Broncho-obstructive syndrome (BOS) is not a separate disease, but a whole complex of symptoms that can be the result of a wide variety of pathological conditions. As a rule, broncho-obstructive syndrome is clinical manifestation acute respiratory failure, proceeding according to the ventilation type.

A wide variety of conditions, including bronchial asthma, can provoke such a disorder. In the vast majority of cases, the pathogenesis of the development of this acute pathological condition includes spasm of small bronchial elements, excessive production of sputum, as well as swelling of the bronchial mucosa. Broncho-obstructive syndrome is most pronounced in children, but in adults, including the elderly, a severe course of this pathological condition can also occur.

Etiology and mechanism of development of broncho-obstructive syndrome

The reasons for the development of broncho-obstructive syndrome are rooted in inflammatory processes of the mucous membrane. In fact, quite a few factors can provoke the development of bronchial obstruction and the appearance of symptomatic manifestations characteristic of this condition. The most common causes of the development of such a condition as broncho-obstructive syndrome include;

These are not all the reasons for the development of bronchial obstruction. According to the severity, there are mild, moderate, severe and obstructive variants of the course of broncho-obstructive syndrome. In the presence of pulmonary obstruction, the disease has the most severe course, and it is not always possible to achieve a significant improvement in the patient’s condition. If there is severe bronchial obstruction and no improvement is achieved, even a lung transplant may be required. The course of bronchial obstruction syndrome may vary depending on the duration of the course. Currently, the duration of the syndrome differs between acute, protracted, recurrent and continuously relapsing variants of the syndrome.

The pathogenesis of the development of bronchial obstruction syndrome in children begins, as a rule, with the adverse influence of various factors, as a result of which it develops inflammatory process combined with minor allergic reaction. This causes a gradual disruption of the functioning of the bronchi, which causes the appearance of various symptoms inherent in this pathological condition.

Symptoms of broncho-obstructive syndrome

Broncho-obstructive syndrome has enough characteristic symptoms, which allow you to quickly determine the essence of the problem respiratory tract. Bronchial obstruction is detected fairly quickly as it has the following signs of development:

• wheezing;
• cyanosis of the skin and mucous membranes;
• dyspnea;
• unproductive cough;
• change in the shape of the chest;
• weight loss;
• use of accessory muscles during breathing.

Obstructive syndrome is a rather dangerous condition because it can cause a number of complications if left untreated. Most dangerous complication is heart rhythm disturbances, as well as acute heart failure. Obstructive syndrome can cause the development of pneumothorax, pulmonary emphysema, and the formation of cor pulmonale, which can subsequently lead to asphyxia.

Diagnosis and treatment of broncho-obstructive syndrome

Diagnosis of broncho-obstructive syndrome is currently not very difficult. First, the pulmonologist conducts a thorough analysis of the patient’s complaints and auscultation of the lungs. To confirm the diagnosis you need:

• herpes test;
• allergy tests;
• radiography;
• sputum tests;
• analysis for helminths.

Treatment of broncho-obstructive syndrome should be primarily aimed at eliminating the primary disease that provoked the appearance of such lung problems. At the same time, it should be taken into account that to eliminate the existing symptomatic manifestations of the respiratory system, targeted bronchodilator and anti-inflammatory therapy is required. For improvement drainage function bronchi, procedures such as:

• rehydration;
• drainage;
• massage;
• therapeutic breathing exercises.

Mucolytic therapy, which should include inhalation and oral administration of certain medications, may be required to thin and remove sticky mucus.

Some can also be used as inhalation folk remedies, for example, boiled potatoes or chamomile infusion.

To improve bronchial function in case of bronchial obstruction, the use of bronchodilators with a short term of action may be indicated. If bacterial microflora was determined during sputum analysis, antibiotics belonging to the following groups may be indicated:

• respiratory fluorophylones;
• macrolides;
• beta-lactams.

In severe cases, glucocorticosteroid drugs and immunostimulants may be prescribed. To relieve spasms, theophylline preparations are usually used. Among other things, oxygen therapy and intravenous infusion of saline may often be required to eliminate severe symptomatic manifestations of bronchial obstruction. Correct therapy usually gives good effect, bronchial obstruction recedes.

Broncho-obstructive syndrome (BOS) - often encountered in medical practice, is severe with the development of respiratory failure. The syndrome occurs in people who often suffer from respiratory ailments, cardiovascular pathologies, poisoning, diseases of the central nervous system - in general, with more than 100 diseases.

It is especially difficult in young children. Why this syndrome develops, how to recognize it and start treatment on time - we will consider further in the article.

Brief characteristics and classification of biofeedback

Broncho-obstructive syndrome (BOS) is not an independent medical diagnosis or disease, biofeedback is a manifestation of individual nosological forms. For example, in children under three years of age, half of the cases of bronchial obstruction syndrome are caused by asthma.

Also in children, cases of biofeedback may occur due to congenital anomalies nasopharynx, swallowing disorders, gastroesophageal reflux and others.

Did you know? Anatomically, the bronchi resemble an inverted tree, which is why they got their name - the bronchial tree. At its base, the width of the lumen is up to 2.5 cm, and the lumen of the smallest bronchioles is 1 mm. The bronchial tree branches into several thousand small bronchioles, which are responsible for gas exchange between the lungs and blood.

Bronchoobstruction is a clinical manifestation of bronchial obstruction with further resistance to air flow. When obstruction occurs, a generalized narrowing of the bronchial lumen of the small and large bronchi occurs, which causes their vibration and whistling “sounds”.

The syndrome develops especially often in children under 3 years of age who have a family history, are prone to allergic reactions and often suffer respiratory diseases. The basis for the occurrence of biofeedback is the following mechanism: inflammation occurs of various etiologies, which entails spasm and further narrowing of the lumen (occlusion). As a result, compression of the bronchi occurs.

Bronchial obstruction syndrome is classified according to its form, duration and severity of the syndrome.

Depending on the form of BFB, it can be:

1. Infectious (viral and bacterial).
2. Hemodynamic (occurs with cardiac pathologies)
3. Obstructive.
4. Allergic.

Depending on the duration of the course, there are:

1. Acute BOS. Accompanied by a pronounced clinical picture, symptoms appear for more than 7 days.
2. Protracted. Clinical manifestations are less pronounced and the course is long-lasting.
3. Recurrent. Acute periods are abruptly replaced by periods of remission.
4. Constantly recurrent. Periods of incomplete remission are followed by exacerbations of the syndrome.

Bronchial obstruction syndrome can occur in mild, moderate and severe forms, which differ in the number of clinical manifestations and indicators of analysis of the composition of gases in the blood. By the way, in practice, syndromes of an allergic and infectious nature are most often encountered.

Reasons for development

Among the diseases that may be accompanied by the occurrence of BOS are:

Functional changes are amenable to conservative treatment, while the elimination of organic changes is carried out only in some cases by surgical intervention and due to the child’s adaptive capabilities.

Functional changes include bronchospasm, large selection sputum during bronchitis, swelling of the bronchial mucosa, inflammation and aspiration. Organic changes include congenital malformations of the bronchi and lungs, stenosis, etc.

Biofeedback in children is due to physiological features at such a young age - the fact is that the child’s bronchi are significantly narrower, and their additional narrowing as a result of edema, even by one millimeter, will already have a noticeable negative effect.

The normal functioning of the bronchial tree can be disrupted in the first months of life due to frequent crying, lying on the back, and prolonged sleep.
Also an important role is played by prematurity, toxicosis and taking medications during pregnancy, complications during pregnancy. birth process, from the mother and so on.

In addition, the baby’s processes have not yet stabilized until they are one year old. immune defense, which also plays a role in the occurrence of bronchial obstruction.

Signs and symptoms

Clinical manifestations of bronchial obstruction syndrome include the following:

• prolonged inhalation;
• the appearance of whistling and wheezing during breathing;
• lingering unproductive;
• increased respiratory movements, participation of auxiliary muscles in the breathing process;
• hypoxemia;
• the appearance of shortness of breath, lack of air;
• chest enlargement;
• breathing becomes loud, weakened, or harsh.

The listed symptoms indicate precisely the occurrence of a narrowing of the bronchial lumen. However general symptoms are largely determined by the underlying pathology that caused the biofeedback.
When the disease occurs, the child exhibits moodiness, sleep and appetite disturbances, weakness, and symptoms of intoxication occur; the temperature may rise and body weight may decrease.

When contacting a therapist or neonatologist, the doctor will interview the baby’s mother for allergies, recent illnesses, identified developmental disorders, and family history.

In addition to presence clinical signs y, to make a diagnosis of BOS, it is necessary to conduct specific physical and functional studies.

The most important test to confirm the diagnosis is spirometry- in this case, the volume of inhaled and exhaled air, lung capacity (vital and forced), the amount of air during forced inspiration, and the patency of the respiratory tract are examined.

Therapeutic procedures may include:

1. Special breathing exercises.
2. Using breathing simulators.
3. Drainage.
4. Vibration chest massage.
5. Speleotherapy.
6. Balneological procedures.
7. Physiotherapy.

In the child’s room, it is necessary to maintain the temperature at +18-19°C, and the air humidity must be at least 65%. Regular ventilation of the room will not be superfluous.

