, over several days; also slowly undergoes reverse development. Severe, prolonged asthma attack, resistant to the action of sympathomimetic agents and xanthine brochodilators, is called an asthmatic condition. In older children with chronic changes in the lungs, the asthmatic condition can last for several days or even weeks. Periods of shortness of breath are replaced by attacks of suffocation, sometimes so severe that they lead to asphyxia and death. The clinical picture of the asthmatic condition is characterized by severe respiratory failure with hypoventilation, hyperkainia and hypoxia. The respiratory rate in children of the 1st year of life increases significantly, in older children it may decrease. An unfavorable prognostic sign is the reduction or disappearance of wheezing in the lungs against the background of increased dyspnea ("silent lung"). From the side of the nervous system - a depressive state, a sluggish reaction to the environment. Often, especially in young children, convulsions occur as a result of brain hypoxia. From the side of the cardiovascular system - tachycardia, weakened tones, systolic murmur over the apex. The asthmatic condition is accompanied by severe functional insufficiency of the adrenal glands, dehydration. Treatment of bronchial asthma can be divided into relief of an attack and anti-relapse measures. Relief of a mild attack of bronchial asthma is possible at home. It is necessary to calm the child, divert his attention, provide optimal access to fresh air. It is advisable to use hot foot and hand baths at a water temperature of 37 ° C to 42 ° C for a duration of 10-15 minutes. Older children can put dry cans on the side surfaces of the chest. If the child tolerates the smell of mustard well, then mustard plasters are used. With the ineffectiveness of these measures, the introduction of bronchodilators orally or by inhalation is indicated. class="Main_text7" style="text-indent:14pt;margin-right:1pt;margin-left:2pt;line-height:10pt;font-size:9pt;">β-adrenergic stimulants are widely used to relieve mild asthmatic attacks drugs. Fenoterol (Berotek) is one of the best selective β-agonists, has a pronounced and persistent bronchodilatory effect, belongs to the group of catecholamines (adrenergic agonists). Selectively exciting Pa-adrenergic receptors of the bronchi, activating adeyylyl cyclase and, thus, contributing to the accumulation of cAMP, causes a bronchodilator effect. In therapeutic doses, it practically does not have a side effect on the heart (due to the almost complete absence of a stimulating effect on Pi-adrenergic receptors of the heart). Apply using a pocket inhaler with a metering device, but 1 breath (0.2 mg of the drug) 2-3 times a day. Salbutamol (albuterol, ventolii) is close in pharmacological action to berotek. It is also used with a pocket inhaler, 1 breath (0.1 mg of the drug) 3-4 times a day. In addition, it can be used orally according to "D tablets (children under 6 years old)," D tablets (6-9 years old), I tablet (over 9 years old) 3-4 times a day. Side effects (tachycardia) are extremely rare. Orciprenaline sulfate (Alunent, Asthmopent) is an adrenergic drug that has a pronounced bronchodilatory effect. Compared with berotek, it has a slightly lower selectivity in relation to the stimulation of bronchial pr-adrenergic receptors; in addition to the latter, it also excites Pi-adrenergic receptors of the heart, and therefore can cause tachycardia, arrhythmia, and worsen myocardial oxygen supply. Apply with a pocket inhaler, 1-2 breaths (with 1 breath, 0.75 mg of the drug enters the body) 3-4 times a day or orally for "/" tablets (children under 6 years), "/ g tablets (6 -9 years old), 1 tablet (starting at 9 years old) 3-4 times a day; 1 tablet contains 0.02 mg of the drug. The bronchodilator effect occurs 10-15 minutes after inhalation, 1 hour after ingestion and lasts 4-5 hours. Terbutaline (bricanil) is close in pharmacodynamics to orciprenaline sulfate. Applied with a pocket inhaler, 1-2 breaths or inside 1.25 mg (children under 6 years), mg (6-9 years), 5 mg (over 9 years) 3-4 times a day; 1 tablet contains 2.5 or 5 mg of the drug. Isadrin (isoprenaline, novodrin, euspiran) is also similar in chemical structure and pharmacological properties to orciprenaline sulfate. Its distinctive feature is an even less selective effect on bronchial P2-adrenergic receptors and, consequently, a less prolonged and pronounced bronchodilator effect and a more pronounced side effect on the cardiovascular system due to stimulation of Pi-adrenergic receptors of the heart. Isadrin is used with a pocket inhaler in the form of a 0.5% and 1% aqueous solution of 0.5-1 ml per inhalation 2-4 times a day or orally (under the tongue) for "/4, A or 1 tablet, depending on age 3-4 times a day, I tablet contains 0.005 g of the drug. Adrenaline excites a- and P-adrenergic receptors. Influencing P-adrenergic receptors, it causes active relaxation of the bronchial muscles, constricts the bronchial vessels, significantly reduces swelling of the bronchial mucosa of the fa- adrenoreceptors), and also enhances automatism of the heart and impairs myocardial metabolism (Pi-adrenergic receptors).Influencing a-adrenergic receptors, adrenaline causes vasoconstriction and impaired blood supply to organs and tissues, increasing LD. Due to the fact that the sensitivity of P-adrenergic receptors to adrenaline is higher than that of a-adrenergic receptors, it is necessary to use small doses of adrenaline that do not have a pronounced effect on a-adrenergic receptors. For mild asthmatic attacks, the drug is used in aerosols, in electrophoresis. It must be remembered that an overdose of adrenostimulants can increase the inflammatory process in the airways or cause severe bronchospasm with adrenaline derivatives that have a P-blocking effect (medicated breathing syndrome). In this regard, epinephrine is now rarely used. Ephedrine is an alkaloid found in various plant species of the ephedra genus. Used as ephedrine hydrochloride. It is a sympathomimetic drug of indirect action that causes blockade of the catecholamine enzyme and thereby promotes the mobilization of endogenous mediators (adrenaline and norepinephrine) in the nerve endings. Like adrenaline, ephedrine excites a- and P-adrenergic receptors. In this regard, in addition to the bronchodilator effect, ephedrine causes the appearance of tachycardia, increased cardiac output, vasoconstriction of the abdominal organs, skin and mucous membranes, and increased blood pressure. Given such a complex mechanism of action, frequent adverse reactions, ephedrine (as well as adrenaline) in recent years is less and less prescribed to children as a bronchodilator, especially parenterally. For mild asthmatic attacks, it is prescribed orally: at the age of up to 1 year - 0.002-0.003 g, 2-5 years - 0.003-0.01 g, 6-12 years - 0.01-0.02 g per reception 2-3 times a day. day, also used in aerosols. In cases of mild asthmatic attacks, antispasmodics (myotropic drugs) are also widely used, which have a relaxing effect on the smooth muscles of the bronchi without affecting p2-adrenergic receptors. Theophylline is a purine alkaloid, a xanthine group, found in tea leaves and coffee. Theophylline is an adenosine antagonist. Thus, it eliminates the effects of adenosine - bronchospasm and suppression of norepinephrine secretion in the non-resynaptic endings of sympathetic nerves. By reducing the activity of phosphodiesterase, theophylline promotes the accumulation of cAMP, the release of calcium from muscle cells and relaxation of the muscles of the bronchi, stabilizes mast cells, preventing the release of mediators of immediate hypersensitivity (histamine, etc.) and the development of bronchospasm, hypersecretion, edema of the mucous membrane. Theophylline improves the ventilation function of the lungs due to increased work of the diaphragm and intercostal muscles, dilates the vessels of the kidneys, lungs, skeletal muscles, reduces peripheral vascular resistance and pulmonary hypertension. A side effect of theophylline is an increase in myocardial oxygen demand, the development of tachycardia. The drug is absolutely indicated for asthma attacks, accompanied by a loss of sensitivity of bronchial P2-adrenergic receptors, which makes the appointment of adrenomimetic agents ineffective. Apply to children aged 2=4 years, 0.01-0.04 g each, 5-6 years old - 0.04-0.06 g each, 7-9 years old - 0.05-0.075 g each, 10-14 years old - 0.05-0.1 g 3-4 times a day; 1 tablet contains 0.1 or 0.2 g of the drug. Eufillin (aminophylline) is a drug containing 80% theophylline and 20% ethylenediamine. Ethylenediamine has an independent antispasmodic effect, and also increases the solubility of theophylline, which makes it possible to prepare aminophylline solutions for injection. Due to the higher efficiency, aminophylline is used much more widely than theophylline. In mild cases, it is prescribed orally according to "/style="background-color:#ffffff;"> Pancreatin contains trypsin and amylase. Use 0.5 mg of the drug in 1-2 ml of isotonic sodium chloride solution per inhalation. Ribonuclease depolymerizes RNA, with This dilutes viscous sputum.Apply 25 mg in 3-4 ml of isotonic sodium chloride solution per inhalation.Deoxyribonuclease depolymerizes DNA, providing a mucolytic effect.Use 5 mg of the drug in 2-3 ml of isotonic sodium chloride solution.Inhalations of proteolytic enzymes do 2- 3 times a day.Due to the possible irritant effect on the mucous membranes, it is recommended to rinse the mouth and nose after inhalation.It is necessary to remember the possibility of strengthening asthmatic phenomena in some patients.In this case, proteolytic enzymes are immediately canceled.Mucolytic drugs must be prescribed