Chronic obstructive pulmonary disease: causes, symptoms, forms. Hoble - what is it and how is it treated Criteria for coble

Chronic obstructive pulmonary disease (COPD definition) is a pathological process characterized by partial restriction of airflow in the airways. The disease causes irreversible changes in the human body, so there is a great threat to life if the treatment was not prescribed on time.

The reasons

The pathogenesis of COPD is not yet fully understood. But experts identify the main factors that cause the pathological process. Typically, the pathogenesis of the disease involves progressive bronchial obstruction. The main factors influencing the formation of the disease are:

1. Smoking.
2. Unfavorable working conditions.
3. Damp and cold climate.
4. Mixed infection.
5. Acute lingering bronchitis.
6. Diseases of the lungs.
7. genetic predisposition.

What are the manifestations of the disease?

Chronic obstructive pulmonary disease is a pathology that is most often diagnosed in patients aged 40 years. The first symptoms of the disease that the patient begins to notice are cough and shortness of breath. Often this condition occurs in combination with wheezing when breathing and sputum secretions. At first, it comes out in a small volume. Symptoms become more pronounced in the morning.

Cough is the very first symptom that worries patients. In the cold season, respiratory diseases are exacerbated, which play an important role in the formation of COPD. Obstructive pulmonary disease has the following symptoms:

1. Shortness of breath, which bothers when performing physical exertion, and then can affect a person during rest.
2. Under the influence of dust, cold air shortness of breath increases.
3. Symptoms are complemented by an unproductive cough with sputum that is difficult to secrete.
4. Dry wheezing at a high rate during exhalation.
5. Symptoms of emphysema.

stages

The classification of COPD is based on the severity of the course of the disease. In addition, it implies the presence of a clinical picture and functional indicators.

The classification of COPD involves 4 stages:

1. The first stage - the patient does not notice any pathological abnormalities. He may be visited by a chronic cough. Organic changes are uncertain, so it is not possible to make a diagnosis of COPD at this stage.
2. The second stage - the disease is not severe. Patients go to the doctor for advice on shortness of breath during exercise. Another chronic obstructive pulmonary disease is accompanied by an intense cough.
3. The third stage of COPD is accompanied by a severe course. It is characterized by the presence of a limited intake of air into the respiratory tract, so shortness of breath is formed not only during physical exertion, but also at rest.
4. The fourth stage is an extremely difficult course. The resulting symptoms of COPD are life-threatening. Obstruction of the bronchi is observed and cor pulmonale is formed. Patients who are diagnosed with stage 4 COPD receive a disability.

Diagnostic methods

Diagnosis of the presented disease includes the following methods:

1. Spirometry is a method of research, thanks to which it is possible to determine the first manifestations of COPD.
2. Measurement of lung capacity.
3. Cytological examination of sputum. This diagnosis allows you to determine the nature and severity of the inflammatory process in the bronchi.
4. A blood test can detect an increased concentration of red blood cells, hemoglobin and hematocrit in COPD.
5. X-ray of the lungs allows you to determine the presence of compaction and changes in the bronchial walls.
6. ECG provide data on the development of pulmonary hypertension.
7. Bronchoscopy is a method that allows you to establish the diagnosis of COPD, as well as view the bronchi and determine their condition.

Treatment

Chronic obstructive pulmonary disease is a pathological process that cannot be cured. However, the doctor prescribes a certain therapy to his patient, thanks to which it is possible to reduce the frequency of exacerbations and prolong the life of a person. The course of prescribed therapy is greatly influenced by the pathogenesis of the disease, because it is very important to eliminate the cause that contributes to the occurrence of pathology. In this case, the doctor prescribes the following measures:

1. Treatment of COPD involves the use of medications, the action of which is aimed at increasing the lumen of the bronchi.
2. To liquefy sputum and remove it, mucolytic agents are used in the therapy process.
3. They help to stop the inflammatory process with the help of glucocorticoids. But their long-term use is not recommended, as serious side effects begin to occur.
4. If there is an exacerbation, then this indicates the presence of its infectious origin. In this case, the doctor prescribes antibiotics and antibacterial drugs. Their dosage is prescribed taking into account the sensitivity of the microorganism.
5. For those suffering from heart failure, oxygen therapy is necessary. In case of exacerbation, the patient is prescribed sanitary-resort treatment.
6. If the diagnosis confirms the presence of pulmonary hypertension and COPD, accompanied by reporting, then treatment includes diuretics. Glycosides help to eliminate the manifestations of arrhythmia.

COPD is a disease that cannot be treated without a properly formulated diet. The reason is that the loss of muscle mass can lead to death.

A patient may be admitted to hospital if he/she has:

• greater intensity of the increase in the severity of manifestations;
• treatment does not give the desired result;
• new symptoms appear
• the rhythm of the heart is disturbed;
• diagnostics determines diseases such as diabetes mellitus, pneumonia, insufficient performance of the kidneys and liver;
• unable to provide medical care on an outpatient basis;
• difficulties in diagnosis.

Preventive actions

Prevention of COPD includes a set of measures, thanks to which each person will be able to warn his body against this pathological process. It consists of the following recommendations:

1. Pneumonia and influenza are the most common causes of COPD. Therefore, it is essential to get flu shots every year.
2. Once every 5 years, vaccinate against pneumococcal infection, thanks to which it is possible to protect your body from pneumonia. Only the attending physician will be able to prescribe vaccination after an appropriate examination.
3. Taboo on smoking.

Complications of COPD can be very diverse, but, as a rule, they all lead to disability. Therefore, it is important to carry out treatment on time and be under the supervision of a specialist all the time. And it is best to carry out high-quality preventive measures in order to prevent the formation of a pathological process in the lungs and warn yourself against this disease.