If a child feels satisfactorily, you should not force him to follow bed rest- physical activity promotes better removal of mucus from the bronchi.

Also make sure your baby gets enough fluids per day: these can be herbal teas, infusions, fruit juices and fruit drinks, unsweetened compotes.

Forecast

The prognosis for the development of biofeedback depends on the primary pathology and its timely treatment. Also, the consequences and severity of the disease are determined by the age of the child: the younger the age, the more expressive the manifestations of the disease and the more complex the course of the underlying disease.

With bronchitis, the prognosis is positive, but with pulmonary dysplasia there is a risk of BOS degenerating into asthma (in 20% of cases). Against the background of bronchiolitis, heart failure and emphysema may occur.

Cases of frequent, unproductive, debilitating cough can lead to nausea and expectoration of blood due to damage to the respiratory tract. Therefore, it is important to seek qualified help as early as possible and begin adequate therapy in order to prevent undesirable consequences.

Did you know? During the day we make up to 23 thousand respiratory movements: inhalations and exhalations.

Basic rules of prevention include the following points:

In 80% of cases, BOS occurs from birth to three years. The syndrome causes a lot of trouble for both the child and the parents. However, if you identify the pathology in time and begin therapeutic actions, serious consequences for the child’s health can be avoided.

Autumn and winter are the season of acute respiratory infections (ARI). One of the forms of ARI is acute bronchitis. The manifestations of acute bronchitis are well known: a dry or unproductive cough, which is sometimes accompanied by a feeling of heaviness or congestion in the chest with difficulty breathing; dry wheezing can be heard on auscultation of the lungs. Spirometry in such patients can reveal signs of bronchial obstruction, which, in combination with the clinical picture, forms the so-called broncho-obstructive syndrome (BOS).

Causes of broncho-obstructive syndrome

Bronchial obstruction in acute bronchitis can be caused by inflammatory edema of the bronchial wall and accumulation of mucus in the lumen of the bronchial tree. It is biofeedback that causes annoying debilitating cough in patients acute bronchitis.

In ARI, inflammation is usually caused by viruses, most often influenza viruses (cough accompanies up to 93% of influenza cases), coronavirus, adenovirus, rhinovirus, respiratory syncytial virus, or bacterial infection (usually Mycoplasma pneumoniae, Chlamydia pneumoniae, Bordetella pertussis, Streptococcus pneumoniae ).

However, in a person with a clear medical history and the absence of chronic respiratory diseases, biofeedback in acute bronchitis, as a rule, does not require medical intervention and goes away within 1-2 weeks without special treatment. However, the doctor must be sure that the patient does not have more serious clinical situations, primarily pneumonia.

But sometimes the cough and symptoms of biofeedback in a patient with acute bronchitis drag on for several weeks or even months. The cause of this condition is almost always some chronic disease that either existed previously, but was not diagnosed in a timely manner, or was initiated by a previous acute respiratory infection, which acted as a trigger. More often, this situation occurs in patients with bronchial asthma (BA) or chronic obstructive pulmonary disease (COPD).

Bronchial asthma often develops in childhood, although this diagnosis is not always made, and the child is treated for chronic bronchitis, viral bronchitis or asthmatic bronchitis. When questioning adult patients in detail about bronchitis suffered in childhood, the doctor often assumes that these bronchitis were a manifestation of asthma, which by the age of 16-18, even in the absence of treatment, went into a state of spontaneous remission.

However, in adulthood, after an episode of another ARI, bronchial asthma may “return”, since respiratory viruses are powerful triggers of exacerbations of asthma. In such cases, broncho-obstructive syndrome against the background of ARI may indicate an exacerbation of the patient’s previously existing, although undiagnosed, bronchial asthma.

In this situation, the first step to making a diagnosis is a detailed analysis of anamnestic data: the presence of similar symptoms against the background of ARI in the past, frequent bronchitis in childhood. The likelihood of bronchial asthma (BA) increases if such a patient has other allergic diseases.

Another option is when respiratory viruses initiate the appearance of asthma in an adult who has not previously had this disease. According to the results published in 2011 by A. Rantala et al. population-based case-control study, the risk of developing bronchial asthma in adults within 12 months after an ARI of the upper respiratory tract increases by more than 2 times, after an ARI of the lower respiratory tract, including acute bronchitis, by more than 7 times.

According to the authors, in individuals with allergic diseases or a predisposition to them, lower respiratory tract infection acts synergistically with atopy, in different ways leading to inflammation in the bronchi. Such cases are more difficult to diagnose, since the appearance of broncho-obstructive syndrome (BOS) in an adult who has no history of chronic respiratory diseases requires differential diagnosis with other possible reasons.

Similarly, ARI can cause an exacerbation of COPD in a smoker who previously had minimal clinical symptoms of this disease, which remained unrecognized for a long time, or ARI can cause an exacerbation of the disease in a patient with a known diagnosis of COPD. In this situation, diagnosis also begins with a medical history: long-term tobacco smoking or long-term contact with smoke and toxic gases in the absence of clinical and radiological indications of other chronic diseases of the bronchopulmonary system.

In addition to the listed situations, the cause of BOS, which first developed against the background of ARI in an adult, can be other diseases. In 2007, in India, an analysis of the causes of 268 cases of BOS in the pulmonology department of a hospital was carried out, among which 63% of cases were due to bronchial asthma, 17% - COPD, 6% - bronchiectasis, 13% - bronchiolitis obliterans and 1% - occupational disease respiratory organs.

Thus, among the variety of causes of broncho-obstructive syndrome (BOS) during acute respiratory infections in adults, the most common remain bronchial asthma and chronic obstructive pulmonary disease.

Diagnosis of broncho-obstructive syndrome

A patient with acute bronchitis lasting no more than 3 weeks does not require any examination, including sputum cultures (level of evidence C) and x-rays (level of evidence B), unless, of course, the doctor suspects the development of pneumonia, which should appear , If clinical picture Acute bronchitis is accompanied by tachycardia more than 100 beats per minute, shortness of breath at rest with a respiratory rate of more than 24 per minute, high fever more than 38°C, as well as auscultatory signs of pneumonia.

If cough and other symptoms of broncho-obstructive syndrome (BOS) persist for more than 3 weeks, the reasons for this course of the disease should be clarified. In this situation, the examination of the patient begins with fluorography or radiography of the lungs, clinical analysis blood and spirometry with bronchodilation test. The results of these studies, together with clinical and anamnestic data, will determine the further diagnostic search.

If bronchiectasis, bronchiolitis obliterans or other diffuse parenchymal lung diseases, including sarcoidosis, are suspected, conventional chest radiography does not always provide sufficient information and there is often a need for computed tomography easy and difficult functional studies(body plethysmography, study of the diffusion capacity of the lungs).

To confirm the diagnosis of bronchial asthma, bronchoprovocation tests are often used, and if this is not possible, peak flowmetry is used for 2-3 weeks. The diagnosis of COPD is made in the presence of relevant risk factors, primarily smoking, and the exclusion of other causes of biofeedback.

Drugs for the treatment of broncho-obstructive syndrome

A patient with uncomplicated acute bronchitis accompanied by biofeedback, as a rule, does not require antibiotics, muco- and bronchodilators.

Antibiotics for broncho-obstructive syndrome . According to the literature, 65-80% of patients with acute bronchitis in the world are treated with antibiotics, despite evidence that in the vast majority of cases antibiotics are ineffective in this situation. Given that the etiology of acute bronchitis is predominantly viral, the prescription of antibiotics for the uncomplicated course of this disease is not recommended (level of evidence A).

The appearance of purulent sputum in uncomplicated acute bronchitis is also not evidence of accession bacterial infection if the duration of the disease does not exceed 3 weeks. However, many patients suffering from acute bronchitis insist on prescribing antibiotics. In this case, the doctor’s task is to explain to the patient why this is not necessary.

Antibiotics will not have an effect on the duration of the disease and the severity of cough, and the unjustified use of these drugs increases the resistance of pathogens among the population as a whole and is associated with unjustified risk the development of side effects in this patient, primarily dysbacteriosis and allergic reactions. An exception may be acute bronchitis caused by Bordetella pertussis (whooping cough), which requires the administration of macrolides.

Bronchodilators for broncho-obstructive syndrome are also not shown en masse. There have been few studies around the world on the effectiveness of these drugs in acute bronchitis, but in most of them, B2 agonists did not affect either the severity or duration of cough. However, there are exceptions to any rule. In patients with dry rales in the lungs and other signs of biofeedback, the administration of B2-agonists may reduce the duration of cough and speed up recovery (evidence level C).

In addition, we must not forget that patients with chronic respiratory diseases can also suffer from acute respiratory infections, which are accompanied by increased cough and bronchial obstruction, and in more cases late dates may cause exacerbation of existing chronic bronchopulmonary diseases. In such situations, it is often necessary to discontinue long-acting B2-agonists and temporarily transfer the patient to inhaled short-acting bronchodilators: salbutamol or fenoterol.

