COPD what to do. Symptoms of COPD - a dangerous disease masquerading as ordinary fatigue. Symptoms and signs of COPD in humans

Chronic obstructive pulmonary disease (COPD) is a disease characterized by progressive, partially reversible bronchial obstruction, which is associated with inflammation respiratory tract arising under the influence of unfavorable environmental factors (smoking, occupational hazards, pollutants, etc.). It has been established that morphological changes in COPD are observed in the central and peripheral bronchi, pulmonary parenchyma and blood vessels. This explains the use of the term “chronic obstructive pulmonary disease” instead of the usual “chronic obstructive bronchitis,” which implies a predominant lesion of the bronchi in the patient.

The morbidity and mortality of patients from COPD continues to increase worldwide, primarily due to the high prevalence of smoking. It has been shown that this disease affects 4-6% of men and 1-3% of women over 40 years of age. In European countries, it causes the death of 200-300 thousand people annually. The high medical and social significance of COPD was the reason for the publication, at the initiative of WHO, of an international consensus document devoted to its diagnosis, treatment, prevention and based on the principles evidence-based medicine. Similar recommendations have been issued by the American and European Respiratory Societies. The 2nd edition was recently published in our country Federal program for COPD.

The goals of COPD therapy are to prevent disease progression, reduce the severity of clinical symptoms, achieve better exercise tolerance and improve the quality of life of patients, prevent complications and exacerbations, and reduce mortality.

The main directions of COPD treatment are reducing the impact of adverse environmental factors (including smoking cessation), patient education, use medicines and non-drug therapy (oxygen therapy, rehabilitation, etc.). Various combinations of these methods are used in patients with COPD in remission and exacerbation.

Reducing the impact of risk factors on patients is an integral part of the treatment of COPD, which helps prevent the development and progression of this disease. It has been established that quitting smoking can slow down the increase in bronchial obstruction. Therefore, treatment of tobacco addiction is important for all patients suffering from COPD. The most effective in this case are conversations with medical personnel (individual and group) and pharmacotherapy. There are three tobacco dependence treatment programs: short (1-3 months), long-term (6-12 months) and a program to reduce smoking intensity.

It is recommended to prescribe medications for patients with whom the doctor’s conversations were not sufficiently effective. A careful approach should be taken to their use in people who smoke less than 10 cigarettes per day, adolescents and pregnant women. Contraindications to nicotine replacement therapy are unstable angina, untreated peptic ulcer duodenum, recently transferred acute heart attack myocardium and cerebrovascular accident.

Increasing patients' awareness allows them to increase their performance, improve their health, develop the ability to cope with the disease, and increase the effectiveness of treatment of exacerbations. Forms of patient education vary from distributing printed materials to holding seminars and conferences. The most effective is interactive training, which is carried out in a small seminar.

The principles of treatment of stable COPD are as follows.

• The volume of treatment increases as the severity of the disease increases. Its decrease in COPD, in contrast to bronchial asthma, as a rule, is impossible.
• Drug therapy is used to prevent complications and reduce the severity of symptoms, the frequency and severity of exacerbations, increase exercise tolerance and the quality of life of patients.
• It should be borne in mind that none of the available drugs affects the rate of decrease in bronchial obstruction, which is the hallmark of COPD.
• Bronchodilators are central to the treatment of COPD. They reduce the severity of the reversible component of bronchial obstruction. These funds are used on an on-demand or regular basis.
• Inhaled glucocorticoids are indicated for severe and extremely severe COPD (with forced expiratory volume in 1 s (FEV 1) less than 50% of predicted and frequent exacerbations, usually more than three in the last three years or one or two in one year, for treatment which use oral steroids and antibiotics.
• Combination therapy with inhaled glucocorticoids and long-acting β 2 -adrenergic agonists has a significant additional effect on pulmonary function and clinical COPD symptoms compared with monotherapy with each drug. Greatest influence on the frequency of exacerbations and quality of life observed in patients with COPD with FEV 1<50% от должного. Эти препараты предпочтительно назначать в ингаляционной форме, содержащей их фиксированные комбинации (салметерол/флутиказон пропионат, формотерол/будесонид).
• Long-term use of tableted glucocorticoids is not recommended due to the risk of developing systemic side effects.
• At all stages of COPD, physical training programs are highly effective, increasing exercise tolerance and reducing the severity of shortness of breath and fatigue.
• Long-term administration of oxygen (more than 15 hours per day) to patients with respiratory failure increases their survival.

Drug treatment of stable COPD

Bronchodilators. These include β 2 -adrenergic agonists, anticholinergics, and theophylline. The forms of release of these drugs and their effect on the course of COPD are given in And .

The principles of bronchodilator therapy for COPD are as follows.

• The preferred route of administration of bronchodilators is inhalation.
• Changes in pulmonary function after short-term administration of bronchodilators are not an indicator of their long-term effectiveness. A relatively small increase in FEV 1 can be combined with significant changes in lung volumes, including a decrease in residual lung volume, which helps reduce the severity of shortness of breath in patients.
• The choice between β 2 -adrenergic agonists, anticholinergics, and theophylline depends on their availability, the individual sensitivity of patients to their action and the absence of side effects. In elderly patients with concomitant diseases of the cardiovascular system (coronary artery disease, heart rhythm disturbances, arterial hypertension, etc.), anticholinergics are preferred as first-line drugs.
• Xanthines are effective for COPD, but due to the possibility of developing side effects, they are classified as “second-line” drugs. When prescribing them, it is recommended to measure the concentration of theophylline in the blood. It should be emphasized that only long-acting theophyllines (but not aminophylline and theophedrine!) have a positive effect on the course of COPD.
• Long-acting inhaled bronchodilators are more convenient, but also more expensive than short-acting ones.
• Regular treatment with long-acting bronchodilators (tiotropium bromide, salmeterol and formoterol) is indicated for moderate, severe and extremely severe COPD.
• The combination of several bronchodilators (for example, anticholinergics and β 2 -agonists, anticholinergics and theophyllines, β 2 -agonists and theophyllines) may increase effectiveness and reduce the likelihood of side effects compared with monotherapy with a single drug.

Metered aerosols, powder inhalers and nebulizers are used to deliver β2-adrenergic agonists and anticholinergics. The latter are recommended in the treatment of exacerbations of COPD, as well as in patients with severe disease who have difficulty using other delivery systems. For stable COPD, metered dose and powder inhalers are preferred.

Glucocorticoids. These drugs have pronounced anti-inflammatory activity, although in patients with COPD it is significantly less pronounced than in patients with asthma. Short (10-14 days) courses of systemic steroids are used to treat exacerbations of COPD. Long-term use of these drugs is not recommended due to the risk of side effects (myopathy, osteoporosis, etc.).

Data on the effect of inhaled glucocorticoids on the course of COPD are summarized in . It has been shown that they have no effect on the progressive decrease in bronchial obstruction in patients with COPD. Their high doses (for example, fluticasone propionate 1000 mcg/day) can improve the quality of life of patients and reduce the frequency of exacerbations of severe and extremely severe COPD.

The reasons for the relative steroid resistance of airway inflammation in COPD are the subject of intense research. This may be due to the fact that corticosteroids increase the lifespan of neutrophils by inhibiting their apoptosis. The molecular mechanisms underlying resistance to glucocorticoids are not well understood. There have been reports of a decrease in the activity of histone deacetylase, which is a target for the action of steroids, under the influence of smoking and free radicals, which may reduce the inhibitory effect of glucocorticoids on the transcription of “inflammatory” genes and weaken their anti-inflammatory effect.

Recently, new data have been obtained on the effectiveness of combination drugs (fluticasone propionate/salmeterol 500/50 mcg, 1 inhalation 2 times a day and budesonide/formoterol 160/4.5 mcg, 2 inhalations 2 times a day, budesonide/salbutamol 100/200 mgk 2 inhalations 2 times a day) in patients with severe and extremely severe COPD. It has been shown that their long-term (12 months) administration improves bronchial patency, reduces the severity of symptoms, the need for bronchodilators, the frequency of moderate and severe exacerbations, and also improves the quality of life of patients compared to monotherapy with inhaled glucocorticoids, long-acting β 2 -adrenergic agonists and placebo .

Vaccines. Influenza vaccination reduces the severity of exacerbations and mortality in patients with COPD by approximately 50%. Vaccines containing killed or inactivated live influenza viruses are usually administered once in October - the first half of November.

There is insufficient data on the effectiveness of the pneumococcal vaccine, containing 23 virulent serotypes of this microorganism, in patients with COPD. However, some experts recommend its use in this disease to prevent pneumonia.

Antibiotics. Currently, there is no convincing data on the effectiveness of antibacterial agents to reduce the frequency and severity of non-infectious exacerbations of COPD.

Antibiotics are indicated for the treatment of infectious exacerbations of the disease, directly affect the duration of elimination of COPD symptoms, and some help lengthen the interval between relapses.

Mucolytics (mucokinetics, mucoregulators). Mucolytics (ambroxol, carbocysteine, iodine preparations, etc.) can be used in a small proportion of patients with viscous sputum. Widespread use of these agents in patients with COPD is not recommended.