in a complex of measures, contributing to the evacuation of sputum from the respiratory tract - chest massage (manual and vibration cationic), draining position Quincke, etc. In an outpatient setting, you can use a number of combined tools. A mixture consisting of a 2% solution of potassium iodide, ephedrine and aminophylline (“iodine” mixture) provides a mucolytic and antispasmodic effect. It is prescribed for 1 teaspoon (children under 5 years old), 1 dessert (6-10 years old), 1 tablespoon (over 10 years old) 3-4-6 times a day inside with milk. The anti-asthma potion (according to Traskov) is an infusion of a number of medicinal plants (nettle leaves, peppermint, horsetail grass, adonis, rose hips, pine needles, anise, fennel), containing 1 liter of 100 g of sodium iodide and potassium iodide. Iodides cause a mucolytic effect, and the herbs that make up the mixture have an antispasmodic effect. It is taken in terms of structure and pharmacological properties close to chlorpromazine. In addition to a strong antihistamine effect, it has a pronounced sedative effect, suppresses conditioned reflex activity like chlorpromazine, reduces spontaneous motor activity, relaxes skeletal muscles. Consciousness is maintained or develops a state close to physiological sleep. In addition, diprazine increases the effect of hypnotics, narcotic drugs and has a hypothermic effect.Applied orally to children under 6 years old at 0.008-0.01 g, over 6 years old - at 0.012-0.015 g 2 times a day.Suprastin (an ethylenediamine derivative) by action similar to other antihistamines, but its sedative effect is less pronounced.Children are prescribed orally, depending on age, 0.006-0.012-0.025 g per dose 2 times a day.Tavegil (pyrrolidone derivative) is superior in antihistamine activity to diphenhydramine, diprazine, suprastin. the effect is less pronounced.Children are prescribed orally 1 /4- "/2, or 1 tablet, depending on age, 2 times a day; 1 tablet contains 0.001 g of the drug. Diazolin has an active antihistamine effect. Unlike the listed drugs, it does not have a sedative and hypnotic effect. Children are prescribed inside 0.02-0.05 g 2-3 times a day. Fencarol is similar in action to diazolin. Does not cause sedation. Assign inside to children under 3 years of 0.005 g, 3-7 years - 0.01 g, over 7 years - 0.01-0.015 g 2 times a day. During an asthma attack, physiotherapeutic procedures are used: electrophoresis of atropine, adrenaline according to the reflex-segmental technique, electrophoresis of nicotinic acid according to Bourguignon, endonasal electrophoresis of diphenhydramine, magnesium salts, calcium, novocaine, ascorbic acid, aloe. With the ineffectiveness of these therapeutic measures in the case of a moderate asthmatic attack, they resort to the introduction of bronchospasmolytic and anti-histamine drugs parenterally - subcutaneously, intramuscularly. Of the sympathomimetic agents, alupent is used parenterally (subcutaneously or intramuscularly, 0.3-1 ml of a 0.05% solution), terbutaline (subcutaneously or intramuscularly, 0.1-0.5 ml of a 0.1% solution), adrenaline (subcutaneously, 0.05% solution). ,1 - 0.5 ml of a 0.1% solution), ephedrine (subcutaneously, 0.1-0.5 ml of a 5% solution). Adrenaline has a quick (after 2-3 minutes), but short-lived (up to 2 hours) effect. The bronchodilatory effect of ephedrine occurs later than with the introduction of adrenaline (after 40-60 minutes), but lasts longer (4-6 hours). Due to the frequent side effects (arrhythmia, tachycardia), epinephrine and ephedrine are currently used less frequently. Of the antispasmodics, eufillin is widely used - the drug of choice in this situation (0.3-1 ml of a 24% solution intramuscularly 2 times a day), no-shpu (0.3-1 ml of a 2% solution intramuscularly 2 times a day) ; it is possible to prescribe papaverine (0.5-2 ml of a 2% solution intramuscularly 2 times a day), platyfillin (0.3-1.5 ml of a 0.2% solution intramuscularly 2 times a day); less often use fenikaberan (0.3-2 ml of a 0.25% solution intramuscularly 2 times a day). Of the antihistamines, 1% diphenhydramine solution, 2.5% diprazine solution, 2% suprastin solution, 1% tavegil solution but 0.3-1 ml intramuscularly 2 times a day are used. Mucolytic agents are used, as in a mild asthma attack, by mouth and in aerosols. Mild and moderate asthma attacks can be stopped, in addition, using various methods of reflexology. In a severe asthma attack, the child must be hospitalized in a separate, burying ventilated ward, periodically give 25-60% humidified oxygen through a mask or nasal catheter. The use of higher oxygen concentrations can lead to an increase in the partial pressure of CO2 and a decrease in pH. Apply intravenously in a stream (slowly) or better drip of a 2.4% solution of aminophylline in a 5% glucose solution. V. A. Gusel, I. V. Markova (1989) recommend the following daily doses of aminophylline: up to 3 years, depending on age - 5-15 mg / kg, from 3 to 8 years - 15 mg / kg, from 9 up to 12 years - 12 mg / kg, over 12 years - 11 mg / kg in 2-3 doses. In addition, a 2% solution of no-shpy, a 2% solution of papaverine, a 0.2% solution of platifillin and irotivistamine preparations are used - 1% solution of diphenhydramine, 2.5% solution of diprazine, 2% solution of suprastin, 1% solution of tavegil (according to 0.3-1 ml intravenously 2 times a day). Perhaps intravenous drip injection of 0.3-t ml of a 0.05% solution of alupeite in 50-100 ml of isotonic sodium chloride solution, in combination with antispasmodic and antihistamines. Be sure to prescribe mucolytic drugs orally and in aerosols (see above), as well as intravenously (sodium bromide, 3-6 ml of a 10% solution). With a concomitant inflammatory bronchopulmonary process, it is necessary to conduct antibiotic therapy (intramuscularly, intravenously, in inhalations). In the event that a severe asthmatic attack is not stopped by the therapeutic complex described above, an asthmatic condition is diagnosed. With it, it is necessary to use intravenous aminophylline at maximum doses twice those indicated for the relief of a severe asthmatic attack: children aged 1 month to 3 years - 10-30 mg / kg, from 3 to 8 years - 30 mg / kg, from 9 to 12 years old -25 mg / kg, over 12 years old - 22 mg / kg (V. A. Gusel, I. V. Markova, 1989). In this case, the method of rapid euphyllinization is used: within 20-30 minutes, a starting dose of the drug is injected intravenously, ensuring the rapid achievement of therapeutic concentrations (children 3-8 years old - 9 mg / kg, 9-12 years old - 7 mg / kg, 13-15 years - 6 mg / kg), then a maintenance dose of aminophylline is administered, approximately equal to the rate of its elimination (children 3-8 years old - 21 mg / kg, 9-12 years old - 18 mg / kg, 13-15 years old 16 mg / kg) . If there is no effect, glucocorticosteroids are prescribed intravenously in loading doses (prednisolone 3-5 mg, up to K) mg / kg body weight drip in 5% glucose solution or isotonic sodium chloride solution). Glucocorticosteroids have a powerful anti-inflammatory, desensitizing, anti-allergic, anti-shock and anti-toxic effect, reduce the number of tissue basophilic granulocytes, inhibit the activity of hyaluronidase, help reduce capillary permeability, delay protein synthesis and breakdown, and inhibit the development of connective tissue. In addition, glucocorticosteroids restore the sensitivity of the bronchi to xanthine bronchodilators and β-agonists. The introduction of prednisolone, even at a dose of 60-90 mg for 3=5 days, can be stopped immediately without a gradual decrease in dosage. In the hormone-dependent form of bronchial asthma, hormone therapy should be carried out for 2-3 weeks, the complete withdrawal of the drug or the transition to maintenance doses should be preceded by a gradual dose reduction. It is advisable to use drugs that stimulate the function of the adrenal cortex - etimizol, glycyram. It is necessary to prescribe detoxification measures (intravenous glucose-salt solutions, hemodez or neocompensan), agents that improve microcirculatory processes (rheopolyglucin, complamin, nicotinic acid), maintain the state of the cardiovascular system (corglicon, panangin, riboxin intravenously), correct COS and be sure to massive antibiotic therapy, continue to use mucolytic agents. In the absence of effect (development of atelectasis, increase in asphyxia), bronchoscopic sanitation is indicated. After sucking the mucus and washing the bronchi, antibiotics, mucolytic agents, and glucocorticoids are injected into the lumen. It is possible to carry out hemosorption, plasmapheresis. With a further increase in acute obstructive insufficiency, intubation is carried out and the child is transferred to controlled breathing, continuing to carry out infusion therapy (glucocorticosteroids, cardiac, antibacterial, glucose-salt solutions and plasma substitutes). The relief of an asthmatic attack of any severity is carried out against the background of prescribing a hypoallergenic diet to the patient and creating a hypoallergenic environment. In the future, after the onset of remission, in addition to the above, various complexes of anti-relapse treatment are recommended: the use of membrane stabilizers (intal, zaditen), immunocorrectors (thymalin, T-activin, decaris, vilozen, thymogen, etc.), specific hyposepsibilization, courses of histaglobulin, in severe cases - the appointment of glucocorticosteroids of local action (beclomethasone dipropionate, becotide, beclomet) or general action (prednisolone, etc.). In addition, breathing exercises, chest massage, sanitation of focal infections, sanatorium treatment (local type sanatoriums, the southern coast of Crimea, highlands, salt mines, including artificial speleotherapy) are mandatory.