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Diseases with similar symptoms:

Asthma is a chronic disease that is characterized by short-term attacks of suffocation, caused by spasms in the bronchi and swelling of the mucous membrane. This disease does not have a certain risk group and age restrictions. But, as medical practice shows, women suffer from asthma 2 times more often. According to official figures, there are more than 300 million people with asthma in the world today. The first symptoms of the disease appear most often in childhood. Older people suffer the disease much more difficult.

This is a progressive disease characterized by an inflammatory component, impaired bronchial patency at the level of the distal bronchi, and structural changes in the lung tissue and blood vessels. The main clinical signs are cough with the release of mucopurulent sputum, shortness of breath, discoloration of the skin (cyanosis or pinkish color). Diagnosis is based on data from spirometry, bronchoscopy, and blood gases. Treatment includes inhalation therapy, bronchodilators

General information

Chronic obstructive disease (COPD) is now isolated as an independent lung disease and delimited from a number of chronic processes of the respiratory system that occur with obstructive syndrome (obstructive bronchitis, secondary pulmonary emphysema, bronchial asthma, etc.). According to epidemiological data, COPD more often affects men over 40 years of age, occupies a leading position among the causes of disability and 4th among the causes of mortality in the active and able-bodied part of the population.

Causes of COPD

Among the causes that cause the development of chronic obstructive pulmonary disease, 90-95% is given to smoking. Among other factors (about 5%), there are occupational hazards (inhalation of harmful gases and particles), respiratory infections of childhood, concomitant bronchopulmonary pathology, and the state of the environment. In less than 1% of patients, COPD is based on a genetic predisposition, expressed in a deficiency of alpha1-antitrypsin, which is formed in the liver tissues and protects the lungs from damage by the elastase enzyme.

COPD is an occupational disease of miners, railroad workers, construction workers in contact with cement, workers in the pulp and paper and metallurgical industries, and agricultural workers involved in the processing of cotton and grain. Among the occupational hazards, the leading causes of COPD development are:

• contacts with cadmium and silicon
• metalworking
• the harmful role of products formed during the combustion of fuel.

Pathogenesis

Environmental factors and genetic predisposition cause chronic inflammatory lesions of the inner lining of the bronchi, leading to impaired local bronchial immunity. At the same time, the production of bronchial mucus increases, its viscosity increases, thereby creating favorable conditions for the reproduction of bacteria, impaired bronchial patency, changes in lung tissue and alveoli. The progression of COPD leads to the loss of a reversible component (edema of the bronchial mucosa, spasm of smooth muscles, mucus secretion) and an increase in irreversible changes leading to the development of peribronchial fibrosis and emphysema. Progressive respiratory failure in COPD may be accompanied by bacterial complications leading to recurrent lung infections.

The course of COPD is aggravated by a gas exchange disorder, manifested by a decrease in O2 and CO2 retention in arterial blood, an increase in pressure in the pulmonary artery and leading to the formation of cor pulmonale. Chronic cor pulmonale causes circulatory failure and death in 30% of patients with COPD.

Classification

International experts distinguish 4 stages in the development of chronic obstructive pulmonary disease. The criterion underlying the classification of COPD is a decrease in the ratio of FEV (forced expiratory volume) to FVC (forced vital capacity)

• Stage 0(predisease). It is characterized by an increased risk of developing COPD, but does not always transform into it. Manifested by persistent cough and sputum secretion with unchanged lung function.
• Stage I(mild COPD). Minor obstructive disorders (forced expiratory volume in 1 second - FEV1> 80% of normal), chronic cough and sputum production are detected.
• Stage II(moderate course of COPD). Progressive obstructive disorders (50%
• Stage III(severe course of COPD). Increased airflow limitation during exhalation (30%
• Stage IV(extremely severe COPD). It is manifested by a severe form of life-threatening bronchial obstruction (FEV, respiratory failure, development of cor pulmonale.

Symptoms of COPD

In the early stages, chronic obstructive pulmonary disease proceeds secretly and is not always detected on time. A characteristic clinic unfolds, starting with the moderate stage of COPD.

The course of COPD is characterized by cough with sputum and shortness of breath. In the early stages, there is an episodic cough with mucus sputum (up to 60 ml per day) and shortness of breath during intense exertion; as the severity of the disease progresses, the cough becomes constant, shortness of breath is felt at rest. With the addition of infection, the course of COPD worsens, the nature of sputum becomes purulent, and its amount increases. The course of COPD can develop in two types of clinical forms:

• Bronchitis type. In patients with the bronchitis type of COPD, the predominant manifestations are purulent inflammatory processes in the bronchi, accompanied by intoxication, cough, and copious sputum. Bronchial obstruction is pronounced significantly, pulmonary emphysema is weak. This group of patients is conditionally referred to as "blue puffers" due to diffuse blue cyanosis of the skin. The development of complications and the terminal stage occur at a young age.
• emphysematous type. With the development of COPD according to the emphysematous type, expiratory dyspnea (with difficult exhalation) comes to the fore in the symptoms. Emphysema prevails over bronchial obstruction. According to the characteristic appearance of patients (pink-gray skin, barrel-shaped chest, cachexia), they are called "pink puffers." It has a more benign course, patients tend to live to old age.

Complications

The progressive course of chronic obstructive pulmonary disease can be complicated by pneumonia, acute or chronic respiratory failure, spontaneous pneumothorax, pneumosclerosis, secondary polycythemia (erythrocytosis), congestive heart failure, etc. In severe and extremely severe COPD, patients develop pulmonary hypertension and cor pulmonale . The progressive course of COPD leads to changes in the daily activity of patients and a decrease in their quality of life.

Diagnostics

The slow and progressive course of chronic obstructive pulmonary disease raises the question of timely diagnosis of the disease, which helps to improve the quality and increase life expectancy. When collecting anamnestic data, it is necessary to pay attention to the presence of bad habits (smoking) and production factors.