Antioxidants. N-acetylcysteine, which has antioxidant and mucolytic activity, can reduce the duration and frequency of exacerbations of COPD. This drug can be used in patients for a long time (3-6 months) at a dose of 600 mg/day.

Immunoregulators (immunostimulants, immunomodulators). Regular use of these drugs is not recommended due to the lack of convincing evidence of effectiveness.

Patients with genetically determined α 1 -antitrypsin deficiency who develop COPD at a young age (up to 40 years) are possible candidates for replacement therapy. However, the cost of such treatment is very high, and it is not available in all countries.

Non-drug treatment of stable COPD

Oxygen therapy

It is known that respiratory failure is the main cause of death in patients with COPD. Correction of hypoxemia using oxygen supply is a pathogenetically based treatment method. There are short-term and long-term oxygen therapy. The first is used for exacerbations of COPD. The second is used for extremely severe COPD (with FEV 1<30% от должного) постоянно или ситуационно (при физической нагрузке и во время сна). Целью оксигенотерапии является увеличение парциального напряжения кислорода (РаO 2) в артериальной крови не ниже 60 мм рт. ст. или сатурации (SaO 2) не менее чем до 90% в покое, при физической нагрузке и во время сна.

In stable COPD, continuous long-term oxygen therapy is preferable. It has been proven that it increases the survival of patients with COPD, reduces the severity of shortness of breath, the progression of pulmonary hypertension, reduces secondary erythrocytosis, the frequency of episodes of hypoxemia during sleep, increases exercise tolerance, quality of life and neuropsychic status of patients.

Indications for long-term oxygen therapy in patients with extremely severe COPD (with FEV 1< 30% от должного или менее 1,5 л):

• PaO 2 is less than 55% of the expected value, SaO 2 is below 88% in the presence or absence of hypercapnia;
• PaO 2 - 55-60% of the expected value, SaO 2 - 89% in the presence of pulmonary hypertension, peripheral edema associated with decompensation of the pulmonary heart or polycythemia (hematocrit more than 55%).

Gas exchange parameters should be assessed only against the background of a stable course of COPD and no earlier than 3-4 weeks after an exacerbation with optimally selected therapy. The decision to prescribe oxygen therapy should be based on measurements obtained at rest and during exercise (eg, a 6-minute walk). Re-evaluation of arterial blood gases should be carried out 30-90 days after the start of oxygen therapy.

Long-term oxygen treatment should be carried out for at least 15 hours a day. The gas flow rate is usually 1-2 l/min, if necessary it can be increased to 4 l/min. Oxygen therapy should never be prescribed to patients who continue to smoke or suffer from alcoholism.

Compressed gas cylinders, oxygen concentrators and liquid oxygen cylinders are used as oxygen sources. Oxygen concentrators are the most economical and convenient for home use.

Oxygen is delivered to the patient using masks, nasal cannulas, and transtracheal catheters. The most convenient and widely used are nasal cannulas, which allow the patient to receive an oxygen-air mixture with 30-40% O2. Oxygen is delivered to the alveoli only in the early phase of inspiration (the first 0.5 s). The gas arriving later is used only to fill the dead space and does not participate in gas exchange. To increase delivery efficiency, there are several types of oxygen-saving devices (reservoir cannulas, devices that supply gas only during inspiration, transtracheal catheters, etc.). In patients with extremely severe COPD who have daytime hypercapnia, the combined use of long-term oxygen therapy and non-invasive ventilation with positive inspiratory pressure is possible. It should be noted that oxygen therapy is one of the most expensive methods of treating patients with COPD. Its introduction into everyday clinical practice is one of the most pressing medical and social tasks in Russia.

Rehabilitation

Rehabilitation is a multidisciplinary program of individualized care for patients with COPD, designed to improve their physical, social adaptation and autonomy. Its components are physical training, patient education, psychotherapy and balanced nutrition.

In our country, this traditionally includes sanatorium-resort treatment. Pulmonary rehabilitation should be prescribed for moderate, severe and extremely severe COPD. It has been shown to improve performance, quality of life and survival of patients, reduce shortness of breath, the frequency and duration of hospitalizations, and suppress anxiety and depression. The effect of rehabilitation remains after its completion. Classes with patients in small (6-8 people) groups with the participation of specialists in various fields for 6-8 weeks are optimal.

In recent years, much attention has been paid to rational nutrition, as weight loss (> 10% within 6 months or > 5% within the last month) and especially loss muscle mass in patients with COPD is associated with high mortality. Such patients should be recommended a high-calorie diet with a high protein content and dosed physical activity that has an anabolic effect.

Surgery

Role surgical treatment in patients with COPD is currently the subject of research. The possibilities of using bullectomy, lung volume reduction surgery, and lung transplantation are currently being discussed.

The indication for bullectomy in COPD is the presence in patients of bullous pulmonary emphysema with large bullae causing the development of shortness of breath, hemoptysis, pulmonary infections and pain in the lungs. chest. This surgery results in decreased shortness of breath and improved lung function.

The value of surgery to reduce lung volume in the treatment of COPD has not yet been sufficiently studied. The results of a recently completed study (National Emphysema Therapy Trial) indicate positive impact this surgical intervention compared with drug therapy on the ability to perform physical activity, quality of life and mortality of COPD patients with predominantly severe upper lobe emphysema and initially low level performance. However, this operation remains an experimental palliative procedure and is not recommended for wide application.

Lung transplantation improves the quality of life, pulmonary function and physical performance of patients. Indications for its implementation are FEV1 е25% of the expected, PaCO2>55 mm Hg. Art. and progressive pulmonary hypertension. Factors limiting the performance of this operation include the problem of selecting a donor lung, postoperative complications and high cost (110-200 thousand US dollars). Operative mortality in foreign clinics is 10-15%, 1-3-year survival rate, respectively, 70-75 and 60%.

Stepwise therapy for stable COPD is shown in the figure.

Treatment of cor pulmonale

Pulmonary hypertension and chronic cor pulmonale are complications of severe and extremely severe COPD. Their treatment involves optimal therapy for COPD, long-term (>15 hours) oxygen therapy, the use of diuretics (in the presence of edema), digoxin (only with atrial fibrillation and concomitant left ventricular heart failure, since cardiac glycosides do not affect contractility and ejection fraction of the right ventricle) . The use of vasodilators (nitrates, calcium antagonists and angiotensin-converting enzyme inhibitors) is controversial. Their use in some cases leads to deterioration of blood oxygenation and arterial hypotension. However, calcium antagonists (nifedipine SR 30-240 mg/day and diltiazem SR 120-720 mg/day) can probably be used in patients with severe pulmonary hypertension when bronchodilators and oxygen therapy are insufficient.

Treatment of exacerbations of COPD

Exacerbation of COPD is characterized by an increase in the patient's shortness of breath, cough, change in the volume and nature of sputum and requires changes in treatment tactics. . There are mild, moderate and severe exacerbations of the disease (see. ).

Treatment of exacerbations involves the use medicines(bronchodilators, systemic glucocorticoids, antibiotics as indicated), oxygen therapy, respiratory support.

The use of bronchodilators involves increasing their doses and frequency of administration. Dosage regimens for these drugs are given in And . Introduction $beta; 2-adrenergic agonists and anticholinergics short acting carried out using compressor nebulizers and metered dose inhalers with a large volume spacer. Some studies have shown equivalent effectiveness of these delivery systems. However, for moderate and severe exacerbations of COPD, especially in elderly patients, preference should probably be given to nebulizer therapy.

Due to the difficulty of dosing and the large number of potential side effects, the use of short-acting theophyllines in the treatment of exacerbations of COPD is the subject of debate. Some authors admit the possibility of their use as “second-line” drugs if inhaled bronchodilators are insufficiently effective, others do not share this point of view. It is likely that the prescription of drugs in this group is possible if the rules of administration are observed and the concentration of theophylline in the blood serum is determined. The most famous of them is the drug aminophylline, which is theophylline (80%) dissolved in ethylenediamine (20%). Its dosage schedule is given in . It should be emphasized that the drug should only be administered intravenously. This reduces the likelihood of developing side effects. It cannot be administered intramuscularly or by inhalation. The administration of aminophylline is contraindicated in patients receiving long-acting theophyllines due to the risk of overdose.

Systemic glucocorticoids are effective in treating exacerbations of COPD. They shorten recovery time and ensure faster recovery of lung function. They are prescribed simultaneously with bronchodilators for FEV 1<50% от должного уровня. Обычно рекомендуется 30-40 мг преднизолона per os или эквивалентная доза внутривенно в течение 10-14 дней. Более длительное его применение не приводит к повышению эффективности, но увеличивает риск развития побочных эффектов. В последние годы появились данные о возможности использования ингаляционных глюкокортикоидов (будесонида), вводимых с помощью небулайзера, при лечении обострений ХОБЛ в качестве альтернативы системным стероидам .

Antibacterial therapy is indicated for patients who have signs of an infectious process (increased amount of sputum, change in the nature of sputum, elevated body temperature, etc.). Its options for various clinical situations are given in .

The advantages of antibacterial therapy are as follows.

