Restoring the drainage function of the bronchi

Restoring the drainage function of the bronchi contributes to the rapid resorption of the inflammatory infiltrate in the lungs. For this purpose, expectorants and mucolytics are prescribed. These remedies are used when the cough becomes “wet.” Potassium iodide solution (washed down with alkaline solutions, Borjomi, milk), marshmallow root, mucaltin, acetylcysteine, bromhexine (bisolvone) have a good effect. Particular importance is attached to bromhexine, which stimulates the production of surfactant, an important component of the local bronchopulmonary protection system. In order to thin sputum and cleanse the bronchi, proteolytic enzymes are also used.

In case of severe acute pneumonia, a sharp violation of the drainage function of the bronchi or abscess formation, sanitary bronchoscopy is performed with a 1% solution of dioxidine or a 1% solution of furagin. Such activities are performed in an intensive care unit or unit.

Normalization of bronchial muscle tone

Often, in patients with acute pneumonia, pronounced bronchospasm is observed, which disrupts the ventilation function of the lungs, promotes the development of hypoxemia, and delays the resorption of the inflammatory focus.

Bronchodilators are used to relieve bronchospasm. Eufimin is most often used intravenously, in suppositories, and sometimes orally. In recent years, extended-release theophylline preparations have been widely used.

To relieve an attack of suffocation, selective beta2-adrenergic receptor stimulants in the form of metered aerosols (Berotek, Ventolin, salbutamol, etc.) can also be used; some beta2-stimulants can also be used orally (alupent, etc.).

In a growing body age the changes mainly come down to the constant restructuring and growth of individual parts of the walls of the trachea and bronchi, and their differentiation does not occur simultaneously and generally ends by the age of 7 (N.P. Bisenkov, 1955).

In old age age processes of involution of the bronchial wall are revealed, consisting of atrophy, a decrease in the number of elastic and muscle fibers, and calcification of cartilage. Such changes lead to a deterioration in the drainage function of the bronchi.

Very characteristic sign in people over 50 years of age, there is a displacement of the distal trachea to the right by the sclerotic aortic arch, sometimes reaching a significant degree. A shift of the trachea to the right may be combined with some narrowing of its lumen, which makes it difficult to examine the bronchi of the left lung during bronchoscopy.

Physiology of the bronchi. The tracheo-bronchial tree has various functions. D. M. Zlydnikov (1959) considers the main functions of the bronchi to be ventilation, equatorial (drainage), secretory, speech, support, etc. There is no doubt that the ventilation and drainage functions of the bronchi play a major role, the first being the conduction of air to the alveoli.- is the direct purpose of the tracheo-bronchial system. The drainage function of the bronchi represents a protective adaptation of the body developed during the process of evolution, ensuring the normal functioning of the bronchopulmonary apparatus in various environmental conditions.

Tracheo-bronchial tree acts as an air duct between the external environment and the alveoli, in which gas exchange occurs. As air passes through the trachea and bronchi, it is warmed and moistened by the secretion of the bronchial glands. Naturally, every violation of bronchial obstruction leads to the development of ventilation failure. Diffuse obstruction of the patency of small bronchi, leading to the appearance of obstructive respiratory failure (see Chapter I), and subsequently pulmonary-heart failure, has a particularly difficult effect on the function of external respiration.

Evidence of active participation bronchi in pulmonary ventilation are the physiological respiratory movements of the bronchi, occurring both as a result of contraction of the bronchial muscles and as a result of the transmission of respiratory movements of the chest wall and lungs to the bronchial tree. The most characteristic respiratory movements of the bronchi include expansion and contraction, lengthening and shortening, angular and torsion movements.

When inhaling the bronchi are expanding, lengthen (the carina drops by 10-20 mm), the angles between them increase, and their external rotation occurs. When exhaling, the opposite changes are observed. The question of the possibility of peristaltic movements of the bronchi in humans cannot be considered completely resolved.

In addition to respiratory movements, transmission pulsation is noticeable in the bronchi, more noticeable in areas of the tracheo-bronchial tree that are in direct contact with the heart and great vessels.

Weakening or strengthening of respiratory and pulse mobility of the bronchi serves as an important sign of the pathological process in the bronchial tree, the surrounding lung tissue or neighboring organs. Thus, the physiological movements of the bronchi completely disappear or are sharply limited during cancer infiltration of the bronchial wall. Aneurysms of the aortic arch cause strong pulsation, especially noticeable in the left tracheobronchial angle.

Drainage function of the bronchi carried out due to the activity of the ciliated epithelium and the cough reflex. The cilia of the ciliated epithelium move continuously. Curving slowly like a swan's neck, they move back and then quickly straighten forward (Kassay). This continuous wave-like movement of the cilia, covered with a thin layer of mucus, ensures a constant current of the latter towards the larynx and pharynx. Dust particles inhaled with air settle and float on the surface of ciliary waves, and a layer of mucus carries dust particles through areas not covered by ciliated epithelium (vocal cords).

Arising due to inflammatory processes metaplasia cylindrical ciliated epithelium into stratified squamous epithelium leads to impaired drainage function, stagnation of bronchial secretions, which are easily infected, which may cause the development of secondary bronchiectasis.

Improving the drainage function of the bronchi is one of the most important conditions for the effective treatment of patients with pneumonia. Impaired bronchial obstruction in this disease is caused by several mechanisms:

A significant volume of viscous purulent exudate flowing from the alma into the bronchi;

Inflammatory swelling of the bronchial mucosa draining the focus of inflammation of the lung tissue;

Damage to the ciliated epithelium of the bronchial mucosa and disruption of the mucociliary transport mechanism;

An increase in the production of bronchial secretions due to the involvement of the bronchial mucosa in the inflammatory process (grenorrhea);

Significant increase in sputum viscosity (discrimination); . increased tone of the smooth muscles of the small bronchi and a tendency to bronchitis

Chospasm, which makes sputum separation even more difficult.