Relevance of the topic. People of young age are more often ill: the majority of asthma develops in childhood. 1/3 under the age of 40. At least 2% of the world suffer from asthma. In the USA, England, Germany, Sweden, France - 5%. Very high incidence in New Zealand, Australia. In Russia, epidemiological outbreaks in Kirishi, Angara, Volgograd, which is associated with the use of fungi of the genus Candida in the production of protein and vitamin concentrates.

There is a steady increase in cases of asthma and increased mortality. Every decade the number of patients increases by 1-2%. There are more severe cases of the disease ending in death. Morbidity is determined mainly by two factors: hereditary and environmental.

Bronchial asthma This is a chronic inflammatory process in the airways, which leads to the development of an asthma attack. The inflammatory process leads to: - Spasm of the smooth muscles of the respiratory tract - Formation of a viscous bronchial secretion - Edema of the mucous membrane - Irreversible sclerotic process in the respiratory tract.

Etiology and forms of AD. Atopic. There are organic and inorganic allergens: plant pollen, dust (more than 30 types of mites were found in house dust), feathers, dander, animal hair, food allergies, drugs, industrial chemicals.

Infectious-allergic. The reason is various microorganisms (flu viruses, bacteria, etc.) Professional. It develops in patients working in woodworking, weaving and other industries. Asthma of physical effort. Cold asthma. psychogenic asthma. The reason is neuropsychic overload. Dishormonal BA. It develops as a result of endocrine disorders.

Pathogenesis: There are 3 stages: 1. Immunological: when the allergen enters the body, it causes the production of antibodies, which, when combined with the antigen, form an immune complex that is fixed on the mast cell membrane, damaging it. 2. Pathochemical: Mast cells begin to release BAS (histamine, serotonin, bradykinin, etc.) 3. Pathophysiological: BAS cause bronchospasm, increase the permeability of the vascular wall and secretion of mucus.

According to the degree of severity, BA is divided into: Mild course - attacks 1-2 times a week, they are of a mild short-term nature, quickly stopped by bronchodilators. Nocturnal asthma attack no more than 1-2 times a month. In the interictal period, there are no signs of the disease. Moderately severe - attacks more than 2 times a week, accompanied by a violation of physical activity, night attacks more than twice a month, stopped by parenteral administration of bronchodilators, signs of bronchospasm are observed in the interictal period. Severe course - Attacks are frequent, prolonged, stop with difficulty. Exacerbations every night. Physical activity is reduced. Asthmatic conditions develop periodically.

Clinical picture: The period of precursors: vasomotor rhinitis, lacrimation, pruritus, tightness in the chest, paroxysmal nocturnal cough. It lasts from several minutes, sometimes days.

The attack of suffocation begins with a persistent unproductive cough, there is a sharp difficulty in exhaling, tightness in the chest, there is no sputum at the beginning. At the height of the attack, viscous sputum appears with a small amount. On examination, the patient takes a forced position "asthmatic posture", sits leaning on his knees or the edge of the bed (to fix the shoulder girdle and turn on the auxiliary respiratory muscles), the face is pale, puffy, with cyanosis, the skin is covered with perspiration. NPV - 10 -14 per minute, breathing is noisy, wheezing, wheezing is heard at a distance. The chest is expanded. Percussion sound box. The elongation of the exit is determined - expiratory dyspnea. Hard or bronchial weakened breathing, scattered dry rales are heard. Tachycardia, blood pressure is normal or slightly elevated.

Regression period. The sputum begins to separate, becoming more and more liquid and plentiful. Wheezing quickly disappears, the exhalation is shortened.

Asthmatic status - A complication of asthma that threatens the life of the patient. This is a state of severe asphyxia, which is not stopped by conventional means for many hours or several days and may result in the development of hypoxic coma and death. An important role in its occurrence is played by a violation of the drainage function of the bronchi - blockage of the bronchioles with mucus, swelling of the bronchial mucosa.

The condition is extremely difficult. There is cyanosis, severe expiratory dyspnea with very rapid and then infrequent shallow breathing. As a result of the formation of mucous plugs, the lumen of the bronchioles and bronchi is clogged and the conduction of sound to the surface of the chest is disturbed, the sonority and the number of dry rales decrease, up to the disappearance of the “silent lung”. Tachycardia and hypotension are noted. In the terminal stage, mental disorders appear: motor restlessness, fear, anxiety, loss of consciousness, bradypnea. BP is not determined. Death comes from asphyxia.

Additional examination methods: Clinical blood test - eosinophilia. Sputum analysis - a large number of eosinophils, Kurshman's spirals (spiral-shaped casts of small bronchi), Charcot-Leyden crystals (eosinophil breakdown products. Allergological tests. Examination of the function of external respiration. Peakflowmetry (forced expiratory speed) X-ray examination of the chest.

First aid for an attack of bronchial asthma. Choking, shortness of breath with difficulty exiting, dry whistling rales, audible at a distance and on auscultation of the lungs, participation in breathing of auxiliary muscles. Forced position - sitting or standing with support.

Nurse tactics: Actions Rationale 1. Provide psychological support 2. Leave a sitting or standing position with support on hands, unfasten tight clothing. 3. Carry out a nursing examination: skin color, pulse, NPV. HELL. 4. Help the patient take 1-2 breaths from a pocket inhaler that he usually uses (salbutamol, berotek). Do not use the inhaler if the patient has already used it on their own. 5. Call a doctor. Reduce emotional stress Reduce hypoxia Eliminate bronchospasm

Prepare medicines for the doctor: Solution of Eufillin 2, 4% - 10 ml. Solution of prednisolone 1 ml. Sodium chloride solution 0.9% 10 ml, 400 ml. Prepare tools.

Treatment of asthma Finding out the cause of the deterioration of the condition Elimination of the provoking factor. Diet therapy - exclude products containing food allergens. Plentiful drink.

Drug therapy: Basic anti-inflammatory. - intal, tailed (only in children) - glucocorticoids: becloson, becotide - are used by inhalation. They have a local effect on the respiratory tract. Before using them, it is necessary to clear the airways from bronchial secretions with bronchodilator inhalers. Do not stop the attack. After using them, rinse your mouth.

Bronchodilators - Sympathomimetics: salbutamol, berotek. Used to relieve seizures. Atimos - long-term action. - Xanthine preparations - eufillin. - Cholinolytics - atrovent, berodual. Effect after 30-90 minutes

Non-drug treatment Acupuncture Exercise therapy massage Speleotherapy (in salt mines) Climatotherapy (sea and mountain climate) Treatment of hunger.

Prevention of BA: Timely treatment of acute respiratory infections Fight against environmental pollution Fight against smoking Creation of "asthma schools" .

State budget educational institution

Moscow city

city ​​of Moscow"

Course work

"Hospital Nurse"

Topic: "Nursing process in bronchial asthma"

Is done by a student:

Course 4

Group 402

Specialty Nursing

Supervisor

20____

Grade:_________________

Moscow

2013

	Page
LIST OF ABBREVIATIONS
INTRODUCTION
1. BRONCHIAL ASTHMA
1.1. Etiology
1.2. Classification
1.3. Clinical picture
1.4. Diagnostics
1.5. Complications
1.6. Help in emergencies
1.7.Features of treatment
1.8. Prevention, rehabilitation, prognosis
2. NURSING PROCESS IN BRONCHIAL ASTHMA
2.1. Manipulations performed by a nurse
2.1.1. Rules for using the PAI
2.1.2. Conducting peak flowmetry
3. PRACTICAL PART
3.1. Observation from practice 1
3.2. Observation from practice 2
3.3. conclusions	2 28
4. CONCLUSION
5. LITERATURE
6. APPS

LIST OF ABBREVIATIONS

BA -bronchial asthma

SARS -acute respiratory viral infection

NSAIDs -non-steroidal anti-inflammatory drugs

ESR- sedimentation rate of erythrocytes

BP -arterial pressure

DAI -metered dose aerosol inhaler

NPV- respiratory rate

heart rate- heart rate

GKS - glucocorticosteroids

PSV - peak expiratory flow

PFM - peak flowmeter

VBI – nosocomial infection

DN- respiratory failure

LS- medicines
INTRODUCTION

The relevance of research

Bronchial asthma is one of the most common human diseases affecting people of all ages. Currently, the number of patients with asthma worldwide has reached 300 million people. In most regions, the incidence continues to increase and by 2025 will increase by 100-150 million. In each of the 250 deaths in the world, asthma is to blame, and most of which could be prevented. An analysis of the causes of death from asthma indicates insufficient basic anti-inflammatory therapy in most patients and untimely emergency care in case of exacerbation. Nevertheless, certain successes have been achieved in the treatment of asthma: new methods of immunotherapy for allergic asthma have begun to be used, existing methods of pharmacotherapy have been reassessed, and new methods of treating severe asthma are being introduced.

