Stepped therapy for asthma. Diagnosis and stepwise approach to the classification and treatment of bronchial asthma

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Treatment of patients bronchial asthma (BA) is complex, it includes medication and non-drug treatment in compliance with the antiallergic regime.

Two types are used for drug treatment of the disease. medicines: drugs for providing emergency assistance and prophylactic drugs for long-term control of asthma.

Emergency medications

Anticholinergics (ipratropium bromide) are less potent bronchodilators than β-agonists and tend to have a later onset of action. It should be noted that ipratropium bromide enhances the effect of 2-agonists when joint use(fixed combination with fenoterol - berodual). The method of administration is inhalation.

System glucocorticosteroids (GKS)(prednisolone, methylprednisolone, triamcinolone, dexamethasone, betamethasone). Method of administration: parenteral or oral. Oral therapy is preferred.

Short-acting theophyllines are bronchodilators that are generally less effective than inhaled ones β-adrenergic stimulants (AdS). Theophylline has significant side effects that can be avoided by properly dosing the drug and monitoring its concentration in the blood plasma. If the patient is receiving drugs with slow release of theophylline, determination of the concentration of theophylline in plasma before its administration is mandatory.

Preventive drugs for long-term control of bronchial asthma

Cromones (sodium cromoglycate and nedocromil) are inhaled non-steroidal anti-inflammatory drugs for long-term control of bronchial asthma. Effective in preventing bronchospasm caused by allergens, physical activity and cold air.

B2-agonists long acting(salmeterol, formoterol, saltos). Particularly effective in preventing nighttime asthma attacks. Used in combination with anti-inflammatory drugs. Methods of administration: oral or inhalation.

Long-acting theophyllines

Leukotriene receptor antagonists (zafirlukast, montelukast) - a new group anti-inflammatory anti-asthmatic drugs. Method of administration: oral. The drugs improve function external respiration (FVD), reduce the need for short-acting 2-agonists, are effective in preventing bronchospasm provoked by allergens and physical activity.

Systemic corticosteroids are used for severe asthma. They should be prescribed in the minimum dose for daily intake or, if possible, apply every other day.

Combination drugs

They are represented on the pharmaceutical market by two drugs: formoterol and salmeterol. The addition of long-acting 2-agonists is recommended if BA is insufficiently controlled by monotherapy with inhaled corticosteroids (starting from step 2). A number of studies have shown that the combination of inhaled corticosteroids with long-acting β2-agonists is more effective than doubling the dose of inhaled corticosteroids and leads to better control of asthma symptoms and a more significant improvement in pulmonary function.

It has also been shown to reduce the number of exacerbations and improve the quality of life in patients receiving combination therapy. Thus, the creation of combination drugs, the components of which are inhaled corticosteroids and long-acting β-agonists, was a consequence of the evolution of views on the treatment of bronchial asthma.

As mentioned above, Seretide and Symbicort are currently used as combination drugs.

Stepped approach to therapy

The goal of step therapy is to achieve asthma control using the least amount of drugs. The amount, frequency of taking and dosage of medications increase (step up) if the course of bronchial asthma worsens, and decrease (step down) if the course of asthma is well controlled. At each stage, trigger factors must be avoided or controlled.

Stage 1. Intermittent (episodic) course of asthma. Long-term therapy with anti-inflammatory drugs is usually not indicated.

Treatment includes prophylactic medication before physical activity, contact with an allergen or other provoking factor (inhaled β-agonists, cromoglycate or nedocromil). As an alternative to inhaled short-acting β-2-agonists, anticholinergics, short-acting oral β-2-agonists, or short-acting theophyllines may be suggested, although these drugs have a delayed onset of action and/or a higher risk of side effects.

Stage 2. Mild persistent course of bronchial asthma. Patients with mild persistent asthma require daily long-term preventive medication: inhaled corticosteroids 200-500 mcg/day or sodium cromoglycate or nedocromil in standard doses.

If symptoms persist despite the initial dose of inhaled corticosteroids, and the doctor is confident that the patient is using the drugs correctly, the dose of inhaled glucocorticosteroids should be increased from 400-500 to 750-800 mcg/day of beclomethasone dipropionate or an equivalent dose of another inhaled corticosteroid. Possible alternative increasing the dose of inhaled GCS, especially to control nighttime symptoms - adding to the dose of inhaled GCS no less than 50 mcg of long-acting 2-agonists (formoterol, salmeterol) at night.