Thus, disturbances of bronchial obstruction in large pneumonias are associated only with the natural drainage of the inflammation focus and the entry of viscous alveolar exudate into the bronchi, but also with the frequent involvement of the bronchi themselves in the inflammatory process. This mechanism is of particular importance in patients with bronchopneumonia of various origins, as well as in patients with concomitant chronic bronchial diseases (chronic obstructive bronchitis, bronchectomy, cystic fibrosis, etc.).

The deterioration of bronchial obstruction, observed in at least some patients with pneumonia, contributes to an even greater disruption of local, including immunological, defense processes, re-contamination of the airways and prevents the healing of the inflammatory focus in the lung tissue and the restoration of pulmonary ventilation. A decrease in bronchial patency contributes to the aggravation of the vascular-perfusion relationship in the lungs and the progression of respiratory failure. Therefore, complex treatment of patients with pneumonia includes the mandatory prescription of drugs with expectorant, mucolytic and brocholytic effects.

It is known that the sputum present in the lumen of the bronchi in patients with pneumonia consists of two layers: the upper, more viscous and dense (gel), lying) with cilia, and the lower liquid layer (zola), in which the eyelashes seem to float and contract. The gel consists of macromolecules of glycoproteins linked to each other by disulfide and hydrogen bonds, which gives it viscous and elastic properties. As the water content in the gel decreases, the viscosity of the sputum increases and the movement of bronchial secretions along the passage* and to the oropharynx slows down or even stops. The speed of this movement becomes even slower if you thin out! a layer of liquid layer (sol), which to a certain extent prevents mucus from sticking to the walls of the bronchi. As a result, mucus and mucous plugs form in the lumen of the small bronchi, which are removed with great difficulty only by a strong expiratory air flow during attacks of painful hacking cough.

Thus, the ability to unhindered removal of sputum from the respiratory tract is, first of all, determined by its rheological properties, the water content in both phases of bronchial secretion (gel and sol), as well as the intensity and coordination of the activity of the cilia of the ciliated epithelium. The use of mucolytic and mucoregulatory agents is precisely aimed at restoring the sol-gel ratio, liquefying sputum, its rehydration, as well as stimulating the activity of the cilia of the ciliated epithelium.

1. Elimination of etiological factors of chronic bronchitis.
2. Inpatient treatment and bed rest for certain indications.
3. Medical nutrition.
4. Antibacterial therapy during exacerbation of purulent chronic bronchitis, including methods of endobronchial administration of drugs.
5. Improving the drainage function of the bronchi: expectorants, bronchodilators, positional drainage, chest massage, herbal medicine, heparin therapy, calcitrin treatment.
6. Detoxification therapy during exacerbation of purulent bronchitis.
7. Correction of respiratory failure: long-term low-flow oxygen therapy, hyperbaric oxygenation, extracorporeal membrane blood oxygenation, humidified oxygen inhalation.
8. Treatment of pulmonary hypertension in patients with chronic obstructive bronchitis.
9. Immunomodulatory therapy and improvement of the function of the local bronchopulmonary defense system.
10. Increased nonspecific resistance of the body.
11. Physiotherapy, exercise therapy, breathing exercises, massage.
12. Spa treatment.

Elimination of etiological factors

Elimination of etiological factors of chronic bronchitis largely slows down the progression of the disease, prevents exacerbation of the disease and the development of complications.

First of all, you must categorically stop smoking. Great importance is attached to the elimination of occupational hazards (various types of dust, fumes of acids, alkalis, etc.), thorough sanitation of foci of chronic infection (in ENT organs, etc.). It is very important to create an optimal microclimate in the workplace and at home.

In the case of a pronounced dependence of the onset of the disease and its subsequent exacerbations on unfavorable weather conditions, it is advisable to move to a region with a favorable dry and warm climate.

Patients with the development of local bronchiectasis are often indicated for surgical treatment. Elimination of the focus of purulent infection reduces the frequency of exacerbations of chronic bronchitis.

Inpatient treatment of chronic bronchitis and bed rest

Inpatient treatment and bed rest are indicated only for certain groups of patients in the presence of the following conditions:

• severe exacerbation of chronic bronchitis with increasing respiratory failure, despite active outpatient treatment;
• development of acute respiratory failure;
• acute pneumonia or spontaneous pneumothorax;
• manifestation or worsening of right ventricular failure;
• the need for certain diagnostic and therapeutic procedures (in particular, bronchoscopy);
• the need for surgical intervention;
• significant intoxication and marked deterioration in the general condition of patients with purulent bronchitis.

The rest of the patients with chronic bronchitis undergo outpatient treatment.

Therapeutic nutrition for chronic bronchitis

In chronic bronchitis with the release of large amounts of sputum, protein loss occurs, and in decompensated cor pulmonale, there is an increased loss of albumin from the vascular bed into the intestinal lumen. These patients are prescribed a protein-enriched diet, as well as intravenous drip transfusion of albumin and amino acid preparations (polyamine, neframin, alvesin).

For decompensated cor pulmonale, diet No. 10 is prescribed with limited energy value, salt and liquid and increased potassium content.