Thus, the main indicator of the effectiveness of asthma therapy is the achievement and maintenance of control over the disease.

The high prevalence and socio-economic impact of BA on the life of society and each patient necessitates the prevention and timely identification of risk factors, the adequacy of the therapy, and the prevention of exacerbations of the disease. This is where the nurse has a big role to play. Therefore, the study of the nursing process in AD is relevant.

Purpose of the study:

study of the nursing process in bronchial asthma.

Research objectives:

explore:

· etiology;

· classification;

· clinical picture;

diagnostics;

· complications;

· treatment features;

prevention;

· rehabilitation, prognosis;

analyze:

· two cases illustrating the tactics of a nurse in the implementation of the nursing process in bronchial asthma;

· the main results of the examination and treatment of the described patients in the hospital necessary to fill out the list of nursing interventions;

to concludeon the implementation of the nursing process in these patients.

Object of study: patients with bronchial asthma.

Subject of study: Nursing process in bronchial asthma.

Research methods:

· scientific and theoretical;

· analytical;

observation;

comparison.

1. BRONCHIAL ASTHMA

Bronchial asthma is a chronic inflammatory disease of the respiratory tract, which involves many cells and cellular elements. Chronic inflammation causes bronchial hyperreactivity, which leads to recurrent episodes of wheezing, shortness of breath, chest tightness, and coughing, especially at night or in the early morning. These episodes are usually associated with widespread but variable airway obstruction in the lungs, which is often reversible, either spontaneously or with treatment.

1.1. Etiology

The reasons are not exactly known.

ü Predisposing factors (genetically determined): atopy and heredity - determine the body's tendency to disease.

Clinical manifestations of atopy: vasomotor rhinitis, conjunctivitis, allergic dermatitis.

ü Causal factors (inductors) - sensitize the respiratory tract and cause the onset of the disease: dust, hair and dander of pets, fungal, cockroach allergen, plant pollen, aspirin, chemicals in the workplace (chlorine-containing, formaldehyde, rosin, etc.)

trigger factors – provoke exacerbations of asthma:

ü allergens (house dust mite, plant pollen, animal dander, mold, cockroaches)

ü irritants (tobacco smoke, air pollutants, strong odors, fumes, soot)

ü physical factors (exercise, cold air, hyperventilation, laughter, screaming, crying)

ü ARVI

ü emotional overload (stress)

ü medications (β - blockers, NSAIDs, nutritional supplements - tartrazine)

ü weather change

ü endocrine factors (menstrual cycle, pregnancy, thyroid disease)

ü time of day (night or early morning)

1.2. Classification

Classification (Ado, Bulatova, Fedoseeva)

1. Stages of BA development:

ü biological defects in apparently healthy people

ü state of betrayal

ü clinically pronounced bronchial asthma

2. Clinical and pathogenetic variants of AD:

ü atopic

ü infectious-dependent

ü autoimmune

ü dishormonal (hormone dependent)

ü neuro-psychic

ü aspirin

ü primary altered bronchial reactivity, etc.

Classification of asthma according to severity:

Intermittent :

symptoms less than once a week; exacerbations are short; nocturnal symptoms no more than 2 times a month.

mild persistent :

symptoms more than once a week, but less than once a day; exacerbations can affect physical activity and sleep: nocturnal symptoms more than 2 times a month.

Persistent moderate :

daily symptoms; exacerbations can affect physical activity and sleep; nighttime symptoms more than once a week; daily intake of short-acting inhaled beta-2 agonists.

severe persistent :

daily symptoms; frequent exacerbations; frequent nocturnal symptoms; limitation of physical activity.

Classification of BA by the level of control:

Controlled BA:

complete absence of all manifestations of asthma and a normal level of spirometry

Partially controlled BA:

limited number of symptoms.

Uncontrolled BA:

exacerbation of asthma within 1 week.

1.3. Clinical picture

The clinical picture of asthma is characterized by the appearance of asthma attacks of mild, moderate or severe.

In the development of an asthma attack, the following periods are conditionally distinguished:

Period of harbingers :

vasomotor reactions from the nasal mucosa, sneezing, dryness in the nasal cavity, itching of the eyes, paroxysmal cough, difficulty in sputum discharge, shortness of breath, general agitation, pallor, cold sweat, frequent urination.

peak period :

suffocation of an expiratory nature, with a feeling of constriction behind the sternum. Forced position, sitting with emphasis on hands; inhalation is short, exhalation is slow, convulsive (2-4 times longer than inhalation), loud whistling rales heard at a distance ("remote" rales); participation of auxiliary muscles in breathing, dry cough, sputum does not go away. The face is pale, with a severe attack - puffy with a bluish tinge, covered with cold sweat; fear, anxiety. The patient has difficulty answering questions. Pulse of weak filling, tachycardia. In a complicated course, it can turn into asthmatic status.

Relapse period:

It has different duration. Sputum liquefies, coughs up better, the number of dry rales decreases, wet rales appear. The suffocation gradually disappears.

The course of the disease is cyclical: an exacerbation phase with characteristic symptoms and data from laboratory and instrumental studies is replaced by a remission phase.

1.4. Diagnostics:

ü Clinical blood test: eosinophilia, may be leukocytosis, increased ESR.

ü General sputum analysis: vitreous sputum, with microscopy - eosinophils, Kurshman spirals, Charcot-Leiden crystals.

ü Allergological examination:

- skin tests (scarification, application, intradermal)

- in some cases - provocative tests ( conjunctival, nasal, inhalation).

ü Studies of immunoglobulins E and G.

ü Chest X-ray: with a long course, increased pulmonary pattern, signs of emphysema.

1.5. Complications:

ü asthmatic status;

ü spontaneous pneumothorax;

Bronchial asthma is a chronic respiratory disease characterized by the development of chronic allergic inflammation and hyperreactivity of the bronchi, with recurring episodes of bronchial obstruction, manifested by shortness of breath, wheezing in the lungs, cough, chest tightness, especially at night or in the early morning.

In the world, about 100 million people suffer from bronchial asthma, which is 5% of the total population of the planet. However, data on the prevalence of asthma fluctuate widely, depending on the climatic zone, air pollution, nutrition, hereditary predisposition, smoking, drug consumption, mental stress, population migration, research methods, definition and interpretation of asthma.

Etiology. All etiological factors leading to the occurrence of bronchial asthma are divided into 5 groups:

In the origin of asthma, hereditary predisposition is of great importance, when changes in the body leading to bronchial hyperreactivity are inherited.

Pathogenesis. Against the background of an inflammatory process under the influence of an etiological factor (allergen, physical effort, neuropsychic effects, aspirin), patients experience spasm and swelling of the airways, they produce an increased amount of mucus, they become hypersensitive to the irritant. In the future, this factor acquires the role of a trigger (provocateur) of an attack. If adequate treatment is carried out, inflammation can decrease for a long time, and the frequency of occurrence of symptoms of the disease can become minimal.

Classification.

Clinical forms:

1. Asthma with a predominance of an allergic component.
2. Nonallergic asthma.
3. Mixed asthma.
4. Asthmatic status.

Variants of the course according to the degree of severity:

Mild intermittent course: asthma symptoms less than 1 time per week, nocturnal symptoms 2 times a month or less.

Mild persistent course: asthma symptoms more than 1 time per week, but less than 1 time per day, nocturnal symptoms more than 2 times a month, but less than 1 time per week.

Moderate asthma: daily asthma symptoms, nocturnal symptoms more than once a week.

Severe asthma: daily asthma symptoms multiple times during the day, frequent nocturnal symptoms, limitation of physical activity.

Phases of the disease: exacerbation and remission (interictal period).

Clinic.

The following symptoms are characteristic of bronchial asthma:

Under the influence of a trigger (provocateur), an attack of bronchial asthma occurs, which is most often manifested by an asthma attack, but can be manifested only by an episode of wheezing or only paroxysmal coughing with thick, viscous sputum discharge, especially at night, or only by a feeling of tightness in the chest.

