Chronic obstructive bronchitis clinical recommendations. Antibacterial therapy for exacerbation of chronic bronchitis. Clinical recommendations Bronchitis recommendations

Bronchitis is one of the most common diseases of the lower respiratory system, which occurs in both children and adults. It can occur due to factors such as allergens, physico-chemical influences, bacterial, fungal or viral infection.

In adults, there are 2 main forms - acute and chronic. On average, acute bronchitis lasts about 3 weeks, and chronic bronchitis lasts at least 3 months throughout the year and at least 2 years in a row. In children, there is another form - recurrent bronchitis (this is the same acute bronchitis, but repeated 3 or more times over the course of a year). If inflammation is accompanied by a narrowing of the lumen of the bronchi, then they speak of obstructive bronchitis.

If you are sick with acute bronchitis, then for a speedy recovery and to prevent the disease from becoming chronic, you should adhere to the following recommendations from specialists:

1. On days when your temperature rises, stay in bed or semi-bed rest.
2. Drink enough liquid (at least 2 liters per day). It will make it easier to cleanse the bronchi from mucus, because it will make it more liquid, and will also help remove toxic substances from the body that are formed as a result of the disease.
3. If the air in the room is too dry, take care of humidifying it: hang wet sheets, turn on the humidifier. This is especially important in winter during the heating season and in summer when it is hot, as dry air intensifies coughing.
4. As your condition improves, start doing breathing exercises, ventilate the room more often, and spend more time in the fresh air.
5. In case of obstructive bronchitis, be sure to avoid contact with allergens and do wet cleaning more often, which will help get rid of dust.
6. If this is not contraindicated by a doctor, then after the temperature has returned to normal, you can do a back massage, especially a drainage massage, apply mustard plasters, and rub the chest area with warming ointments. Even such simple procedures as a hot foot bath, to which you can add mustard powder, can help improve blood circulation and speed up recovery.
7. To soften a cough, regular steam inhalations with soda and decoctions of anti-inflammatory herbs will be useful.
8. To improve phlegm discharge, drink milk with honey, tea with raspberries, thyme, oregano, sage, and alkaline mineral waters.
9. Make sure that during sick days your diet is enriched with vitamins and proteins - eat fresh fruits, onions, garlic, lean meat, dairy products, drink fruit and vegetable juices.
10. Take the medications prescribed by your doctor.

As a rule, when treating acute bronchitis, the doctor recommends the following groups of drugs:

• Those that thin sputum and improve its removal - for example, Ambroxol, ACC, Mucaltin, licorice root, marshmallow.
• In case of obstruction phenomena - Salbutamol, Eufillin, Teofedrine, antiallergic drugs.
• Strengthening the immune system and helping to fight viral infection - Groprinosin, vitamins, drugs based on interferon, eleutherococcus, echinacea, etc.
• In the first days, if a dry and unproductive cough is debilitating, antitussives are also prescribed. However, on the days you take them, expectorants should not be used.
• With a significant increase in temperature, antipyretic and anti-inflammatory drugs are indicated - for example, Paracetamol, Nurofen, Meloxicam.
• If a second wave of temperature occurs or the sputum becomes purulent, then antibiotics are added to the treatment. For the treatment of acute bronchitis, amoxicillins protected with clavulanic acid are most often used - Augmentin, Amoxiclav, cephalosporins, macrolides (Azithromycin, Clarithromycin).
• If the cough continues for more than 3 weeks, then it is necessary to take an x-ray and consult a pulmonologist.

In case of recurrent or chronic bronchitis, following the recommendations of specialists can reduce the frequency of exacerbations of the disease, and also in most cases prevent the occurrence of diseases such as lung cancer, bronchial asthma of an infectious-allergic nature, and the progression of respiratory failure.

1. Quit smoking completely, including passive inhalation of tobacco smoke.
2. Don't drink alcohol.
3. Annually undergo preventive examinations with a doctor, fluorography of the chest organs, ECG, take a general blood test, sputum tests, including for the presence of mycobacterium tuberculosis, and in case of obstructive bronchitis, also do spirography.
4. Strengthen your immune system by leading a healthy lifestyle, engage in physical therapy, breathing exercises, harden yourself, and in the autumn-spring period, take adaptogens - preparations based on echinacea, ginseng, and eleutherococcus. If bronchitis is bacterial in nature, then it is recommended to undergo a full course of therapy with Bronchomunal or IRS-19.
5. With obstructive bronchitis, it is very important to avoid work that involves inhaling any chemical vapors or dust containing particles of silicon, coal, etc. Also avoid being in stuffy, unventilated rooms. Make sure you get enough vitamin C daily.
6. Outside of exacerbation, sanatorium-resort treatment is indicated.

During an exacerbation of chronic or recurrent bronchitis, the recommendations correspond to those for the treatment of the acute form of the disease. In addition, the administration of drugs using a nebulizer, as well as sanitation of the bronchial tree using a bronchoscope, are widely used.

– a specific disease that occurs as a result of inflammation of the lining of the bronchi, caused by viruses (respiratory, adenoviruses), bacteria, infections, allergens and other physicochemical factors. The disease can occur in chronic and acute forms. In the first case, damage to the bronchial tree is observed, which is a diffuse change in the airways under the influence of irritants (changes in the mucous membrane, harmful agents, sclerotic changes in the walls of the bronchi, dysfunction of this organ, etc.). Acute bronchitis is characterized by acute inflammation of the lining of the bronchi, as a result of an infectious or viral lesion, hypothermia or decreased immunity. This disease is often caused by fungi and chemical factors (paints, solutions, etc.).

This disease occurs in patients of any age, but most often the peak incidence falls on the age of the working population from 30-50 years. According to WHO recommendations, the diagnosis of chronic bronchitis is made after the patient complains of a severe cough that has lasted for 18 months or more. This form of the disease often leads to changes in the composition of pulmonary secretions, which linger in the bronchi for a long time.