With severe hypercapnia, a carbohydrate load can cause acute respiratory acidosis due to increased formation of carbon dioxide and reduced sensitivity of the respiratory center. In this case, it is suggested to use a hypocaloric diet of 600 kcal with carbohydrate restriction (30 g carbohydrates, 35 g protein, 35 g fat) for 2-8 weeks. Positive results were observed in patients with excess and normal body weight. Subsequently, a diet of 800 kcal per day is prescribed. Dietary treatment for chronic hypercapnia appears to be quite effective.

Antibiotics for chronic bronchitis

Antibacterial therapy is carried out during the period of exacerbation of purulent chronic bronchitis for 7-10 days (sometimes with severe and prolonged exacerbation for 14 days). In addition, antibacterial therapy is prescribed for the development of acute pneumonia against the background of chronic bronchitis.

When choosing an antibacterial agent, the effectiveness of previous therapy is also taken into account. Criteria for the effectiveness of antibacterial therapy during an exacerbation:

• positive clinical dynamics;
• mucous nature of sputum;

reduction and disappearance of indicators of an active infectious-inflammatory process (normalization of ESR, leukocyte count, biochemical indicators of inflammation).

For chronic bronchitis, the following groups of antibacterial agents can be used: antibiotics, sulfonamides, nitrofurans, trichopolum (metronidazole), antiseptics (dioxidine), phytoncides.

Antibacterial drugs can be prescribed in the form of aerosols, orally, parenterally, endotracheally and endobronchially. The last two methods of using antibacterial drugs are the most effective, as they allow the antibacterial substance to penetrate directly into the site of inflammation.

Antibiotics are prescribed taking into account the sensitivity of the sputum flora to them (sputum must be examined using the Mulder method or sputum obtained during bronchoscopy should be examined for flora and sensitivity to antibiotics). Sputum microscopy with Gram stain is useful for prescribing antibacterial therapy before obtaining the results of bacteriological examination. Typically, an exacerbation of the infectious-inflammatory process in the bronchi is caused not by one infectious agent, but by an association of microbes, often resistant to most drugs. Often the pathogens include gram-negative flora and mycoplasma infection.

The correct choice of antibiotic for chronic bronchitis is determined by the following factors:

• microbial spectrum of infection;
• sensitivity of the infectious pathogen to infection;
• distribution and penetration of the antibiotic into sputum, the bronchial mucosa, bronchial glands, and lung parenchyma;
• cytokinetics, i.e. the ability of the drug to accumulate inside the cell (this is important for the treatment of infections caused by “intracellular infectious agents” - chlamydia, legionella).

Yu. B. Belousov et al. (1996) provide the following data on the etiology of acute and exacerbation of chronic bronchitis:

• Haemophilus influenzae 50%
• Streptococcus pneumoniae 14%
• Pseudomonas aeruginosas 14%
• Moraxella (Neiseria or Branhamella) catarrhalis 17%
• Staphylococcus aureus 2%
• Other 3%

According to Yu. Novikov (1995), the main pathogens during exacerbation of chronic bronchitis are:

• Streptococcus pneumoniae 30.7%
• Haemophilus influenzae 21%
• Str. haemolitjcus 11%
• Staphylococcus aureus 13.4%
• Pseudomonas aeruginosae 5%
• Mycoplasma 4.9%
• Unidentified pathogen 14%

Quite often, in chronic bronchitis, a mixed infection is detected: Moraxella catairhalis + Haemophilus influenzae.

According to Z. V. Bulatova (1980), the proportion of mixed infection in exacerbation of chronic bronchitis is as follows:

• microbes and mycoplasma - in 31% of cases;
• germs and viruses - in 21% of cases;
• microbes, imicoplasma viruses - in 11% of cases.

Infectious agents secrete toxins (for example, N. influenzae - peptidoglycans, lipooligosaccharides; Str. pneumoniae - pneumolysin; P. aeruginosae - pyocyanin, rhamnolipids), which damage the ciliated epithelium, slow down ciliary fluctuations and even cause death of the bronchial epithelium.

When prescribing antibacterial therapy after identifying the type of pathogen, the following circumstances are taken into account.

H. influenzae is resistant to beta-lacgam antibiotics (penicillin and ampicillin), which is due to the production of the TEM-1 enzyme, which destroys these antibiotics. Inactive against N. influenzae and erythromycin.

Recently, a significant spread of Str. strains has been reported. pneumoniae, resistant to penicillin and many other beta-lactam antibiotics, macrolides, and tetracycline.

M. catarrhal is a normal saprophytic flora, but quite often it can cause exacerbation of chronic bronchitis. A feature of Moraxella is its high ability of adhesion to oropharyngeal cells, and this is especially typical for people over the age of 65 with chronic obstructive bronchitis. Moraxella most often causes exacerbation of chronic bronchitis in areas with high air pollution (centers of the metallurgical and coal industries). Approximately 80% of Moraxella strains produce beta-lactamases. Combined preparations of ampicillin and amoxicillin with clavulanic acid and sulbactam are not always active against beta-lactamase-producing strains of moraxella. This pathogen is sensitive to Septrim, Bactrim, Biseptol, and is also highly sensitive to 4-fluoroquinolones and erythromycin (however, 15% of Moraxella strains are not sensitive to it).

For a mixed infection (Moraxella + Haemophilus influenzae) that produces β-lactamases, ampicillin, amoxicillin, and cephalosporins (ceftriaxone, cefuroxime, cefaclor) may not be effective.

When choosing an antibiotic in patients with exacerbation of chronic bronchitis, you can use the recommendations of P. Wilson (1992). He proposes to distinguish the following groups of patients and, accordingly, groups of antibiotics.