• Reducing the duration of exacerbations of the disease.
• Preventing the need for hospitalization of patients.
• Reducing the period of temporary disability.
• Prevention of pneumonia.
• Prevention of progression of airway damage.
• Increased duration of remission.

In most cases, antibiotics are prescribed orally, usually for 7-14 days (with the exception of azithromycin).

Oxygen therapy is usually prescribed for moderate and severe exacerbations of COPD (with PaO 2< 55 мм рт. ст., SaO 2 <88%). Применяются в этих случаях носовые катетеры или маска Вентури. Для оценки адекватности оксигенации и уровня РаСО 2 контроль газового состава крови должен осуществляться каждые 1-2 ч . При сохранении у больного ацидоза или гиперкапнии показана искусственная вентиляция легких. Продолжительность оксигенотерапии после купирования обострения при наличии гипоксемии обычно составляет от 1 до 3 мес.

If the patient's condition is severe, non-invasive or invasive artificial pulmonary ventilation (ALV) should be performed. They differ in the way the patient and the respirator communicate.

Non-invasive ventilation consists of providing the patient with ventilation support without tracheal intubation. It involves the delivery of oxygen-enriched gas from a respirator through a special mask (nasal or oral-nasal) or mouthpiece. This method of treatment differs from invasive mechanical ventilation in that it reduces the likelihood of mechanical damage to the oral cavity and respiratory tract (bleeding, strictures, etc.), the risk of developing infectious complications (sinusitis, hospital-acquired pneumonia, sepsis), and does not require the administration of sedatives, muscle relaxants and analgesics, which may have an adverse effect on the course of an exacerbation.

The most commonly used non-invasive ventilation mode is positive pressure respiratory support.

It has been established that non-invasive mechanical ventilation reduces mortality, reduces the time of patient stay in hospital and the cost of treatment. It improves pulmonary gas exchange, reduces the severity of shortness of breath and tachycardia.

Indications for non-invasive mechanical ventilation:

• respiratory rate > 25 per minute;
• acidosis (pH 7.3-7.35) and hypercapnia (PaCO 2 - 45-60 mm Hg).

Invasive mechanical ventilation involves intubation of the airway or tracheostomy. Accordingly, the connection between the patient and the respirator is carried out through endotracheal or tracheostomy tubes. This creates a risk of developing mechanical damage and infectious complications. Therefore, invasive mechanical ventilation should be used in severe condition of the patient and only when other treatment methods are ineffective.

Indications for invasive mechanical ventilation:

• severe shortness of breath with the participation of accessory muscles and paradoxical movements of the anterior abdominal wall;
• respiratory rate > 35 per minute;
• severe hypoxemia (pO 2< <40 мм рт. ст.);
• severe acidosis (pH<7,25) и гиперкапния (РаСО 2 >60 mmHg Art.);
• respiratory arrest, impaired consciousness;
• hypotension, heart rhythm disturbances;
• the presence of complications (pneumonia, pneumothorax, pulmonary embolism, etc.).

Patients with mild exacerbations can be treated on an outpatient basis.

Outpatient treatment of mild exacerbations of COPD includes the following steps.

• Assessment of the level of patient education. Checking inhalation technique.
• Prescription of bronchodilators: short-acting β2-adrenergic agonist and/or ipratropium bromide through a metered-dose inhaler with a large-volume spacer or through a nebulizer in the “on demand” mode. If ineffective, intravenous administration of aminophylline is possible. Discuss the possibility of prescribing long-acting bronchodilators if the patient has not received these drugs previously.
• Prescription of glucocorticoids (doses may vary). Prednisolone 30-40 mg per os for 10-14 days. Discussion of the possibility of prescribing inhaled glucocorticoids (after completion of treatment with systemic steroids).
• Prescribing antibiotics (according to indications).

Patients with moderate exacerbations usually need to be hospitalized. Their treatment is carried out according to the following scheme.

• Bronchodilators: short-acting β2-adrenergic agonist and/or ipratropium bromide via a metered-dose inhaler with a large-volume spacer or an on-demand nebulizer. If ineffective, intravenous administration of aminophylline is possible.
• Oxygen therapy (for Sa< <90%).
• Glucocorticoids. Prednisolone 30-40 mg per os for 10-14 days. If oral administration is not possible, an equivalent dose is administered intravenously (up to 14 days). Discuss the possibility of prescribing inhaled glucocorticoids via a metered dose inhaler or nebulizer (after completion of treatment with systemic steroids).
• Antibiotics (according to indications).

Indications for referring patients to specialized departments are:

• a significant increase in the severity of symptoms (for example, the occurrence of shortness of breath at rest);
• lack of effect from the treatment;
• the appearance of new symptoms (eg, cyanosis, peripheral edema);
• severe concomitant diseases (pneumonia, heart rhythm disturbances, congestive heart failure, diabetes mellitus, renal and liver failure);
• new occurrence of heart rhythm disturbances;
• elderly and senile age;
• impossibility of providing qualified medical care on an outpatient basis;
• diagnostic difficulties.

The risk of death in a hospital is higher if patients develop respiratory acidosis, have severe concomitant diseases and require ventilation support.

With severe exacerbations of COPD, patients are often hospitalized in the intensive care unit; indications for this are:

• severe shortness of breath that cannot be controlled by bronchodilators;
• disturbance of consciousness, coma;
• progressive hypoxemia (PaO 2<50 мм рт. ст.), гиперкапния (РаСО 2 >60 mmHg Art.) and/or respiratory acidosis (pH<7,25), несмотря на использование оксигенотерапии и неинвазивной вентиляции легких.

Treatment of severe exacerbations of COPD in the emergency department involves the following steps.

• Oxygen therapy.
• Ventilation support (non-invasive, less often invasive).
• Bronchodilators. Short-acting β2-adrenergic agonist and/or ipratropium bromide via a metered-dose inhaler with a large-volume spacer, two puffs every 2-4 hours, or via a nebulizer. If ineffective, intravenous administration of aminophylline is possible.
• Glucocorticoids. Prednisolone 30-40 mg per os for 10-14 days. If oral administration is not possible, use an equivalent dose intravenously (up to 14 days). Discuss the possibility of prescribing inhaled glucocorticoids via a metered dose inhaler or nebulizer (after completion of treatment with systemic steroids).
• Antibiotics (according to indications).

In the next 4-6 weeks, the patient should be re-examined by a doctor, and his adaptation to everyday life, FEV 1, correctness of inhalation technique, understanding of the need for further treatment are assessed, blood gases or oxygen saturation are measured to study the need for long-term oxygen therapy. If it was prescribed only during an exacerbation during hospital treatment, then, as a rule, it should be continued for 1-3 months after discharge.

To prevent exacerbations of COPD, it is necessary to: reduce exposure to risk factors; optimal bronchodilator therapy; inhaled glucocorticoids in combination with long-acting β 2 -adrenergic agonists (for severe and extremely severe COPD); annual flu vaccination. n

Literature

A. V. Emelyanov, d Doctor of Medical Sciences, Professor
St. Petersburg State Medical University, St. Petersburg

In our country, approximately one million people have chronic obstructive pulmonary disease. But it is possible that this figure is much higher.

The main cause of COPD is smoking. And it doesn’t matter whether it’s passive or active.

This lung disease is characterized by progression and gradual loss of lung function. In this article we will talk about the complications of COPD, as well as preventive methods that will prevent the development of this disease.

COPD - definition of the disease

According to statistics, men are more likely to suffer from it after forty years of age. Chronic lung disease is one of the causes of disability and ranks fourth among the causes of death among the working population.

There are four stages depending on the volume of forced expiration and forced vital capacity of the lungs:

• Zero stage (pre-disease stage). It is characterized by an increased risk of developing chronic obstructive pulmonary disease, but may not always develop into it. Signs: constant cough with sputum, but the lungs are still functioning.
• First stage (mild stage). Minor obstructive disorders can be detected, and a chronic cough with sputum occurs.
• Second stage (moderate stage). There is a progression of disorders.
• Third stage (severe stage). As you exhale, airflow limitation increases.
• Stage four (extremely severe stage). It manifests itself as a severe form of bronchial obstruction and poses a threat to life.

The mechanism of development of COPD: tobacco smoke or other negative factor affects the receptors of the vagus nerve, which causes spasm of the bronchi and stops the movement of their ciliated epithelium. Therefore, bronchial mucus cannot come out naturally, and its cells begin to produce even more mucus (a protective reaction). This is how a chronic cough occurs. Many smokers believe that nothing serious will happen, and they cough because of smoking.

But after a while, a chronic focus of inflammation develops, which clogs the bronchi even more. As a result, overstretching of the alveoli occurs, which compress small bronchioles, further impairing patency.

It should be remembered that at the beginning of the disease, blockage is still reversible, since it occurs due to bronchospasm and hypersecretion of mucus.

Therapy of the disease is aimed primarily at slowing the progression of obstruction and the development of respiratory failure. Treatment helps reduce the likelihood of exacerbations and also makes them less severe and longer lasting. Treatment helps to increase vital activity and increases. It is very important to eliminate the cause of the disease.

Causes and treatment during exacerbation

In nine out of ten cases, COPD is caused by smoking. Other factors that influence the development of the disease to a lesser extent include harmful production conditions (for example, inhalation of harmful gases), respiratory diseases suffered in childhood, bronchopulmonary pathologies, and poor ecology.