The attack of suffocation is characterized by: a forced position of the body - sitting with an inclination forward and resting hands on objects in front, remote wheezing (i.e., wheezing is heard at a distance), cyanosis, increased sweating; severe dyspnea of ​​an expiratory nature, cough with difficult to separate thick, viscous, vitreous sputum.

Each asthma attack occurs in a certain sequence and has three periods:

1. precursors (itching in the nose, sneezing, discharge of clear watery mucus from the nose, etc.);
2. high fever (coughing fit with sputum difficult to separate, wheezing or chest congestion, choking, or a combination of both),
3. reverse development.

Asthmatic status. This is a syndrome of acute respiratory failure that has developed in patients with bronchial asthma due to airway obstruction that is resistant to bronchodilator therapy.

Common causes of asthmatic status are excessive consumption of sleeping pills, sedatives, taking drugs that cause an allergic reaction from the bronchi (salicylates, analgin, antibiotics, etc.), excessive intake of inhaled bronchodilators (more than 6 times a day). All this must be taken into account by the nurse when caring for patients with bronchial asthma.

In asthmatic status, in response to the introduction of an antispasmodic or inhalation of a bronchodilator, instead of improving the condition, suffocation increases, pain in the heart, palpitations appear, and blood pressure rises. This corresponds to the I stage of asthmatic status.

As the process progresses, the condition continues to worsen. Breathing becomes frequent, superficial, in the lungs the number of dry wheezing decreases until they disappear (“silent lung”), which indicates stage II asthmatic status.

If the treatment is inadequate, the patient loses consciousness and falls into a coma. Stage III status asthmaticus begins.

Complications of bronchial asthma: acute and chronic respiratory failure, pulmonary heart failure, cor pulmonale, pulmonary emphysema, atelectasis, pneumothorax; during an attack, a potential problem for the patient is status asthmaticus.

Diagnostics.

Diagnosis of asthma is mainly based on the assessment of symptoms, physical findings and evaluation of lung function.

On physical examination, diffuse dry whistling rales are heard in the lungs.

Evaluation of lung function includes: determination of the volume and rate of forced expiratory flow (using spirography, pneumotachymetry), peak expiratory flow rate (using peak flowmetry). Tests with bronchodilators are carried out to determine the reversibility of obstruction, which is of great importance for the diagnosis of bronchial asthma. They are also necessary for the selection of drugs and evaluation of the effectiveness of the treatment.

In the general blood test, ESR and eosinophilia are moderately elevated.

A general analysis of sputum reveals a large number of eosinophils, sometimes Kurshman's spirals, Charcot-Leiden crystals.

To identify an allergen or a group of allergens in bronchial asthma, allergen sensitivity tests, in particular, scarification tests, are used. The indication for skin tests is the need to confirm the history and clinical data indicating the role of a particular allergen or group of allergens in the occurrence of symptoms of bronchial asthma. Allergological testing is carried out only during the period of clinical remission of bronchial asthma and after the rehabilitation of foci of chronic infection. The examination is not carried out during the period of exacerbation of atopic dermatitis and allergic rhinitis, often combined with bronchial asthma, in the treatment of hormonal and anti-allergic drugs (they distort (reduce) skin sensitivity).

X-ray in bronchial asthma reveals signs of emphysema (increased airiness of the lung tissue).

Treatment of bronchial asthma.

The regime is assigned free, diet B (basic diet), according to the previous instructions, table No. 15, hypoallergenic (the amount of fluid consumed increases to 2 liters per day, fish, milk, citrus fruits, eggs, poultry meat, chocolate, coffee are excluded).

Non-drug treatment is required. It includes: 1) hypoallergenic diet; 2) sanitation of foci of infection in the ENT organs; 3) control over triggers (hypoallergenic life); 4) breathing exercises; chest massage; 5) psychotherapy; 6) exercise therapy; 7) physiotherapy, acupuncture, psychotherapy; 8) allergen immunotherapy is used, it is effective with a small number of causally significant allergens (1-3).

Medical treatment. The asthma treatment strategy provides for a stepwise approach, in which the volume of therapy increases according to severity - 4 stages of therapy, respectively, 4 degrees of severity.

There are two main groups of drugs used to treat asthma.

1. drugs that relieve asthma symptoms (bronchodilators).

These can be short-acting bronchodilators - they are prescribed by the attending physician to relieve an attack:

1. short-acting inhaled beta-2-agonists (salbutamol, berotek, etc.),
2. anticholinergics (ipratropium bromide aerosol (atrovent), etc.), are prescribed in cases of intolerance to beta-2-agonists or in the presence of side effects during their use;
3. short-acting theophyllines (eufillin orally and parenterally and other drugs) - are prescribed in cases of intolerance to beta-2-agonists and anticholinergic drugs or in case of side effects when using them.

To relieve an attack of any severity, it is optimal to use short-acting beta-2 agonists.

Long-acting bronchodilators include:

• long-acting inhaled beta-2 agonists - salmeterol in a metered dose aerosol,
• long-acting oral theophyllines - teodur, teopec tablets.

Their action begins after a long time (2-3 hours) after administration and lasts 12 or more hours. Therefore, they are usually taken in the evening. They are not to be taken for emergency purposes.

2. The second group of drugs currently forms the basis of the treatment of bronchial asthma (basic therapy). These are long-acting anti-inflammatory drugs that allow you to control the disease. They themselves do not relieve an attack, but in combination with drugs of the first type, they help prevent the onset of asthma attacks. These drugs include:

• non-steroidal anti-inflammatory drugs of non-systemic action: intal (sodium cromoglycate) in capsules for inhalation and metered aerosol; nedocromil-sodium (Tyled) in inhalation.
• inhaled glucocorticosteroids (budesonide, beclomethasone),
• systemic glucocorticosteroids (prednisolone, betamethasone), they are prescribed for the treatment of severe asthma.

The intake of glucocorticosteroids begins with an inhalation form, in the absence of an effect, they switch to taking systemic corticosteroids. Long-term use of systemic glucocorticosteroids causes the following complications: arterial hypertension, osteoporosis, depression of the hypothalamic-pituitary-adrenal system, diabetes mellitus, cataracts, obesity, muscle weakness, which should be considered by the nurse as potential problems for patients.

To control the course of bronchial asthma and evaluate the effectiveness of the treatment, peak flowmetry is used, which can be performed by the patient at home independently. The peak flow meter contains zone marks necessary for the doctor to determine the stage of the treatment program. The peak flow zones are marked with multi-colored plastic arrows, which are placed in the groove opposite the scale. The red, yellow and green zones indicate the placement of arrows of the corresponding colors opposite the accepted value.

The green zone indicates that there are no or minimal asthma symptoms. Asthma under control.

yellow zone. There are mild symptoms of asthma. Medical supervision is required.

The red zone indicates an alarm. Asthma symptoms are noted at rest. The patient should immediately take two breaths of Berotek or another short-acting drug and seek emergency medical attention.

The use of a peak flow meter for monitoring bronchial asthma must be carried out under the supervision of a physician.

First aid for an attack of bronchial asthma.

Information: A patient with bronchial asthma suddenly developed an asthma attack. The patient sits with his hands on the back of the chair, wheezing breath, "remote" dry wheezing, cough with sputum difficult to separate. The chest is swollen, auxiliary muscles are involved in the act of breathing, breathing is rapid, tachycardia.

Nurse Tactics

Actions	Rationale
1. Call a doctor through a third party.	To provide qualified medical care
2. Calm down, unfasten tight clothes, provide fresh air access, give a comfortable position with emphasis on hands.	Psycho-emotional unloading, reduce hypoxia
3. Control of blood pressure, respiratory rate, pulse.	Condition control
4. Give 30-40% humidified oxygen.	Reduce hypoxia
5. Inhale berotek (salbutamol): 1-2 breaths of metered-dose aerosol.	To relieve bronchospasm
6. Until the doctor arrives, the patient should be prohibited from using his pocket inhaler.	To prevent the development of resistance to bronchodilators and the transition of an attack to status asthmaticus
7. Give hot drinks, hot foot and hand baths.	For reflex reduction of bronchospasm
8. If the above measures are ineffective, enter parenterally as prescribed by a doctor: eufillin 2.4% solution 10 ml; prednisolone 60-90 mg.	For the relief of an attack of moderate severity and a severe attack
9. Prepare for the arrival of the doctor: Ambu bag, ventilator.	To carry out resuscitation, if necessary

If there is no effect, it is necessary to ensure the transfer of the patient for treatment to the intensive care unit (reanimation). In the department, if necessary, the patient is given artificial lung ventilation (ALV). During mechanical ventilation, a nurse evacuates sputum from the respiratory tract with an electric suction every 30-40 minutes and irrigates them with an alkaline solution.

Care.