• Group 1 - Previously healthy individuals with post-viral bronchitis. These patients, as a rule, have viscous purulent sputum; antibiotics do not penetrate well into the bronchial mucosa. This group of patients should be recommended to drink plenty of fluids, expectorants, and herbal mixtures that have bactericidal properties. However, if there is no effect, antibiotics amoxicillin, ampicillin, erythromycin and other macrolides, tetracyclines (doxycycline) are used.
• Group 2 - Patients with chronic bronchitis, smokers. These include the same recommendations as for people in group 1.
• Group 3 - Patients with chronic bronchitis with concomitant severe somatic diseases and a high probability of having resistant forms of pathogens (Moraxella, Haemophilus influenzae). This group is recommended beta-lactamase-resistant cephalosporins (cefaclor, cefixime), fluoroquinolones (ciprofloxacin, ofloxacin, etc.), amoxicillin with clavulanic acid.
• Group 4 - Patients with chronic bronchitis with bronchiectasis or chronic pneumonia, producing purulent sputum. The same drugs are used that were recommended for patients in group 3, as well as ampicillin in combination with sulbactam. In addition, active drainage therapy and physiotherapy are recommended. In bronchiectasis, the most common pathogen found in the bronchi is Haemophylus influenzae.

In many patients with chronic bronchitis, exacerbation of the disease is caused by chlamydia, legionella, and mycoplasma.

In these cases, macrolides are highly active and, to a lesser extent, doxycycline. The highly effective macrolides ozithromycin (sumamed) and roxithromycin (rulid), rovamycin (spiramycin) deserve special attention. After oral administration, these drugs penetrate well into the bronchial system, remain in tissues for a long time in sufficient concentration, and accumulate in polymorphonuclear neutrophils and alveolar macrophages. Phagocytes deliver these drugs to the site of the infectious and inflammatory process. Roxithromycin (rulid) is prescribed 150 mg 2 times a day, azithromycin (sumamed) - 250 mg 1 time a day, rovamycin (spiramycin) - 3 million IU 3 times a day orally. The duration of the course of treatment is 5-7 days.

When prescribing antibiotics, individual tolerance to the drugs should be taken into account, this especially applies to penicillin (it should not be prescribed for severe bronchospastic syndrome).

Antibiotics in aerosols are currently rarely used (an antibiotic aerosol can provoke bronchospasm, and in addition, the effect of this method is not great). Antibiotics are most often used orally and parenterally.

When identifying gram-positive coccal flora, the most effective is the administration of semi-synthetic penicillins, mainly combined (ampiox 0.5 g 4 times a day intramuscularly or orally), or cephalosporins (kefzol, cephalexin, claforan 1 g 2 times a day intramuscularly), with gram-negative coccal flora - aminoglycosides (gentamicin 0.08 g 2 times a day intramuscularly or amikacin 0.2 g 2 times a day intramuscularly), carbenicillin (1 g intramuscularly 4 times a day) or the latest generation cephalosporins (fortum 1 g 3 times a day intramuscularly).

In some cases, broad-spectrum macrolide antibiotics can be effective (erythromycin 0.5 g 4 times a day orally, oleandomycin 0.5 g 4 times a day orally or intramuscularly, erycycline - a combination of erythromycin and tetracycline - in capsules 0.25 g, 2 capsules 4 times a day orally), tetracyclines, especially long-acting ones (methacycline or rondomycin 0.3 g 2 times a day orally, doxycycline or vibramycin capsules 0.1 g 2 times a day orally).

Thus, according to modern concepts, first-line drugs for the treatment of exacerbation of chronic bronchitis are ampicillin (amoxicillin), including in combination with beta-lactamase inhibitors (clavulanic acid augmentin, amoxiclav or sulbactam unasin, sulacillin), oral cephalosporins of the second or third generation , fluoroquinolone drugs. If you suspect the role of mycoplasmas, chlamydia, legionella in exacerbation of chronic bronchitis, it is advisable to use macrolide antibiotics (especially azithromycin - sumamed, roxithromycin - rulide) or tetracyclines (doxycycline, etc.). The combined use of macrolides and tetracyclines is also possible.

Sulfonamide drugs for chronic bronchitis

Sulfonamide drugs are widely used for exacerbation of chronic bronchitis. They have chemotherapeutic activity against gram-positive and non-negative flora. Long-acting medications are usually prescribed.

Biseptol in tablets of 0.48 g. Prescribed orally, 2 tablets 2 times a day.

Sulfatone in tablets of 0.35 g. On the first day, 2 tablets are prescribed in the morning and evening, on subsequent days, 1 tablet in the morning and evening.

Sulfamonomethoxine in tablets of 0.5 g. On the first day, 1 g is prescribed in the morning and evening, on subsequent days 0.5 g in the morning and evening.

Sulfadimethoxine is prescribed in the same way as sulfamonomethoxine.

Recently, the negative effect of sulfonamides on the function of the ciliated epithelium has been established.

Nitrofuran drugs

Nitrofuran drugs have a wide spectrum of action. Preferably furazolidone is prescribed 0.15 g 4 times a day after meals. Metronidazole (Trichopolum), a broad-spectrum drug, can also be used in tablets of 0.25 g 4 times a day.

Antiseptics

Among broad-spectrum antiseptics, dioxidin and furatsilin deserve the greatest attention.

Dioxidin (0.5% solution of 10 and 20 ml for intravenous administration, 1% solution in ampoules of 10 ml for abdominal and endobronchial administration) is a drug with broad antibacterial action. Slowly inject intravenously 10 ml of a 0.5% solution in 10-20 ml of isotonic sodium chloride solution. Dioxidin is also widely used in the form of aerosol inhalations - 10 ml of a 1% solution per inhalation.