In this case, it is appropriate to prescribe the combination drug Berodual (Boehringer Ingelheim), since in addition to the B2-agonist fenoterol, it contains the anticholinergic ipratropium bromide, which can reduce the severity of cough in patients with chronic bronchitis and/or ARI.

Fenoterol and ipratropium bromide cause bronchodilation in different ways and, when simultaneously entering the bronchial tree, enhance each other's effects. At the same time, it is more convenient for the patient to inhale the combination drug from one inhaler than to use two inhalers separately.

Berodual can be prescribed either as a metered dose aerosol inhaler or as a solution via a nebulizer. This makes it possible to select therapy for patients with different severity of the disease and different learning abilities. Thus, it can be difficult for older people and children to master the technique of inhalation through a metered dose aerosol inhaler (MDI), even with a spacer, and it is easier for them to inhale the medicine through a nebulizer, the use of which does not require special skills.

Mucolytics and antitussives. Antitussives are prescribed for acute bronchitis only for persistent, prolonged cough for a short time (level of evidence C). Mucolytics and expectorants can be used when there is an increase in the volume and difficult discharge of sputum to facilitate coughing up, but should not be prescribed without fail, since their effect in acute bronchitis has not been proven.

Therapy of broncho-obstructive syndrome

Acute bronchitis is a disease that, despite its high incidence, does not have strictly proven therapy. Treatment tactics are determined by the individual circumstances of the patient: the presence or absence of chronic bronchopulmonary diseases, biofeedback, severity of cough, volume of sputum and difficulties in coughing.

Treatment of broncho-obstructive syndrome (BOS) is recommended to begin with the use of B2-agonists (for example, fenoterol), and to obtain an additional therapeutic effect, it is advisable to combine them with an anticholinergic (ipratropium bromide). Such fixed combination active ingredients are represented in Russia by the drug Berodual in two forms - MDI and solution for inhalation.

To reduce annoying cough, it is possible to use antitussive drugs. If necessary, mucolytics and expectorants can be used to improve coughing up of viscous sputum. Antibiotics in most cases are not indicated for patients with acute bronchitis.

© Svetlana Chikina

Broncho-obstructive syndrome(BOS) or bronchial obstruction syndrome is a symptom complex associated with a violation of bronchial patency of a functional or organic origin. Clinical manifestations of biofeedback consist of prolongation of exhalation, the appearance of expiratory noise (wheezing, noisy breathing), attacks of suffocation, participation of auxiliary muscles in the act of breathing, and an unproductive cough often develops. With severe obstruction, there may be noisy exhalation, an increase in respiratory rate, the development of fatigue of the respiratory muscles and a decrease in PaO2.

The term “Broncho-obstructive syndrome” cannot be used as an independent diagnosis. Broncho-obstructive syndrome is a symptom complex of a disease, the nosological form of which should be established in all cases of development of bronchial obstruction.

Epidemiology

Bronchial obstruction syndrome is quite common in children, especially in children of the first three years of life. Its occurrence and development is influenced by various factors and, above all, respiratory viral infection.

The incidence of bronchial obstruction developed against the background of acute respiratory diseases in children early age ranges, according to various authors, from 5% to 50%. In children with a family history of allergies, BOS usually develops more often, in 30-50% of cases. The same trend exists in children, who often suffer from respiratory infections more than 6 times a year.

Risk factors for developing BOS

Predisposing anatomical and physiological factors to the development of biofeedback in young children is the presence of hyperplasia glandular tissue, secretion of predominantly viscous sputum, relative narrowness of the respiratory tract, smaller volume of smooth muscles, low collateral ventilation, insufficiency of local immunity, structural features of the diaphragm.

The influence of premorbid background factors on the development of biofeedback is recognized by most researchers. This is a burdened allergic history, hereditary predisposition to atopy, bronchial hyperreactivity, perinatal pathology, rickets, malnutrition, thymic hyperplasia, early artificial feeding, and a history of respiratory disease at the age of 6-12 months.

Among the environmental factors that can lead to the development of obstructive syndrome, particularly important is the unfavorable environmental situation and passive smoking in the family. Under the influence of tobacco smoke, hypertrophy of the bronchial mucous glands occurs, mucociliary clearance is disrupted, and the movement of mucus slows down. Passive smoking contributes to the destruction of the bronchial epithelium. Tobacco smoke is an inhibitor of neutrophil chemotaxis. The number of alveolar macrophages under its influence increases, but their phagocytic activity decreases. With prolonged exposure, tobacco smoke affects immune system: reduces the activity of T-lymphocytes, inhibits the synthesis of proteins of the main classes, stimulates the synthesis of immunoglobulins E, increases activity vagus nerve. Children in the first year of life are considered especially vulnerable.

Parental alcoholism also has a certain influence. It has been proven that children with alcoholic fetopathy develop bronchial atony, mucociliary clearance is impaired, and the development of protective immunological reactions is inhibited.

Thus, in the development of bronchial obstruction in children, an important role is played by age-related characteristics of the respiratory system, characteristic of children in the first years of life. Undoubted influence on respiratory dysfunction in small child Factors such as longer sleep, frequent crying, and preferential lying on your back in the first months of life also have an effect.

Etiology

The reasons for the development of bronchial obstruction in children are very diverse and numerous. At the same time, the debut of biofeedback in children develops, as a rule, against the background of acute respiratory distress. viral infection and in the vast majority of patients it is one of the clinical manifestations of acute obstructive bronchitis or bronchiolitis. Respiratory infections are the most common cause development of bronchial obstruction in children. At the same time, it is necessary to take into account that the development of bronchial obstruction against the background of ARVI can also be a manifestation of a chronic disease. Thus, according to the literature, in young children, bronchial asthma is a variant of the course of biofeedback in 30-50% of cases.

Broncho-obstructive syndrome in children usually develops against the background of an acute respiratory viral infection. The main causes of bronchial obstruction in children are acute obstructive bronchitis and bronchial asthma.

Pathogenesis of the formation of bronchial obstruction in children

The formation of bronchial obstruction largely depends on the etiology of the disease that caused the biofeedback. The genesis of bronchial obstruction lies in various pathogenetic mechanisms, which can be divided into functional or reversible (bronchospasm, inflammatory infiltration, edema, mucociliary insufficiency, hypersecretion of viscous mucus) and irreversible (congenital bronchial stenosis, their obliteration, etc.). Physical signs in the presence of bronchial obstruction are due to the fact that increased intrathoracic pressure is required to produce exhalation, which is ensured by increased work of the respiratory muscles. Increased intrathoracic pressure causes compression of the bronchi, which leads to their vibration and the occurrence of whistling sounds.

Regulation of bronchial tone is controlled by several physiological mechanisms, including complex interactions of the receptor-cellular link and the system of mediators. These include cholinergic, adrenergic and neurohumoral (non-cholinergic, non-adrenergic) regulatory systems and, of course, the development of inflammation.

Inflammation is an important factor in bronchial obstruction in children and can be caused by infectious, allergic, toxic, physical and neurogenic influences. The mediator that initiates the acute phase of inflammation is interleukin-1 (IL-1). It is synthesized by phagocytic cells and tissue macrophages when exposed to infectious or non-infectious factors and activates a cascade of immunological reactions that promote the release of type 1 mediators (histamine, serotonin, etc.) into the peripheral bloodstream. These mediators are constantly present in mast cell granules and basophils, which ensures their very rapid biological effects during degranulation of producer cells. Histamine is released, as a rule, during an allergic reaction when an allergen interacts with allergen-specific IgE antibodies. However, degranulation of mast cells and basophils can also be caused by non-immunological mechanisms, including infectious ones. In addition to histamine, type 2 meditators (eicosanoids), generated during early inflammatory reaction. The source of eicosanoids is arachidonic acid, which is formed from phospholipids of cell membranes. Under the influence of cyclooxygenase from arachidonic acid Prostaglandins, thromboxane and prostacyclin are synthesized, and leukotrienes are synthesized under the action of lipoxygenase. It is histamine, leukotrienes and pro-inflammatory prostaglandins that are associated with increased vascular permeability, the appearance of edema of the bronchial mucosa, hypersecretion of viscous mucus, the development of bronchospasm and, as a consequence, the formation of clinical manifestations of biofeedback. In addition, these events initiate the development of a late inflammatory reaction, which contributes to the development of hyperreactivity and alteration (damage) of the epithelium of the mucous membrane of the respiratory tract.

Damaged tissues have increased sensitivity of bronchial receptors to external influences, including viral infection and pollutants, which significantly increases the likelihood of developing bronchospasm. In addition, pro-inflammatory cytokines are synthesized in damaged tissues, degranulation of neutrophils, basophils, and eosinophils occurs, resulting in an increase in the concentration of biologically active substances such as bradykinin, histamine, free oxygen radicals and NO, which are also involved in the development of inflammation. Thus, the pathological process takes on the character of a “vicious circle” and predisposes to a long course of bronchial obstruction and superinfection.

Inflammation is the main pathogenetic link in the development of other mechanisms of bronchial obstruction, such as hypersecretion of viscous mucus and swelling of the bronchial mucosa.