If control of bronchial asthma cannot be achieved, which is expressed more frequent symptoms, an increase in the need for short-acting bronchodilators or a decrease in PEF values, then you should move to step 3.

Level 3. Average severe course BA. Patients with moderate severity of asthma require daily intake of preventive anti-inflammatory drugs to establish and maintain control of bronchial asthma. The dose of inhaled GCS should be at the level of 800-2000 mcg of beclomethasone dipropionate or an equivalent dose of another inhaled GCS.

Long-acting bronchodilators can also be prescribed in addition to inhaled corticosteroids, especially to control nocturnal symptoms (theophyllines and long-acting β-agonists can be used). Symptoms should be treated with short-acting β-agonists or alternative drugs. For more severe exacerbations, a course of treatment with oral corticosteroids should be administered.

If asthma control is not achieved, resulting in more frequent symptoms, increased need for bronchodilators, or falls peak expiratory flow (PSV), then you should go to step 4.

Stage 4. Severe asthma. In patients with severe bronchial asthma, asthma cannot be completely controlled. The goal of treatment is to achieve the best possible results: a minimum number of symptoms, a minimum requirement for short-acting β-agonists, the best possible PEF values, minimal PEF variability and minimal side effects from taking medications. Treatment is usually done with large quantity drugs that control the course of asthma.

Primary treatment includes inhaled corticosteroids in high doses (800-2000 mcg/day beclomethasone dipropionate or equivalent doses of other inhaled corticosteroids). It is recommended to add long-acting bronchodilators to inhaled corticosteroids. An anticholinergic drug (ipratropium bromide) may be used, especially in patients who experience side effects from β2-agonists.

Short-acting inhaled β-agonists can be used, if necessary, to relieve symptoms, but the frequency of dosing should not exceed 3-4 times per day. A more severe exacerbation may require a course of oral corticosteroids.

Methods for optimizing anti-asthma therapy

Block 1. The patient’s first visit to the doctor, assessment of severity, determination of patient management tactics. If the patient's condition requires emergency care, it is better to hospitalize him. At the first visit, it is difficult to accurately determine the degree of severity, since this requires knowing the fluctuations in PEF and severity clinical symptoms in a week. Be sure to consider the amount of therapy performed before your first visit to the doctor. Already prescribed therapy should be continued during the monitoring period. If necessary, additional short-acting AdS can be recommended.

If the patient is suspected to have mild asthma or medium degree severity does not require emergency treatment in full, then an introductory one-week monitoring period is prescribed. Otherwise, it is necessary to provide adequate treatment and monitor the patient for 2 weeks. The patient fills out a diary of clinical symptoms and records PEF indicators in the evening and morning hours.

Block 2. Determination of the severity of asthma and selection of appropriate treatment is carried out based on the classification of bronchial asthma by severity. A visit to the doctor is envisaged a week after the first visit, if full therapy is not prescribed.

Block 3. Two-week monitoring period during therapy. The patient fills out a diary of clinical symptoms and records PEF values.

Block 4. Assessing the effectiveness of therapy. Visit after 2 weeks during therapy.

Step up. The volume of therapy should be increased if asthma control cannot be achieved. However, it is necessary to assess whether the patient is taking medications at the appropriate level correctly and whether there is any contact with allergens or other provoking factors.

Control of bronchial asthma is considered unsatisfactory if the patient:

Episodes of coughing, wheezing, or difficulty breathing occur more than 3 times a week;
- symptoms appear at night or in the early morning hours;
- the need for the use of short-acting bronchodilators increases;
- the spread of PSV indicators increases.

Step down. A reduction in maintenance therapy is possible if asthma remains under control for at least 3 months. This helps reduce the risk of side effects and increases the patient's sensitivity to the planned treatment. Therapy should be reduced stepwise, gradually lowering the dose or eliminating additional medications. Symptoms need to be monitored clinical manifestations and physical activity indicators.

Thus, although asthma is an incurable disease, it is reasonable to expect that control over the course of the disease can and should be achieved in most patients.

It is also important to note that the approach to the diagnosis, classification and treatment of bronchial asthma, taking into account the severity of its course, allows for the creation of flexible treatment plans and special treatment programs depending on the availability of anti-asthmatic drugs, the regional healthcare system and the characteristics of a particular patient.

