Medical aid at ambulatory – polyclinic stage list and volume.

Criteria of respiratory function violence.

- decrease of peak volume in 1 second (FEV 1.0) 80% of proper.

- expressed reversibility of bronchial obstruction – increasing of PVES and FEV 1.0 12% (or 200 ml) by results of pharmacological test with short action β -agonist.

- daily variation PVES and FEV 1.0 20%.

Medical aid at ambulatory – polyclinic stage list and volume.

Diagnostic tests:

1. External breathing function (EBF), (PVES and FEV 1.0)
2. Allergologic tests (allergologic anamnesis – allergic rhinitis, atopic dermatitis presence at patient or BA or atopic diseases at his family members; positive skin tests with allergens general and specific 1gE level increasing.
3. Studying of bronchi hyperreactivity is carried out at patients with clinical symptoms, which are characteristic for BA but at absence of characteristic EBF violations; is estimated by results of provocative tests with histamines metacholine, physical loading.

Classification

BA is classified by rate of course severity by complex analysis of bronchi obstruction clinical and functional symptoms. Answer on treatment in the period between attacks. Functional indexes changes estimation for disease severity determination is conducted in period without expiratory breathlessness episodes. BA classification according to rate of severity is especially important at solution of a question of disease management at patient’s condition primary examination

Intermitting (episodic), persistent (permanent stable) (mild, moderate severity, severe) course are distinguished.

Intermitting BA: symptoms (episodes of cough whistling breathing, breathlessness) are transitory, arise rarely than 1 time a week during at least 3 months; exacerbations of short duration, night symptoms arise not more frequently than 2 times a month. Between exacerbations symptoms are absent, normal indexes of EBF: PVES or FEV 1.0 ≥ 80% of proper; daily variation PVES and FEV < 20%.

Mild persistent BA: symptoms arise at least 1 time a week, but more rarely than 1 time a day during more than 3 months. Symptoms of exacerbation may disturb activity and sleep; presence of chronic symptoms, which requires symptomatic treatment almost every day; night asthma symptoms arise more than 2 times a month, PVES or FEV 1.0 ≥ 80% of proper; daily variation of PVES or FEV 1.0 20-30%.

Permanent BA of moderate severity: everyday symptoms; exacerbations disturb activity and sleep; night symptoms of asthma arise more than 1 time a week; necessity of short action β 2 agonists every day intake, PVES or FEV 1.0 > 30%.

Severe permanent BA: presence of variable to a considerable extent, prolonged symptoms; frequent night symptoms, limiting of activity, severe exacerbations in spite of treatment, which is conducted, proper decease control is absent: prolonged, daily symptoms are constantly present; frequently night symptoms, frequently severe exacerbations; conditioned by BA limiting of physical activity. PVES or FEV 1.0 < 60% of proper; PVES or FEV 1.0 daily variation > 30%. Achievement of the BA control may be impossible.

For the purpose of determination of the possible best results of treatment, answer the questions how the patient must react on prescribed treatment, conception “BA control” is introduced.

They distinguish: controlled course absence or minimal (≤ 2 times a week) daily symptoms, absence of activity limiting, night symptoms, absence or minimal (≤ 2/week) necessity in bronchial spasmolytic to relieve symptoms, normal PVES index, exacerbations absence;

Partly control (any symptom may occur in any week) non controlled course (≥ 3 symptoms of partly control are present at any week);

Control lever and extend of treatment at the present moment determinate the choice of proper tactic of further treatment.

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Laboratory Findings:

The sputum is characteristically tenacious and mucoid, containing " plugs" and " spirals." Eosinophils are seen microscopically. The differential blood count may show eosinophilia. In severe, acute bronchospasm, arterial hypoxemia may be present as a result of disturbed perfusion /ventilation relationships, alveolar hypoventilation, or functional right-to-left shunts.

X-Ray Findings: Chest films usually show no abnormalities. Reversible hyperexpansion may occur in severe paroxysms, or hyperexpansion may persist in long-standing cases. Transient, migratory pulmonary infiltrations may be present. Severe attacks are sometimes complicated by pneumothorax.

Pharmacotherapy of patients with BA.

BA patients medical treatment is conducted with use of different ways of medicines introductions: inhalation, oral, parenteral.

Inhalations, which provide expressed local action of medicines in lung don’t cause their undesirable system action, enable an opportunity to accelerate positive treatment effect using lesser doses of medicines has the greatest advantages.

Controlling medicines.

Are taking every day, to the basis, for a long term, to achieve and keep up the control of persistent BA.

Include: inhalation glucocorticosteroids (GCS) (first choice), system GCS, cromones, leucotriens modificators, prolonged action bronchial spasmolitics (inhalation prolonged action β ₂-agonists), oral prolonged action β ₂-agonists, prolonged action xantines) and system steroid – sparring therapy.

System action GCS (oral) may be prescribed as basis control therapy at some severe BA patients but their using must be limited because of risk of considerable side effects development.

Oral GCS long-term therapy is worth prescribing just in cases of non-efficiency of other methods of BA treatment, including inhalation steroids in high doses in combination with bronchi spasmolytics of prolonged action and continuing just then, when relieving of clinical symptoms, bronchial obstruction and frequency of severe exacerbations occurring is a success.

Short action medicines (prednisolone, methilprednisolone) are recommended for intake; daily supporting dose should be taken in in the morning, and if it is possible should be changed to intermitting therapy.

It is advisable to take minimal efficient doses of system GCS, and if it is possible to decrease their dose or to stop taking them, pass to high doses of inhalation GCS (2000 mkg/day), combination of the last and prolonged action bronchi spasmolitics.

Cromones may be used as controlling therapy at mild persistent BA, although their effect is considerably lesser in comparison with taking inhalation GCS.

Xantines have relatively low bronchi spasmolytic effect and risk of side effect if are used in high doses. Xantines are characterized by some anti-inflammatory action if low doses are prescribed in prolonged BA treatment.

Prolonged action β 2-agonists (salmeterole, formoterole fumaratis) have prolonged (duration more then 12 hours) bronchi spasmolytic effect and some anti-inflammatory action. The mentioned medicines are prescribed additionally (instead of inhalation GCS doses increasing), when basis therapy with standard doses of inhalation GCS is not enough to achieve control of the disease.

Using of combinations (fluticasone propionatis+ salmeteroli, budesonide + formoterole fumoratis) makes possible achievement of high level control of disease at most moderate severity, severe persistent BA patients. Fixed combination budesonide + formoterole fumaratis, in favour of rapid beginning of its action (beginning of the salmeterole’s action – in 4-3 minutes after inhalation) may be taken “When needed”.

Symptomatic therapy:

“first aid” preparations are used to relieve attacks of acute bronchi spasm and other BA symptoms: first of all short action β ₂-agonists (salbutamole sulfatis, fenoterole hydrobromide); additionally – short action anticholinergic drug (fenoterole hydrobromide + ipratropium bromide; salbutamole sulfatis + ipratropii bromide).

Stepped method of BA patients pharmacotherapy