The main occupational hazards are working with cadmium and silicon, metal processing, and fuel combustion products also affect the development of COPD. Therefore, chronic obstructive pulmonary disease occurs among miners, railway workers, construction workers, workers in the pulp and paper and metallurgical industries, and agricultural workers.

It is very rare that people have a genetic predisposition to COPD. In this case, there is a deficiency of the protein alpha-1-antitrypsin, which is produced by liver tissue. It is this protein that protects the lungs from damage by the enzyme elastase.

All of the above reasons cause chronic inflammatory damage to the inner lining of the bronchi, as a result of which local bronchial immunity is impaired. Bronchial mucus is produced and becomes more viscous. Because of this, good conditions are created for the activation of pathogenic bacteria, bronchial obstruction occurs, and lung tissue and alveoli change. As a person's condition worsens with COPD, swelling of the bronchial mucosa develops, smooth muscles spasm, a lot of mucus is produced, and the number of irreversible changes increases.

Symptoms and diagnostic methods

At the initial stage of the disease, a periodic cough occurs. But the further you go, the more often it bothers you (even at night).

When coughing, a small amount of sputum is produced, the volume of which increases with exacerbation. Sometimes it may contain pus.

Another symptom of chronic obstructive pulmonary disease is shortness of breath. It can appear very late, even after a decade.

COPD patients are divided into two groups:

1. "Pink Puffers" These people are generally of thin build and suffer from shortness of breath, causing them to puff and puff out their cheeks. The skin becomes pinkish-gray.
2. "Cyanotic swellings." Usually these are overweight people. They suffer from a strong cough with phlegm, as well as swelling of the legs. Their skin has a blue tint.

The first group of patients has the emphysematous type of COPD. In this case, the main symptom is expiratory shortness of breath (difficulty exhaling). Emphysema prevails over bronchial obstruction.

The second group has purulent inflammatory processes occurring in the bronchi and accompanied by symptoms of intoxication, cough with copious sputum (bronchitis type of COPD). Bronchial obstruction is more pronounced than pulmonary emphysema.

Complications

Because COPD progresses over time, complications may sometimes arise. But you can reduce the risk of their occurrence. To do this, sometimes you just need to quit smoking and avoid inhaling tobacco smoke and other chemicals.

If the symptoms of COPD suddenly worsen, it is called an exacerbation of the disease. Exacerbation can be caused by infection, environmental pollution, and so on. It can occur up to several times a year.

Complications of chronic obstructive pulmonary disease include:

• Respiratory failure.
• Pneumothorax (entry of air into the pleural cavity).
• (pneumonia). May be caused by bacteria. Pneumonia caused by streptococci is considered the most common cause of bacterial pneumonia in COPD.
• Blockage of blood vessels (thromboembolism).
• Deformation of the bronchi (bronchiectasis).
• Pulmonary hypertension (high pressure in the pulmonary artery).
• Cor pulmonale (thickening and expansion of the right chambers of the heart with dysfunction).
• Lungs' cancer.
• Chronic heart failure, stroke.
• Atrial fibrillation (heart rhythm disturbance).
• Depression. Emotional disorders may be associated with a decrease in activity in life in general.

Prevention

The main direction of prevention of chronic obstructive pulmonary disease is quitting smoking. You need to lead a healthy lifestyle, eat healthy and balanced, and strengthen your immune system.

Physical activity should include walking at a moderate pace, swimming in the pool and breathing exercises that strengthen the respiratory muscles.

Do not forget about timely treatment of any infectious diseases of the respiratory tract.

Those whose work involves exposure to hazardous substances should remember safety precautions and the use of personal protective equipment.

COPD needs to be treated at an early stage. And in order to detect the problem in time, it is recommended to undergo medical examination.

Unfortunately, the progression of COPD can lead to disability of the patient. An unfavorable outcome is possible with severe concomitant diseases, cardiac and respiratory failure, old age, and bronchitis type of disease.

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conclusions

It is a progressive disease. It cannot be completely cured in the later stages, so patients should lead an appropriate lifestyle, control symptoms, which can slow down the development of chronic obstruction.

COPD is dangerous due to its complications. To prevent their occurrence, proper treatment is necessary, the goal of which is to slow down all progressive processes in the lungs, relieve obstruction and eliminate respiratory failure.

Chronic obstructive pulmonary disease (COPD) is an acute and progressive pulmonary disease. However, early diagnosis and appropriate treatment can significantly improve patients' prospects.

Early signs of COPD include cough, excess mucus, shortness of breath and fatigue.

COPD is a long-term medical condition that causes airway obstruction and difficulty breathing. This is a progressive disease, that is, it tends to take on more severe forms over time. Without treatment, COPD can be life-threatening.

According to the World Health Organization (WHO), COPD affected approximately 251 million people worldwide in 2016. In 2015, COPD caused 3.17 million deaths.

COPD is an incurable disease, but proper medical care can reduce symptoms, reduce the risk of death and improve quality of life.

In the current article we will describe the early signs of COPD. We will also explain in what situations it is necessary to contact a doctor for examination.

Early signs and symptoms

In the early stages of COPD, people may experience a chronic cough

In the early stages, COPD symptoms usually do not appear at all or are so mild that people may not notice them right away.

In addition, each person's symptoms are different and vary in severity. But since COPD is a progressive disease, over time they begin to manifest themselves more and more acutely.

Early symptoms of COPD include the following.

Chronic cough

Persistent or frequent is one of the first signs of COPD. People may experience a chesty cough that does not go away on its own. Doctors usually consider a cough to be chronic if it lasts longer than two months.

Coughing is a defense mechanism that is triggered by the body in response to irritants, such as cigarette smoke, that enters the respiratory tract and lungs. Coughing also helps clear phlegm or mucus from the lungs.

However, if a person has a persistent cough, it may indicate a serious lung problem such as COPD.

Excess mucus production

Producing too much mucus can be an early symptom of COPD. Mucus is important for keeping the airways moist. In addition, it traps microorganisms and irritants that enter the lungs.

When a person inhales irritants, their body produces more mucus, which can lead to coughing. Smoking is a common cause of excessive mucus production and coughing.

Long-term exposure to irritants in the body can damage the lungs and lead to COPD. In addition to cigarette smoke, these irritants include the following:

• chemical fumes, such as those from paints and cleaning products;
• dust;
• air pollution, including vehicle exhaust;
• perfumes, hairsprays and other aerosol cosmetics.

Shortness of breath and fatigue

Airway obstructions can make breathing difficult, causing people to feel short of breath. Shortness of breath is another early symptom of COPD.

Initially, shortness of breath may appear only after physical activity, but over time this symptom usually worsens. Some people, trying to avoid breathing problems, reduce their activity levels and quickly become unfit.

People with COPD require more effort to breathe. This often leads to a decrease in overall energy levels and a constant feeling of fatigue.

Other symptoms of COPD

Chest pain and tightness are potential symptoms of COPD

Because people with COPD don't have lungs that function properly, their bodies are more likely to develop respiratory infections, including colds, flu, and pneumonia.

Other symptoms of COPD include the following:

• tightness in the chest;
• unintentional weight loss;
• swelling in the lower legs.

People with COPD may experience flares, which are periods of worsening symptoms of the disease. Factors that trigger outbreaks include chest infections and exposure to cigarette smoke or other irritants.

When should you see a doctor?

If a person experiences any of the above symptoms, they should see a doctor. It is likely that these symptoms have nothing to do with COPD, as they can be caused by other medical conditions.

The doctor can usually quickly distinguish COPD from other diseases. Early diagnosis of COPD allows people to more quickly receive treatment that slows the progression of the disease and prevents it from progressing to a form that can be life-threatening.

Diagnostics

Initially, your doctor will ask questions about your symptoms and personal medical history. In addition, the specialist will find out whether the patient smokes and how often his lungs are exposed to irritants.

In addition, the doctor may perform a physical examination and check the patient for signs of wheezing and other lung problems.

To confirm the diagnosis, the patient may be offered special diagnostic procedures. Below are the most common ones.

• Spirometry. In this procedure, the patient breathes into a tube that is attached to a device called a spirometer. Using a spirometer, the doctor evaluates the quality of lung function. Before performing this test, the doctor may ask the person to inhale a bronchodilator. This is a type of medication that opens the airways.
• X-ray examination and computed tomography (CT) of the chest. These are imaging diagnostic procedures that allow doctors to see the inside of the chest and check for signs of COPD or other medical conditions.
• Blood tests. Your doctor may suggest a blood test to check your oxygen levels or rule out other medical conditions that have symptoms that mimic those of COPD.

What is COPD?

COPD is a medical term used to describe a group of diseases that tend to become more severe over time. Examples of such diseases are emphysema or chronic bronchitis.

The lungs are made up of numerous channels or airways, which branch into even smaller channels. At the end of these small channels are tiny air bubbles that inflate and deflate during breathing.

When a person inhales, oxygen is directed into the respiratory tract and enters the bloodstream through air bubbles. When a person exhales, carbon dioxide leaves the bloodstream and exits the body through the air bubbles and airways.