It should be recalled once again that one of the central places in the treatment of asthma is currently occupied by an educational program for patients and clinical observation.

Saperov V.N., Andreeva I.I., Musalimova G.G.

In the last few decades, bronchial asthma, which was previously very terrible disease both for patients and for doctors themselves, it has turned into a completely controllable disease. Today, with this pathology, you can not only breathe freely, but also actively engage in sports. And the undoubted merit in this is the joint efforts of doctors and scientists from all over the world, who formed the basic rules for the diagnosis and treatment of bronchial asthma and described them in the international conciliation document GINA. One of the chapters in this document presents a stepwise approach to treating asthma.

The main goal in the treatment of bronchial asthma in all age groups is to achieve and maintain clinical control of asthma. This concept was introduced into the vocabulary of doctors not so long ago (about 10 years). To explain approaches to prescribing stepwise therapy, one cannot do without explaining the concept of “control.”

Asthma control is a concept that applies when a patient is receiving treatment for a condition in which there are no or minimal asthma symptoms. There are levels of control that determine the stepwise treatment of asthma.

In order to determine the level of control, the following components need to be assessed:

• Frequency of attacks during the day.
• Limiting physical activity or any other activities you normally do without special effort. This may include attendance at work, and children being assessed for absences from school due to asthma.
• Frequency of attacks at night that cause the person to wake up.
• The need to take fast-acting drugs to dilate the bronchi (Salbutamol, Ventolin and others) and the number of doses used per day.
• PEF1 indicators (peak expiratory flow in the first second, measured by a peak flow meter, which ideally every asthmatic should have).

Depending on how pronounced these changes are, different levels of asthma control are distinguished. And the special significance of such gradation is that a person himself, without the intervention of a doctor, can assess his level of control and objectively understand whether treatment needs to be changed.

The following levels of asthma control are distinguished:

1. Full control. In this case, the occurrence of asthma symptoms (paroxysmal dry cough, shortness of breath, asthma attacks) is allowed, which go away after the use of short-acting beta2-agonists, and occur no more than twice a week. There are no nighttime symptoms or restrictions on any of the patient’s activities. The PSV1 value is within normal limits.


2. Partial control. There are both daytime and nighttime symptoms of asthma, which occur more than 2 times a week, but not daily, the need for emergency medications increases, and there is a limitation in physical activity or other types of activity. PSV1 is reduced to less than 80% of the individual norm.
3. Uncontrolled asthma. Daytime and nighttime attacks occur daily, significantly affecting the patient’s quality of life and activities. By and large, this level of control is an exacerbation of asthma and requires a decision from the doctor - whether to treat asthma as an exacerbation or increase the volume of basic medications.

A change in the degree of control means the need to review therapy and move to another stage of treatment. Extensive educational programs for asthmatics, where they are taught how to use inhalers, what to do in the event of an exacerbation of asthma or changes in its control, to the point that each child or adult is given a plan of action and medication adjustments.

Understanding and assessing the level of control of bronchial asthma is necessary in order to timely notice changes in the patient’s condition (both for improvement and for deterioration) and to review the amount of prescribed therapy using a stepwise approach.

Goals of step therapy

The ultimate goal of this treatment approach is to achieve complete asthma control and remission. The intermediate goal is to keep the patient in a state in which he can carry out his daily activities without being affected by the symptoms of the disease. This is achieved through constant monitoring of emerging signs and influencing them with medication according to their severity. All this happens step by step, that is, treatment of bronchial asthma is used in stages.

Achieving the goals of stepwise therapy is impossible without patient education and constant assessment of the level of compliance (patient adherence to treatment). Bronchial asthma is one of those diseases with which most patients can live with minimal loss of quality of life. But all this is only possible if you constantly work together with a doctor, since it has long been proven that there will be no effect from treatment if the patient agrees with the recommendations at the appointment, but at home does not do anything suggested.

Therefore, one of the intermediate goals of stepwise treatment of bronchial asthma is to show the patient that control of his disease is possible, you just need to put in a little effort.

In addition, one of the indirect, but no less important goals of this concept is to reduce the dose of glucocorticosteroids to the minimum at which control is possible. This is actually why all the research is being conducted and various methods and treatment regimens. This is due to the fact that when long-term use large doses of glucocorticoids develop side effects which are difficult to control and treat.