The nurse provides: the provision of first aid in case of an asthma attack; precise implementation of the regimen of motor activity and diet prescribed by the doctor; provides the patient with an individual spittoon, conducts its timely disinfection; implementation of measures for personal hygiene of patients (care for the oral cavity, skin, mucous membranes, genital organs during physiological administration); control over the transfer of products to the patient by relatives; precise implementation of doctor's prescriptions; control of blood pressure, respiratory rate, pulse. She also conducts: conversations about the importance of the systematic use of anti-inflammatory drugs; about the importance of monitoring asthma symptoms with a peak flow meter; teaching patients the rules for taking medications, using a peak flow meter, an inhaler. Patient education. The patient should be given recommendations on the regimen, diet, methods and ways of taking bronchodilator drugs. In the home first aid kit, the patient should have all the necessary drugs for the constant control of asthma. The patient should know the signs of worsening asthma and what he should do about it, what medications to take, in what doses, in what cases and where to seek medical help. shows patients how to use an inhaler, peak flowmeter. Currently, asthma schools are functioning in healthcare institutions, teaching patients.

Prevention. Primary: physical activity, rational nutrition, the formation of healthy lifestyle skills, the exclusion of bad habits. Secondary: carrying out activities aimed at preventing the progression of asthma. With allergic asthma, it is important to identify allergens and eliminate contact with them. Before exposure to a trigger, a beta-2 agonist must be taken (eg, take Berotek before exercise). In necessary cases, it is recommended to confiscate pets (cats, dogs), domestic flowers, food products, and the use of anti-inflammatory drugs (for aspirin asthma) is excluded. Patients with bronchial asthma are subject to dispensary observation with a general clinical examination (complete blood count, urine, ECG), as well as sputum examination, including mycobacterium tuberculosis, and X-ray examination of the chest.

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1 76 Pediatrics / 2012 / Volume 91 / 3 Geppe N.A., 2012 N.A. Geppe THE RELEVANCE OF THE PROBLEM OF BRONCHIAL ASTHMA IN CHILDREN SBEI HPE First Moscow State Medical University. THEM. Sechenova, Moscow Bronchial asthma (BA) is a chronic disease with which patients must cope throughout life and the impact of which can be reduced or controlled in most cases. 235 million people worldwide suffer from this disease. The availability of good quality care, including timely diagnosis, understanding of management tactics and the availability of necessary drugs, helps to avoid adverse outcomes and complications. According to epidemiological and long-term observations, the burden of asthma has been increasing over the past 30 years, especially among people with low and middle incomes. The problem of AD in children is extremely relevant. In 2011, the UN meeting on Noncommunicable Diseases (NCDs) focused on the increasing threat of AD and other noncommunicable diseases to global health, social well-being and economic development. AD usually develops in early childhood. More than 3/4 of children who develop asthma symptoms before the age of 7 may have symptoms of asthma by the age of 16. However, AD can develop at any age, including adulthood. Although asthma has puzzled physicians since the time of Hippocrates and there were clear descriptions of patients with asthma exacerbations in the 2nd century with various factors leading to airway obstruction, controversy regarding this disease continues to this day. The evolution in understanding has been reflected in the many attempts to define asthma and classify it, which continue to be the subject of controversy. N.F. Filatov in 1880, in the first edition of Semiotics, defined asthma as “a disease dependent on spasm of the muscle fibers of the small bronchi, characterized by the appearance of recurrent bouts of severe shortness of breath with a loud, thin (high) whistle in the chest, audible even at a distance and accompanied by venous congestion blood and cyanosis. Subsequently, similarities with anaphylaxis, the connection of exacerbations with allergens led to the consideration of asthma as an allergic disease. The strong association of allergies and asthma that is observed in high-income countries is not so evident in low- and middle-income countries. In the 1960s, reversible airway obstruction, a cardinal symptom of asthma, became the basis for the definition of asthma. In 1962, at the ATS (American Thoracic Society) conference, it was confirmed that "asthma is a disease characterized by wide fluctuations over a short period of time in resistance to flow in the airways in the lungs." In developing this definition, the characteristic of airway hyperresponsiveness is introduced, a feature that should normally (but not always) be present in asthma. Subsequently, it was shown that people with clinical asthma may have normal bronchial reactivity, and in the absence of clinical asthma, bronchial reactivity may be increased, and a weak correlation between the existing severity of asthma and the degree of bronchial hyperreactivity was also shown. New data on the role of chronic inflammation in the development of the disease showed that in sensitive people this inflammation causes symptoms that are usually associated with widespread but variable airway obstruction, which is often reversible either spontaneously or under the influence of therapy. In the International Consensus Report on Diagnosis and Treatment of Asthma (GINA), this provision was included in the definition: “chronic Contact information: Geppe Natalia Anatolyevna MD, prof., head. cafe children's diseases SBEI HPE First Moscow State Medical University. THEM. Sechenov Address: Moscow, st. B. Pirogovskaya, 19 Tel.: (499) , Article received, accepted for publication

2 N.A. Geppe 77 is an inflammatory disease of the airways in which many cells play a role, including mast cells and eosinophils." These three components of chronic inflammation, reversible obstruction and increased bronchial reactivity form the basis for the current definition of asthma. They also represent the pathophysiological events leading to the clinical manifestations (wheezing, dyspnea, chest tightness, cough, and sputum production) by which clinicians clinically diagnose the disease. In the definition, which is presented in the National program "Bronchial asthma in children. Treatment strategy and prevention" notes the allergic nature of the disease, in which sensitization to allergens and continued exposure lead to clinical asthma through the development of airway inflammation, reversible obstruction and increased bronchial reactivity. However, it is known that there are cases of asthma with non-allergic inflammation of the airways. These non-allergic mechanisms are currently not well understood. The combination of allergic and non-allergic mechanisms in the development of the disease leads to a debate about whether asthma is a disease with a single underlying causative mechanism, or is it a grouping of different conditions resulting in variable airway obstruction. Much clinical and basic scientific research is devoted to improving our understanding of changes in the lungs and their impact on the mechanics of breathing in asthma, as well as changes in immunity. Research has identified numerous molecules secreted by cells that either cause inflammation or interact with other cells involved in this process. However, the mechanisms by which the immune system can move from a well-regulated to a dysfunctional situation (as occurs in allergies) have not yet been established. In addition, the role of viruses or bacteria, the most common obstructive factors that can mutate over time, is also still completely unknown. There is an opinion about the potential importance of the influence on the immunity of the environment of the developing fetus, the "programming" of the immune system during fetal development. Variants of the course of asthma depend on the interaction of the genetic component and environmental factors, which ultimately form the phenotypic features of asthma, depending on age, the timing of onset, and the variability of the underlying allergic inflammatory process in the bronchi. Given the large number of opinions and studies on asthma, it was natural that guidelines on the principles of asthma management based on the principles of evidence-based medicine appeared. The aim of the guidelines was to educate physicians in diagnosing asthma and to standardize the management of patients with asthma. Patient care during an asthma attack or exacerbation should be organized in such a way that follow-up is long and regular. In addition to the education of physicians, a trend began to develop in the education of patients. Patients should be sent to an asthma school, which, in accordance with age characteristics, will offer a cycle of information and psychological training. The first guides were created in the late 1980s and have been actively developed in subsequent years. The founding document was the Global Initiative in Asthma GINA. National guidelines play an important role in the management of patients, focusing on assessment of asthma symptoms and severity, recommendations for effective treatment of children, and non-pharmacological methods. National asthma programs have evolved with extensive input into existing clinical guidelines from experts such as paediatricians, pulmonologists, allergists, experts from other health sectors such as public health. Despite the success of the use of guidelines in asthma management, more efforts are needed to improve adherence and increase attention to the quality of asthma care. When asked by staff from 105 countries, 69 (75%) answered that they had used the guidelines for children and 71 (77%) answered that they had used them for adults. 84% of countries have their own national asthma guidelines. Experience in Finland has shown that from 1993 to 2003 As a result of this program, the burden of asthma in Finland has been significantly reduced. Main indicators: the number of days of hospitalization decreased by 86% and disability by 76%. In recent years, only a few deaths/year have been reported from asthma, and there is no actual death from asthma among patients in younger age groups. Of patients requiring regular treatment for persistent asthma, up to 75% received medical reimbursement. 15 years have passed (1997), when, on the initiative of the Chairman of the Russian Respiratory Society, Academician of the Russian Academy of Medical Sciences A.G. Chuchalin, leading Russian pediatricians developed the first National Program “Bronchial Asthma in Children. Treatment strategy and prevention”. For the first time in Russia, a specialized document was created reflecting the opinions of leading