Treatment of the chronic form of the disease begins with the prescription of mucolytics, taking into account the peculiarity of their action:

1. Drugs that affect adhesion. This group includes “Lazolvan”, “Ambraxol”, “Bromhexine”. These drugs contain the substance mucoltin, which promotes the rapid removal of mucus from the bronchi. Depending on the intensity and duration of the cough, mucolytics are prescribed in a daily dosage of 70-85 mg. Taking these medications is indicated in the absence of sputum or when a small amount is discharged, without shortness of breath and bacterial complications.
2. Medicines with antioxidant properties are Bromhexine bromide and ascorbic acid. 4-5 inhalations per day are prescribed, after completion of the course of treatment, consolidation therapy with mucolytics in tablets “Bromhexine” or “Mukaltin” is carried out. They help thin mucus and also affect its elasticity and viscosity. The dosage is selected individually by the attending physician.
3. Medicines that affect mucus synthesis (containing carbocysteine).

Standards of treatment

Treatment of chronic bronchitis occurs according to symptoms:

Cough

Periodic cough that occurs in the spring-autumn period of mild or moderate intensity.

Treatment: mucolytics in tablets “Bromhexine”, “Mukoltin”; inhalation "Bromhexie bromide" 1 ampoule + ascorbic acid 2 g (3-4 times a day).

Severe cough, causing the veins in the neck to dilate and the face to swell.

Treatment: oxygen therapy, diuretics, mucolytics.

Catarrhal bronchitis

Catarrhal bronchitis - discharge of mucopurulent sputum.

Treatment: during the period of infectious exacerbation - macrolide antibiotics (Clarithromycin, Azithromycin, Erythromycin); after the exacerbation subsides - antiseptic drugs in inhalation in combination with immunotherapy with the Bronchovax, Ribumunil, and Bronchomunal vaccines.

Obstructive bronchitis

Obstructive bronchitis is manifested by wheezing, shortness of breath, and whistling in the lungs.

Treatment: mucolytics “Bromhexine”, “Lazolvan”; during exacerbation - inhalation through a nebulizer with mucolytics in combination with corticosteroids enterally; if conservative treatment is ineffective - bronchoscopy.

Labored breathing

Treatment: drugs whose principle of action is based on blocking calcium channels (ACE blockers).

Skin redness

Redness of the skin and mucous membranes (polycythemia) when the diagnosis is confirmed by test results.

Treatment: prescription of anticoagulants, in advanced cases - bloodletting of 250-300 ml of blood until the test results normalize.

The disease in its acute form occurs as a result of inflammation of the bronchial mucosa due to an infectious or viral lesion. Treatment of the acute form in adults is carried out in a day hospital or at home, and for young children on an outpatient basis. For viral ethology, antiviral drugs are prescribed: “Interferon” (in inhalation: 1 ampoule diluted with purified water), “Interferon-alpha-2a”, “Rimantadine” (on the first day 0.3 g, subsequent days until recovery 0.1 d.) is taken orally. After recovery, therapy is carried out to strengthen the immune system with vitamin C.

In case of acute illness with the addition of an infection, antibacterial therapy is prescribed (antibiotics intramuscularly or in tablets): Cefuroxime 250 mg per day, Ampicillin 0.5 mg twice a day, Erythromycin 250 mg three times a day. When inhaling toxic fumes or acids, inhalation of ascorbic acid 5% diluted with purified water is indicated. Bed rest and plenty of warm (not hot!) drinks, mustard plasters, cups and warming ointments are also indicated. If fever occurs, it is recommended to take acetylsalicylic acid 250 mg or paracetomol 500 mg. three times a day. Mustard plasters can be used only after the temperature has dropped.

C In order to select the optimal tactics for managing patients with exacerbation of chronic bronchitis (CB), it is advisable to distinguish the so-called "infectious" And "non-infectious" exacerbations of chronic disease requiring an appropriate therapeutic approach. An infectious exacerbation of chronic disease can be defined as an episode of respiratory decompensation not associated with objectively documented other causes, and primarily with pneumonia.

Diagnosis of infectious exacerbation of chronic disease includes use of the following clinical, radiological, laboratory, instrumental and other methods of examining the patient:

Clinical study of the patient;

Study of bronchial patency (according to FEV 1);

X-ray examination of the chest (to rule out pneumonia);

Cytological examination of sputum (counting the number of neurophils, epithelial cells, macrophages);

Sputum Gram stain;

Laboratory tests (leukocytosis, neutrophil shift, increased ESR);

Bacteriological examination of sputum.

These methods make it possible, on the one hand, to exclude syndrome-like diseases (pneumonia, tumors, etc.), and, on the other hand, to determine the severity and type of exacerbation of chronic disease.

Clinical symptoms of exacerbations of chronic disease

Increased cough;

Increased amount of sputum discharge;

Change in the nature of sputum (increased purulence of sputum);

Increased shortness of breath;

Increased clinical signs of bronchial obstruction;

Decompensation of concomitant pathologies (heart failure, arterial hypertension, diabetes mellitus, etc.);

Fever.

Each of these symptoms can be isolated or combined with each other, and also have varying degrees of severity, which characterizes the severity of the exacerbation and allows us to tentatively suggest the etiological spectrum of pathogens. According to some data, there is a connection between isolated microorganisms and indicators of bronchial obstruction in patients with exacerbation of chronic bronchitis. As the degree of bronchial obstruction increases, the proportion of gram-negative microorganisms increases with a decrease in gram-positive microorganisms in the sputum of patients with exacerbation of CB.

Depending on the number of symptoms present, different types of exacerbation of chronic bronchitis are distinguished, which acquires important prognostic significance and can determine the treatment tactics for patients with exacerbation of chronic bronchitis (Table 1).

