Bronkhospastichesky reactions — one of the most frequent manifestations of RODS. The risk of their development increases at patients with hyperreactivity of respiratory tracts. NPVS, in particular ASK, cause a bronchospasm in 5 — 10% of patients with bronchial asthma. Against reception of APF inhibitors the bronchospasm develops at 3 — 20% of patients.
Bronkhospastichesky reaction or medicinal bronchial asthma can develop against therapy by the most different medicines. The only nosological form of medicinal bronchial asthma existing today — "aspirinovy" asthma.
Etiology and pathogeny of a disease
the medicines which are most often leading to development of a bronchospasm: • in - adrenoblockers; • blockers of calcium channels; • cholinesterase inhibitors; • ASK and other NPVS; • APF inhibitors; • penicillin. The mechanism a bronchospasm ravitiya at reception of various medicines differs. At patients with a chronic obstructive pulmonary disease cardioselective means at increase of a dose of medicines lose selectivity. Inhibitors of cholinesterase cause a bronchospasm due to cholinergic properties.
In a bronchospasm pathogeny at reception of ASK and NPVS blockade of a cyclooxygenase way of a metabolism of arachidonic acid and activation of the "shunting" lipoksigenazny way with formation of leukotrienes against genetic predisposition has the leading value. Pathogeny APF-indutsirovannogo of cough and bronchospasm is insufficiently studied so far. It is known that APF participates in a metabolism of kinin and substance P. As a result of decrease of the activity of APF under the influence of medicines concentration of the kinin and substance P irritating mucous bronchial tubes and possessing properties of vasoconstriction increases. Other explanation consists in activation of an exchange of arachidonic acid and increase in concentration of its metabolites. In development of a bronchospasm at reception of penicillin the leading value belongs to allergic reactions. Bronchospasm at inhalation of bronchial spasmolytics, especially aerosols kromoglitsiye-howl acids, beclomethasone, adrenergi-cheskiyekh medicines belongs to the category of casuistry. Perhaps, such side effect of these medicines is caused by a direct irritant action on respiratory tracts, including at the expense of a way of delivery and keeping in structure of an inhaler of ethanol. Igalyation in-adrenomimetikov in high doses sometimes cause paradoxical in - adrenergic blockade.
Clinical signs and symptoms of an illness
The bronchospasm is clinically shown by difficulty of the act of an exhalation (an expiratory asthma or asthma). For "aspirinovy" to bronchial asthma the combination of the following clinical signs is characteristic: • rhinitis; • nose polyposes; • intolerance of NPVS. The first displays of vasculomotor rhinitis are followed by watery allocations from a nose, in the subsequent develops nose polyposes, and most of patients with reaction to ASK with 20 — 30-year age show the developed picture of bronchial asthma. Such symptoms as sneezing, swelled mucous a nose, face reddening, dyspepsia, appear in 2 hours after reception of ASK. Clinical displays and criteria of weight of bronchial asthma are in detail described above.
The diagnosis and the recommended clinical trials
The diagnosis is established on the basis of a combination of data of the anamnesis (emergence of a syndrome of bronchial obstruction at reception of medicines) with clinicodiagnostic criteria, typical for bronchial asthma.
Clinical blood test
Increase of level of eosinophils, IgE is characteristic of bronchial asthma.
X-ray analysis of lungs
Symptoms of emphysema, emergence of "flying" infiltrates is possible.
Research of function of external respiration
Dysfunctions of external respiration on obstructive type.
The differential diagnosis of "aspirinovy" bronchial asthma can represent big difficulties in any age category. It is necessary to carry out differential diagnosis with the atopic and mixed form of bronchial asthma, a bronkhoobstruk-tivny syndrome against a viral infection (especially at children).
General principles of treatment
GKS Easy current Prednisolonum in 15 mg/days (before stopping of symptoms); in/in 90 — 120 mg/days (before stopping of symptoms)
Medium-weight current Before stopping of symptoms: Prednisolonum in 30 mg/days + Prednisolonum in/in 90 — 120 mg/days + Flutikazon in inhalations (it is preferable via the nebulizer) on 200 mkg 4 r / days or Beclomethasone in inhalations (it is preferable via the nebulizer) on 250 mkg to 4 r / days After achievement of clinical effect: Prednisolonum in 15 mg/days of 10 days
Heavy current Before stopping of symptoms: Prednisolonum in 1 mg/kg + Prednisolonum in/in 300 mg/days + Beclomethasone in inhalations (it is preferable via the nebulizer) 800 — 1600 mkg/days or Flutikazon in inhalations (it is preferable via the nebulizer) 800 — 1600 mkg/days After achievement of clinical effect: Prednisolonum inside 1mg/kg with a dose decline on 5 mg/week, before full cancellation At the medium-weight and heavy course of bronchial asthma of GKS appoint in combination with bronchodilators.
Medium-weight current Ipratropiya bromide in inhalations of 500 mkg/days before stopping of symptoms or Ipratropiya bromide in inhalations of 20 mkg before stopping of symptoms + Fenoterolum in inhalations of 50 mkg on 1 dose 1 — 2 r / days before stopping of symptoms or Salmeterol in inhalations of 50 mkg/days before stopping of symptoms
Heavy current Scheme 1 Ipratropiya bromide in inhalations of 500 mkg/days before stopping of symptoms Scheme 2 Before stopping of symptoms: Ipratropiya bromide in inhalations of 20 mkg + Fenoterolum in inhalations of 50 mkg on To 1 dose 1 — 2 r / days or Salmeterol in inhalations 100 mkg/days or Salbutamol in inhalations on 1 dose on requirement (no more 2 r / days) Before stopping of symptoms and within the next 1 month: Zafirlukast inside on 20 — 40 mg 2 r / days or Ketotifenum in 1 mg 1 r / days or Kromoglitsiyevy acid inside on 200 mg 4 r / days; in inhalations on 1 dose 4 r / days or Loratadin in 10 mg 1 r / days Treatment of "aspirinovy" asthma in a phase of remission is carried out by the principles described in chapter 28. "Bronchial asthma", is possible the desensibilizing therapy of ASK.
Assessment of efficiency of treatment
Criterion of efficiency of treatment is disappearance of clinical manifestations.
Complications and side effects of treatment
GKS even at short use (especially in high doses) can lead to development of such complications as: • disturbance of tolerance to glucose; • candidiasis, aspergillomycosis; • a local irritant action on mucous membranes of respiratory tracts (at inhalations); • tromboembolic episodes. Ketotifenum possesses sedation. Purpose of a zafirlukast can lead to development of a paradoxical eosinophilia.
Mistakes and unreasonable appointments
Have to be applied by Adrenomimetiki in the minimum doses, short courses, according to strict indications because of risk of aggravation of a bronchospasm. Purpose of v2-agonists in the mode and doses accepted at not medicinal bronchial asthma can strengthen allergic reaction.
The forecast at a bronchospasm favorable, at bronchial asthma — serious.