In people with COPD, chronic inflammation of the lungs blocks the airways, which can make breathing difficult. COPD also causes coughing and increased mucus production, which leads to further blockages.

As a result, the airways can become damaged and less flexible.

The most common cause of COPD is smoking cigarettes or other tobacco products. According to the US National Heart, Lung, and Blood Institute, up to 75% of people with COPD either smoke or have previously smoked. However, long-term exposure to other irritants or harmful fumes can also cause COPD.

Genetic factors may also increase the risk of developing COPD. For example, people with a deficiency of a protein called alpha-1 antitrypsin are more likely to develop COPD, especially if they smoke or are regularly exposed to other irritants.

Signs and symptoms of COPD in most cases first begin to appear in people after the age of forty.

Conclusion

COPD is a common medical condition. However, some people mistake its symptoms for signs of the body's natural aging process, which is why they are not diagnosed or treated. Without treatment, COPD can progress rapidly.

Sometimes COPD causes significant disability. People with acute COPD may have difficulty performing everyday tasks, such as climbing stairs or standing at the stove for long periods of time while preparing food. COPD flares and complications can also have a serious impact on a person's health and quality of life.

COPD cannot be cured, but early diagnosis and treatment greatly improves patients' prospects. An appropriate treatment plan and positive lifestyle changes can reduce symptoms and slow or control the progression of COPD.

Treatment options include medications, oxygen therapy, and pulmonary rehabilitation. Lifestyle changes include doing regular exercise, eating a healthy diet and quitting smoking.

Doctor of Medical Sciences, Prof. S.I. Ovcharenko, Department of Faculty Therapy No. 1, State Educational Institution of Higher Professional Education MMA named after. THEM. Sechenov

Chronic obstructive pulmonary disease (COPD) is one of the widespread diseases, which is largely due to the increasing impact of adverse factors (risk factors): environmental pollution, tobacco smoking and recurrent respiratory infectious diseases.

COPD is characterized by airflow limitation that is not completely reversible and is steadily progressive.

A diagnosis of COPD should be considered in every person who coughs, produces sputum and has risk factors. In all these cases, spirometry must be performed. A decrease in the ratio of forced expiratory volume in 1 second to forced vital capacity (FEV 1 /FVC) of less than 70% is an early and reliable sign of airflow limitation, even if FEV 1 remains >80% of the normal value. Moreover, obstruction is considered chronic (and the patient must be considered suffering from COPD) if it is recorded three times within one year. The stage of the disease (its severity) is reflected by the FEV 1 value in the post-bronchodilator test. Chronic cough and excess sputum production long precede ventilation disorders leading to the development of shortness of breath.

The main goals of treatment of patients with COPD are clearly formulated in the International Program “Global Strategy: Diagnosis, Treatment and Prevention of COPD”, created on the basis of the principles of evidence-based medicine (2003) and in the Federal Program of the Russian Federation for the diagnosis and treatment of COPD (2004). They are aimed at:

Prevention of disease progression;

Increased tolerance to physical activity;

Reduction of symptoms;

Improving quality of life;

Prevention and treatment of exacerbations and complications;

Decrease in mortality.

The implementation of these provisions is carried out in the following areas:

Reducing the influence of risk factors;

Implementation of educational programs;

Treatment of COPD in stable condition;

Treatment of exacerbation of the disease.

Smoking cessation is the first major step in the COPD treatment program, preventing progression of the disease, and is currently the most effective measure to reduce the risk of developing COPD. Special programs for the treatment of tobacco addiction have been developed:

Long-term treatment program with the goal of completely quitting smoking;

A short treatment program to reduce the amount of tobacco smoked and increase motivation to completely quit smoking;

Smoking reduction program.

A long-term treatment program is intended for patients with a strong desire to quit smoking. The program lasts from 6 months to 1 year and consists of periodic conversations between the doctor and the patient (more frequent in the first 2 months of quitting smoking), and an appointment with the patient nicotine-containing drugs(NSP). The duration of taking the drugs is determined individually and depends on the degree of nicotine addiction of the patient.

The short treatment program is intended for patients not wanting to quit smoking, but not rejecting this possibility in the future. In addition, this program can be offered to patients who want to reduce their smoking intensity. The duration of the short program is from 1 to 3 months. Treatment for 1 month can reduce smoking intensity by an average of 1.5 times, and for 3 months - by 2-3 times. A short treatment program is built on the same principles as a long one: doctor’s conversations, development of a strategy for the patient’s behavior, nicotine replacement therapy, identification and treatment of chronic bronchitis and prevention of its exacerbation as a result of quitting smoking. For this purpose, acetylcysteine ​​is prescribed - 600 mg once a day in a blister. The difference between this program is that complete smoking cessation is not achieved.

The smoking cessation program is intended for patients who do not want to quit smoking, but are ready to reduce their smoking intensity. The essence of the program is that the patient continues to receive nicotine at his usual level, combining cigarette smoking with taking NSP, but at the same time reducing the number of cigarettes smoked per day. Within a month, the intensity of smoking can be reduced by an average of 1.5-2 times, i.e. the patient reduces the intake of harmful substances contained in cigarette smoke, which is undoubtedly a positive result of treatment. This program also uses doctor conversations and the development of patient behavior strategies.

The effectiveness of a combination of two methods has been confirmed: nicotine replacement therapy and conversations between doctors and medical staff and the patient. Even short three-minute consultations aimed at stopping smoking are effective and should be used at every medical appointment. Quitting smoking does not lead to normalization of lung function, but it does help slow down the progressive deterioration of FEV 1 (subsequently, the decline in FEV 1 occurs at the same rate as in non-smoking patients.)

Play a major role in encouraging smoking cessation, in improving the skills of inhalation therapy in patients with COPD and their ability to cope with the disease. educational programs.

For COPD patients, education should address all aspects of disease management and can take a variety of forms: consultations with a doctor or other health care provider, home-based or out-of-home programs, and comprehensive pulmonary rehabilitation programs. For patients with COPD, it is necessary to understand the nature of the disease, risk factors leading to the progression of the disease, and clarify one’s own role and the role of the doctor to achieve an optimal treatment result. Training must be tailored to the needs and environment of the individual patient, interactive, aimed at improving quality of life, easy to implement, practical and appropriate to the intellectual and social level of the patient and those caring for him.

To give up smoking;

Basic information about COPD;

Basic approaches to therapy;

Specific treatment issues (in particular the correct use of inhaled drugs);

Skills in self-management (peak flowmetry) and decision-making during an exacerbation. Patient education programs should include the distribution of printed materials and educational sessions and seminars aimed at providing information about the disease and teaching patients specific skills.

It has been found that training is most effective when conducted in small groups.

The choice of drug therapy depends on the severity (stage) of the disease and its phase: stable condition or exacerbation of the disease.

According to modern ideas about the essence of COPD, the main and universal source of pathological manifestations that develop as the disease progresses is bronchial obstruction. It follows that bronchodilators should occupy and currently occupy a leading place in the complex therapy of patients with COPD. All other means and methods of treatment should be used only in combination with bronchodilators.

Treatment of COPD in stable patient condition

Treatment of patients with stable COPD is necessary to prevent and control symptoms of the disease, reduce the frequency and severity of exacerbations, improve general condition and increase exercise tolerance.

The management of patients with COPD in a stable condition is characterized by a stepwise increase in the volume of therapy, depending on the severity of the disease.

It should be emphasized once again that currently the leading place in the complex therapy of patients with COPD is occupied by bronchodilators. All categories of bronchodilators have been shown to increase exercise tolerance even in the absence of an increase in FEV 1 values. Inhalation therapy is preferred (level of evidence A). The inhalation route of drug administration ensures direct penetration of the drug into the respiratory tract and, thus, contributes to a more effective drug effect. In addition, the inhalation route of administration reduces the potential risk of developing side systemic effects.

Particular attention should be paid to teaching patients the correct inhalation technique in order to increase the effectiveness of inhalation therapy. m-Ancholinergics and beta 2 agonists are used mainly through metered dose inhalers. To increase the efficiency of drug delivery to the site of pathological reactions (i.e., to the lower respiratory tract), spacers can be used - devices that allow increasing the flow of the drug into the airways by 20%.

In patients with severe and extremely severe COPD, bronchodilator therapy is carried out with special solutions through a nebulizer. Nebulizer therapy is also preferred, as is the use of a metered-dose aerosol with a spacer, in the elderly and patients with cognitive impairment.

To reduce bronchial obstruction in patients with COPD, short- and long-acting anticholinergic drugs, short- and long-acting beta 2-agonists, methylxanthines and their combinations are used. Bronchodilators are prescribed on an on-demand or regular basis to prevent or reduce symptoms of COPD. The sequence of use and combination of these drugs depends on the severity of the disease and individual tolerance.