Phytoncidal preparations

Phytoncides include chlorophyllipt, a preparation made from eucalyptus leaves that has a pronounced antistaphylococcal effect. A 1% alcohol solution is used internally, 25 drops 3 times a day. You can administer intravenously slowly 2 ml of a 0.25% solution in 38 ml of sterile isotonic sodium chloride solution.

Garlic (in inhalation) or for oral administration also belongs to phytoncides.

Endobronchial sanitation

Endobronchial sanitation is performed by endotracheal infusions and fibrobronchoscopy. Endotracheal infusions using a laryngeal syringe or rubber catheter are the simplest method of endobronchial sanitation. The number of infusions is determined by the effectiveness of the procedure, the amount of sputum and the severity of its suppuration. Usually, 30-50 ml of isotonic sodium chloride solution heated to 37 °C is first poured into the trachea. After coughing up sputum, antiseptics are administered:

• furatsilin solution 1:5000 - in small portions of 3-5 ml during inhalation (total 50-150 ml);
• dioxidine solution - 0.5% solution;
• Kalanchoe juice diluted 1:2;
• in the presence of bronchoecgases, 3-5 ml of antibiotic solution can be administered.

Fibrobronchoscopy under local anesthesia is also effective. To sanitize the bronchial tree, the following are used: furatsilin solution 1:5000; 0.1% furagin solution; 1% solution of rivanol; 1% solution of chlorophyllipt in a 1:1 dilution; dimexide solution.

Aerosoltherapy

Aerosol therapy with phytoncides and antiseptics can be performed using ultrasonic inhalers. They create homogeneous aerosols with optimal particle sizes that penetrate to the peripheral parts of the bronchial tree. The use of drugs in the form of aerosols ensures their high local concentration and uniform distribution of the drug in the bronchial tree. Using aerosols, you can inhale the antiseptics furatsilin, rivanol, chlorophyllipt, onion or garlic juice (diluted with 0.25% novocaine solution in a ratio of 1:30), fir infusion, lingonberry leaf condensate, dioxidin. After aerosol therapy, postural drainage and vibration massage are performed.

In recent years, the aerosol drug bioparoxocobtal has been recommended for the treatment of chronic bronchitis. It contains one active component, fusanfungin, a drug of fungal origin that has antibacterial and anti-inflammatory effects. Fusanfungin is active against predominantly gram-positive cocci (staphylococci, streptococci, pneumococci), as well as intracellular microorganisms (mycoplasma, legionella). In addition, it has antifungal activity. According to White (1983), the anti-inflammatory effect of fusanfungin is associated with the suppression of the production of oxygen radicals by macrophages. Bioparox is used in the form of dosed inhalations - 4 breaths every 4 hours for 8-10 days.

Improving the drainage function of the bronchi

Restoring or improving the drainage function of the bronchi is of great importance, as it contributes to the onset of clinical remission. In patients with chronic bronchitis, the number of mucus-forming cells and sputum in the bronchi increases, its character changes, it becomes more viscous and thick. A large amount of sputum and an increase in its viscosity disrupts the drainage function of the bronchi, ventilation-perfusion relationships, and reduces the activity of the local bronchopulmonary defense system, including local immunological processes.

To improve the drainage function of the bronchi, expectorants, postural drainage, bronchodilators (in the presence of bronchospastic syndrome), and massage are used.

Expectorants, herbal medicine

According to the definition of B.E. Votchal, expectorants are substances that change the properties of sputum and facilitate its discharge.

There is no generally accepted classification of expectorants. It is advisable to classify them according to their mechanism of action (V. G. Kukes, 1991).

Classification of expectorants

1. Remedies for expectoration:
   • drugs that act reflexively;
   • resorptive drugs.
2. Mucolytic (or secretolytic) drugs:
   • proteolytic drugs;
   • derivatives of amino acids with an SH group;
   • mucoregulators.
3. Mucus secretion rehydrators.

Sputum consists of bronchial secretions and saliva. Normally, bronchial mucus has the following composition:

• water with sodium, chlorine, phosphorus, calcium ions dissolved in it (89-95%); The consistency of sputum depends on the water content; the liquid part of sputum is necessary for the normal functioning of mucociliary transport;
• insoluble macromolecular compounds (high and low molecular weight, neutral and acidic glycoproteins - mucins), which determine the viscous nature of the secretion - 2-3%;
• complex plasma proteins - albumins, plasma glycoproteins, immunoglobulins of classes A, G, E;
• antiproteolytic enzymes - 1-antichymotrilsin, 1-a-antitrypsin;
• lipids (0.3-0.5%) - surfactant phospholipids from alveoli and bronchioles, glycerides, cholesterol, free fatty acids.

Bronchodilators for chronic bronchitis

Bronchodilators are used for chronic obstructive bronchitis.

Chronic obstructive bronchitis is a chronic diffuse non-allergic inflammation of the bronchi, leading to a progressive impairment of pulmonary ventilation and gas exchange of the obstructive type and manifested by cough, shortness of breath and sputum production, not associated with damage to other organs and systems (Consensus on chronic obstructive bronchitis of the Russian Congress of Pulmonologists, 1995) . As chronic obstructive bronchitis progresses, pulmonary emphysema forms, among the reasons for this are exhaustion and impaired production of protease inhibitors.

The main mechanisms of bronchial obstruction:

• bronchospasm;
• inflammatory edema, infiltration of the bronchial wall during exacerbation of the disease;
• hypertrophy of the bronchial muscles;
• hypercrinia (increase in the amount of sputum) and discrinia (change in the rheological properties of sputum, it becomes viscous, thick);
• collapse of small bronchi during exhalation due to a decrease in the elastic properties of the lungs;
• fibrosis of the bronchial wall, obliteration of their lumen.