Disturbance of bronchial secretion develops with any adverse effect on the respiratory system and in most cases is accompanied by an increase in the amount of secretion and an increase in its viscosity. The activity of the mucous and serous glands is regulated by the parasympathetic nervous system; acetylcholine stimulates their activity. This reaction is initially defensive in nature. However, stagnation of bronchial contents leads to disruption of the ventilation and respiratory function of the lungs, and inevitable infection leads to the development of endobronchial or bronchopulmonary inflammation. In addition, the thick and viscous secretion produced, in addition to inhibiting cialial activity, can cause bronchial obstruction due to the accumulation of mucus in the respiratory tract. In severe cases, ventilation disorders are accompanied by the development of atelectasis.

Edema and hyperplasia of the mucous membrane airways are also one of the causes of bronchial obstruction. Developed lymphatic and circulatory system The respiratory tract of a child provides him with many physiological functions. However, under pathological conditions, edema is characterized by thickening of all layers of the bronchial wall - the submucosal and mucous layers, the basement membrane, which leads to impaired bronchial patency. With recurrent bronchopulmonary diseases, the structure of the epithelium is disrupted, its hyperplasia and squamous metaplasia are noted.

Bronchospasm is certainly one of the main causes of broncho-obstructive syndrome in older children and adults. At the same time, there are indications in the literature that young children, despite the poor development of the bronchial smooth muscle system, can sometimes experience typical, clinically pronounced bronchospasm. Currently, several mechanisms of the pathogenesis of bronchospasm, which are clinically realized in the form of biofeedback, have been studied.

It is known that cholinergic regulation of the bronchial lumen is carried out by a direct effect on the smooth muscle receptors of the respiratory organs. It is generally accepted that cholinergic nerves terminate on smooth muscle cells, which have not only cholinergic receptors, but also H-1 histamine receptors, β2 adrenergic receptors and neuropeptide receptors. It has been suggested that smooth muscle cells of the respiratory tract also have receptors for prostaglandins F2α.

Activation of cholinergic nerve fibers leads to an increase in the production of acetylcholine and an increase in the concentration of guanylate cyclase, which in turn promotes the entry of calcium ions into the smooth muscle cell, thereby stimulating bronchoconstriction. This process can be enhanced by the influence of prostaglandins F 2α. M-cholinergic receptors in infants are quite well developed, which on the one hand determines the characteristics of the course of broncho-obstructive diseases in children of the first years of life (tendency to develop obstruction, production of very viscous bronchial secretions), on the other hand explains the pronounced bronchodilator effect of M-cholinergic drugs in this category of patients .

It is known that stimulation of β 2 adrenergic receptors by catecholamines, as well as increasing the concentration of cAMP and prostaglandins E2, reduce the manifestations of bronchospasm. Hereditary blockade of adenylate cyclase reduces the sensitivity of β2 adrenergic receptors to adrenomimetics, which is quite common in patients with bronchial asthma. Some researchers point to the functional immaturity of β2 adrenergic receptors in children in the first months of life.

In recent years, there has been increased interest in the relationship between inflammation and the neuropeptide system, which integrates the nervous, endocrine and immune systems. In children of the first years of life, this relationship is more pronounced and determines the predisposition to the development of bronchial obstruction. It should be noted that the innervation of the respiratory organs is more complex than previously thought. In addition to the classical cholinergic and adrenergic innervation, there is non-cholinergic non-adrenergic innervation (NANC). The main neurotransmitters or mediators of this system are neuropeptides. Neurosecretory cells, in which neuropeptides are formed, are isolated in separate category- "APUD" - system (amino precursor uptake decarboxylase). Neurosecretory cells have the properties of exocrine secretion and can cause a distant humoral-endocrine effect. The hypothalamus, in particular, is the leading link in the neuropeptide system. The most studied neuropeptides are substance P, neurokines A and B, calciotonin gene-related peptide, vasoactive intestinal peptide (VIP). Neuropeptides can interact with immunocompetent cells, activate degranulation, increase bronchial hyperreactivity, regulate NO synthetase, directly affect smooth muscle and blood vessels. The neuropeptide system has been shown to play an important role in the regulation of bronchial tone. Thus, infectious pathogens, allergens or pollutants, in addition to the vagal response (bronchoconstriction), stimulate sensory nerves and the release of substance P, which increases bronchospasm. At the same time, VIP has a pronounced bronchodilator effect.

Thus, there are several main mechanisms for the development of bronchial obstruction. The proportion of each of them depends on the cause of the pathological process and the age of the child. The anatomical, physiological and immunological characteristics of young children determine the high incidence of BOS in this group of patients. It should be noted the important role of the premorbid background on the development and course of bronchial obstruction. Important feature The formation of reversible bronchial obstruction in children of the first years of life is the predominance of inflammatory edema and hypersecretion of viscous mucus over the bronchospastic component of obstruction, which must be taken into account in complex treatment programs.

Classification

About a hundred diseases are known that are accompanied by bronchial obstruction syndrome. However, to date there is no generally accepted classification of biofeedback. Working groups, as a rule, are a list of diagnoses that occur with bronchial obstruction.

Based on literature data and our own observations, we can distinguish the following groups of diseases accompanied by bronchial obstruction syndrome in children:

1.Respiratory diseases.

1.1. Infectious and inflammatory diseases (bronchitis, bronchiolitis, pneumonia).

1.2. Bronchial asthma.

1.3. Aspiration of foreign bodies.

1.4. Bronchopulmonary dysplasia.

1.5. Malformations of the bronchopulmonary system.

1.6. Obliterating bronchiolitis.

1.7. Tuberculosis.

2.Diseases gastrointestinal tract(chalasia and achalasia of the esophagus, gastroesophageal reflux, tracheoesophageal fistula, diaphragmatic hernia).

3. Hereditary diseases (cystic fibrosis, alpha-1-antitrypsin deficiency, mucopolysaccharidosis, rickets-like diseases).

5.Diseases of cardio-vascular system.

6. Diseases of the central and peripheral nervous system (birth trauma, myopathies, etc.).

7. Congenital and acquired immunodeficiency conditions.

8. Impact of various physical and chemical environmental factors.

9. Other causes (endocrine diseases, systemic vasculitis, thymomegaly, etc.).

From a practical point of view, we can distinguish 4 main groups of causes of broncho-obstructive syndrome:

• infectious
• allergic
• obstructive
• hemodynamic

According to the duration of the course, broncho-obstructive syndrome can be acute (clinical manifestations of BOS last no more than 10 days), protracted, recurrent and continuously relapsing. Based on the severity of obstruction, we can distinguish mild degree severity, moderate, severe and hidden bronchial obstruction. Criteria for the severity of bOS marking are the presence of wheezing, shortness of breath, cyanosis, participation of auxiliary muscles in the act of breathing, indicators of external respiratory function (PEF) and blood gases. Cough is observed with any degree of severity of biofeedback.

A mild course of biofeedback is characterized by the presence of wheezing on auscultation, the absence of shortness of breath and cyanosis at rest. Blood gas values ​​are within normal limits, and external respiratory function indicators (forced expiratory volume in the first second, maximum expiratory flow, maximum volumetric flow rates) are moderately reduced. The child’s well-being, as a rule, does not suffer.

The course of biofeedback of moderate severity is accompanied by the presence at rest of shortness of breath of an expiratory or mixed nature, cyanosis of the nasolabial triangle, and retraction of the compliant areas of the chest. Wheezing can be heard from a distance. The respiratory function indicators are reduced, but the CBS is slightly impaired (PaO 2 is more than 60 mm Hg, PaCO 2 is less than 45 mm Hg).

In severe cases of an attack of bronchial obstruction, the child’s well-being suffers, characterized by noisy difficulty breathing with the participation of auxiliary muscles, characterized by noisy difficulty breathing with the participation of auxiliary muscles, and the presence of cyanosis. The respiratory function indicators are sharply reduced, there are functional signs of generalized bronchial obstruction (PaO2 less than 60 mm Hg, PaCO 2 more than 45 mm Hg). With hidden bronchial obstruction, clinical and physical signs of biofeedback are not determined, but when studying the function of external respiration, a positive test with a bronchodilator is determined.

The severity of broncho-obstructive syndrome depends on the etiology of the disease, the age of the child, premorbid background and some other factors. It is necessary to take into account that BOS is not an independent diagnosis, but a symptom complex of a disease, the nosological form of which should be established in all cases of the development of bronchial obstruction.

Clinical symptoms of broncho-obstructive syndrome can be of varying degrees of severity and consist of prolonged exhalation, the appearance of wheezing, noisy breathing. An unproductive cough often develops. In severe cases, the development of attacks of suffocation is characteristic, which is accompanied by retraction of the compliant areas of the chest and the participation of auxiliary muscles in the act of breathing. During physical examination, dry wheezing is detected by auscultation. In young children, moist rales of various sizes are often heard. When percussing, a boxy sound appears. Severe obstruction is characterized by noisy exhalation, an increase in respiratory rate, the development of fatigue of the respiratory muscles and a decrease in PaO 2.

Severe cases bronchial obstruction, as well as all repeated cases of diseases occurring with broncho-obstructive syndrome, require mandatory hospitalization to clarify the genesis of biofeedback, conduct adequate therapy, prevention and assessment of the prognosis of the further course of the disease.