• FVD research. The most important method of functional diagnostics is spirometry, which reveals the first signs of COPD. It is mandatory to measure the speed and volume indicators: vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in 1 second. (FEV1) and others in the post-bronchodilator test. The summation and ratio of these indicators makes it possible to diagnose COPD.
• Sputum analysis. Cytological examination of sputum in patients with COPD makes it possible to assess the nature and severity of bronchial inflammation, to exclude cancer alertness. Outside of exacerbation, the nature of sputum is mucous with a predominance of macrophages. In the acute phase of COPD, sputum becomes viscous, purulent.
• Blood analysis. A clinical blood test for COPD reveals polycythemia (an increase in the number of red blood cells, hematocrit, hemoglobin, blood viscosity) as a result of the development of hypoxemia in the bronchitis type of the disease. In patients with severe symptoms of respiratory failure, the gas composition of the blood is examined.
• Chest X-ray. X-ray of the lungs excludes other diseases with similar clinical manifestations. In patients with COPD, the x-ray shows compaction and deformation of the bronchial walls, emphysematous changes in the lung tissue.

ECG changes are characterized by hypertrophy of the right heart, indicating the development of pulmonary hypertension. Diagnostic bronchoscopy in COPD is indicated for differential diagnosis, examination of the bronchial mucosa and assessment of its condition, sampling of bronchial secretions for analysis.

COPD treatment

The goals of chronic obstructive pulmonary disease therapy are to slow down the progression of bronchial obstruction and respiratory failure, reduce the frequency and severity of exacerbations, improve the quality and increase the life expectancy of patients. A necessary element of complex therapy is the elimination of the cause of the disease (primarily smoking).

COPD treatment is carried out by a pulmonologist and consists of the following components:

• patient education in the use of inhalers, spacers, nebulizers, criteria for assessing their condition and self-care skills;
• the appointment of bronchodilators (drugs that expand the lumen of the bronchi);
• the appointment of mucolytics (drugs that thin sputum and facilitate its discharge);
• appointment of inhaled glucocorticosteroids;
• antibiotic therapy during exacerbations;
• oxygenation of the body and pulmonary rehabilitation.

In the case of a comprehensive, methodical and adequately selected treatment of COPD, it is possible to reduce the rate of development of respiratory failure, reduce the number of exacerbations and prolong life.

Forecast and prevention

Regarding complete recovery, the prognosis is unfavorable. The steady progression of COPD leads to disability. The prognostic criteria for COPD include: the possibility of excluding the provoking factor, the patient's compliance with recommendations and therapeutic measures, the social and economic status of the patient. An unfavorable course of COPD is observed in severe concomitant diseases, heart and respiratory failure, elderly patients, bronchitis type of the disease. A quarter of patients with severe exacerbations die within a year. COPD prevention measures include exclusion of harmful factors (smoking cessation, compliance with labor protection requirements in the presence of occupational hazards), prevention of exacerbations and other bronchopulmonary infections.

Stage II COPD - moderate

Complaints of shortness of breath during heavy exertion, exacerbations 1 time per year, FEV1 from 50% to 69% of the due value, exercise tolerance 50-75% of the level of DMPK, respiratory failure of the G degree, pulmonary heart failure hidden, detected only when physical activity, functional class - II.

Stage III COPD - severe

Complaints of shortness of breath during normal physical exertion, cough with sputum, exacerbations 2-3 times a year, unstable remissions. FEV1 - 35-49% of Respiratory Respiratory insufficiency of II degree, Pulmonary heart failure of I-II stages. Limited daily activities. Functional class - III.

Stage IV COPD - extremely severe

Complaints of persistent cough with sputum, sometimes purulent, possible hemoptysis, shortness of breath at rest, attacks of expiratory suffocation, continuously relapsing course. Completely incapacitated, in need of care. The FEV1 indicator is 35% or less of the proper value, stress tests are not possible, according to indirect data, exercise tolerance is less than 25% of the DMPC. Respiratory insufficiency III degree. Pulmonary heart failure stage II. Functional class - IV.

Prevention of chronic bronchitis

In the process of life and labor activity, a person is exposed to a whole range of factors in various combinations (dust, gases, industrial aerosols, temperature changes, drafts, smoking, etc.) According to our data, in the production of the Novgorod region, workers are exposed to the harmful effects of dust, gas pollution , 7% of respondents, the same number work in drafty conditions, 46, 3% noted the presence of irritating odors in the air of the working area. The study revealed a high prevalence of tobacco smoking among the population of the Novgorod region - 34.1% (men 57.7%, women 11.0%). In persons with a verified diagnosis of chronic bronchitis, the prevalence of tobacco smoking, according to

compared with healthy ones, 2 times higher. Moreover, the majority of smokers suffering from chronic bronchitis are men, of whom 85% have been smoking for more than 10 years. In the identified group of COPD, chronic bronchitis is 67%. The level of susceptibility to chronic bronchitis in different industries ranges from 18 to 35%, reaching 40% in some cases. At the same time, only 6-8% of this pathology is detected during periodic preventive examinations, when the disease is already at the stage of a detailed clinical picture, often with complications. As experience shows, preventive measures are most effective at the early, preclinical stages, while secondary prevention measures are less effective and require significantly higher material costs.

In this regard, the COPD prevention system should first of all provide for the identification of persons with premorbid conditions or those with an initial stage of disease development. The subsequent implementation of complex preventive measures is aimed at preventing or developing the disease.

Currently, COPD risk factors are divided into external and internal, which can be of established, high and possible significance.

Among these, smoking is of the greatest importance, because this factor is not only of independent importance in the genesis of the disease, but also significantly exacerbates the impact on the respiratory organs of unfavorable conditions of the working environment, the external atmosphere.