For mild COPD, short-acting bronchodilators are used “on demand”. In moderate, severe and extremely severe cases of the disease, long-term and regular treatment with bronchodilators is a priority, which reduces the rate of progression of bronchial obstruction (evidence level A). The most effective combination of bronchodilators with different mechanisms of action, because the bronchodilator effect is enhanced and the risk of side effects is reduced compared with increasing the dose of one of the drugs (evidence level A).

m-Cholinolytics occupy a special place among bronchodilators, due to the role of the parasympathetic (cholinergic) autonomic nervous system in the development of the reversible component of bronchial obstruction. Prescribing anticholinergic drugs (ACP) is advisable for any severity of the disease. The most well-known short-acting ACP is ipratropium bromide, which is usually prescribed 40 mcg (2 doses) 4 times a day (evidence level B). Due to its slight absorption through the bronchial mucosa, ipratropium bromide practically does not cause systemic side effects, which allows it to be widely used in patients with cardiovascular diseases. ACPs do not have a negative effect on the secretion of bronchial mucus and the processes of mucociliary transport. Short-acting m-anticholinergics have a longer-lasting bronchodilator effect compared to short-acting beta 2 agonists (evidence level A).

A distinctive feature of short-acting beta 2 agonists (salbutamol, fenoterol) is the speed of action on bronchial obstruction. Moreover, the more pronounced the damage to the distal bronchi, the higher the bronchodilator effect. Patients feel an improvement in breathing within a few minutes and often prefer them in “on-demand” therapy (for mild COPD - stage I). However, routine use of short-acting beta 2 agonists as monotherapy for COPD is not recommended (Evidence Level A). In addition, short-acting beta 2 agonists should be used with caution in elderly patients with concomitant heart pathology (with ischemic heart disease and arterial hypertension), because these drugs, especially in combination with diuretics, can cause transient hypokalemia, and, as a result, heart rhythm disturbances.

Many studies have shown that long-term use of ipratropium bromide is more effective for the treatment of COPD than long-term monotherapy with short-acting beta 2-agonists (Evidence Level A). However, the use of ipratropium bromide in combination with short-acting beta 2 agonists has a number of advantages, including a reduction in the frequency of exacerbations, and thereby reducing the cost of treatment.

Regular treatment with long-acting bronchodilators (tiotropium bromide, salmeterol, formoterol) is recommended for moderate, severe and extremely severe COPD (level of evidence A). They are more effective and easier to use than short-acting bronchodilators, but their treatment is more expensive (evidence level A). In this regard, patients with severe COPD can be prescribed short-acting bronchodilators in various combinations (see Table 1).

Table 1

Selection of bronchodilators depending on the severity of COPD

Ipratropium bromide is prescribed 40 mcg (2 doses) 4 times a day, tiotropium bromide - 1 time per day at a dose of 18 mcg via HandiHaler, salbutamol - 100-200 mcg up to 4 times a day, fenoterol - 100-200 mcg up to 4 times a day, salmeterol - 25-50 mcg 2 times a day, formoterol 4.5-12 mcg 2 times a day. When using inhaled short-acting bronchodilators, preference is given to freon-free dosage forms.

A representative of the new generation of ACP is tiotropium bromide, a long-acting drug whose bronchodilator effect lasts for 24 hours (level of evidence A), which makes it possible to use this drug once a day. The low frequency of side effects (dry mouth, etc.) indicates the sufficient safety of using this drug for COPD. Early studies have shown that tiotropium bromide not only significantly improves lung volumes and peak expiratory flow in patients with COPD, but also reduces the incidence of exacerbations with long-term use.

The anticholinergic effect of tiotropium bromide, inhaled by patients with COPD using the HandiHaler metered-dose powder inhaler, is approximately 10 times superior to ipratropium bromide.

The results of controlled 12-month studies showed a significant superiority of tiotropium bromide over ipratropium bromide in terms of the effect of:

For indicators of bronchial patency;

Severity of shortness of breath;

Need for short-acting bronchodilators;

Frequency and severity of exacerbations.

Long-acting beta 2 agonists (salmeterol, formoterol) are also recommended for regular use in the treatment of COPD. They, regardless of changes in bronchial obstruction indicators, can improve clinical symptoms and quality of life of patients, reduce the number of exacerbations (level of evidence B). Salmeterol improves the condition of patients when used at a dose of 50 mcg twice a day (evidence level B). Formoterol, like salmeterol, acts for 12 hours without loss of effectiveness (level of evidence A), but the effect of formoterol develops faster (after 5-7 minutes) than that of salmeterol (after 30-45 minutes).

Long-acting beta 2 agonists, in addition to the bronchodilator effect, exhibit other positive qualities in the treatment of patients with COPD:

Reduce hyperinflation of the lungs;

Activate mucociliary transport;

Protects the cells of the mucous membrane of the respiratory tract;

They exhibit antineutrophil activity.

Treatment with a combination of an inhaled beta 2 -agonist (fast-acting or long-acting) and an anticholinergic agent improves bronchial patency to a greater extent than monotherapy with either drug (Evidence Level A).

Methylxanthines (theophylline), if ACP and beta 2-agonists are insufficiently effective, can be added to regular inhaled bronchodilator therapy for more severe COPD (level of evidence B). All studies showing the effectiveness of theophylline in COPD concern long-acting drugs. The use of long-acting forms of theophylline may be indicated for nocturnal symptoms of the disease. The bronchodilating effect of theophylline is inferior to that of beta 2-agonists and ACP, but its oral administration (long-acting forms) or parenteral administration (inhaled methylxanthines are not prescribed) causes a number of additional effects: reduction of pulmonary hypertension, increased diuresis, stimulation of the central nervous system, improvement of respiratory muscle tone , which may be useful in a number of patients.

Theophylline may be beneficial in the treatment of COPD, but inhaled bronchodilators are preferred due to its potential side effects. Currently, theophylline is classified as a second-line drug, i.e. is prescribed after ACP and beta 2-agonists or their combinations, or for those patients who cannot use inhaled delivery devices.

In real life, the choice between ACP, beta 2 -agonists, theophylline or a combination of these depends largely on the availability of drugs and the individual response to treatment in the form of relief of symptoms and the absence of side effects.

Inhaled glucocorticoids (IGCs) are prescribed in addition to bronchodilator therapy for patients with clinical symptoms of the disease, an FEV value of 1<50% от должного (тяжелое теение ХОБЛ — стадия III и крайне тяжелое течение ХОБЛ — стадия IV) и повторяющимися обострениями (3 раза и более за последние три года) (уровень доказательности А). Предпочтительно применение ИГК длительного действия — флутиказона или будесонида. Эффективность лечения оценивается через 6-12 недель применения ИГК.

The combination with long-acting beta 2 agonists increases the effectiveness of corticosteroid therapy (the effect is superior to the results of separate use). This combination demonstrates the synergistic effect of drugs when affecting various parts of the pathogenesis of COPD: bronchial obstruction, inflammation and structural changes in the airways, mucociliary dysfunction. The combination of long-acting beta 2-agonists and IGCs (salmeterol/fluticasone and formoterol/budesonide) provides a more advantageous risk/benefit ratio compared to the individual components.

Long-term treatment with systemic glucocorticoids is not recommended due to the unfavorable balance between efficacy and risk of adverse events (Evidence Level A).

Mucolytic (mucoregulators, mucokinetics) and expectorant drugs are indicated for a very limited group of COPD patients with a stable course in the presence of viscous sputum and do not significantly affect the course of the disease.

To prevent exacerbation of COPD, long-term use of the mucolytic acetylcysteine ​​(preferably 600 mg in a blister), which simultaneously has antioxidant activity, seems promising. Taking acetylcysteine ​​for 3-6 months at a dose of 600 mg/day is accompanied by a significant decrease in the frequency and duration of exacerbations of COPD.

Application antibacterial agents for preventive purposes in patients with COPD should not be a daily practice, because According to the results of modern studies, antibiotic prophylaxis of exacerbations of COPD has low, but statistically significant effectiveness, manifested in a reduction in the duration of exacerbations of the disease. However, there is a risk of adverse drug events in patients and the development of pathogen resistance.

In order to prevent exacerbation of COPD during epidemic outbreaks of influenza, it is recommended vaccines, containing killed or inactivated viruses. Vaccines are prescribed to patients once, in October - the first half of November, or twice (in autumn and winter) annually (evidence level A). The influenza vaccine can reduce the severity and mortality in patients with COPD by 50%. A pneumococcal vaccine containing 23 virulent serotypes is also used, but data on its effectiveness in COPD are insufficient (level of evidence B).

Non-drug treatment in stable COPD includes oxygen therapy. Correction of hypoxemia with oxygen is the most pathophysiologically based method of treating respiratory failure. Patients with chronic respiratory failure are advised to undergo continuous multi-hour low-flow (more than 15 hours per day) oxygen therapy. Long-term oxygen therapy is currently the only treatment method that can reduce mortality in patients with extremely severe COPD (level of evidence A).

Effective for patients with COPD at all stages of the process physical training programs, increasing exercise tolerance and reducing shortness of breath and fatigue. Physical training must include exercises to develop strength and endurance of the lower extremities (metered walking, bicycle ergometer). In addition, they may include exercises that increase the strength of the muscles of the upper shoulder girdle (hand ergometer, dumbbells).