For infectious exacerbation of CB, the main treatment method is empirical antibacterial therapy (AT). It has been proven that AT promotes faster relief of symptoms of exacerbation of CB, eradication of etiologically significant microorganisms, increasing the duration of remission, and reducing costs associated with subsequent exacerbations of CB.

Choice of antibacterial drug for exacerbation of chronic disease

When choosing an antibacterial drug, you must consider:

Clinical situation;

The activity of the drug against the main (most likely in this situation) pathogens of infectious exacerbation of the disease;

Taking into account the likelihood of antibiotic resistance in a given situation;

Pharmacokinetics of the drug (penetration into sputum and bronchial secretions, half-life, etc.);

No interaction with other medications;

Optimal dosing regimen;

Minimal side effects;

Cost indicators.

One of the guidelines for empirical antibiotic therapy (AT) for CB is the clinical situation, i.e. variant of CB exacerbation, severity of exacerbation, presence and severity of bronchial obstruction, various factors of poor response to AT, etc. Taking into account the above factors allows us to tentatively assume the etiological significance of a particular microorganism in the development of exacerbation of CB.

The clinical situation also allows us to assess the likelihood of antibiotic resistance of microorganisms in a particular patient (penicillin resistance of pneumococci, products H. influenzae(lactamases), which may be one of the guidelines when choosing the initial antibiotic.

Risk factors for penicillin resistance in pneumococci

Age up to 7 years and over 60 years;

Clinically significant concomitant pathology (heart failure, diabetes mellitus, chronic alcoholism, liver and kidney diseases);

Frequent and long-term previous antibiotic therapy;

Frequent hospitalizations and stays in places of charity (boarding schools).

Optimal pharmacokinetic properties of an antibiotic

Good penetration into sputum and bronchial secretions;

Good bioavailability of the drug;

Long half-life of the drug;

No interaction with other medications.

Among the aminopenicillins most frequently prescribed for exacerbations of chronic disease, amoxicillin, produced by Sintez OJSC under the brand name, has optimal bioavailability Amosin® , JSC "Sintez", Kurgan, which in this regard has advantages over ampicillin, which has rather low bioavailability. When taken orally, amoxicillin ( Amosin® ) has high activity against the main microorganisms etiologically associated with exacerbation of CB ( Str. Pneumoniae, H. influenzae, M. cattharalis). The drug is available in 0.25, 0.5 g No. 10 and in capsules 0.25 No. 20.

A randomized, double-blind, double-placebo-controlled study compared the effectiveness and safety of amoxicillin at a dose of 1 g 2 times a day (group 1) and 0.5 g 3 times a day (group 2) in 395 patients with exacerbation of CB. The duration of treatment was 10 days. Clinical effectiveness was assessed on days 3-5, days 12-15 and days 28-35 after the end of treatment. Among the ITT population (who did not completely complete the study), clinical efficacy in patients of groups 1 and 2 was 86.6% and 85.6%, respectively. At the same time, in the RR population (completion of the study according to the protocol) - 89.1% and 92.6%, respectively. Clinical relapse in the ITT and RR populations was observed in 14.2% and 13.4% in group 1 and 12.6% and 13.7% in group 2. Statistical data processing confirmed the comparable effectiveness of both treatment regimens. Bacteriological effectiveness in groups 1 and 2 among the ITT population was noted in 76.2% and 73.7%.

Amoxicillin ( Amosin® ) is well tolerated, except in cases of hypersensitivity to beta-lactam antibiotics. In addition, it has virtually no clinically significant interaction with other medications prescribed to patients with chronic disease, both in connection with exacerbation and concomitant pathology.

Risk factors for poor response to AT during exacerbation of CB

Elderly and senile age;

Severe bronchial obstruction;

Development of acute respiratory failure;

Concomitant pathology;

Frequent previous exacerbations of chronic disease (more than 4 times a year);

The nature of the pathogen (antibiotic-resistant strains, Ps. aeruginosa).

The main options for exacerbation of chronic disease and AT tactics

Simple chronic bronchitis:

Simple chronic bronchitis:

Patients' age is less than 65 years;

The frequency of exacerbations is less than 4 per year;

FEV 1 more than 50% of predicted;

Main etiologically significant microorganisms: St. pneumoniae H. influenzae M. cattarhalis(resistance to b-lactams is possible).

First line antibiotics:

Aminopenicillins (amoxicillin ( Amosin® )) 0.5 g x 3 times orally, ampicillin 1.0 g x 4 times a day orally). Comparative characteristics of ampicillin and amoxicillin ( Amosin® ) is presented in Table 2.

Macrolides (azithromycin (Azithromycin - AKOS, JSC Sintez, Kurgan) 0.5 g per day on the first day, then 0.25 g per day for 5 days, clarithromycin 0.5 g x 2 times a day orally .

Tetracyclines (doxycycline 0.1 g 2 times a day) can be used in regions with low pneumococcal resistance.

Alternative antibiotics:

Protected penicillins (amoxicillin/clavulanic acid 0.625 g every 8 hours orally, ampicillin/sulbactam (Sultasin®, Sintez OJSC, Kurgan) 3 g x 4 times a day),

Respiratory fluoroquinolones (sparfloxacin 0.4 g once daily, levofloxacin 0.5 g once daily, moxifloxacin 0.4 g once daily).

Complicated chronic bronchitis:

Age over 65 years;

Frequency of exacerbations more than 4 times a year;

Increased volume and purulence of sputum during exacerbations;

FEV 1 is less than 50% of predicted;

More severe symptoms of exacerbation;

Main etiologically significant microorganisms: the same as in group 1 + St. aureus+ gram-negative flora ( K. pneumoniae), frequent resistance to b-lactams.