Early detection of COPD

The early detection program for COPD should include three main steps: I stage - preliminary fluorographic examination, preferably in three projections. If pathological changes are detected on the fluorogram, further examination is carried out by a general practitioner, pulmonologist, occupational pathologist, phthisiatrician. For employees of enterprises, according to pr. No. 555 of 29.11.89, a study of the function of external respiration must be carried out. If this is not necessary, then the patient is invited to 2 stage examination ~ screening questionnaire according to the program developed by the Department of Pulmonology of the St. Petersburg Medical Academy of Postgraduate Education based on the recommendations of WHO experts. (see appendix No. 1 - questionnaire)

Application No. 1 Questionnaire

Full name Age_ __m/f

address works (where, by whom) ______

Registered by disease

The low efficiency of the existing organizational forms of medical preventive examinations requires the development and implementation of more rational examination systems in healthcare practice using computer-based mathematical diagnostic methods based on screening.

It is known that the value of various symptoms is not the same in making a diagnosis. The processing of a large amount of medical data by various highly qualified specialists made it possible to accurately determine the diagnostic value of various symptoms and give a quantitative (discrete) expression of their significance in the form of diagnostic coefficients (DC) (Appendix, Table 1). Given that the diagnostic value of clinical and social signs at different stages of the development of chronic bronchitis is different, DC are presented in two versions:

DK1 - gives the value of the sign when distinguishing between the states of "healthy" and "sick COPD";

DK 2 - gives an assessment of the sign when recognizing the states "healthy", "initial manifestation of COPD - conditionally healthy".

The diagnostic procedure carried out by a paramedic or a shop nurse begins with a survey on the most informative signs characterizing the manifestation of bronchopulmonary pathology. In the table, these signs are numbered from 1 to 12. If the sum of the coefficients is less than -20, then the patient is diagnosed with COPD. It should be noted that the diagnostic threshold can also be achieved by summing DC1 of just a few signs. In this case, the survey is terminated and the diagnosis "sick with COPD" is made. If the sum of DK1 is greater than or equal to +20, then the diagnosis is "conditionally healthy". In the case when the value of the DC sum is greater than -20 and less than +20, the poll continues. The accumulation of diagnostic information continues until the sum of DK1 and DK 2 becomes less than -40 (diagnosed as "sick with COPD") or more than +40 (diagnosed as "healthy"). If the sum of DK1 and DK 2 after answering all 19 questions,

presented in the diagnostic table, remain less than +40 or more than -40, then the patient belongs to the COPD risk group.

The calculation of the total values ​​of DC is carried out using a simple microcalculator, and on a computer according to a specially compiled program.

According to the results of screening, taking into account the stages of formation of the main forms of COPD, three groups are distinguished:

Healthy faces, without any signs of pulmonary pathology.

Risk group - workers with preclinical manifestations of the onset of the disease, which are reversible. For what it is enough to stop irritation of the bronchopulmonary apparatus.

Patients are persons with a clinically pronounced form of COPD, which occurs both without a violation of the ventilation function of the lungs, and with its violations, as well as with the development of complications.

Persons recognized as healthy are invited to a similar examination in a year.

On the 3 stage, persons at risk and patients are examined by a therapist. Given the high prevalence of chronic diseases of the upper respiratory tract (ENT - organs), as well as extrapulmonary manifestations of allergies, an examination by an otorhinolaryngologist, allergist, pulmonologist is necessary.

Persons at risk should be employed in a timely manner in order to eliminate the effect of an irritating factor on the bronchopulmonary apparatus and are under dispensary observation with preventive measures 1-2 times a year with an assessment of the dynamics of the clinical condition.

To clarify the clinical and pathogenetic form of the disease, the severity of functional and morphological changes, patients with COPD undergo an in-depth clinical examination by a local, shop therapist (clinical blood test, sputum, examination of the function of external respiration with a pharmacological test, electrocardiography). If necessary, additional

X-ray examination, endoscopy. If it is impossible to reliably

to verify the diagnosis on an outpatient basis, the patient is sent to a specialized department of the hospital.

It is expedient to carry out a comprehensive examination according to the recommended scheme at the stage of preliminary medical examinations, when applying for a job. This will exclude cases of employment at enterprises with adverse production factors of persons with a history of allergic reactions, hay fever or aggravated heredity for respiratory diseases.

All patients and the risk group should be registered with a local, shop general practitioner or pulmonology room. They are subject to regular examination and anti-relapse treatment twice a year during the cold period.

Medical examination, prevention.

According to existing ideas about dispensary observation, it is advisable to divide the population attached to health care facilities into three groups, as mentioned earlier.

IGroup- healthy, i.e. persons who do not complain about the respiratory system and who have no chronic lung diseases in their history and during the examination. This category of the population is not subject to dispensary registration. A questionnaire survey and computer testing are conducted once every two years in order to timely identify risk factors for the development of the disease. Anti-tobacco propaganda is important.

IIGroup- these are persons with a threat of developing COPD or in a state of pre-illness. They are placed on the dispensary account. Of decisive importance for this group of people is the rejection of bad habits, the termination of contact with COPD risk factors. Of great importance are: therapeutic measures to harden the body, sanitation of foci of chronic infection, sanatorium treatment, teaching patients the principles of preventing the development of COPD. Examination is carried out 1-2 times a year with a fluorographic examination, measurement of respiratory function twice a year,

clinical blood tests, sputum. Efficiency criterion: the proportion of people (in %) who did not move to the COPD group during the year (III).