In order to establish a diagnosis of a disease occurring with biofeedback, it is necessary to study in detail the clinical and anamnestic data, paying special attention to the presence of atopy in the family, previous diseases, and the presence of relapses of bronchial obstruction.

Newly diagnosed mild BOS, which developed against the background of a respiratory infection, does not require additional examination methods.

In case of recurrent BOS, the complex of examination methods should include:

• peripheral blood test
• examination for the presence of chlamydial, mycoplasma, cytomegalovirus, herpes and pneumocystis infections. Serological tests are performed more often (specific immunoglobulins of classes M and G are required, IgA testing is desirable). In the absence of IgM and diagnostic IgG titers it is necessary to repeat the study after 2-3 weeks (paired sera). Bacteriological, virological examination methods and PCR diagnostics are highly informative only when collecting material during bronchoscopy; smear examination characterizes mainly the flora of the upper respiratory tract
• comprehensive examination for the presence of helminthiases (toxocariasis, ascariasis)
• allergy examination (level of total IgE, specific IgE, skin prick tests or “prick” tests); other immunological examinations are carried out after consultation with an immunologist
• Children with noisy breathing syndrome are advised to consult an otolaryngologist.

Chest X-ray is not a mandatory method of examination in children with biofeedback. The study shows:

• if a complicated course of biofeedback is suspected (for example, the presence of atelectasis)
• to exclude acute pneumonia
• if a foreign body is suspected
• in case of recurrent course of biofeedback (if x-rays were not previously performed)

A study of external respiration functions (ERF) in the presence of noisy breathing syndrome in children over 5-6 years of age is mandatory. The most informative indicators in the presence of bronchial obstruction are a decrease in forced expiratory volume in 1 second (FEV1) and peak expiratory flow (PEF). The level of obstruction of the bronchial tree is characterized by maximum volumetric expiratory flow rates (MOF25-75). In the absence of pronounced signs of bronchial obstruction, a test with a bronchodilator is indicated to exclude hidden bronchospasm, as evidenced by an increase in FEV1 by more than 12% after inhalation with a bronchodilator. In order to determine bronchial hyperreactivity, tests are performed with methacholine, histamine, dosed physical activity, etc.

Children under 5-6 years of age are not able to perform the forced expiration technique, so it is impossible to conduct these highly informative studies in them. In the first years of a child’s life, a study of peripheral airway resistance (flow interruption technique) and body plethysmography are carried out, which make it possible, with a certain degree of probability, to identify and evaluate obstructive and restrictive changes. Oscillometry and bronchophonography can provide some assistance in differential diagnosis in children of the first years of life, but to date these methods have not yet found application in widespread pediatric practice.

The differential diagnosis of broncho-obstructive syndrome, especially in children in the first years of life, is quite complicated. This is largely determined by the characteristics of pulmonary pathology during the period early childhood, a large number of possible etiological factors for the formation of BOS and the absence of highly informative signs for bronchial obstruction of various origins.

In the vast majority of cases, broncho-obstructive syndrome in children develops against the background of an acute respiratory infection and is more often a manifestation of acute obstructive bronchitis. At the same time, it must be remembered that the development of bronchial obstruction against the background of ARVI may be the first clinical manifestation of bronchial asthma or other clinical disease.

Symptoms of bronchial obstruction are sometimes taken extrapulmonary causes noisy breathing, such as congenital stridor, stenosing laryngotracheitis, laryngeal dyskinesia, hypertrophy of the tonsils and adenoids, cysts and hemangiomas of the larynx, retropharyngeal abscess, etc.

With repeated episodes of biofeedback due to respiratory infections, a differentiated approach should be taken to assessing the causes of recurrent bronchial obstruction. Several groups of factors can be identified that most often contribute to the recurrence of biofeedback due to a respiratory infection:

1. Recurrent bronchitis, the cause of which is often the presence of bronchial hyperactivity, which developed as a result of an acute respiratory infection of the lower respiratory tract.
2. The presence of bronchial asthma (BA), the onset of which in children often coincides with the development of intercurrent acute respiratory disease.
3. Latent course of chronic bronchopulmonary disease (for example, cystic fibrosis, ciliary dyskinesia, etc.). In this case, against the background of acute respiratory viral infection, the deterioration of the latent biofeedback can create the illusion of a recurrent course of biofeedback.

Broncho-obstructive syndrome in children with acute respiratory infection (ARI) usually occurs in the form acute obstructive bronchitis and acute bronchiolitis.

Of the etiological factors of ARI highest value have viruses, less often - viral-bacterial associations. The viruses that most often cause obstructive syndrome in children include respiratory syncytial virus (RS), adenovirus, parainfluenza virus type 3, and somewhat less frequently - influenza viruses and enterovirus. In the works of recent years, the importance of coronovirus is noted in the etiology of BOS in young children, along with RS viral infection. Persistent course of cytomegalovirus and herpetic infection in children of the first years of life can also cause the appearance of bronchial obstruction. There is convincing evidence of the role of mycoplasma and chlamydial infections in the development of BOS.

Inflammation of the mucous membrane of the bronchial tree, developing against the background of an acute respiratory infection (ARI), contributes to the formation of bronchial obstruction. In the genesis of bronchial obstruction in ARI, swelling of the bronchial mucosa, its inflammatory infiltration, and hypersecretion of viscous mucus are of primary importance, resulting in impaired mucociliary clearance and bronchial obstruction. Under certain conditions, hypertrophy of the muscular tissue of the bronchi and mucosal hyperplasia may occur, which subsequently contribute to the development of recurrent bronchospasm. RS viral infection is characterized by hyperplasia of small bronchi and bronchioles, “cushion-shaped” proliferation of the epithelium, which leads to severe and intractable bronchial obstruction, especially in children in the first months of life. Adenovirus infection accompanied by a pronounced exudative component, significant mucous deposits, loosening and rejection of the epithelium of the bronchial mucosa. VA of a lesser degree in children of the first three years of life with ARI expresses the mechanism of bronchospasm, which is caused by the development of hyperreactivity of the bronchial tree during viral infection. Viruses damage the bronchial mucosa, which leads to hypersensitivity interoreceptors of the cholinergic link of the VNS and blockade of β2-adrenergic receptors. In addition, a clear effect of a number of viruses on increasing the level of IgE and IgG and suppressing the T-suppressor function of lymphocytes was noted.

Clinical manifestations of bronchial obstruction in children with sharpobstructive bronchitis can be different and vary from moderate signs of bronchial obstruction with the presence of multiple scattered dry wheezing without symptoms of respiratory failure to quite pronounced, with moderate and severe biofeedback.

Bronchoobstruction develops more often on days 2-4 of acute respiratory infection, already against the background of pronounced catarrhal symptoms and a non-productive, “dry” cough. The child develops shortness of breath of an expiratory nature without pronounced tachypnea (40-60 breaths per minute), sometimes - distant wheezing in the form of noisy, wheezing breathing, percussion - a boxy tone of sound, with auscultation - prolonged exhalation, dry whistling (musical) wheezing, moist wheezing of various sizes on both sides. An X-ray of the chest reveals an increase in the pulmonary pattern, and sometimes an increase in transparency. Broncho-obstructive syndrome lasts for 3-7-9 or more days, depending on the nature of the infection, and disappears gradually, parallel to the subsidence of inflammatory changes in the bronchi.

Acute bronchiolitis It is observed mainly in children in the first half of life, but can also occur up to 2 years. Most often caused by respiratory syncytial infection. With bronchiolitis, small bronchi, bronchioles and alveolar ducts are affected. Narrowing of the lumen of the bronchi and bronchioles, due to edema and cellular infiltration of the mucous membrane, leads to the development of severe respiratory failure. Bronchospasm in bronchiolitis is not of great importance, which is confirmed by the lack of effect from the use of bronchospasmolytics.

The clinical picture is determined by severe respiratory failure: perioral cyanosis, acrocyanosis, tachypnea (depending on age) up to 60-80-100 breaths per minute, with a predominance of the expiratory component, “oral” crepitus, retraction of the compliant areas of the chest. Percussion reveals a box-shaped percussion-type shade over the lungs; on auscultation - many small moist and crepitating rales throughout all fields of the lungs during inhalation and exhalation, exhalation is prolonged and difficult; with shallow breathing, exhalation can have a normal duration with a sharply reduced tidal volume. This clinical picture of the disease develops gradually, over several days, less often acutely, against the background of acute respiratory infections and is accompanied by sharp deterioration condition. In this case, a paroxysmal cough occurs, vomiting may occur, and anxiety appears. The reaction temperature and symptoms of intoxication are determined by the course of the respiratory infection. An X-ray examination of the lungs reveals swelling of the lungs, a sharp increase in the bronchial pattern with a high prevalence of these changes, a high position of the dome of the diaphragm, and a horizontal arrangement of the ribs. Broncho-obstruction persists for quite a long time, at least two to three weeks.