Exercise is the main component pulmonary rehabilitation. In addition to physical training, rehabilitation measures include: psychosocial support, educational programs, nutritional support. One of the objectives of rehabilitation is to identify and correct the causes of nutritional status disorders in patients with COPD. The most rational diet is frequent intake of small portions of protein-rich foods. The optimal way to correct a deficiency in body mass index is to combine additional nutrition with physical training, which has a nonspecific anabolic effect. The positive effect of rehabilitation programs is also achieved through psychosocial interventions.

There are no absolute contraindications to pulmonary rehabilitation. Ideal candidates for inclusion in rehabilitation programs are patients with moderate to severe COPD, i.e. patients whose disease imposes serious restrictions on the usual level of functional activity.

In recent years, there have been reports of the use of methods surgical treatment in patients with severe COPD. Surgical correction of lung volumes using the method bullectomies, which leads to decreased shortness of breath and improved pulmonary function. However, this method is a palliative surgical procedure with unproven effectiveness. The most radical surgical method is lung transplant in carefully selected patients with very severe COPD. The selection criterion is FEV 1<35% от должной величины, pО 2 <55-60 мм рт. ст., pСО 2 >50 mmHg and the presence of signs of secondary pulmonary hypertension.

Treatment of COPD during exacerbation

The primary causes of exacerbation of COPD include tracheobronchial infections (usually viral etiology) and exposure to airborne pollutants.

Among the so-called secondary causes of exacerbation of COPD include: thromboembolism of the branches of the pulmonary artery, pneumothorax, pneumonia, chest injury, prescription of beta-blockers and other drugs, heart failure, cardiac arrhythmias, etc.

All exacerbations should be considered as a factor in the progression of COPD, and therefore more intensive therapy is recommended. First of all, this applies to bronchodilator therapy: the doses of drugs are increased and the methods of their delivery are modified (preference is given to nebulizer therapy). For this purpose, special solutions of bronchodilators are used - ipratropium bromide, fenoterol, salbutamol or a combination of ipratropium bromide with fenoterol.

Depending on the severity and degree of exacerbation of COPD, treatment can be carried out both on an outpatient basis (mild exacerbation or moderate exacerbation in patients with mild COPD) and in an inpatient setting.

As a bronchodilator for exacerbation of severe COPD, it is recommended to prescribe nebulized solutions short-acting beta 2 agonists (level of evidence A). A regimen of high doses of bronchodilators can bring a significant positive effect in acute respiratory failure.

In the treatment of severe patients with multiple organ pathologies, tachycardia, and hypoxemia, the role of ACP drugs increases. Ipratropium bromide is prescribed both as monotherapy and in combination with beta 2 agonists.

The generally accepted dosing regimen of inhaled bronchodilators for exacerbation of COPD is given in Table 2.

table 2

Dosing regimens of inhaled bronchodilators for exacerbation of COPD

The prescription of any other bronchodilators or their dosage forms (xanthines, bronchodilators for intravenous administration) should be preceded by the use of maximum doses of these drugs prescribed through a nebulizer or spacer.

The advantages of inhalation through a nebulizer are:

No need to coordinate inspiration with inhalation;

Ease of performing the inhalation technique for elderly and critically ill patients;

Possibility of administering a high dose of a medicinal substance;

Possibility of including a nebulizer in an oxygen supply circuit or a ventilation circuit;

Lack of freon and other propellants;

Ease of use.

Due to the variety of adverse effects of theophylline, its use requires caution. At the same time, if, for various reasons, it is impossible to use inhaled forms of drugs, as well as if the use of other bronchodilators and glucocorticoids is insufficiently effective, theophylline preparations can be prescribed. The use of theophylline in exacerbations of COPD is debated, since in controlled studies the effectiveness of theophylline in patients with exacerbations of COPD was not high enough, and in some cases the treatment was accompanied by undesirable reactions such as hypoxemia. The high risk of unwanted side reactions necessitates measuring the concentration of the drug in the blood, which is very difficult in medical practice.

To stop an exacerbation, along with bronchodilator therapy, antibiotics, glucocorticoids are used, and in a hospital setting - controlled oxygen therapy and non-invasive ventilation.

Glucocorticoids. With exacerbation of COPD, accompanied by a decrease in FEV 1<50% от должного, используют глюкокортикоиды параллельно с бронхолитической терапией. Предпочтение отдают системным глюкокортикоидам: например, назначают по 30-40 мг преднизолонав течение 10-14 дней с последующим переводом на ингаляционный путь введения.

Therapy with systemic glucocorticoids (orally or parenterally) promotes a more rapid increase in FEV 1, decreased shortness of breath, improved oxygenation of arterial blood, and shortened hospitalization (level of evidence A). They should be prescribed as early as possible, even upon admission to the emergency department. Oral or intravenous administration of glucocorticoids during exacerbations of COPD in the hospital is carried out in parallel with bronchodilator therapy (if indicated in combination with antibiotics and oxygen therapy). The recommended dosage has not been fully determined, but given the serious risk of adverse events with high-dose steroid therapy, 30-40 mg of prednisolone for 10-14 days should be considered an acceptable compromise between efficacy and safety (Evidence Level D). Further continuation of oral administration does not lead to increased effectiveness, but increases the risk of adverse events.

Antibacterial agents indicated for increased shortness of breath, increased volume of sputum and its purulent nature. In most cases, during exacerbations of COPD, antibiotics can be prescribed by mouth. The duration of antibacterial therapy is from 7 to 14 days (see Table 3).

Table 3

Antibacterial therapy for exacerbation of COPD

For uncomplicated exacerbations, the drug of choice is amoxicillin (respiratory fluoroquinolones or amoxicillin/clavulanate, as well as “new” macrolides - azithromycin, clarithromycin, can be used as an alternative). For complicated exacerbations, the drugs of choice are respiratory fluoroquinolones (levofloxacin, moxifloxacin) or II-III generation cephalosporins, including those with antipseudomonal activity.

Indications for parenteral use of antibiotics are:

Lack of oral form of the drug;

Gastrointestinal disorders;

Severe exacerbation of the disease;

Low compliance with the patient.

Oxygen therapy is one of the key areas of complex treatment of patients with exacerbation of COPD in a hospital setting. An adequate level of oxygenation, namely pO 2 >8.0 kPa (more than 60 mm Hg) or pCO 2 >90%, as a rule, is quickly achieved in uncomplicated exacerbations of COPD. After starting oxygen therapy through nasal catheters (flow rate - 1-2 l/min) or Venturi mask (oxygen content in the inhaled oxygen-air mixture 24-28%), the gas composition of the blood should be monitored after 30-45 minutes (adequacy of oxygenation, exclusion of acidosis , hypercapnia).

Assisted ventilation. If, after 30-45 minutes of oxygen inhalation to a patient with acute respiratory failure, the effectiveness of oxygen therapy is minimal or absent, a decision should be made on assisted ventilation. Recently, special attention has been paid to non-invasive positive pressure ventilation. The effectiveness of this method of treating respiratory failure reaches 80-85% and is accompanied by normalization of the gas composition of arterial blood, a decrease in shortness of breath, and, more importantly, a decrease in patient mortality, a decrease in the number of invasive procedures and associated infectious complications, as well as a decrease in the duration of the hospital treatment period (Level of evidence A).

In cases where non-invasive ventilation is ineffective (or unavailable) in a patient undergoing a severe exacerbation of COPD, invasive ventilation is indicated.

A schematic diagram of treatment for exacerbation of COPD is shown in the figure below.

Drawing. Schematic diagram of treatment for exacerbation of COPD

Unfortunately, patients with COPD seek medical help, as a rule, in the later stages of the disease, when they already have respiratory failure or develop cor pulmonale. At this stage of the disease, treatment is extremely difficult and does not give the expected effect. In connection with the above, early diagnosis of COPD and timely implementation of the developed treatment program remain extremely relevant.

COPD can develop as an independent disease; it is characterized by restriction of air flow caused by an abnormal inflammatory process, which, in turn, occurs as a result of constant irritating factors (smoking, hazardous industries). Often the diagnosis of COPD combines two diseases at once, for example, chronic bronchitis and emphysema. This combination is often observed in long-term smokers.

One of the main causes of disability in the population is COPD. Disability, decreased quality of life and, unfortunately, mortality - all this accompanies this disease. According to statistics, about 11 million people suffer from this disease in Russia, and the incidence is increasing every year.

Risk factors

The following factors contribute to the development of COPD:

• smoking, including passive smoking;
• frequent pneumonia;
• unfavorable environment;
• hazardous industries (work in a mine, exposure to cement dust from construction workers, metal processing);
• heredity (lack of alpha1-antitrypsin can contribute to the development of bronchiectasis and emphysema);
• prematurity in children;
• low social status, unfavorable living conditions.

COPD: symptoms and treatment

At the initial stage of development, COPD does not manifest itself in any way. The clinical picture of the disease occurs with prolonged exposure to unfavorable factors, for example, smoking for more than 10 years or working in hazardous industries. The main symptoms of this disease are chronic cough, which is especially disturbing in the morning, large sputum production when coughing, and shortness of breath. At first it appears during physical activity, and as the disease progresses, even with slight stress. It becomes difficult for patients to eat, and breathing requires a lot of energy, shortness of breath appears even at rest.