III- Group- make up patients with COPD with subdivision according to the type of nosology. They are registered for life. All of them need systematic observation and treatment by a general practitioner, a pulmonologist. The frequency of examinations, the volume of studies, the tactics of treatment, rehabilitation are determined strictly differentiated, taking into account the variant of COPD, the state of the ventilation capacity of the lungs, the presence and nature of complications. With an exacerbation of the disease, treatment is carried out inpatient or outpatient, depending on the severity of the condition. Shown seasonal anti-relapse treatment twice a year, taking into account the pathological process in a sanatorium, rehabilitation department. The purpose of clinical examination is to combat progressive respiratory failure, heart failure, maintain residual working capacity and vitality. It is important to teach the patient the skills to successfully control the course of the disease as part of an individual plan for therapeutic and preventive measures. Efficiency criteria:

The technique of anti-relapse treatment for all patients is almost the same, the principles of this therapy are based on etiopathogenetic factors in development disease and individual characteristics of the course of the disease. This takes into account the presence and severity of the inflammatory process and functional disorders, existing complications, comorbidities. The complex of treatment should include measures aimed at: restoring or improving bronchial patency and drainage function of the bronchi; to eliminate the inflammatory process; increase in the general nonspecific resistance of the organism; to fight infection; to improve the functioning of the cardiovascular system. In addition to drug therapy with an anti-relapse goal, it is necessary to apply various methods of physical influence on the body (physiotherapy, sauna, bath, laser therapy, aerosol therapy, exercise therapy, etc.), as well as a set of measures for the sanitation of the bronchial tree (positional drainage, bronchoscopic and endobronchial sanitation).

A prerequisite for ongoing anti-relapse treatmentwith COPD is that it should be in addition to the basictherapy, which, if prescribed, the patient should receiveconstantly.

For all prophylactic patients with NLD, an explanation of the dangers of smoking, the correct work orientation is important. Heavy physical activity, work with chemicals, work in a dusty room and in adverse weather conditions are contraindicated for these patients. At each regular examination in the process of dynamic observation, the doctor clarifies the previously established diagnosis, determines therapeutic measures and the frequency of repeated examinations in accordance with changes in the course of the disease, according to the indications, conducts the necessary additional consultations and studies.

At the end of the year, for each dispensary patient, an individual plan of therapeutic and preventive measures for the next year is necessarily drawn up, indications are determined

for sanatorium treatment, referral to a sanatorium, for examination and treatment in specialized hospitals.

These measures are developed taking into account the peculiarities of the course of the bronchial process, the presence of concomitant diseases, the age and profession of the patient, the conditions of his work and life. For all patients taken for dispensary observation, the "Control card of dispensary observation" is filled out. The dynamics in changing the state of health is reflected in the medical record of the outpatient (f. 025 / y). In addition to an individual assessment of the effectiveness of the medical examination of each patient, a report is compiled annually on the results of the medical examination of the entire observed contingent of patients, which reflects the following indicators: the frequency and duration of temporary disability per 1 patient per year; data on the initial exit to disability, on labor rehabilitation; the number of patients transferred from one dispensary registration group to another; mortality information. According to the State Research Center for Pulmonology of the Ministry of Health of the Russian Federation (St. Petersburg), a properly organized clinical examination with courses of anti-relapse therapy reduces the frequency of COPD exacerbations and the number of days of disability by 2-3 times.

The legislative basis of the proposed scheme is the order of the Ministry of Health of the Russian Federation dated 20.10.1997. No. 307 "On measures to improve the organization of pulmonological care for the population of the Russian Federation", its annexes No. 2, 3.

Application No. 2 Standard values ​​for peak expiratory volume flow-sv (l/min)

children (up to 15 years old)

Application №3

Estimated annual requirement for inhaled medicinal productsdrugs used to treat COPD

"With a positive response to trial treatment with corticosteroids - drugs.

Emelyanov A. V. The use of nebulizer therapy for emergency care in patients with obstructive pulmonary diseases, S-P. 2001, page 36

Kokosov A. N. Definition and classification of chronic bronchitis // In the book. "Chronic obstructive pulmonary disease", ed. A. G. Chuchalina, M. S-P. 1998, pp. 111-117

Kokosov A. N. Chronic simple (non-obstructive) bronchitis. // In the book. "Chronic obstructive pulmonary disease", ed. A. G. Chuchalina, M. S-P. 1998, pp. 117-129

Klyachkin L. M. Rehabilitation programs for COPD. // In the book. "Chronic obstructive pulmonary disease", ed. A. G. Chuchalina, M. S-P. 1998, pp. 303-305

Comprehensive prevention of COPD in industrial enterprises. // St. Petersburg, 1993 Guidelines. Prof. Korovina O. V., Gorbenko P. P. and others, p. thirty

Order of the Ministry of Health of the Russian Federation of 9. 10. 1998 No. 300 "Standards (protocols) for the diagnosis and treatment of patients with nonspecific lung diseases (adult population)".

Solovyov K. I. The prevalence of chronic nonspecific lung diseases in the population of the Novgorod region. // Interuniversity collection of the CIS countries "Clinical Medicine", v. 6, V. Novgorod, Alma-Ata, pp. 290-293.

Chronic obstructive pulmonary disease. Federal program Moscow, 1999, p. 40

Shmelev E. I., Ovcharenko S. I., Khmelkov N. G. Chronic obstructive bronchitis, // Guidelines, M. 1997, p. 16

Chronic obstructive pulmonary disease (COPD) is a disease accompanied by impaired ventilation of the lungs, that is, air entering them through. At the same time, a violation of the air supply is associated precisely with an obstructive decrease in bronchial patency. Bronchial obstruction in patients is only partially reversible, the lumen of the bronchi is not completely restored.

Pathology has a gradually progressive course. It is associated with an excessive inflammatory and obstructive response of the respiratory organs to the presence of harmful impurities, gases, and dust in the air.

Chronic obstructive pulmonary disease - what is it?

Traditionally, COPD includes obstructive bronchitis and emphysema (bloating) of the lungs.

Chronic (obstructive) bronchitis is an inflammation of the bronchial tree, which is determined clinically. A patient with has a cough with sputum. Over the past two years, a person must have been coughing for at least three months in total. If the duration of the cough is shorter, then the diagnosis of chronic bronchitis is not made. If you have, consult a doctor - early initiation of therapy can slow the progression of the pathology.