The cause of recurrent bronchitis is quite often the presence of bronchial hyperreactivity, which developed as a result of an acute respiratory infection of the lower respiratory tract. Bronchial hyperreactivity is understood as a condition of the bronchial tree in which there is an inadequate response, usually manifested in the form of bronchospasm, to adequate stimuli. Bronchial hyperreactivity can be of immune origin (in patients with bronchial asthma) and non-immune, which is a consequence of a respiratory infection and is temporary. In addition, bronchial hyperreactivity may occur in healthy people and not manifest itself clinically in any way. It has been established that bronchial hyperreactivity develops in more than half of children who have had pneumonia or ARVI and can become one of the leading pathophysiological mechanisms in the development of recurrent bronchial obstruction. In some cases, the presence of hyperreactivity is a predisposing factor to recurrent diseases of the respiratory system.

It has been proven that a respiratory viral infection leads to damage and desquamation of the ciliated epithelium of the respiratory tract, “exposure” and increased threshold sensitivity of irritant receptors, a decrease in the functional activity of the ciliated epithelium and impaired mucociliary clearance. This chain of events leads to the development of hypersensitivity and the development of broncho-obstructive syndrome to increased physical activity, inhalation of cold air, strong odors and other irritant factors, to the appearance of attacks of “unreasonable paroxysmal cough.” Upon contact with respiratory pathogens the likelihood of reinfection increases many times over. The literature indicates different durations of this phenomenon - from 7 days to 3-8 months.

Predisposing factors for the development of nonimmune (nonspecific) bronchial hyperreactivity are aggravated premorbid background (prematurity, alcoholic fetopathy, rickets, malnutrition, perinatal encephalopathy, etc.), frequent and/or long-term respiratory infections, and a history of mechanical ventilation. All this, in turn, increases the likelihood of BOS relapse in this group of patients.

At the same time, all patients with recurrent obstructive syndrome and children with attacks of recurrent paroxysmal cough, having an atopic history and/or hereditary predisposition to allergic diseases, with careful examination and exclusion of other causes, should be included in the risk group for bronchial asthma. At the age of 5-7 years, biofeedback does not recur. Older children with recurrent BOS need an in-depth examination to clarify the cause of the disease.

Bronchial asthma(BA), as noted above, is a common cause of biofeedback, and in most patients, BA first manifests itself in early childhood. The initial manifestations of the disease, as a rule, are of the nature of broncho-obstructive syndrome that accompanies respiratory viral infections. Hiding under the mask of an acute respiratory viral infection with obstructive bronchitis, bronchial asthma sometimes goes unrecognized for a long time and patients are not treated. Quite often, the diagnosis of asthma is made 5-10 years after the appearance of the first clinical symptoms of the disease.

Considering that the course and prognosis of asthma largely depend on timely established diagnosis and carrying out therapy adequate to the severity of the disease, it is necessary to pay close attention to the early diagnosis of BA in children with bronchial obstruction syndrome. If a child in the first three years of life has:

• more than 3 episodes of broncho-obstructive syndrome due to
• ARVI marked atopic diseases in family
• the presence of an allergic disease in a child (atopic dermatitis, etc.)

it is necessary to monitor this patient as a patient with bronchial asthma, including conducting additional allergological examination and deciding on the prescription of basic therapy.

However, it should be noted that in children in the first 6 months of life there is a high probability that repeated episodes of obstructive syndrome are not asthma. In addition, in a significant proportion of children in the first three years of life, BOS, which usually occurs against the background of an acute respiratory infection, may not indicate the onset of asthma, but only the presence of a predisposition to its development.

Treatment of asthma in young children corresponds to the general principles of therapy for this disease and is set out in the relevant guidelines (4,16,17). However, the predominance of edema of the bronchial mucosa and hypersecretion of viscous mucus over bronchospasm in the pathogenesis of bronchial obstruction in young children determines the somewhat lower effectiveness of bronchodilator therapy in patients in the first three years of life and the particular importance of anti-inflammatory and mucolytic therapy.

The outcomes of bronchial asthma in children are determined by many factors, among which the main importance is given to the severity of the disease and adequate therapy. The cessation of recurrent attacks of difficulty breathing was observed mainly in patients with mild bronchial asthma. It is impossible not to notice, however, that the concept of “recovery” in bronchial asthma should be treated with great caution, since recovery in bronchial asthma is essentially only a long-term clinical remission, which can be disrupted under the influence of various reasons.

TREATMENT OF BRONCHO-OBSTRUCTIVE SYNDROMEFOR ACUTE RESPIRATORY INFECTION IN CHILDREN

Treatment of broncho-obstructive syndrome should first of all be aimed at eliminating the cause of the disease that led to the development of bronchial obstruction.

Treatment of biofeedback for acute respiratory infection in children should include measures to improving the drainage function of the bronchi, bronchodilator and anti-inflammatory therapy.

A severe attack of bronchial obstruction requires oxygenation of inhaled air, and sometimes mechanical ventilation. Children with severe bronchial obstruction require mandatory hospitalization. Treatment of biofeedback for acute respiratory infection in young children should be carried out taking into account the pathogenesis of the formation of bronchial obstruction in this age period. As is known, the genesis of bronchial obstruction in this group of patients is dominated by inflammatory edema and hypersecretion of viscous mucus, which leads to the development of biofeedback. Bronchospasm, as a rule, is slightly expressed. However, with recurrent BOS, increasing bronchial hyperreactivity increases the role of bronchospasm.

An important feature of the formation of reversible bronchial obstruction in children of the first years of life is the predominance of inflammatory edema and hypersecretion of viscous mucus over the bronchospastic component of obstruction, which must be taken into account in complex treatment programs.

Improving the drainage function of the bronchi includes active oral rehydration, the use of expectorants and mucolytic drugs, massage, postural drainage, and breathing exercises. It is better to use alkaline mineral waters as a drink; the additional daily volume of liquid is about 50 ml/kg of the child’s weight.

For inhalation therapy of broncho-obstructive syndrome, special devices for inhalation therapy: nebulizers and metered aerosols with a spacer and face mask (aerochamber, babyhaler). A spacer is a chamber that holds an aerosol and eliminates the need to coordinate inhalation with pressing the inhaler. The principle of operation of nebulizers is the generation and spraying of aerosol particles with an average size of 5 microns, which allows them to penetrate into all parts of the bronchial tree.

The main goal of nebulizer therapy is to deliver a therapeutic dose of the required drug in aerosol form in a short period of time, usually 5-10 minutes. Its advantages include: an easy-to-perform inhalation technique, the ability to deliver a higher dose of the inhaled substance and ensure its penetration into poorly ventilated areas of the bronchi. In young children it is necessary to use a mask of the appropriate size; from 3 years of age it is better to use a mouthpiece than a mask. The use of a mask in older children reduces the dose of the inhaled substance due to its deposition in the nasopharynx. Treatment with a nebulizer is recommended for mucolytic, bronchodilator and anti-inflammatory therapy in young children and in patients with severe broncho-obstruction. Moreover, the dose of a bronchodilator administered through a nebulizer may exceed the dose of the same drug administered by other inhalation systems several times.

In children with bronchial obstruction and the presence of an unproductive cough with viscous sputum, it is advisable to combine the inhalation (via nebulizer) and oral route of administration of mucolytics, the best of which are ambroxol preparations (Ambrobene, Lasolvan, Ambrohexal, etc.). These drugs have proven themselves in complex therapy of biofeedback in children. They have a pronounced mucolytic and mucokinetic effect, a moderate anti-inflammatory effect, increase the synthesis of surfactant, do not increase bronchial obstruction, and practically do not cause allergic reactions. Ambroxol preparations for respiratory infections in children are prescribed 7.5-15 mg × 2-3 times a day in the form of syrup, solution and/or inhalation.

For mild to moderate BOS in children of the first three years of life, acetylcysteine ​​(ACC, Fluimucin) can be used as a mucolytic, especially in the first days of a respiratory infection, because the drug also has an antioxidant effect. At an early age, 50-100 mg × 3 times a day is prescribed. In young children, acetylcysteine ​​does not increase bronchospasm, while in older children an increase in bronchospasm is noted in almost a third of cases. Inhaled forms of acetylcysteine ​​are not used in pediatric practice, because the drug has an unpleasant odor of hydrogen sulfide.

For children with an obsessive, ineffective cough and lack of sputum, it is advisable to prescribe expectorant medications: alkaline drinks, herbal remedies, etc. Herbal remedies should be prescribed to children with allergies with caution. We can recommend plantain syrup and coltsfoot decoction. A combination of expectorants and mucolytic drugs is possible.

Thus, the program of mucolytic and expectorant therapy must be built strictly individually, taking into account the clinical features of the course of bronchial obstruction in each specific case, which should help restore adequate mucociliary clearance in the patient.

BOS that developed against the background of an acute respiratory infection is not an indication for use. antihistamines. The use of antihistamines in children with respiratory infection is justified only if acute respiratory infections are accompanied by the appearance or intensification of any allergic manifestations, as well as in children with concomitant allergic diseases in the remission stage. In this case, preference should be given to second-generation drugs that do not affect the viscosity of sputum, which is more preferable in the presence of bronchial obstruction. From 6 months of age, cetirizine (Zyrtec) is allowed at a dose of 0.25 mg/kg × 1-2 times a day (1 ml = 20 drops = 10 mg). For children over 2 years of age, lorotadine (Claritin), deslorotadine (Erius) may be prescribed; for children over 5 years of age, fexofenadine (Telfast). These drugs also have an anti-inflammatory effect. The use of first generation antihistamines (suprastin, tavegil, diphenhydramine) is limited, because they act on M-cholinergic receptors, and therefore have a pronounced “drying” effect, which is often not justified in the presence of thick and viscous bronchial secretions in children with BOS.