Bronchodilators improve bronchial patency by eliminating bronchospasm. In addition, methylxanthines and beta2-agonists stimulate the function of the ciliated epithelium and increase sputum production.

Bronchodilators are prescribed taking into account the daily rhythms of bronchial patency. Sympathomimetic agents (beta-adrenergic receptor stimulants), anticholinergic drugs, purine derivatives (phosphodiesterase inhibitors) - methylxanthines - are used as bronchodilators.

Sympathomimetic drugs stimulate beta-adrenergic receptors, which leads to an increase in adenyl cyclase activity, the accumulation of cAMP and then a bronchodilator effect. Use ephedrine (stimulates beta-adrenergic receptors, which provides bronchodilation, as well as alpha-adrenergic receptors, which reduces swelling of the bronchial mucosa) 0.025 g 2-3 times a day, the combination drug theophedrine 1/2 tablet 2-3 times a day, broncholithin (combined preparation, 125 g of which contains glaucine 0.125 g, ephedrine 0.1 g, sage oil and citric acid 0.125 g each) 1 tablespoon 4 times a day. Broncholithin causes a bronchodilator, antitussive and expectorant effect.

It is especially important to prescribe ephedrine, theophedrine, and broncholithin in the early morning hours, since this is the time when bronchial obstruction peaks.

When treated with these drugs, side effects associated with stimulation of both beta1 (tachycardia, extrasystole) and alpha-adrenergic receptors (arterial hypertension) are possible.

In this regard, the greatest attention is paid to selective beta2-adrenergic stimulants (selectively stimulate beta2-adrenergic receptors and have virtually no effect on beta1-adrenergic receptors). Typically used are Solbutamol, Terbutaline, Ventolin, Berotec, and also partially the beta2-selective stimulant Asthmopent. These drugs are used in the form of metered aerosols, 1-2 puffs 4 times a day.

With long-term use of beta-adrenergic receptor stimulants, tachyphylaxis develops - a decrease in the sensitivity of the bronchi to them and a decrease in the effect, which is explained by a decrease in the number of beta2-adrenergic receptors on the membranes of the smooth muscles of the bronchi.

In recent years, long-acting beta2-adrenergic stimulants have begun to be used (duration of action is about 12 hours) - salmeterol, formaterol in the form of metered aerosols 1-2 puffs 2 times a day, spiropent 0.02 mg 2 times a day orally. These drugs are less likely to cause tachyphylaxis.

Purine derivatives (methylxanthines) inhibit phosphodiesterase (this promotes the accumulation of cAMP) and bronchial adenosine receptors, which causes bronchodilation.

In case of severe bronchial obstruction, euphylline is prescribed 10 ml of a 2.4% solution in 10 ml of isotonic sodium chloride solution intravenously very slowly, intravenously by drip to prolong its action - 10 ml of 2.4% solution of euphylline in 300 ml of isotonic sodium chloride solution.

For chronic bronchial obstruction, you can use aminophylline preparations in tablets of 0.15 g 3-4 times a day orally after meals or in the form of alcohol solutions, which are better absorbed (eufillin - 5 g, ethyl alcohol 70% - 60 g, distilled water - up to 300 ml, take 1-2 tablespoons 3-4 times a day).

Of particular interest are extended-release theophylline preparations, which act for 12 hours (taken 2 times a day) or 24 hours (taken once a day). Theodur, teolong, teobilong, theotard are prescribed 0.3 g 2 times a day. Uniphylline ensures a uniform level of theophylline in the blood throughout the day and is prescribed 0.4 g 1 time per day.

In addition to the bronchodilator effect, extended-release theophyllines for bronchial obstruction also cause the following effects:

• reduce pressure in the pulmonary artery;
• stimulate mucociliary clearance;
• improve the contractility of the diaphragm and other respiratory muscles;
• stimulate the release of glucocorticoids by the adrenal glands;
• have a diuretic effect.

The average daily dose of theophylline for non-smokers is 800 mg, for smokers - 1100 mg. If the patient has not previously taken theophylline preparations, then treatment should be started with smaller doses, gradually (after 2-3 days) increasing them.

Anticholinergic drugs

Peripheral M-anticholinergics are used; they block acetylcholine receptors and thereby promote bronchodilation. Preference is given to inhaled forms of anticholinergics.

Arguments in favor of wider use of anticholinergics in chronic obstructive bronchitis are the following circumstances:

• anticholinergics cause bronchodilation to the same extent as beta2-adrenergic receptor stimulants, and sometimes even more pronounced;
• the effectiveness of anticholinergics does not decrease even with prolonged use;
• with increasing age of the patient, as well as with the development of pulmonary emphysema, the number of beta2-adrenergic receptors in the bronchi progressively decreases and, consequently, the effectiveness of beta2-adrenergic receptor stimulants decreases, and the sensitivity of the bronchi to the bronchodilatory effect of anticholinergics remains.

Ipratropium bromide (Atrovent) is used - in the form of a dosed aerosol 1-2 breaths 3 times a day, oxytropium bromide (oxyvent, ventilate) - a long-acting anticholinergic, prescribed in a dose of 1-2 breaths 2 times a day (usually in the morning and before bedtime) , if there is no effect - 3 times a day. The drugs are practically free of side effects. They exhibit a bronchodilator effect after 30-90 minutes and are not intended to relieve an attack of suffocation.