Prevalence and significance of chronic obstructive pulmonary disease

Pathology is recognized as a global problem. In some countries, it affects up to 20% of the population (for example, in Chile). On average, among people older than 40 years, chronic obstructive pulmonary disease occurs in about 11-14% of men and 8-11% of women. Among the rural population, pathology occurs approximately twice as often as among urban residents. With age, the incidence of COPD increases, and by the age of 70, every second rural resident - a man suffers from obstructive pulmonary disease.

Chronic obstructive pulmonary disease is the fourth leading cause of death in the world. Mortality from it is increasing, and there is a trend towards an increase in mortality from this pathology among women.

The economic costs associated with COPD rank first, bypassing the cost of treating patients with asthma by a factor of two. The greatest losses fall on inpatient care for patients with an advanced stage, as well as on the treatment of exacerbations of the obstructive process. Taking into account temporary disability and reduced efficiency when returning to work, economic losses in Russia exceed 24 billion rubles a year.

Chronic obstructive pulmonary disease is an important social and economic problem. It significantly impairs the quality of life of a particular patient and places a heavy burden on the healthcare system. Therefore, prevention, timely diagnosis and treatment of this disease is very important.

Causes and development of COPD

In 80-90% of cases, chronic obstructive pulmonary disease is caused by smoking. The group of smokers has the highest mortality from this pathology, they have faster irreversible changes in pulmonary ventilation, more pronounced symptoms. However, in non-smokers, pathology also occurs.

An exacerbation can develop gradually, or it can occur abruptly, for example, against the background of a bacterial infection. A severe exacerbation may result in the development or acute heart failure.

Forms of COPD

Manifestations of chronic obstructive pulmonary disease largely depend on the so-called phenotype - the totality of the individual characteristics of each patient. Traditionally, all patients are divided into two phenotypes: bronchitis and emphysematous.

In the bronchitis obstructive type, the clinic is dominated by manifestations of bronchitis - cough with sputum. In the emphysematous type, shortness of breath predominates. However, "pure" phenotypes are rare, usually there is a mixed picture of the disease.

Some clinical signs of phenotypes in COPD:

In addition to these forms, there are other phenotypes of obstructive disease. So, recently a lot has been written about the overlap phenotype, that is, the combination of COPD and. This form develops in smoking patients with asthma. It has been shown that about 25% of all patients with COPD have reversible, and eosinophils are found in their sputum. In the treatment of such patients, the use is effective.

Allocate a form of the disease, accompanied by two or more exacerbations per year or the need for hospitalization more than once a year. This indicates a severe course of obstructive disease. After each exacerbation, lung function worsens more and more. Therefore, an individual approach to the treatment of such patients is necessary.

Chronic obstructive pulmonary disease causes the body's response in the form of systemic inflammation. First of all, it affects the skeletal muscles, which increases weakness in patients with COPD. Inflammation also affects blood vessels: the development of atherosclerosis is accelerated, the risk of coronary heart disease, myocardial infarction, and stroke increases, which increases mortality among patients with COPD.

Other manifestations of systemic inflammation in this disease are osteoporosis (decrease in bone density and fractures) and anemia (decrease in the amount of hemoglobin in the blood). Neuropsychiatric disorders in COPD are represented by sleep disturbance, nightmares, depression, memory impairment.

Thus, the symptoms of the disease depend on many factors and change during the life of the patient.

Read about the diagnosis and treatment of obstructive disease.

Chronic obstructive pulmonary disease (COPD)- symptoms and treatment

What is chronic obstructive pulmonary disease (COPD)? We will analyze the causes of occurrence, diagnosis and methods of treatment in the article of Dr. Nikitin I. L., an ultrasound doctor with an experience of 25 years.

Definition of disease. Causes of the disease

Chronic obstructive pulmonary disease (COPD)- a disease that is gaining momentum, advancing in the ranking of causes of death for people over 45 years old. To date, the disease is in 6th place among the leading causes of death in the world, according to WHO forecasts in 2020, COPD will take the 3rd place.

This disease is insidious in that the main symptoms of the disease, in particular, with smoking, appear only 20 years after the start of smoking. It does not give clinical manifestations for a long time and can be asymptomatic, however, in the absence of treatment, airway obstruction imperceptibly progresses, which becomes irreversible and leads to early disability and a reduction in life expectancy in general. Therefore, the topic of COPD seems to be especially relevant today.

It is important to know that COPD is a primary chronic disease in which early diagnosis is important in the initial stages, since the disease tends to progress.

If the doctor has diagnosed Chronic Obstructive Pulmonary Disease (COPD), the patient has a number of questions: what does this mean, how dangerous is it, what to change in lifestyle, what is the prognosis for the course of the disease?

So, chronic obstructive pulmonary disease or COPD is a chronic inflammatory disease with damage to the small bronchi (airways), which leads to respiratory failure due to narrowing of the bronchial lumen. Over time, emphysema develops in the lungs. This is the name of a condition in which the elasticity of the lungs decreases, that is, their ability to contract and expand during breathing. At the same time, the lungs are constantly as if in a state of inhalation, there is always a lot of air in them, even during exhalation, which disrupts normal gas exchange and leads to the development of respiratory failure.

Causes of COPD are:

• exposure to harmful environmental factors;
• smoking;
• occupational hazard factors (dust containing cadmium, silicon);
• general environmental pollution (car exhaust gases, SO 2 , NO 2);
• frequent respiratory tract infections;
• heredity;
• deficiency of α 1 -antitrypsin.

If you experience similar symptoms, consult your doctor. Do not self-medicate - it is dangerous for your health!

Symptoms of chronic obstructive pulmonary disease

COPD- a disease of the second half of life, often develops after 40 years. The development of the disease is a gradual long process, often imperceptible to the patient.

Appeared forced to consult a doctor dyspnea and cough- the most common symptoms of the disease (shortness of breath is almost constant; cough is frequent and daily, with sputum in the morning).

The typical COPD patient is a 45-50 year old smoker who complains of frequent shortness of breath on exertion.