As bronchodilator therapy in children with bronchial obstruction of infectious origin, short-acting β2-agonists, anticholinergic drugs, short-acting theophyllines and their combination are used. Preference should be given to inhalation forms of drug administration.

It is noted that Short-acting β2-agonists(berodual, salbutamol, terbutaline, fenoterol) are the drugs of choice for reducing acute bronchial obstruction. When used inhaled, they provide a rapid (within 5-10 minutes) bronchodilator effect. They should be prescribed 3-4 times a day. Drugs in this group are highly selective and therefore have minimal side effects. However, with long-term uncontrolled use of short-acting β2-agonists, an increase in bronchial hyperreactivity and a decrease in the sensitivity of β2-adrenergic receptors to the drug. A single dose of salbutamol (Ventolin) inhaled through a spacer or air chamber is 100 - 200 mcg (1-2 doses); when using a nebulizer, a single dose can be significantly higher and is 2.5 mg (nebulas of 2.5 ml 0.1 % solution). In severe cases of BOS that is torpid to treatment, three inhalations of a short-acting β2-agonist are allowed as “emergency therapy” within 1 hour with an interval of 20 minutes.

Taking short-acting β2-agonists orally, including combined ones (Ascoril), quite often in children can be accompanied by side effects (tachycardia, tremor, convulsions). This certainly limits their use.

From the group of β2-agonists long-acting in children with acute obstructive bronchitis, only clenbuterol is used, which has a moderate bronchodilator effect.

Anticholinergic drugs block muscarinic M3 receptors for acetylcholine. The bronchodilator effect of the inhaled form of ipratropium bromide (Atrovent) develops 15-20 minutes after inhalation. Through a spacer, 2 doses (40 mcg) of the drug are inhaled once, through a nebulizer - 8-20 drops (100-250 mcg) 3-4 times a day. Anticholinergic drugs in cases of biofeedback arising from a respiratory infection are somewhat more effective than short-acting β-agonists. However, the tolerability of Atrovent in young children is somewhat worse than that of salbutamol.

A physiological feature of young children is the presence of relatively large quantityβ2-adrenergic receptors, with age there is an increase in their number and an increase in sensitivity to the action of mediators. The sensitivity of M-cholinergic receptors, as a rule, is quite high from the first months of life. These observations served as a prerequisite for the creation combination drug ov.

Most often in the complex therapy of biofeedback in children, the combination drug Berodual is currently used, combining 2 mechanisms of action: stimulation of β 2 -adrenergic receptors and blockade of M-cholinergic receptors. Berodual contains ipratropium bromide and fenoterol, the action of which in this combination is synergistic. In the best way The drug is delivered by nebulizer; a single dose in children under 5 years of age is on average 1 drop/kg body weight 3-4 times a day. In the nebulizer chamber, the drug is diluted with 2-3 ml of physiological solution.

Short-acting theophyllines (aminophylline) in our country to this day, unfortunately, they are the main drugs for relieving bronchial obstruction, including in young children. The reasons for this are the low cost of the drug, its fairly high effectiveness, ease of use and lack of awareness among doctors.

Eufillin, having bronchodilator and, to a certain extent, anti-inflammatory activity, has a large number of side effects. The main serious circumstance limiting the use of aminophylline is its small “therapeutic breadth” (the proximity of therapeutic and toxic concentrations), which requires its mandatory determination in blood plasma. It has been established that the optimal concentration of aminophylline in plasma is 8-15 mg/l. An increase in concentration to 16-20 mg/l is accompanied by a more pronounced bronchodilator effect, but at the same time it is fraught with a large number of undesirable effects on the part of the digestive system (the main symptoms are nausea, vomiting, diarrhea), the cardiovascular system (the risk of developing arrhythmias), central nervous system (insomnia, hand tremors, agitation, convulsions) and metabolic disorders. In patients taking antibioticsmacrolides or carrying a respiratory infection, observedslowing down the clearance of aminophylline, which can cause the development of complicationsdoubts even with standard dosage of the drug. The European Respiratory Society recommends the use of theophylline preparations only when monitoring its serum concentration, which does not correlate with the administered dose of the drug.

Currently, aminophylline is usually classified as a second-line drug and is prescribed when short-acting β2-agonists and M-anticholinergics are insufficiently effective. Young children are prescribed aminophylline in a mixture at the rate of 5-10 mg/kg per day, divided into 4 doses. In case of severe bronchial obstruction, aminophylline is prescribed intravenously (in saline or glucose solution) at a daily dose of up to 16-18 mg/kg divided into 4 administrations. It is not recommended to administer aminophylline intramuscularly to children, because painful injections can increase bronchial obstruction.

ANTI-INFLAMMATORYTHERAPY

Inflammation of the bronchial mucosa is the main link in the pathogenesis of bronchial obstruction that develops against the background of a respiratory infection. Therefore, the use of only mucolytic and bronchodilator drugs in these patients often cannot eliminate the “vicious circle” of disease development. In this regard, it is urgent to search for new medications aimed at reducing the activity of inflammation.

In recent years, fenspiride (Erespal) has been successfully used as a nonspecific anti-inflammatory drug for respiratory diseases in children. The anti-inflammatory mechanism of action of Erespal is caused by blocking H1-histamine and α-adrenergic receptors, reducing the formation of leukotrienes and other inflammatory mediators, suppressing the migration of effector inflammatory cells and cellular receptors. Thus, Erespal reduces the effect of the main pathogenetic factors that contribute to the development of inflammation, mucus hypersecretion, bronchial hyperreactivity and bronchial obstruction. Erespal is the drug of choice for mild to moderate BOS of infectious origin in children, especially in the presence of a hyperproductive response. The best therapeutic effect was observed with early (on the first or second day of ARI) administration of the drug.

Severe bronchial obstruction in children with acute respiratory infection of any origin requires the administration of topical glucocorticosteroids.

Severe bronchial obstruction in children with respiratory infection requires the prescription of topical (ICS) or, less commonly, systemic corticosteroids. Algorithm for the treatment of severe biofeedback, which has developedagainst the background of ARVI, is the same for biofeedback of any origin, includingbronchial asthma. This allows for timely and short-term relief of bronchial obstruction in a child, followed by a differential diagnosis to clarify the etiology of the disease.

Pulmicort can be prescribed to all children with severe bronchial obstruction that developed against the background of ARVI, regardless of the etiology of the disease that caused the development of BOS. However, these children require further examination to establish the nosological form of the disease.

The purpose of modern ICS is highly efficient and safe method therapy for severe biofeedback. In children from 6 months of age and older, the best option is inhalation of budesonide (Pulmicort) through a nebulizer at a daily dose of 0.25-1 mg/day (the volume of the inhaled solution is adjusted to 2-4 ml by adding physiologicalsky solution). The drug can be prescribed once a day; at the height of a severe attack of biofeedback in children of the first years of life, inhalation of the drug 2 times a day is more effective. In patients who have not previously received ICS, it is advisable to start with a dose of 0.25 mg every 12 hours, and on days 2-3, with a good therapeutic effect, switch to 0.25 mg once a day. It is advisable to prescribe IGS after 15-20 minutes after inhalation of a bronchodilator. The duration of therapy with inhaled corticosteroids is determined by the nature of the disease, the duration and severity of the course of biofeedback, as well as the effect of the therapy. In children with acute obstructive bronchitis with severe bronchial obstruction, the need for ICS therapy is usually 5-7 days.

INDICATIONS FOR HOSPITALIZATION OF CHILDREN WITH BRONCHO-OBSTRUCTIVE SYNDROME DEVELOPED AGAINST ARVI

Children with broncho-obstructive syndrome that developed against the background of AR-VI, including patients with bronchial asthma, should be sent to hospital treatment in the following situations:

• ineffectiveness within 1-3 hours of treatment at home;
  • severe severity of the patient’s condition;
  • children at high risk of complications
  • for social reasons;
  • if it is necessary to establish the nature and selection of therapy for the first attacks of suffocation.

The main therapeutic direction in the complex treatment of severe biofeedback in children with ARVI is anti-inflammatory therapy. The first choice drugs in this case are inhaled glucocorticosteroids (ICS), and the optimal means of delivery is a nebulizer.

Currently, only one ICS is registered for use in pediatric practice, inhalation of which is possible through a nebulizer: budesonide, produced by AstraZeneca (UK) under the name Pulmicort (suspension).

Budesonide is characterized by a rapid development of anti-inflammatory effect. So, when using Pulmicort suspension, the onset of the anti-inflammatory effect is noted within the first hour, and the maximum improvement in bronchial patency is observed after 3-6 hours. In addition, the drug significantly reduces bronchial hyperreactivity, and an improvement in functional indicators is noted within the first 3 hours from the start of therapy. Pulmicort is characterized by a high safety profile, which allows its use in children from 6 months of age.