Anticholinergics can be prescribed (in the absence of a bronchodilator effect) in combination with beta2-agonists. The combination of Atrovent with the beta2-adrenergic stimulant fenoterol (Berotec) is produced in the form of a dosed aerosol of Berodual, which is used in 1-2 doses (1-2 puffs) 3-4 times a day. The simultaneous use of anticholinergics and beta2-agonists enhances the effectiveness of bronchodilator therapy.

In case of chronic obstructive bronchitis, it is necessary to individually select basic therapy with bronchodilator drugs in accordance with the following principles:

• achieving maximum bronchodilation throughout the entire day, basic therapy is selected taking into account the circadian rhythms of bronchial obstruction;
• when selecting basic therapy, they are guided by both subjective and objective criteria for the effectiveness of bronchodilators: forced expiratory volume in 1 s or peak expiratory flow in l/min (measured using an individual peak flow meter);

With moderately severe bronchial obstruction, bronchial obstruction can be improved with the combination drug theophedrine (which, along with other components, includes theophylline, belladonna, ephedrine) 1/2, 1 tablet 3 times a day or by taking powders of the following composition: ephedrine 0.025 g, platifimine 0.003 g, aminophylline 0.15 g, papaverine 0.04 g (1 powder 3-4 times a day).

The first-line drugs are ipratrotum bromide (Atrovent) or oxytropium bromide; if there is no effect from treatment with inhaled anticholinergics, beta2-adrenergic receptor stimulants (fenoterol, salbutamol, etc.) are added or the combination drug berodual is used. In the future, if there is no effect, it is recommended to sequentially add prolonged theophyllines to the previous steps, then inhaled forms of glucocorticoids (inhacort (flunisolide hemihydrate) is the most effective and safe), in its absence, becotide is used, and, finally, if the previous stages of treatment are ineffective, short courses of oral glucocorticoids are used. O. V. Alexandrov and Z. V. Vorobyova (1996) consider the following scheme effective: prednisolone is prescribed with a gradual increase in dose to 10-15 mg over 3 days, then the achieved dose is used for 5 days, then it is gradually reduced over 3-5 days Before the stage of prescribing glucocorticoids, it is advisable to add anti-inflammatory drugs (Intal, Tailed) to bronchodilators, which reduce swelling of the bronchial wall and bronchial obstruction.

The administration of glucocorticoids orally is, of course, undesirable, but in cases of severe bronchial obstruction in the absence of effect from the above bronchodilator therapy, it may be necessary to use them.

In these cases, it is preferable to use short-acting drugs, i.e. prednisolone, urbazone, try to use small daily doses (3-4 tablets per day) for a short time (7-10 days), with a subsequent transition to maintenance doses, which are advisable to prescribe in the morning in an intermittent manner (double the maintenance dose every other day). Part of the maintenance dose can be replaced by inhalation of Becotide, Ingacort.

It is advisable to carry out differentiated treatment of chronic obstructive bronchitis depending on the degree of dysfunction of external respiration.

There are three degrees of severity of chronic obstructive bronchitis depending on the forced expiratory volume in the first second (FEV1):

• mild - FEV1 is equal to or less than 70%;
• average - FEV1 within 50-69%;
• severe - FEV1 less than 50%.

Positional drainage

Positional (postural) drainage is the use of a certain body position for better discharge of sputum. Positional drainage is performed in patients with chronic bronchitis (especially purulent forms) when the cough reflex is reduced or the sputum is too viscous. It is also recommended after endotracheal infusions or administration of expectorants in aerosol form.

It is performed 2 times a day (morning and evening, but it can be done more often) after preliminary intake of bronchodilators and expectorants (usually infusion of thermopsis, coltsfoot, wild rosemary, plantain), as well as hot linden tea. 20-30 minutes after this, the patient alternately takes positions that promote maximum emptying of sputum from certain segments of the lungs under the influence of gravity and “draining” to the cough reflexogenic zones. In each position, the patient first performs 4-5 deep, slow breathing movements, inhaling air through the nose and exhaling through pursed lips; then, after a slow deep breath, makes 3-4 shallow coughs 4-5 times. A good result is achieved by combining drainage positions with various methods of vibration of the chest over the drained segments or compression with the hands while exhaling, massage done quite vigorously.

Postural drainage is contraindicated in cases of hemoptysis, pneumothorax, and significant shortness of breath or bronchospasm during the procedure.

Massage for chronic bronchitis

Massage is included in the complex therapy of chronic bronchitis. It promotes the removal of sputum and has a bronchial relaxant effect. Classic, segmental, acupressure massage is used. The latter type of massage can cause a significant bronchial relaxation effect.

Heparin therapy

Heparin prevents degranulation of mast cells, increases the activity of alveolar macrophages, has an anti-inflammatory effect, antitoxic and diuretic effect, reduces pulmonary hypertension, and promotes sputum discharge.

The main indications for heparin in chronic bronchitis are:

• the presence of reversible bronchial obstruction;
• pulmonary hypertension;
• respiratory failure;
• active inflammatory process in the bronchi;
• ICE syndrome;
• significant increase in sputum viscosity.

Heparin is prescribed 5000-10,000 units 3-4 times a day under the skin of the abdomen. The drug is contraindicated in hemorrhagic syndrome, hemoptysis, peptic ulcer.

The duration of heparin treatment is usually 3-4 weeks, followed by gradual withdrawal by reducing the single dose.

Use of calcitonin

In 1987, V.V. Namestnikova proposed treatment of chronic bronchitis with colcitrin (calcitrin is an injectable dosage form of calcitonin). It has an anti-inflammatory effect, inhibits the release of mediators from mast cells, and improves bronchial patency. It is used for obstructive chronic bronchitis in the form of aerosol inhalation (1-2 units in 1-2 ml of water per 1 inhalation). The course of treatment is 8-10 inhalations.