Patients lose weight and become physically weaker. Symptoms of COPD periodically intensify and exacerbation occurs. The disease occurs with periods of remission and exacerbation. Deterioration in the physical condition of patients during periods of exacerbation can range from minor to life-threatening. Chronic obstructive pulmonary disease lasts for years. The further the disease develops, the more severe the exacerbation occurs.

Four stages of the disease

There are only 4 degrees of severity of this disease. Symptoms do not appear immediately. Patients often seek medical help late, when an irreversible process has already developed in the lungs and they are diagnosed with COPD. Stages of the disease:

1. Mild - usually does not manifest clinical symptoms.
2. Moderate - there may be a cough in the morning with or without sputum, shortness of breath during exercise.
3. Severe - cough with large sputum discharge, shortness of breath even with slight exertion.
4. Extremely severe - threatens the patient’s life, the patient loses weight, shortness of breath even at rest, cough.

Often, patients in the initial stages do not seek help from a doctor; precious time for treatment has already been lost, and this is the insidiousness of COPD. The first and second degrees of severity usually occur without pronounced symptoms. The only thing that bothers me is the cough. Severe shortness of breath appears in the patient, as a rule, only at the 3rd stage of COPD. Degrees from the first to the last in patients can occur with minimal symptoms in the remission phase, but as soon as you get a little cold or catch a cold, the condition worsens sharply, and an exacerbation of the disease occurs.

Diagnosis of the disease

Diagnosis of COPD is based on spirometry - this is the main test for making a diagnosis.

Spirometry is a measurement of respiratory function. The patient is asked to take a deep breath and exhale as much as possible into the tube of a special device. After these steps, the computer connected to the device will evaluate the indicators, and if they differ from the norm, the study is repeated 30 minutes after inhaling the medicine through the inhaler.

This test will help your pulmonologist determine whether cough and shortness of breath are symptoms of COPD or another disease, such as asthma.

To clarify the diagnosis, the doctor may prescribe additional examination methods:

• general blood analysis;
• blood gas measurement;
• general sputum analysis;
• bronchoscopy;
• bronchography;
• RCT (X-ray computed tomography);
• ECG (electrocardiogram);
• X-ray of the lungs or fluorography.

How to stop the progression of the disease?

Quitting smoking is an effective proven method that can stop the development of COPD and the decline in pulmonary function. Other methods can alleviate the course of the disease or delay the exacerbation, but cannot stop the progression of the disease. In addition, the treatment provided to patients who quit smoking is much more effective than to those who were unable to give up this habit.

Prevention of influenza and pneumonia will help prevent exacerbation of the disease and further development of the disease. It is necessary to get a flu shot every year before the winter season, preferably in October.

Every 5 years, booster vaccination against pneumonia is required.

Treatment of COPD

There are several treatments for COPD. These include:

• drug therapy;
• oxygen therapy;
• pulmonary rehabilitation;
• surgery.

Drug therapy

If drug therapy for COPD is chosen, treatment consists of constant (lifelong) use of inhalers. An effective drug that helps relieve shortness of breath and improve the patient’s condition is selected by a pulmonologist or therapist.

Short-acting beta-agonists (rescue inhalers) can quickly relieve shortness of breath and are used only in emergency situations.

Short-acting anticholinergics can improve lung function, relieve severe symptoms of the disease and improve the general condition of the patient. For mild symptoms, they may not be used continuously, but only as needed.

For patients with severe symptoms, long-acting bronchodilators are prescribed in the final stages of COPD treatment. Preparations:

• Long-acting beta2-adrenergic agonists (Formoterol, Salmeterol, Arformoterol) can reduce the number of exacerbations, improve the patient’s quality of life and alleviate the symptoms of the disease.
• Long-acting M-anticholinergic drugs (Tiotropium) will help improve pulmonary function, reduce shortness of breath and alleviate symptoms of the disease.
• For treatment, a combination of beta 2-adrenergic agonists and anticholinergic drugs is often used - this is much more effective than using them individually.
• Theophylline (Teo-Dur, Slo-bid) reduces the frequency of exacerbations of COPD; treatment with this drug complements the effect of bronchodilators.
• Glucocorticoids, which have potent anti-inflammatory effects, are widely used to treat COPD in the form of tablets, injections or inhalations. Inhaled drugs, such as Fluticasone and Budisonine, can reduce the number of exacerbations and increase the period of remission, but will not improve respiratory function. They are often prescribed in combination with long-acting bronchodilators. Systemic glucocorticoids in the form of tablets or injections are prescribed only during periods of exacerbation of the disease and for a short time, because have a number of adverse side effects.
• Mucolytic drugs, such as Carbocestein and Ambroxol, significantly improve sputum discharge in patients and have a positive effect on their general condition.
• Antioxidants are also used to treat this disease. The drug "Acetylcesteine" can increase periods of remission and reduce the number of exacerbations. This drug is used in combination with glucocorticoids and bronchodilators.

Treatment of COPD with non-drug methods

In combination with medications, non-drug methods are also widely used to treat the disease. These are oxygen therapy and rehabilitation programs. In addition, patients with COPD should understand that it is necessary to completely quit smoking, because Without this condition, not only recovery is impossible, but the disease will also progress at a faster pace.

Particular attention should be paid to high-quality and nutritious nutrition for patients with COPD. Treatment and improvement of the quality of life for patients with a similar diagnosis largely depends on themselves.

Oxygen therapy

Patients with a similar diagnosis often suffer from hypoxia - this is a decrease in oxygen in the blood. Therefore, not only the respiratory system suffers, but also all organs, because they are not sufficiently supplied with oxygen. Patients may develop a number of side diseases.

To improve the condition of patients and eliminate hypoxia and the consequences of respiratory failure in COPD, treatment is carried out with oxygen therapy. Patients' blood oxygen levels are first measured. To do this, a test such as measuring blood gases in arterial blood is used. Blood sampling is carried out only by a doctor, because Blood for testing should be taken exclusively from arterial blood; venous blood is not suitable. It is also possible to measure oxygen levels using a pulse oximeter device. It is put on your finger and a measurement is taken.

Patients should receive oxygen therapy not only in a hospital setting, but also at home.

Nutrition

About 30% of patients with COPD experience difficulty eating, this is associated with severe shortness of breath. Often they simply refuse to eat and significant weight loss occurs. Patients will weaken, immunity decreases, and in this state infection may occur. You cannot refuse to eat. For such patients, split meals are recommended.

Patients with COPD should eat frequently and in small portions. Eat foods rich in proteins and carbohydrates. It is advisable to rest a little before eating. Your diet should include multivitamins and nutritional supplements (they are an additional source of calories and nutrients).

Rehabilitation

Patients with this disease are recommended to undergo annual spa treatment and special pulmonary programs. In physical therapy rooms, they can be taught special breathing exercises that need to be done at home. Such interventions can significantly improve the quality of life and reduce the need for hospitalization in patients diagnosed with COPD. Symptoms and traditional treatment were discussed. Let us once again emphasize that much depends on the patients themselves; effective treatment is only possible with complete cessation of smoking.

Treatment of COPD with folk remedies can also bring positive results. This disease existed before, only its name changed over time and traditional medicine dealt with it quite successfully. Now that there are scientifically based treatment methods, folk experience can complement the effect of medications.

In folk medicine, the following herbs are successfully used for the treatment of COPD: sage, mallow, chamomile, eucalyptus, linden flowers, sweet clover, licorice root, marshmallow root, flax seeds, anise berries, etc. Decoctions, infusions are prepared from these medicinal raw materials or used for inhalations.

COPD - medical history

Let's look at the history of this disease. The concept itself - chronic obstructive pulmonary disease - appeared only at the end of the 20th century, and terms such as “bronchitis” and “pneumonia” were first used only in 1826. Further, 12 years later (1838), the famous clinician Grigory Ivanovich Sokolsky described another disease - pneumosclerosis. At that time, most medical scientists assumed that the cause of most diseases of the lower respiratory tract was precisely pneumosclerosis. This damage to the lung tissue is called “chronic interstitial pneumonia.”

Over the next few decades, scientists around the world studied the course and proposed treatments for COPD. The history of the disease includes dozens of scientific works by doctors. For example, the great Soviet scientist, organizer of the pathological-anatomical service in the USSR, Ippolit Vasilyevich Davydovsky, made invaluable contributions to the study of this disease. He described diseases such as chronic bronchitis, lung abscess, bronchiectasis, and called chronic pneumonia “chronic nonspecific pulmonary consumption.”

In 2002, candidate of medical sciences Aleksey Nikolaevich Kokosov published his work on the history of COPD. In it, he pointed out that in the pre-war period and during the Second World War, the lack of correct and timely treatment, coupled with enormous physical exertion, hypothermia, stress and malnutrition led to an increase in cardiopulmonary failure among front-line veterans. Many symposiums and works by doctors were devoted to this issue. At the same time, Professor Vladimir Nikitich Vinogradov proposed the term COPD (chronic nonspecific lung disease), but this name did not take root.

A little later, the concept of COPD appeared and was interpreted as a collective concept that includes several diseases of the respiratory system. Scientists around the world continue to study the problems associated with COPD and offer new diagnostic and treatment methods. But regardless of them, doctors agree on one thing: quitting smoking is the main condition for successful treatment.