Currently, obstructive bronchial syndrome is being diagnosed more and more often. It is characterized by their complete or partial obstruction, as a result of which a person’s breathing becomes difficult.

During an attack, patients experience strong fear death due to the inability to take a full breath. The disease occurs equally in adults and children.

This condition requires periodic observation by a doctor, as well as compliance with all recommendations and elimination of provoking factors.

What happens in the body

Bronchial obstruction is a spasm of their smooth muscles, which appears due to blockage of the lumen of the organ.

During an attack, swelling of the lung tissue occurs, which is accompanied by the release of a large amount of mucous secretion from the lungs. Phlegm obstructs air circulation, causing a person to feel severe shortness of breath and fear of death.

This can happen for a number of reasons. It is impossible to cure the disease completely. First aid involves relieving the spasm, after which it is necessary to undergo a course of treatment and carry out lifelong prevention of relapses.

Reasons for appearance

A condition such as bronchial obstruction can develop due to many reasons. Diseases influence the appearance of spasms respiratory system, and chronic diseases, not directly related to the lungs. Many predisposing factors contribute to obstructive syndrome.

The appearance of primary broncho-obstructive syndrome is always associated with the patient’s history of bronchial asthma, the main manifestation of which is a narrowing of the bronchopulmonary lumen.

Secondary broncho-obstructive syndrome is caused by:

• various allergic reactions;
• infectious diseases (for example, pneumonia, tuberculosis, cystic fibrosis and any respiratory infection);
• entry into the bronchial lumen foreign body, fluid or vomit;
• malignant and benign tumors of the lungs;
• diseases of the cardiovascular system;
• occupational hazards (for example, working with dust, gases, etc.).

Treatment will never give the desired result if there are situations in the patient’s life that predispose to obstructive syndrome. Concomitant diseases should also be cured or their stable remission achieved.

Predisposing factors

If there are factors in a person’s life that can cause bronchial obstruction syndrome, the person must eliminate them. This is especially true for patients who already have other pulmonary diseases or are genetically predisposed to them. Also, attention should be paid to predisposing factors in cases where pulmonary spasm has already been observed previously.

What indirectly affects the development of broncho-obstructive syndrome:

1. Smoking. The entry of smoke into the lungs provokes them to secrete more viscous secretion in order to get rid of foreign particles. Besides myself smoke is a strong allergen that can cause tissue swelling.
2. Alcohol abuse. Regular entry into the body ethyl alcohol significantly undermines the immune system. Due to this, the body cannot fully resist the infections that enter it. A person begins to suffer from respiratory diseases more often, which subsequently cause bronchospasm.
3. Polluted air, unsuitable living and working conditions. If a patient has to regularly deal with dust, mold or exhaust fumes, this will definitely affect the health of his respiratory system.
4. Childhood. In this case, the syndrome is explained by the immaturity of the respiratory system and weak immunity. In many ways, the appearance of bronchial obstruction in a baby is influenced by the mother’s failure to comply with all recommendations during pregnancy.

When a patient has a history of chronic diseases, and several predisposing factors are present, it is only a matter of time before lung problems appear.

Symptoms of the disease

Bronchial obstruction differs in the severity of the clinical picture and the symptoms that appear. They grow rapidly, causing a person to experience fear. Taking certain medications quickly relieves all signs of the disease, leaving no trace of it.

What indicates bronchospasm:

• expiratory shortness of breath - during it a person cannot fully exhale, while inhalation is carried out almost unhindered;
• cough - accompanied by poorly separated sputum or occurs without it;
• forced position of the body - the victim finds relief only while sitting, in a horizontal position the symptoms intensify;
• secondary signs are headache, increased heart rate, pale or bluish skin, and swollen veins in the neck.

Treatment of broncho-obstructive syndrome should be carried out by a pulmonologist after examining the patient and conducting all necessary tests. Otherwise, taking inappropriate medications can cause increased spasm.

Diagnostics

A competent specialist can make a diagnosis already at the stage of collecting anamnesis, examination and auscultation. Expiratory shortness of breath almost always indicates bronchial obstruction. If there are several predictive factors in the patient's life, the pulmonologist can be almost confident in his assumptions.

However, to confirm the diagnosis and carry out differential diagnosis, X-ray studies are performed, as well as external respiration function (PEF). This helps eliminate more serious illnesses pulmonary system.

If the spasm is caused by an allergic reaction, a blood test will indicate a significant increase in eosinophils. After all the necessary examinations, the specialist makes a final conclusion.

Treatment

Treatment of bronchial obstruction syndrome involves relieving spasms to make breathing easier.. Some medications will have to be taken in a course. As a rule, it does not last more than 2 weeks. Then maintenance therapy is prescribed, which consists of preventive measures.

All predisposing factors are excluded from a person’s life, and breathing exercises are prescribed. The victim must comply with all clinical guidelines, otherwise episodes of suffocation will be repeated on a regular basis.

First aid

When a person nearby begins to choke, anyone will become bewildered and begin to experience horror. However, at this moment the victim can and should be helped. Moreover, you don’t need to do anything supernatural for this.

How to help a patient with bronchial obstruction:

1. A window should be opened indoors. Remove suffocating clothing items and unfasten the top buttons.
2. The victim should not be placed in a horizontal position. It is better to put pillows under his back and sit him in them, preferably near a window.
3. If the attack is caused by an allergy, you should eliminate its source and drink antihistamine, which was prescribed in advance by an allergist.
4. You can take the medicine by inhalation if it is recommended by a pulmonologist.

A patient who has had a bronchospasm needs to calm down, as nervous tension can intensify symptoms.

If after all the manipulations done there is no improvement or the cause of the obstruction is a foreign body in the bronchi, it is necessary to call for medical help.

Bronchoobstruction syndrome in children

Bronchial hyperactivity syndrome in young children is not as rare a disease as it might seem at first glance. Its appearance is influenced by many different reasons. Most of them appear due to parental misbehavior or ignorance.

Possible causes of broncho-obstructive syndrome in children:

• imperfection of the respiratory system;
• allergic diseases in a child or his genetic predisposition to them(parental history is burdened with allergies or bronchial asthma);
• severe pregnancy of the mother, her smoking or chronic diseases affecting proper development crumbs;
• smoking near the baby;
• heart defects and other cardiovascular diseases;
• previous bronchitis, pneumonia;
• entry of a foreign body into the bronchi;
• various respiratory diseases, especially in the first year of life.

It is known that bronchial obstruction in children may occur due to artificial feeding, the presence of rickets or dystrophy, as well as immaturity of the immune system due to prematurity.

Symptoms that parents should pay attention to:

• the appearance of wheezing;
• extended exhalation;
• dry cough.

The child's breathing changes, becomes frequent and shallow. As a rule, shortness of breath appears only in severe forms of the disease. The baby may have trouble falling asleep or wake up in the middle of the night, take a forced position and cry in fear. In this case, parents should not panic, as this may frighten the baby even more.

Diagnosis and treatment

The child must be examined for concomitant diseases, especially if he has a regular cough and shortness of breath, which bother him in the evening and at night.

To do this, you need to undergo examination by a therapist and pulmonologist, and you may need consultations with other specialized doctors. The specialist will prescribe blood and urine tests, chest x-rays, and a respiratory function test..

Obstructive syndrome in children is easily eliminated by inhalation with various drugs. The action of the medications is aimed at relieving swelling of the mucous membrane of the lung tissue and unhindered removal of accumulated sputum.

If the baby has already experienced bronchospasm, it is necessary to pay due attention to its further prevention. Parents should monitor the air in their child's bedroom. The recommended humidity is at least 40%.

To control the atmosphere in your home, you can purchase a special air washer or humidifier.. Such a device cleans the air space in the room, eliminates volatile allergens, dust, fur, and even respiratory infections if someone is sick in the house.

The pulmonologist will also prescribe physiotherapy, which is treatment with ultrasound, current or light. To facilitate the discharge of sputum, percussion massage is indicated. You can do it yourself at home or in the hospital.

Prevention

Bronchial obstruction is the lungs' response to external stimuli . Therefore, in order to carry out high-quality prevention, these irritants should be completely or at least partially eliminated from the patient’s life.

What can be done for prevention:

1. Forget about smoking. The sick person should not smoke himself or be in a room where others are doing so. It is especially prohibited for pregnant women or relatives who are at a distance of several meters from the child to smoke.
2. Provide supportive therapy if there is a history of allergic diseases. You should regularly see a specialist and eliminate as much as possible from your daily life all factors that irritate the immune system.
3. Do not take any medications without consulting a doctor, as they can also cause bronchospasm.
4. Try to breathe sea or forest air more often, walk after rain, when the environment is maximally saturated with ozone.
5. Fulfill breathing exercises, exercise or at least do exercises.
6. Treat respiratory diseases promptly and completely.

The lack of quality therapy and prevention aggravates the further course of the disease. Relapses begin to appear more often, last much longer, and more and more serious medications are required to eliminate the symptoms. Subsequently, this can lead to the development of bronchial asthma, heart failure, pneumothorax, asphyxia and other serious conditions.

In most cases, high quality preventive actions guarantee persistent, long-term relapse.