Cough- one of the earliest symptoms of the disease. It is often underestimated by patients. In the initial stages of the disease, the cough is episodic, but later becomes daily.

Sputum also a relatively early symptom of the disease. In the first stages, it is released in small quantities, mainly in the morning. Slimy character. Purulent copious sputum appears during an exacerbation of the disease.

Dyspnea occurs in the later stages of the disease and is noted at first only with significant and intense physical exertion, increases with respiratory diseases. In the future, shortness of breath is modified: the feeling of lack of oxygen during normal physical exertion is replaced by severe respiratory failure and intensifies over time. It is shortness of breath that becomes a common reason to see a doctor.

When can COPD be suspected?

Here are a few questions of the COPD early diagnosis algorithm:

• Do you cough several times a day? Does it bother you?
• Does coughing produce phlegm or mucus (often/daily)?
• Do you get short of breath faster/more often than your peers?
• Are you over 40?
• Do you smoke or have you ever smoked before?

If more than 2 questions are answered positively, spirometry with a bronchodilator test is necessary. When the test indicator FEV 1 / FVC ≤ 70, COPD is suspected.

Pathogenesis of chronic obstructive pulmonary disease

In COPD, both the airways and the tissue of the lung itself, the lung parenchyma, are affected.

The disease begins in the small airways with blockage of their mucus, accompanied by inflammation with the formation of peribronchial fibrosis (densification of the connective tissue) and obliteration (overgrowth of the cavity).

With the formed pathology, the bronchitis component includes:

The emphysematous component leads to the destruction of the final sections of the respiratory tract - the alveolar walls and supporting structures with the formation of significantly expanded air spaces. The absence of a tissue framework of the airways leads to their narrowing due to the tendency to dynamically collapse during expiration, which causes expiratory bronchial collapse.

In addition, the destruction of the alveolar-capillary membrane affects the gas exchange processes in the lungs, reducing their diffuse capacity. As a result, there is a decrease in oxygenation (oxygen saturation of the blood) and alveolar ventilation. Excessive ventilation of insufficiently perfused zones occurs, leading to an increase in the ventilation of the dead space and a violation of the removal of carbon dioxide CO 2 . The area of ​​the alveolar-capillary surface is reduced, but may be sufficient for gas exchange at rest, when these anomalies may not appear. However, during exercise, when the need for oxygen increases, if there are no additional reserves of gas exchange units, then hypoxemia occurs - a lack of oxygen in the blood.

The hypoxemia that appeared during long-term existence in patients with COPD includes a number of adaptive reactions. Damage to the alveolar-capillary units causes a rise in pressure in the pulmonary artery. Since the right ventricle of the heart under such conditions must develop more pressure to overcome the increased pressure in the pulmonary artery, it hypertrophies and expands (with the development of right ventricular heart failure). In addition, chronic hypoxemia can cause an increase in erythropoiesis, which subsequently increases blood viscosity and exacerbates right ventricular failure.

Classification and stages of development of chronic obstructive pulmonary disease

Complications of chronic obstructive pulmonary disease

Complications of COPD are infections, respiratory failure, and chronic cor pulmonale. Also in patients with COPD, bronchogenic carcinoma (lung cancer) is more common, although it is not a direct complication of the disease.

Respiratory failure- the state of the external respiration apparatus, in which either the maintenance of the O 2 and CO 2 tension in the arterial blood at a normal level is not ensured, or it is achieved due to the increased work of the external respiration system. It manifests itself mainly as shortness of breath.

Chronic cor pulmonale- an increase and expansion of the right parts of the heart, which occurs with an increase in blood pressure in the pulmonary circulation, which, in turn, has developed as a result of pulmonary diseases. The main complaint of patients is also shortness of breath.

Diagnosis of chronic obstructive pulmonary disease

If patients have cough, sputum production, shortness of breath, and risk factors for chronic obstructive pulmonary disease have been identified, then they should all be assumed to have a diagnosis of COPD.

In order to establish a diagnosis, data are taken into account clinical examination(complaints, anamnesis, physical examination).

Physical examination may reveal symptoms characteristic of long-term bronchitis: "watch glasses" and / or "drumsticks" (deformity of the fingers), tachypnea (rapid breathing) and shortness of breath, a change in the shape of the chest (a barrel-shaped form is characteristic of emphysema), small its mobility during breathing, the retraction of the intercostal spaces with the development of respiratory failure, the descent of the boundaries of the lungs, the change in percussion sound to a box sound, weakened vesicular breathing or dry wheezing, which increase with forced expiration (that is, a quick exhalation after a deep breath). Heart sounds can be heard with difficulty. In the later stages, diffuse cyanosis, severe shortness of breath, and peripheral edema may occur. For convenience, the disease is divided into two clinical forms: emphysematous and bronchitis. Although in practical medicine, cases of a mixed form of the disease are more common.

The most important step in diagnosing COPD is analysis of respiratory function (RF). It is necessary not only to determine the diagnosis, but also to establish the severity of the disease, draw up an individual treatment plan, determine the effectiveness of therapy, clarify the prognosis of the course of the disease and assess the ability to work. Establishing the percentage of FEV 1 / FVC is most often used in medical practice. A decrease in forced expiratory volume in the first second to the forced vital capacity of the lungs FEV 1 / FVC up to 70% is the initial sign of airflow limitation even with a preserved FEV 1 > 80% of the proper value. A low peak expiratory airflow rate that does not change significantly with bronchodilators also favors COPD. With newly diagnosed complaints and changes in respiratory function, spirometry is repeated throughout the year. Obstruction is defined as chronic if it occurs at least 3 times per year (regardless of treatment), and COPD is diagnosed.

FEV monitoring 1 is an important method for confirming the diagnosis. Spireometric measurement of FEV 1 is carried out repeatedly over several years. The norm of the annual fall in FEV 1 for people of mature age is within 30 ml per year. For patients with COPD, a typical indicator of such a drop is 50 ml per year or more.