First line antibiotics:

• Protected penicillins (amoxicillin/clavulanic acid 0.625 g every 8 hours orally, ampicillin/sulbactam 3 g x 4 times a day intravenously);
• 1-2 generation cephalosporins (cefazolin 2 g x 3 times a day IV, cefuroxime 0.75 g x 3 times a day IV;
• “Respiratory” fluoroquinolones with antipneumococcal activity (sparfloxacin 0.4 g once a day, moxifloxacin 0.4 g per day orally, levofloxacin 0.5 g per day orally).

Alternative antibiotics:

3rd generation cephalosporins (cefotaxime 2 g x 3 times a day IV, ceftriaxone 2 g once a day IV).

Chronic purulent bronchitis:

Any age;

Constant release of purulent sputum;

Frequent concomitant pathology;

Frequent presence of bronchiectasis;

FEV 1 less than 50%;

Severe symptoms of exacerbation, often with the development of acute respiratory failure;

Main etiologically significant microorganisms: the same as in group 2 + Enterobactericae, P. aeruginosa.

First line antibiotics:

• 3rd generation cephalosporins (cefotaxime 2 g x 3 times a day IV, ceftazidime 2 g x 2-3 times a day IV, ceftriaxone 2 g once a day IV);
• Respiratory fluoroquinolones (levofloxacin 0.5 g once daily, moxifloxacin 0.4 g once daily).

Alternative antibiotics:

“Gram-negative” fluoroquinolones (ciprofloxacin 0.5 g x 2 times orally or 400 mg IV x 2 times a day);

4th generation cephalosporins (cefepime 2 g x 2 times a day IV);

Antipseudomonas penicillins (piperacillin 2.5 g x 3 times a day IV, ticarcillin/clavulanic acid 3.2 g x 3 times a day IV);

Meropenem 0.5 g x 3 times a day i.v.

In most cases of exacerbations of chronic disease, antibiotics should be prescribed orally. Indications for parenteral use of antibiotics are :

Gastrointestinal disorders;

Severe exacerbation of chronic disease;

The need for mechanical ventilation;

Low bioavailability of oral antibiotic;

Non-compliance of patients.

The duration of AT for exacerbations of chronic disease is 5-7 days. It has been proven that 5-day courses of treatment are no less effective than longer use of antibiotics.

In cases where there is no effect from the use of first-line antibiotics, a bacteriological examination of sputum or BALF is performed and alternative drugs are prescribed taking into account the sensitivity of the identified pathogen.

When assessing the effectiveness of AT for exacerbations of CB, the main criteria are :

Direct clinical effect (rate of regression of clinical symptoms of exacerbation, dynamics of bronchial patency indicators;

Bacteriological effectiveness (achievement and timing of eradication of an etiologically significant microorganism);

Long-term effect (duration of remission, frequency and severity of subsequent exacerbations, hospitalization, need for antibiotics);

Pharmacoeconomic effect taking into account the drug cost/treatment effectiveness indicator.

Table 3 shows the main characteristics of oral antibiotics used to treat exacerbations of CB.

Literature:

1 Anthonisen NR, Manfreda J, Warren CP, Hershfield ES, Harding GK, Nelson NA. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann. Intern. Med. 1987; 106; 196-204

2 Allegra L, Grassi C, Grossi E, Pozzi E. Ruolo degli antidiotici nel trattamento delle riacutizza della bronchite cronica. Ital.J.Chest Dis. 1991; 45; 138-48

3 Saint S, Bent S, Vittinghof E, Grady D. Antibiotics in chronic obstructive pulmonary disease exacerbations. A meta-analysis. JAMA. 1995; 273; 957-960

4. R Adams S.G., Melo J., Luther M., Anzueto A. - Antibiotics are associated with lower relapse rates in outpatients with acute exacerbations of COPD. Chest, 2000, 117, 1345-1352

5. Georgopoulos A., Borek M., Ridi W. - Randomised, double-blind, double-dummy study comparing the efficacy and safety of amoxycillin 1g bd with amoxycillin 500 mg tds in the treatment of acute exacerbations of chronic bronchitis JAC 2001, 47, 67-76

6. Langan S., Clecner V., Cazzola C.M., et al. Short-course cefuroxime axetil therapy in the treatment of acute exacerbations of chronic bronchitis. Int J Clin Pract 1998; 52:289-97.),

7. Wasilewski M.M., Johns D., Sides G.D. Five-day dirithromycin therapy is as effective as 7-day erythromycin therapy for acute exacerbations of chronic bronchitis. J Antimicrob Chemother 1999; 43:541-8.

8. Hoepelman I.M., Mollers M.J., van Schie M.H., et al. A short (3-day) coarse of azithromycin tablets versus a 10-day course of amoxycillin-clavulanic acid (co-amoxiclav) in the treatment of adults with lower respiratory tract infections and the effect on long-term outcome. Int J Antimicrob Agents 1997; 9:141-6.)

9. R.G. Masterton, C.J. Burley, . Randomized, Double-Blind Study Comparing 5- and 7-Day Regimens of Oral Levofloxacin in Patients with Acute Exacerbation of Chronic Bronchitis International Journal of Antimicrobial Agents 2001;18:503-13.)

10. Wilson R., Kubin R., Ballin I., et al. Five day moxifloxacin therapy compared with 7 day clarithromycin therapy for the treatment of acute exacerbations of chronic bronchitis. J Antimicrob Chemother 1999; 44:501-13)

Severe form of inflammation of the respiratory system, chronic obstructive bronchitis develops as a result of untimely or improper treatment acute stage of the disease.

The disease is accompanied by structural changes and disruption of the respiratory function of the bronchi.

At an early stage of the chronic process, changes can be completely cured.

In advanced cases, the pathological process becomes irreversible.