3 78 Pediatrics/2012/Vol. 91/ 3 specialists working in the field of asthma. When preparing subsequent versions of the National Program (1997, 2006, 2008, 2012), the recommendations of the joint report of the WHO and the National Heart, Lung, Blood Institute (USA) GINA “Bronchial Asthma. Global Strategy” (gg.), as well as the European Respiratory Society and the best practices of a number of foreign countries in the treatment of asthma in children. The creation of a pediatric program made it possible to pay attention to the features of the course of asthma in children associated with the anatomical and physiological characteristics of the respiratory tract, the immune system, the metabolism of drugs and their delivery routes, which determine approaches to diagnosis, therapy, prevention and educational programs. The wide implementation of the National Program made it possible to form a unified position in the fight against asthma in children and achieve significant success in the diagnosis and treatment of this disease, reduce mortality and disability of patients. Attention is drawn to the need to expand clinical trials in children. At the same time, due to ethical considerations in pediatrics, especially in young children, there are difficulties in strictly following the principles of randomized controlled trials. These studies include a limited cohort of children with strict selection criteria, which does not allow extrapolating the results to all children with AD with age, individual characteristics, and concomitant diseases. Therefore, the preparation of the National Program also takes into account the opinions of specialists based on real clinical practice, comparison of scientific evidence with the nuances of the clinical picture, the state of the child's environment, the safety of medicines, and economic realities. The result of the implementation of the National Program in the Russian Federation was an improvement in the diagnosis and prognosis of BA in children. The total number of children and adolescents with BA in Russia, according to official statistics, is more than 350,000. Thanks to the introduction of unified criteria for severity and planned therapy, the structure of BA severity has changed towards an increase in mild and moderate forms. The proportion of seriously ill patients, their disability, and mortality have decreased. In the years new provisions on the procedure for providing medical care to children and adults with pulmonary and allergic diseases were prepared by experts and approved by orders of the Ministry of Health of the SR RF, in which much attention is paid to asthma, both at the outpatient and inpatient stages. Since the 1980s, over the next 20 years, an increase in the prevalence of asthma has been reported in many English-speaking countries. The advent of a worldwide epidemiological research program, the ISAAC International study asthma and allergy in children, has provided population-based data on the prevalence and severity of asthma in children. In 2004, ISAAC was listed in the Guinness Book of Records as the largest epidemiological study of asthma, rhinitis, eczema among children, and includes 196 million children, 306 research centers in 105 countries, whose population is 86.9% of the world. The first phase of ISAAC (gg.) and the third phase (gg.) included two age groups of schoolchildren: 6 7 years and years. The second phase of the ISAAC (s) was an intensive study involving clinical trials in children aged 1 years and was designed to explore the relative importance of refining the hypotheses of influence that emerged in the first phase. The ISAAC program has revealed significant variability in asthma symptoms across regions and even within the same country. Identification of difficult wheezing required an in-depth examination and an individual program to eliminate risk factors to prevent the progression of allergic diseases. Variations in the prevalence of asthma symptoms up to 15 times between countries have been noted. Compared to the 1980s, the 1990s saw a continued increase in the prevalence of asthma. However, in most countries with a high prevalence of asthma, especially in English-speaking countries, the prevalence of asthma symptoms between the first and third phase (s) even decreased. In Russia, studies carried out under the ISAAC program in Moscow in 1993 included questioning only the older age group. A survey of two age contingents was first conducted in Novosibirsk under the guidance of prof. CM. Gavalov on the initiative of Academician of the Russian Academy of Medical Sciences prof. A.G. Chuchalin and under the patronage of prof. D. Charpin (France) and then in many other regions of the country, which made it possible to improve the diagnosis of asthma in children in Russia. Russian studies show that in both age groups the prevalence of asthma symptoms was comparable to the world average and northeastern European indicators. In contrast, the frequency of diagnoses established in practical health care institutions was lower than world values, especially among younger schoolchildren, but close to European data. Contradictory results have been obtained regarding the prevalence of asthma symptoms in urban and rural areas. Some studies have shown a lower incidence of

4 N.A. Geppe 79 levy in the city, in others in the countryside, which requires when comparing indicators to take into account the place of residence of children, possible environmental problems in the region. Comparison in the dynamics of epidemiological data obtained using a standardized methodology is possible at this stage only in two regions. In Novosibirsk, a comparison of the results of 1996 and 2002 indicates a stable frequency of BA symptoms in older and younger schoolchildren (these are the only data for Russia that were included in the results of the ISAAC Phase III program presented above). The prevalence of mild, rarely recurring forms of pathology in both age groups remains (81.2 and 81.5%, respectively), a progressive increase in severe asthma attacks in 8th graders was noted, an increase in combined lesions of the upper and lower respiratory tract was registered (from 3.7 to 4.8%). An analysis of the results of the implementation of the ISAAC program in Russia shows that even in published works there are inaccuracies in the research methodology and interpretation of the data obtained. The reasons for this can be considered the lack of a single coordinating center for conducting such studies in Russia. Despite the rather high specificity and sensitivity of each question, an in-depth clinical, functional and allergological examination is necessary for the final diagnosis. Currently, the results of the ISAAC Phase III program, which is a repetition of the Phase I study after 5-10 years in 106 centers from 56 countries, have been published. In most countries, the prevalence of asthma symptoms did not change significantly between phases I and III (s) and even decreased in some English-speaking countries. In Western Europe, the prevalence of current asthma symptoms decreased by 0.07% per year in children, but increased by 0.2% per year in younger schoolchildren. Although, overall, the prevalence of current asthma symptoms has changed little, the percentage of children reporting asthma has increased significantly, reflecting perhaps greater awareness of the disease and/or changes in diagnosis. According to the GINA, the severity of the disease was divided into intermittent or persistent, or if persistent, then severe, moderate and mild. According to the developed approaches in domestic pediatrics, the classification of BA by severity makes it possible to ensure the selection of rational therapy by practical doctors in different age periods, to maintain continuity in the transition to adult specialists, and to conduct an adequate expert assessment. When evaluating the effectiveness of prescribed therapy and developing treatment tactics, the category of achieving disease control can be used. The GINA notes that control of asthma means control of the clinical manifestations of the disease. The term control can mean the prevention of a disease or even a complete cure. However, with asthma, these goals are unattainable and control means eliminating the manifestations of the disease. Ideally, this should apply not only to clinical manifestations, but also to laboratory markers of inflammation, pathophysiological signs of the disease. However, given the high cost and inaccessibility of research (endobronchial biopsy, sputum eosinophils, nitric oxide levels in exhaled air), it is recommended to carry out treatment aimed at achieving control over the clinical manifestations of asthma, including impaired lung function. Severe persistent asthma was relatively more common in Eastern and Central Europe (22% of all asthma and 41% of all persistent asthma) and less common in the Asia-Pacific region. A continuous increase in sensitization has been demonstrated among people born from the 1940s to the 1970s. A broad group of factors are known to cause asthma, but no specific cause or biological environment has been unambiguously identified. Both genetic and non-genetic factors are involved in the development of the disease, which can determine the severity and persistence of asthma. There are trigger mechanisms for asthma attacks (which are widely known) and the causes of the underlying asthmatic process (which is much less known). Asthma often runs in families, and identical twins will most likely both be asthmatics. Large studies of asthma in the general population have recently identified a small number of genetic variants influencing asthma risk, mainly in children. Asthma attacks are most commonly triggered by upper respiratory tract infections and exercise. Less often, they are associated with acute emotional stress or with the use of certain foods, drinks, or medications. Environmental factors that can trigger asthma attacks include inhalant allergens (house dust, animal dander, plant pollen, etc.) and inhalant irritants (tobacco smoke, heater fumes, vehicle exhaust, cosmetics, aerosols). Exposure to pet allergens is often less common among children with asthma due to the targeted restriction of exposure or removal of pets in families with allergies. There is insufficient evidence that pets are a risk factor for disease or have protective