Bronchodilator test- primary examination, in which the maximum FEV 1 is determined, the stage and severity of COPD are established, and bronchial asthma is excluded (if the result is positive), the tactics and volume of treatment are selected, the effectiveness of therapy is assessed and the course of the disease is predicted. It is very important to distinguish COPD from bronchial asthma, since these common diseases have the same clinical manifestation - broncho-obstructive syndrome. However, the approach to treating one disease is different from another. The main distinguishing feature in the diagnosis is the reversibility of bronchial obstruction, which is a characteristic feature of bronchial asthma. It has been found that people with a diagnosis of CO BL after taking a bronchodilator, the percentage increase in FEV 1 - less than 12% of the original (or ≤200 ml), and in patients with bronchial asthma, it usually exceeds 15%.

Chest x-rayhas an auxiliary value chenie, since changes appear only in the later stages of the disease.

ECG can detect changes that are characteristic of cor pulmonale.

echocardiography necessary to detect symptoms of pulmonary hypertension and changes in the right heart.

General blood analysis- it can be used to evaluate hemoglobin and hematocrit (may be increased due to erythrocytosis).

Determining the level of oxygen in the blood(SpO 2) - pulse oximetry, a non-invasive study to clarify the severity of respiratory failure, as a rule, in patients with severe bronchial obstruction. Blood oxygen saturation of less than 88%, determined at rest, indicates severe hypoxemia and the need for oxygen therapy.

Treatment of chronic obstructive pulmonary disease

Treatment for COPD helps:

• reduction of clinical manifestations;
• increasing tolerance to physical activity;
• prevention of disease progression;
• prevention and treatment of complications and exacerbations;
• improving the quality of life;
• reduction in mortality.

The main areas of treatment include:

• weakening the degree of influence of risk factors;
• educational programs;
• medical treatment.

Weakening the degree of influence of risk factors

Smoking cessation is required. This is the most effective way to reduce the risk of developing COPD.

Occupational hazards should also be controlled and reduced using adequate ventilation and air cleaners.

Educational programs

Educational programs for COPD include:

• basic knowledge about the disease and general approaches to treatment with the encouragement of patients to stop smoking;
• training on how to properly use individual inhalers, spacers, nebulizers;
• the practice of self-control using peak flow meters, the study of emergency self-help measures.

Patient education plays an important role in patient management and influences subsequent prognosis (Evidence A).

The method of peak flowmetry enables the patient to independently control the peak forced expiratory volume on a daily basis - an indicator that closely correlates with the FEV 1 value.

Patients with COPD at each stage are shown physical training programs in order to increase exercise tolerance.

Medical treatment

Pharmacotherapy for COPD depends on the stage of the disease, the severity of symptoms, the severity of bronchial obstruction, the presence of respiratory or right ventricular failure, and concomitant diseases. Drugs that fight COPD are divided into drugs to relieve an attack and to prevent the development of an attack. Preference is given to inhaled forms of drugs.

To stop rare attacks of bronchospasm, inhalations of short-acting β-agonists are prescribed: salbutamol, fenoterol.

Preparations for the prevention of seizures:

• formoterol;
• tiotropium bromide;
• combined preparations (berotek, berovent).

If the use of inhalation is not possible or their effectiveness is insufficient, then theophylline may be necessary.

With a bacterial exacerbation of COPD, antibiotics are required. Can be used: amoxicillin 0.5-1 g 3 times a day, azithromycin 500 mg for three days, clarithromycin SR 1000 mg 1 time per day, clarithromycin 500 mg 2 times a day, amoxicillin + clavulanic acid 625 mg 2 times a day, cefuroxime 750 mg twice a day.

Glucocorticosteroids, which are also administered by inhalation (beclomethasone dipropionate, fluticasone propionate), also help relieve symptoms of COPD. If COPD is stable, then the appointment of systemic glucocorticosteroids is not indicated.

Traditional expectorants and mucolytics have little positive effect in patients with COPD.

In severe patients with a partial pressure of oxygen (pO 2) of 55 mm Hg. Art. and less at rest, oxygen therapy is indicated.

Forecast. Prevention

The prognosis of the disease is affected by the stage of COPD and the number of recurrent exacerbations. At the same time, any exacerbation negatively affects the general course of the process, therefore, the earliest possible diagnosis of COPD is highly desirable. Treatment of any exacerbation of COPD should begin as early as possible. It is also important to fully treat the exacerbation, in no case is it permissible to carry it “on the legs”.

Often people decide to see a doctor for medical help, starting from the II moderate stage. At stage III, the disease begins to have a rather strong effect on the patient, the symptoms become more pronounced (increased shortness of breath and frequent exacerbations). At stage IV, there is a noticeable deterioration in the quality of life, each exacerbation becomes a threat to life. The course of the disease becomes disabling. This stage is accompanied by respiratory failure, the development of cor pulmonale is not excluded.

The prognosis of the disease is affected by patient compliance with medical recommendations, adherence to treatment and a healthy lifestyle. Continued smoking contributes to the progression of the disease. Smoking cessation leads to slower progression of the disease and slower decline in FEV 1 . Due to the fact that the disease has a progressive course, many patients are forced to take drugs for life, many require gradually increasing doses and additional funds during exacerbations.

The best means of preventing COPD are: a healthy lifestyle, including good nutrition, hardening of the body, reasonable physical activity, and the exclusion of exposure to harmful factors. Smoking cessation is an absolute condition for the prevention of exacerbations of COPD. Existing occupational hazards, when diagnosing COPD, are a sufficient reason to change jobs. Preventive measures are also avoiding hypothermia and limiting contact with those with SARS.

In order to prevent exacerbations, patients with COPD are shown annual influenza vaccination. People with COPD aged 65 years or older and patients with an FEV1< 40% показана вакцинация поливалентной пневмококковой вакциной.