– diffuse inflammation of the bronchial tree, characterized by persistent swelling of the mucous membrane and increased sputum production.

Accumulating inside the bronchial tract, phlegm blocks the path to air.

The acute form of the disease develops as a result of inadequate treatment of ARVI or with prolonged exposure to polluted air on the bronchi.

Ineffective treatment of acute obstructive bronchitis provokes its transition to a chronic form.

According to ICD 10, chronic bronchitis is classified as obstructive pulmonary disease, and therefore has the same code as COPD J44.

WHO experts consider a form of bronchitis to be chronic if the disease lasts more than 2 months with exacerbation more than 2 times a year.

Stages of development of the chronic form

The disease goes through several stages in its development:

The result of constant filling of the airways with mucus is structural changes in the walls of the airways.

The serous glands that produce bronchial secretions hypertrophy. At the last stage, “bald bronchus” syndrome develops, caused by the complete death of bronchial cilia.

Impaired gas exchange in the lungs due to blockage of the bronchial channels gradually leads to the development of pneumosclerosis.

Classification

The development of the disease is classified according to severity. The classification is based on the volume of formed inspiration - FEV:

• light: FEV 70% of the norm for a healthy respiratory system;
• average: from 50 to 69%;
• heavy: 50% or less.

Based on the nature of the sputum formed in the bronchi, the disease is divided into the following types:

1. Catarrhal– the mildest form with diffuse inflammation.
2. Catarrhal-purulent– inflammation is accompanied by the formation of pus.
3. Purulent obstructive– the patient produces purulent sputum.

In the later stages, the inflammatory process affects the deep tissues of the bronchi and lungs, structural changes in the tissues become irreversible, and the disease develops into COPD.

Causes of inflammation

The medical history includes primary and secondary causes. Primary ones serve as an impetus for inflammation, secondary ones contribute to the progression of the disease:

Primary reasons:

Secondary causes that contribute to the development of inflammation under the influence of irritating substances are associated with the state of human health and the conditions of his life.

Predisposing factors that accelerate the development of the disease are:

• tendency to allergic reactions;
• weakened immune system;
• genetic predisposition;
• frequent colds;
• living in unfavorable climatic conditions.

Video consultation: Causes of obstructive bronchitis.

Dr. Komarovsky will list the causes of obstructive bronchitis. Recommendations, conclusions, advice.

Symptoms

The main sign of the development of the disease is slowly progressive obstruction with gradually increasing respiratory failure.

The pathological process reaches its peak at approximately 40-50 years of age.

At this time, the narrowing of the bronchi is no longer amenable to the usual effects of bronchodilators.

COB occurs with periodic exacerbations and remissions. Symptoms during exacerbation:

• headache;
• cough with purulent mucous sputum;
• chills, fever;
• nausea, dizziness.

During remission, the following clinical manifestations are observed:

In the later stages of COB, visual signs appear that are noticeable even to a non-specialist:

• movements of the respiratory muscles;
• swelling of the veins in the neck;
• bloated chest;
• blue skin;
• horizontal arrangement of ribs.

Oxygen starvation causes damage to other organs and the development of associated symptoms:

1. Pressure surges, heart rhythm disturbances, bluish lips with damage to the cardiovascular system;
2. Lower back pain, swelling of the legs due to damage to the urinary system;
3. Impaired consciousness, absent-mindedness, memory loss, hallucinations, blurred vision are evidence of central nervous system damage;
4. Loss of appetite, pain in the epigastric region due to disruption of the gastrointestinal tract.

IMPORTANT! Chronic hypoxia leads to further deterioration of the body's condition; chronic diseases of the liver, kidneys, and circulatory system gradually develop.

Diagnostics

Diagnosis and treatment of COB is carried out by local therapists or pulmonologists.

The diagnosis is based on examination of the patient and analysis of complaints about the condition of the body.

The main method of making an initial diagnosis is listening to the lungs with special instruments.

Signs confirming the diagnosis:

• the sound when tapping the lungs is boxy;
• hard breathing at the beginning of the disease, whistling in the lungs as inflammation develops;
• symmetrical vocal tremors in the initial stages, weakening of the voice in the later stages.

To confirm the diagnosis, the doctor prescribes the following tests:

• inhalation tests - inhalation of a bronchodilator to determine the reversibility of obstruction;
• blood test for acid-base balance and gas composition;
• chest x-ray;
• spirometry - measuring lung volume by charting inhalation and exhalation;
• bronchography;

To assess the degree, a study of external respiration function - FVD - is performed.

Before the examination, smoking patients are asked to give up their bad habit for a day; the patient is also prohibited from drinking coffee, strong tea and alcohol and avoiding physical activity.

30 minutes before the procedure, the patient should be in a state of complete physical and psychological rest.

Measurements are carried out with a special device - a spirometer.

The patient is seated in a chair with armrests and asked to exhale into the device after a deep breath.

A decrease in indicators with each exhalation means the presence of chronic obstructive bronchitis.

Treatment

Treatment of COB is complex and consists of taking medications, physiotherapeutic procedures and breathing exercises.

Mild to moderate disease is treated on an outpatient basis.

The patient is issued a sick leave certificate for a period of 15 to 30 days. A severe stage of exacerbation requires hospitalization of the patient.

Medication

The main group of medications for the treatment of COB are bronchodilators:

• Ipratropium bromide, Salmeterol, Formoterol - drugs for inhalation that restore the mucous membrane;
• Fenoterol (Salbutamol, Terbutaline) is used during periods of exacerbation to relieve inflammation.

An important part of therapy is the use of expectorants. The components of the drugs thin the mucus and promote the regeneration of mucosal cells.

The most popular drugs in this group are:

• "Carbocysteine";
• "Fluimucil";
• "Lazolvan";
• "Bromhexine";
• "Herbion".