5 80 Pediatrics/2012/Volume 91/ 3rd effect. A lower prevalence of asthma among children living on farms has been shown, but no specific causes have been identified that have a protective effect. It is noted that asthma symptoms are more common among children who were treated with antibiotics in early childhood. However, symptoms of obstruction, which usually first develop in infancy, can be treated with antibiotics before they are recognized as early manifestations of asthma. The same "reverse causality" situation is possible between the use of acetaminophen in infancy and the development of asthma in school age. Paracetamol may be used for early symptoms of asthma, or for infections that themselves may increase the risk of asthma. Prolonged exclusive breastfeeding is seen as protection against allergic diseases, including asthma. Many components of the diet in later childhood and adulthood have also been studied, and it is suggested that diets may slightly reduce the risk of allergies. A large number of experimental, clinical and epidemiological studies indicate that environmental factors, rapid urbanization, poor control of environmental pollution, and the complex nature of air pollution play a role in exacerbating asthma symptoms. It has been proven that the prevalence of asthma symptoms is higher in children living near sources of traffic pollution. There is fairly strong evidence that air pollution and exposure to allergens exacerbate respiratory symptoms and increase the incidence of upper and lower respiratory tract infections in children. A large number of studies around the world prove that passive smoking, including prenatal exposure, is the cause of obstructive diseases in early childhood, especially in interaction with acute respiratory viral infections. Guidelines to be achieved (GINA) have been developed for successful asthma control. These include disease control with no or minimal symptoms, few or no flare-ups and emergency room visits, no activity restriction, respiratory function normal for age, minimal use of rescue medications, and no side effects from treatment. . Asthma has a significant impact on the lives of patients with significant loss of school and work days. The current level of asthma control worldwide is unsatisfactory. A US national population survey found that only 26.2% of people with persistent asthma symptoms in the previous month report inhaling corticosteroids. A study in Europe found that 46% of patients had daytime symptoms and 30% had asthma-related sleep disturbances at least once a week. Moreover, over the past 12 months, 25% of patients reported an unscheduled urgent visit to the doctor; 10% had one or more emergencies; 7% were hospitalized. According to the results of the study in the previous 4 weeks, 63% of patients used bronchodilators and only 23% inhaled corticosteroids. In the Asia-Pacific region, only 13.6% reported current use of inhaled glucocorticosteroids. In patients with persistent asthma, this indicates a lack of understanding of the importance of long-term management of patients with asthma. The program for the management of children with asthma provides for an integrated approach with the appointment of a wide range of activities. The main directions of the program for asthma in children include the following: elimination of the impact of causative factors (elimination), development of individual plans for basic anti-inflammatory therapy, individual plans for the relief of exacerbations, a plan for rehabilitation and dispensary observation, education and training of sick children and family members, and prevention of disease progression. Based on the pathogenesis of asthma, modern therapy is aimed at eliminating allergic inflammation of the bronchial mucosa, reducing bronchial hyperreactivity, restoring bronchial patency and preventing structural changes in the bronchial wall. The choice of treatment is determined by the severity of the course and the period of asthma. However, in any case, an individual approach is required in the choice of means and methods of treatment. In the pharmacotherapy of asthma, a “graded” approach is recommended, which includes increasing or decreasing the amount of therapy depending on the severity of clinical symptoms. In complex therapy, non-drug methods of treatment should also be used, although the effectiveness of some of them is debatable and needs further study. Successful treatment of asthma is impossible without the establishment of partnerships, trusting relationships between a doctor, a sick child, his parents and relatives. The basis of the pharmacotherapy of asthma is basic (anti-inflammatory) therapy, which is understood as the regular long-term use of drugs that stop allergic inflammation in the mucous membrane of the respiratory tract. In children older than 6 years, basic therapy is carried out under the control of the function of external respiration.

6 N.A. Geppe 81 Basic therapy drugs include glucocorticosteroids (inhaled and systemic), leukotriene receptor antagonists, prolonged β 2 -agonists, cromones (cromoglycic acid, nedocromil sodium), prolonged theophyllines, monoclonal antibodies to IgE, allergen-specific immunotherapy. Inhaled glucocorticosteroids (IGCS) act mainly locally and have a pronounced anti-inflammatory activity. They are able to suppress both acute and chronic inflammation. The reverse development of inflammation in the bronchial mucosa observed under the influence of ICS is accompanied by a decrease in their hyperreactivity, a decrease in asthma attacks and contributes to the achievement of remission. The dose of inhaled corticosteroids is used, corresponding to the severity of the disease, and when control is achieved, the dose is titrated to the minimum maintenance dose. ICS affect inflammation but do not cure the disease. When treatment is stopped, the symptoms of the disease may recur. Modern ICS (beclomethasone, budesonide, fluticasone) have a minimal overall effect. The results of studies indicate the need for long-term use of inhaled corticosteroids in severe cases (at least 6-8 months), however, even with prolonged remission after discontinuation of the drug, symptoms of the disease may resume. Inhaled corticosteroids are very effective in reducing the severity of bronchial inflammation, and their side effects have been minimized in recent years both by creating safe molecules and by creating combinations with long-acting bronchodilators. The discovery of a synergistic effect when adding long-acting bronchodilators to ICS was a milestone in asthma management 15 years ago. In the last 15 years, only two new drugs have been created and put into practice: leukotriene receptor antagonists and monoclonal antibodies to IgE (key molecules in the allergic inflammation pathway). One of the directions of modern pharmacotherapy in children with mild and moderate AD is leukotriene receptor antagonists, which block leukotriene receptors and prevent the activation of target cells. These drugs are the first mediator-specific therapy for AD. Leukotriene receptor antagonists (montelukast, zafirlukast) improve the symptoms of asthma and provide a bronchoprotective effect in asthma in preschool children. Montelukast is used in children with asthma and associated allergic rhinitis from 2 years of age. No signs of tolerance development were observed during the 8-week treatment period. The onset of action of the drug is noted after the first dose. Montelukast reduces the frequency of exacerbations of asthma caused by a viral infection in children aged 2-5 years. Treatment with leukotriene receptor antagonists provides a distinct additional therapeutic effect in patients receiving ICS. The effectiveness of leukotriene receptor antagonists in patients with intolerance to aspirin and other non-steroidal anti-inflammatory drugs and with bronchospasm on physical activity has been shown. The economic impact of asthma is the largest among non-communicable diseases. Costs cover a wide range of human resources, supplies and facilities needed for asthma specialist training, pre-acute care, long-term pharmacotherapy, and patient planning and education. The main indirect costs are related to the loss of productivity due to absenteeism from work and school. The costs of asthma are enormous. Although the exact cost of asthma worldwide cannot be determined, in 2009 a systematic review (8 national studies) reported the total cost per year. Expenses in 2008 in US dollars were, for example, $654 million in Canada, $2,740 million in Germany, and $1,413 million in Switzerland. As the number of people with asthma increases, all of these costs will increase. One of the main ways to reduce costs is to achieve good asthma control. Given the complex interactions between environmental exposure, genetic susceptibility, immunological mechanisms, and social factors involved in the development of asthma, an interdisciplinary approach seems to be the most promising, as it integrates epidemiology, social science, biomedical and clinical research. The national program, as well as the guidelines of various countries, is not a "frozen" document, which would lead to its limited use. To create more perfect recommendations, the constant active participation of specialists in various fields in their updating is required. REFERENCES 1. Global initiative for asthma (GINA). Global strategy for asthma management and prevention. Bethesda, USA: National institutes of health, Bethesda, National Program on Bronchial Asthma in Children. Treatment strategy and prevention”. 3rd ed. M.: Ed. House "Atmosphere", 2008: 108 p. 3. Global Initiative for asthma (GINA). Global strategy for asthma management and prevention. Bethesda (MD): GINA, Fitzgerald JM, Quon BS. The impact of asthma guidelines. Lancet. 2010; 376 (9743): Haahtela T, Tuomisto L, Pietinalho A, et al. 10 years

7 82 Pediatrics/2012/Vol. 91/ 3 asthma program in Finland:major change for the better. Thorax. 2006; 61: Revyakina V.A., Filatova T.A. From atopic dermatitis to bronchial asthma in children. Lech. doctor. 2006; 1: Lai CKW, Beasley R, Crane J, et al. Global variation in the prevalence and severity of asthma symptoms: Phase three of the international study of asthma and allergies in childhood (ISAAC). Thorax. 2009; 64 (6): Asher MI, Montefort S, Björkstén B, et al. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and three repeat multicountry crosssectional surveys. Lancet. 2006; 368 (9537): Pearce N, Apt-Khaled N, Beasley R, et al. Worldwide trends in the prevalence of asthma symptoms: Phase III of the international study of asthma and allergies in childhood (ISAAC). Thorax. 2007; 62 (9): Kondyurina E.G. Dynamics of prevalence of bronchial asthma in children in Novosibirsk. Pulmonology. 2003; 6: Drozhzhev M.E., Lev N.S., Kostyuchenko M.V. Modern indicators of the prevalence of bronchial asthma among children. Pulmonology. 2002; 1: Tantisira K, Weiss S. The pharmacogenetics of asthma treatment. Curr. allergy asthma Rep. 2009; 9 (1): WHO European center for environment and health. Effects of air pollution on children's health and development - a review of the evidence. WHO Regional Office For Europe, Bonn, Omenaas E, Svanes C, Janson C, et al. What can we learn about asthma and allergy from the follow-up of the RHINE and the ECRHS studies? Clin. Respir. J. 2008; 2 (Suppl. 1): World Health Organization. Preventionand control of chronic respiratory diseases in low and middle-income African countries: a preliminary report. Geneva: World health organization, ARIA Report. Eur. J. Allergy Clin. Immunol. 2008; Suppl. 17. Ait-Khaled N, Enarson DA, Bissell K, et al. Access to inhaled corticosteroids is key to improving the quality of care for asthma in developing countries. Allergy. 2007; 62 (3): The global asthma report Paris, France: The International Union against tuberculosis and lung disease, Baranov A.A., Namazova-Baranova L.S., 2012

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