Detoxification therapy

For detoxification purposes, during the period of exacerbation of purulent bronchitis, intravenous drip infusion of 400 ml of hemodez (contraindicated in cases of severe allergization, bronchospastic syndrome), isotonic sodium chloride solution, Ringer's solution, 5% glucose solution is used. In addition, it is recommended to drink plenty of fluids (cranberry juice, rosehip infusion, linden tea, fruit juices).

Correction of respiratory failure

The progression of chronic obstructive bronchitis and pulmonary emphysema leads to the development of chronic respiratory failure, which is the main cause of deterioration in the quality of life and disability of the patient.

Chronic respiratory failure is a condition of the body in which, due to damage to the external respiratory system, either the maintenance of normal blood gas composition is not ensured, or it is achieved primarily by turning on the compensatory mechanisms of the external respiratory system itself, the cardiovascular system, the blood transport system and metabolic processes in tissues.

TACTICS FOR RESTORING THE PROTECTIVE AND CLEANING FUNCTIONS OF THE RESPIRATORY SYSTEM

At the very beginning of this part, we identified four main strategic tasks that need to be solved in the process of cleansing the lungs in order to restore them to Lost physiological purity and health. Now it’s the turn to decide how and by what means the tasks will be solved.

So, let's start in order.

1. Restoration of protective barriers of the upper respiratory tract

To restore the protective mechanisms of the upper respiratory tract, it is advisable to use aqueous extracts from medicinal plant raw materials (medicinal plant raw materials) that enhance the formation and release of protective secretions, containing essential oils and phytoncides: infusion of birch, poplar, wild rosemary herbs, heather, oregano, mint, lemon balm, thyme, leaves of eucalyptus, sage, etc.; decoctions of calamus rhizomes, rhizomes with elecampane roots, coriander fruits, thyme, fennel, onion and garlic juices, you can also use honey and propolis.

To enhance the secretion of the resulting secretion, you can use the juices of Kalanchoe, aloe and beets. They are diluted 10-20 times in boiled water and instilled with one drop into each nostril. They have a mild irritant effect and increase sneezing, promoting secretion.

2. Restoration of the drainage function of the bronchi

The drainage function of the bronchi is restored:
a) expectorant plants that provide sputum discharge - calamus, marshmallow, anise, speedwell, elecampane, oregano, mullein, coltsfoot, lungwort, primrose, cyanosis, licorice, thermopsis, thyme, violet, etc.;
b) mucolytics, i.e., those with the ability to dissolve mucus - marshmallow, wild rosemary, valerian, speedwell, sweet clover, hyssop, istod, flax, Icelandic moss, pine buds, etc.

3. Fighting infection

The success of antimicrobial therapy is determined by the correct choice of agents to which the causative agent of the infectious disease is sensitive. Wherein:
a) it is necessary to combine, i.e. joint, the use of medicinal plants with antimicrobial and antiviral properties;
b) combining plants with various active ingredients, which not only allows to achieve a bactericidal effect, but also prevents the emergence of strains resistant (immune to herbal medicine);
c) for oral administration, it is advisable to use preparations and rinses, constantly alternating different groups of antimicrobial active ingredients, which have been identified in calamus, geraniums, oregano, cinquefoil erect, onions, raspberries (leaves), lemon balm, sage, garlic, eucalyptus.

4. Correction of anti-infective immunity

It is preferable to implement this direction using the following groups of medicinal plants:
a) interferon stimulants: coltsfoot, plantain, Icelandic cetraria;
b) activators of alveolar phagocytic activity: arnica montana, astragalus, borage, capillary, stinging nettle;
c) stimulants of local immunity: anise, arnica, watch, knotweed, birch, sage, etc.

It should be noted that throughout the entire path to restoring the normal functioning of the respiratory system, constant and targeted use of anti-inflammatory and antihypoxic agents of plant origin is necessary: ​​linden leaves, calendula and chamomile flowers, string grass, horsetail, sage, etc.

From the first day of cleansing, it is also necessary to use highly effective vitamin complexes, since they contain enzymes and microelements that significantly increase the bioavailability of vitamins. At the same time, medicinal plants rich in vitamins, which include lingonberries, cranberries, strawberries, blackberries, red rowan, sea buckthorn, dandelion leaves, nettles, primroses, should be included in the main collection or taken additionally in the form of tea.
Considering that effective cleansing is impossible without increased water load, it is necessary to increase the volume of drinking to 2.5-3 liters per day, unless, of course, there are contraindications from the cardiovascular and urinary systems.

And in conclusion of this chapter, I would like to remind you once again that many diseases are much easier to prevent than to cure, therefore it is advisable to gradually increase the resistance of the respiratory system to colds and infections through general hardening of the body and, if you have enough willpower and common sense, to refuse or at least stop abuse alcohol and tobacco. Both habits are closely related to breathing. Indeed, in addition to the general harmful effect on the body, causing profound dysfunction of the nervous system and many other organs, alcohol has a detrimental effect directly on the tissue of the lungs and mucous membranes of the respiratory tract, because through them it and its oxidation products, aldehydes and ketones, are eliminated from the body. This, by the way, explains the characteristic disgusting smell from the mouth after drinking alcoholic beverages.

As for smoking, its harmful effect on the respiratory organs is perhaps even worse than alcohol, since, among other things, tobacco smoke inhibits the production of surfactant and thereby increases the surface tension of the alveoli. Because of this, a smoker has to make greater efforts to inhale compared to non-smokers.

But we have already talked about the dangers of smoking. Now it’s time to talk about the main thing.