In the acute stage, inflammation is relieved with antibiotics from the macrolide group, cephalosporins or penicillins.

In some cases, patients are prescribed antiviral drugs: Acyclovir, Cernilton, Arbidol.

To maintain immunity, the treatment complex includes immunomodulators: “Immunal”, “Imudon”, “Bronchomunal”, “IRS-19”, “Ekhinacin”.

IMPORTANT! During the period of remission, salty air has a beneficial effect on the state of the respiratory system of patients. Therefore, annual trips to the seashore, as well as procedures in salt chambers (halotherapy), are recommended for patients with bronchitis.

Physiotherapy

Physiotherapeutic procedures in the treatment of bronchitis are aimed at stimulating mucus production and correcting respiratory function.

The following methods are used:

The set of procedures and duration of the course depend on the stage of the disease and the general condition of the patient.

Traditional methods

Traditional methods of treating chronic bronchitis complement the intake of medications and help speed up recovery.

According to patient reviews, the following folk remedies are most effective:

Prevention

The main conditions for preventing the development of chronic obstructive bronchitis are timely treatment of acute respiratory infections and acute forms of the disease, as well as minimizing risk factors for negative effects on the respiratory system.

To give up smoking, Hardening, maintaining a healthy lifestyle, and a balanced diet are the basis for preventing the disease.

People with weak respiratory systems should pay attention to living and working conditions.

It is recommended to do daily wet cleaning and ventilation of the room.

Maintain optimal humidity levels.

If inflammation of the bronchi is provoked by the environment or working conditions, it is worth changing your place of residence and work.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2015

Acute lower respiratory tract respiratory infection, unspecified (J22), Acute bronchiolitis (J21), Acute bronchitis (J20)

Pulmonology

general information

Short description

Expert advice

RSE on REM "Republican Center for Health Development"

Ministry of Health and Social Development of the Republic of Kazakhstan

Protocol No. 18

Acute bronchitis- limited inflammation of the large airways, the main symptom of which is cough. Acute bronchitis usually lasts 1-3 weeks. However, in some patients the cough can be prolonged (up to 4-6 weeks) due to the characteristics of the etiological factor.

Acute bronchitis can be diagnosed in patients with a cough, productive or not, without chronic bronchopulmonary diseases, and not explained by other causes (sinusitis, asthma, COPD).

I. INTRODUCTORY PART:

Protocol name: Acute bronchitis in adults.

Protocol code:

ICD-10 code(s)

J20 Acute tracheobronchitis

J20.0 Acute bronchitis caused by Mycoplasma pneumoniae

J20.1 Acute bronchitis caused by Haemophilus influenzae (Afanasyev-Pfeiffer bacillus)

J20.2 Acute bronchitis caused by streptococcus

J20.3 Acute bronchitis caused by Coxsackie virus

J20.4 Acute bronchitis caused by parainfluenza virus

J20.5 Acute bronchitis caused by respiratory syncytial virus

J20.6 Acute bronchitis caused by rhinovirus

J20.7 Acute bronchitis caused by echovirus

J20.8 Acute bronchitis caused by other specified agents

J20.9 Acute bronchitis, unspecified

J21 Acute bronchiolitis included: with bronchospasm

J21.0 Acute bronchiolitis caused by respiratory syncytial virus

J21.8 Acute bronchiolitis caused by other specified agents

J21.9 Acute bronchiolitis, unspecified

J22 Acute respiratory infection of the lower respiratory tract, unspecified.

Abbreviations:

IgE immunoglobulinE - immunoglobulin E

DTP associated pertussis-diphtheria-tetanus vaccine

BC bacillus Koch

URT upper respiratory tract

O2 oxygen

AB acute bronchitis

ESR erythrocyte sedimentation rate

PE pulmonary embolism

COPD chronic obstructive pulmonary disease

Heart rate number of heartbeats

Date of development of the protocol: year 2013.

Date of protocol revision: 2015

Protocol users: General practitioners, therapists, pulmonologists.

Assessment of the degree of evidence of the recommendations provided.
Level of evidence scale:

A	High-quality meta-analysis, systematic review of RCTs or large RCTs with very low probability (++) of bias results.
IN	High-quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control studies with a very low risk of bias or RCTs with a low (+) risk of bias.
WITH	Cohort or case-control study or controlled trial without randomization with low risk of bias (+). Results that can be generalized to the relevant population or RCTs with very low or low risk of bias (++ or +) whose results cannot be directly generalized to the relevant population.
D	Case series or uncontrolled study or expert opinion.
GPP	Best pharmaceutical practice.

Classification

Clinical classification

The epidemiology of acute bronchitis is related to the epidemiology of influenza and other respiratory viral diseases. Most often occurs in the autumn-winter period. The main etiological factor of acute bronchitis (80-95%) is a viral infection, which is confirmed by many studies.
The most common viral agents are influenza A and B, parainfluenza, rhinosyncytial virus, less common are coronoviruses, adenoviruses and rhinoviruses. Among bacterial pathogens, a certain role in the etiology of acute bronchitis is assigned to such pathogens as mycoplasma, chlamydia, pneumococcus, and Haemophilus influenzae. No special studies have been conducted on the epidemiology of acute bronchitis in Kazakhstan. According to international data, acute bronchitis is the fifth most common acute disease, debuting with cough.

Acute bronchitis is classified into non-obstructive and obstructive. In addition, there is a protracted course of acute bronchitis, when the symptoms persist for up to 4-6 weeks.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

List of main diagnostic measures:

General blood test according to indications:

Cough for more than 3 weeks;

Age over 75 years;

Febrile fever more than 38.0 C;

Fluorography according to indications:

Cough for more than 3 weeks;

Age over 75 years;

Suspicion of pneumonia;

For the purpose of differential diagnosis.

