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Chronic bronchitis

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Chronic bronchitis
Treatment

Chronic bronchitis — the chronic inflammatory disease of bronchial tubes which is characterized by morphological reorganization of their mucous membrane.

Chronic bronchitis is shown by cough with expectoration during> 3 months in a year on an extent> 2 years.

Epidemiology

Among adult population of Russia incidence of chronic bronchitis varies from 10 to 20% (it is calculated on the basis of negotiability of patients; true prevalence of a disease can be much higher).

Classification of chronic bronchitis

Alternation of phases of remission and aggravation is characteristic of chronic bronchitis.
According to modern classification, chronic bronchitis is subdivided on:
• the idle time neoput;
• obstructive;
• purulent.

Etiology and pathogeny of a disease

Development of chronic bronchitis can be caused by the following factors:
• smoking;
• long influence of adverse ecological, professional and household factors (such as dust content, an air gas contamination, steam inhalation of acids and alkalis, dioxides are gray, etc.);
• frequent viral infections;
• deficit of a1-antitrypsin.
More than in half of cases of an exacerbation of chronic bronchitis are caused by accession of a consecutive bacterial infection which defines the further course and progressing of a disease. The role of various microorganisms in development of aggravations at different forms of chronic bronchitis is specified in the table.

The most probable activators at various forms of chronic bronchitis

Forms of chronic bronchitis

The most probable activators

Simple uncomplicated chronic bronchitis

Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis (resistance to a beta laktamnym to antibiotics is possible), viruses

Obstructive chronic bronchitis

H. influenzae, S. pneumoniae, M. oattarhalis Staphylococcus aureus, Klebsiella pneumoniae

Purulent chronic bronchitis

The same, as for 2 forms + Enterobacteriaceae Pseudomonas spp.

However exacerbations of chronic bronchitis can provoke also noninfectious factors, such as:
• congestive heart failure;
• cardiac arrhythmias;
• thromboembolism of a pulmonary artery;
• gastroesophagal reflux, etc.
Various etiological factors damage system of local protection of respiratory tracts at various levels (including disturbance of mukotsiliarny clearance, a cellular and humoral link of immunity). At the same time conditions for microbic colonization of a mucous membrane of bronchial tubes are created, inflammatory reaction with release of a number of mediators and inflow of neutrophils develops that stimulates products of slime and has the further damaging effect on epithelial cells. Besides, some waste products of microorganisms in itself have the damaging effect on a mucous membrane of respiratory tracts for the account:
• disturbances of mukotsiliarny clearance;
• increases in production of slime;
• local destruction of immunoglobulins;
• oppressions of phagocytal activity of neutrophils and alveolar macrophages;
• damages of a tracheobronchial epithelium.
Conditions for adhesion of microorganisms to new, rather intact sites of mucous result.
The bronchial obstruction at chronic bronchitis is caused:
• hypostasis of a mucous membrane of respiratory tracts;
• accumulation in their gleam of a dense and viscous secret with adverse rheological properties;
• bronchospasm;
• loss of an elastic energy of pulmonary fabric.
It plays an essential role in development and maintenance of a respiratory hypoxia and increase of respiratory insufficiency.

Clinical signs and symptoms of an illness

In a stage of remission of patients cough with constant department of a phlegm can disturb, however these symptoms significantly do not break quality of life. Usually the exacerbation of chronic bronchitis which is characterized is the cause for the address to the doctor:
• strengthening of cough;
• increase in quantity of the separated phlegm;
• change of character of a phlegm on purulent;
• emergence or strengthening of symptoms of bronchial obstruction;
• emergence or strengthening of signs of respiratory insufficiency (vary from the insignificant asthma not always noted by the patient before the heavy disturbances of ventilation of the lungs demanding an intensive care up to use of IVL);
• a decompensation of the accompanying somatopathies (increase of heart failure at ischemic heart disease patients, brain hypoxias at distsirkulyatorny encephalopathy, increase of level of glucose in blood at a diabetes mellitus, etc.);
• fever (does not treat typical clinical manifestations; however the fervescence, as a rule, to subfebrile figures which is not connected with other reasons and combined with other symptoms of damage of airways can testify to an exacerbation of chronic bronchitis).

Main symptoms of bronchial obstruction:
• lengthening of an exhalation;
• the "whistling" breath;
• breath through close lips;
• swelling of cervical veins on an exhalation;
• the dry whistling rattles (quite often can be listened only in horizontal position or at the forced exhalation).
About weight of an exacerbation of chronic bronchitis judge by existence and expressiveness of bronchial obstruction (the most objective indicator), respiratory insufficiency, a decompensation of associated diseases.

Simple uncomplicated chronic bronchitis is characterized by infrequent aggravations (<4 in a year), followed by increase in quantity of a phlegm which can gain purulent character. The expressed bronchial obstruction is absent (OFV1> 50% of norm).

Obstructive chronic bronchitis proceeds with more frequent aggravations which are characterized by the increase in quantity and emergence of a purulent phlegm which were more expressed by disturbances of bronchial passability (OFV1 <50% of norm). Persons are ill mainly 65 years which often have associated diseases are more senior.

Purulent chronic bronchitis occurs at patients of any age, is characterized by continuous allocation of a purulent phlegm, existence of bronchiectasias (often), decrease in OFV1 (<50% of norm). Quite often there are associated diseases. Exacerbations of purulent chronic bronchitis can be followed by development of acute respiratory insufficiency.

The diagnosis and the recommended clinical trials

The purposes of inspection of patients with expected chronic bronchitis:
• verification of the diagnosis;
• identification of a stage of a disease (aggravation, remission);
• definition of a basic reason of an aggravation.
Researches which need to be carried out at an exacerbation of chronic bronchitis (for specification of weight of process):
• physical inspection;
• the general blood test (the leukocytosis, a deviation to the left, increase in SOE are characteristic);
• serological tests (increase in blood of credits of specific antimicrobic antibodies is noted);
• microscopic (including coloring across Gram) and bacteriological research of a phlegm of which detection or increase in a phlegm of quantity of bacteria, neutrophils and mediators of an inflammation is characteristic. At difficulty of collecting a phlegm at heavy patients carrying out bronchoalveolar lavage is shown;
• research of bronchial passability (by means of pneumotachometry);
• X-ray inspection of a thorax (for a pneumonia exception);
• a computer tomography of bodies of a thorax (at suspicion on existence of bronchiectasias).

Differential diagnosis

It is necessary to carry out differential diagnosis with the diseases having similar clinical manifestations such as:
• pneumonia;
• tumors of respiratory tracts;
• bronchial asthma;
• mucoviscidosis, etc.



 
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