List of additional diagnostic measures:

General sputum analysis (if available);

Microscopy of sputum with Gram stain;

Bacteriological examination of sputum;

Sputum microscopy for CD;

Spirography;

X-ray of the chest organs;

Electrocardiography.

Diagnostic criteria

Complaints and anamnesis:

History of risk factors may include: b:

Contact with a patient with a viral respiratory infection;

Seasonality (winter-autumn period);

Hypothermia;

Having bad habits (smoking, drinking alcohol),

Exposure to physical and chemical factors (inhalation of sulfur, hydrogen sulfide, chlorine, bromine and ammonia vapors).

Main complaints:

The cough is first dry, then with sputum, painful, annoying (a feeling of “scratching” behind the sternum and between the shoulder blades), which goes away when sputum appears;

General weakness, malaise;

Pain in muscles and back.

Physical examination:

Body temperature is low-grade or normal;

On auscultation - hard breathing, sometimes scattered dry rales.

Laboratory research

In a general blood test, slight leukocytosis and accelerated ESR are possible.

Instrumental studies:

In the typical course of acute bronchitis, the use of radiation diagnostic methods is not recommended. Fluorography or chest x-ray is indicated for prolonged cough (more than 3 weeks), physical detection of signs of pulmonary infiltrate (local shortening of percussion sound, appearance of moist rales), patients over 75 years of age, because their pneumonia often has blurred clinical signs.

Indications for consultation with specialists:

Consultation with a pulmonologist (if differential diagnosis is necessary and therapy is ineffective);

Consultation with an otorhinolaryngologist (to exclude pathology of the upper respiratory tract (URT));

Consultation with a gastroenterologist (to exclude gastroesophageal reflux in patients with gastroduodenal pathology).

Differential diagnosis

Differential diagnosis

Differential diagnosis of acute bronchitis is carried out according to the symptom “Cough”.

DIAGNOSIS	DIAGNOSTIC CRITERIA
Acute bronchitis	Cough without rapid breathing Runny nose, nasal congestion Increased body temperature, fever
Community-acquired pneumonia	Febrile fever over ≥ 38.0 Chills, chest pain Shortening of percussion sound, bronchial breathing, crepitus, moist rales Tachycardia > 100 bpm Respiratory failure, respiratory rate >24/min, decreased O2 saturation< 95%
Bronchial asthma	Allergy history Paroxysmal cough The presence of concomitant allergic diseases (atopic dermatitis, allergic rhinitis, manifestations of food and drug allergies). Eosinophilia in the blood. High level of IgE in the blood. The presence in the blood of specific IgE to various allergens.
TELA	Acute severe shortness of breath, cyanosis, respiratory rate more than 26-30 per minute Previous long-term limb immobilization Presence of malignant neoplasms Deep vein thrombosis of the leg Hemoptysis Pulse over 100/min No fever
COPD	Chronic productive cough Signs of bronchial obstruction (exhalation prolongation and wheezing) Respiratory failure develops Severe disturbances in the ventilation function of the lungs
Congestive heart failure	Crackles in the basal regions of the lungs Orthopnea Cardiomegaly Signs of pleural effusion, congestive infiltration in the lower parts of the lungs on a radiograph Tachycardia, protodiastolic gallop rhythm Worsening of cough, shortness of breath and wheezing at night, in a horizontal position

In addition, the cause of a lingering cough can be whooping cough, seasonal allergies, postnasal drip in the pathology of the upper respiratory tract, gastroesophageal reflux, and a foreign body in the respiratory tract.

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment goals:

Relieving the severity and reducing the duration of cough;

Restoration of working capacity;

Elimination of symptoms of intoxication, improvement of well-being, normalization of body temperature;

Recovery and prevention of complications.

Treatment tactics

Non-drug treatment

Treatment of uncomplicated acute bronchitis is usually done at home;

To reduce intoxication syndrome and facilitate sputum production - maintain adequate hydration (drink plenty of water, up to 2-3 liters of fruit drinks per day);

Stop smoking;

Eliminating the patient's exposure to environmental factors that cause coughing (smoke, dust, strong odors, cold air).

Drug treatment:

Since the infectious agent in the vast majority of cases is viral in nature, it is not recommended to routinely prescribe antibiotics. Green color of sputum in the absence of other signs of infection of the lower respiratory tract indicated above is not a reason for prescribing antibacterial drugs.

Empirical antiviral therapy is not usually performed in patients with acute bronchitis. Only in the first 48 hours from the onset of symptoms of the disease, in an unfavorable epidemiological situation, is it possible to use antiviral drugs (ingavirin) and neuraminidase inhibitors (zanamivir, oseltamivir) (level C).

For a limited group of patients, the prescription of antibiotics is indicated, but there is no clear data on the identification of this group. Obviously, this category includes patients with no effect and persistence of intoxication symptoms for more than 6-7 days, as well as persons over 65 years of age with the presence of concomitant nosologies.

The choice of antibiotic is based on activity against the most common bacterial pathogens of acute bronchitis (pneumococcus, Haemophilus influenzae, mycoplasma, chlamydia). The drugs of choice are aminopenicillins (amoxicillin), including protected ones (amoxicillin/clavulanate, amoxicillin/sulbactam) or macrolides (spiramycin, azithromycin, clarithromycin, josamycin), an alternative (if it is impossible to prescribe the former) are 2-3 generation cephalosporins per os. The estimated average duration of antibacterial therapy is 5-7 days.

Principles of pathogenetic treatment of acute bronchitis:

Normalization of the quantity and rheological properties of tracheobronchial secretion (viscosity, elasticity, fluidity);

Anti-inflammatory therapy;

Elimination of annoying non-productive cough;

Normalization of bronchial smooth muscle tone.

If acute bronchitis is caused by inhalation of a known toxic gas, it is necessary to find out the existence of its antidotes and the possibility of their use. For acute bronchitis caused by acid vapors, inhalation of vapors of a 5% sodium bicarbonate solution is indicated; if after inhalation of alkaline vapors, then inhalation of vapors of a 5% solution of ascorbic acid is indicated.

In the presence of viscous sputum, mucoactive drugs are indicated (ambroxol, bisolvon, acetylcysteine, carbocisteine, erdosteine); It is possible to prescribe reflex drugs, expectorants (usually expectorant herbs) orally.

Bronchodilators are indicated for patients with symptoms of bronchial obstruction and airway hyperresponsiveness. The best effect is achieved by short-acting beta-2 agonists (salbutamol, fenoterol) and anticholinergics (ipratropium bromide), as well as combination drugs (fenoterol + ipratropium bromide) in inhalation form (including through a nebulizer).

It is possible to use oral combination drugs containing expectorants, mucolytics, and bronchodilators.

If a lingering cough persists and signs of respiratory tract hyperreactivity appear, it is possible to use anti-inflammatory non-steroidal drugs (fenspiride); if they are ineffective, inhaled glucocorticosteroid drugs (budesonide, beclomethasone, fluticasone, ciclesonide), including through a nebulizer (budesonide suspension). The use of fixed combination inhaled drugs (budesonide/formoterol or fluticasone/salmeterol) is acceptable.

In the absence of sputum during therapy, an obsessive, dry hacking cough, antitussives (cough suppressants) of peripheral and central action are used: prenoxdiazine hydrochloride, cloperastine, glaucine, butamirate, oxeladin.

Preventive actions:

In order to prevent acute bronchitis, possible risk factors for acute bronchitis should be eliminated (hypothermia, dust and gas contamination of work areas, smoking, chronic infection of the upper respiratory tract). Vaccination against influenza is recommended, especially for persons at increased risk: pregnant women, patients over 65 years of age with concomitant diseases.

Further management:

After relief of general symptoms, further observation and medical examination are not required.

Indicators of treatment effectiveness and safety of diagnostic and treatment methods:

Elimination of clinical manifestations within 3 weeks and return to work.

Drugs (active ingredients) used in treatment

Azithromycin

Ambroxol

Amoxicillin

Ascorbic acid

Acetylcysteine

Beclomethasone

Budesonide

Butamirate

Glaucine

Josamycin

Zanamivir

Imidazolyl ethanamide pentandioic acid

Ipratropium bromide

Carbocisteine

Clavulanic acid

Clarithromycin

Cloperastine

Sodium hydrocarbonate

Oxeladin

Oseltamivir

Prenoxdiazine

Salbutamol

Spiramycin

Sulbactam

Fenoterol

Fenspiride

Fluticasone

Ciclesonide

Erdosteine

Information

Sources and literature

1. Minutes of meetings of the Expert Council of the RCHR of the Ministry of Health of the Republic of Kazakhstan, 2015
   1. 1) Wenzel R.P., Flower A.A. Acute bronchitis. //N. Engl. J. Med. - 2006; 355 (20): 2125-2130. 2) Braman S.S. Chronic cough due to bronchitis: ACCP evidence-based clinical practice guidelines. //Chest. – 2006; 129:95-103. 3) Irwin R.S. et al. Diagnosis and management of cough. ACCP evidence–based clinical practice guidelines. Executive summary. Chest 2006; 129:1S–23S. 4) Ross A.H. Diagnosis and treatment of acute bronchitis. //Am. Fam. Physician. - 2010; 82 (11): 1345-1350. 5) Worrall G. Acute bronchitis. //Can. Fam. Physician. - 2008; 54: 238-239. 6) Clinical Microbiology and Infection. Guidelines for the management of adult lower respiratory tract infections. ERS Task Force. // Infect.Dis. – 2011; 17 (6): 1-24, E1-E59. 7) Uteshev D.B. Management of patients with acute bronchitis in outpatient practice. //Russian medical journal. – 2010; 18(2): 60–64. 8) Smucny J., Flynn C., Becker L., Glazer R. Beta-2-agonists for acute bronchitis. //Cochrane Database Syst. Rev. – 2004; 1:CD001726. 9) Smith S.M., Fahey T., Smucny J., Becker L.A. Antibiotics for acute bronchitis. // Cochrane Database Syst. Rev. – 2010; 4: CD000245. 10) Sinopalnikov A.I. Community-acquired respiratory tract infections // Health of Ukraine – 2008. – No. 21. - With. 37–38. 11) Johnson AL, Hampson DF, Hampson NB. Sputum color: potential implications for clinical practice. RespiraCare. 2008. vol.53. – No. 4. – pp. 450–454. 12) Ladd E. The use of antibiotics for viral upper respiratory tract infections: an analysis of nurse practitioner and physician prescribing practices in ambulatory care, 1997–2001 // J Am Acad Nurse Pract. – 2005. – vol.17. – No. 10. – pp. 416–424. 13) Rutschmann OT, Domino ME. Antibiotics for upper respiratory tract infections in ambulatory practice in the United States, 1997–1999: does physician specialty matter? // J Am Board FamPract. – 2004. – vol.17. – No. 3. – pp.196–200.
   
   

   Attached files

   Attention!

   • By self-medicating, you can cause irreparable harm to your health.
   • The information posted on the MedElement website and in the mobile applications "MedElement", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Guide" cannot and should not replace a face-to-face consultation with a doctor. Be sure to contact a medical facility if you have any illnesses or symptoms that concern you.
   • The choice of medications and their dosage must be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and condition of the patient’s body.
   • The MedElement website and mobile applications "MedElement", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Directory" are exclusively information and reference resources. The information posted on this site should not be used to unauthorizedly change doctor's orders.
   • The editors of MedElement are not responsible for any personal injury or property damage resulting from the use of this site.