Principles of step therapy

In English literature there are such concepts as step up and step down, which means “step up” and “step down”. This means that treatment is changed depending on the current level of control: either going up one treatment step, or going down one step, as if acting step by step, and not in a chaotic order applying everything possible drugs, which are effective against asthma.

Everything is very simple. If asthma control is insufficient with the treatment that the patient is currently receiving, then the volume of therapy needs to be increased (move to a higher level). If asthma control is achieved with medication to such an extent that there are no symptoms for three months, then you can try to reduce the amount of treatment by going down one step. This approach has been tested over years of work with different patients and today it is the most effective in long-term treatment of asthma.

There are five steps to step therapy, which are more clearly presented in the table.

Steps for stepwise therapy of bronchial asthma:

Note: ICS – inhaled glucocorticosteroids; GCS – glucocorticosteroids; LABAs are long-acting β2-agonists; IgE – immunoglobulin E.

It should be remembered that decisions about changing the scope of treatment to a lower or higher level rest with the doctor.

But a well-instructed patient who knows his body, his disease and has a clear plan of action, agreed upon with the doctor in advance, can make changes in therapy himself. Naturally, by calling and notifying your allergist or pulmonologist.

Stepped therapy for bronchial asthma in children has the same principles as treatment in adults. The same groups of drugs are used, with the exception of slow-release theophyllines. Typically, these drugs can be used in patients older than 6 years. And if the child has not previously received inhaled steroids, then it is better to start therapy for bronchial asthma with anti-leukotriene drugs, thus we leave ourselves a wider field for maneuver.

An example of the use of “step up” therapy

Take a closer look at the table. The cells of the first row indicate the stages of treatment for bronchial asthma, and the columns under each stage indicate the permissible amount of treatment at each. For example, the first step of treatment is the use of beta2-agonists on demand. This is the therapy that an asthmatic in remission receives. Such treatment is permissible only when the patient has attacks extremely rarely (once every month or two or less).

If in a child or adult the level of control suddenly changes for some reason, asthma becomes partially controlled from controlled (when daytime attacks occur 2 times a week, the need for taking salbutamol increases to 2 or more times a week, etc. diagram), then move to a higher level. That is, they begin to use so-called long-term anti-inflammatory therapy, which includes several groups of drugs. In this case, either low doses of ICS or antileukotriene drugs can be used. Please note that only one thing is used. Both types of treatment are quite effective, but glucocorticoids still have their effect faster. This is an example of a step up treatment.

An example of using the "step down" treatment

“Step down” treatment is relevant when, after the prescribed amount of medication, the patient remains stable for at least three months. The criterion for this is the frequency of use of short-acting β2-agonists. If Salbutamol is used less than once a week, there are no nocturnal attacks or restrictions on activity at all, and the PSV1 level corresponds to the individual norm, then you can go one step down in treatment.

For example, the patient receives the volume of therapy corresponding to step 5: high doses of ICS + LABA + extended-release theophylline + tableted oral GCS. With this powerful and side-effect-free (let's be honest) treatment, the patient achieved control and maintained it for three months. Then the volume of treatment begins to decrease. The first step is to remove systemic tablet hormones, since they give maximum amount side effects, and we know that this is what doctors try to avoid. Such treatment will already correspond to stage 4. The patient remains on this therapy for at least another 3 months, and preferably more, since since such a volume of treatment was required, the severity of asthma is high and the degree of inflammation is in respiratory tract also high. Therefore, it is better to keep the patient on this treatment longer, so that you do not have to go back one step higher, that is, to systemic corticosteroids.

The next action in such a patient would be to remove the long-acting theophylline, wait 3 months, then reduce the ICS dose to medium, leaving the patient on the “medium-dose ICS + LABA” treatment, and gradually reduce the amount of treatment until complete control of asthma is achieved , that is, a person will not be able to do without drug treatment at all.

Thus, the choice of a step-up or step-down treatment option depends on the individual patient's current asthma control. And achieving good control depends almost entirely on the efforts of the patient himself.

Description of drugs

What groups of drugs help in implementing a stepwise approach to treatment and what is the effect of each of them?

This includes the following medications:

1. Short-acting beta2-agonists. These are “first aid” drugs. They quickly eliminate spasm of the smooth muscles of the bronchi, thereby expanding their lumen, and it becomes easier for a person to breathe. They act for 4–6 hours and, in case of overdose, tend to cause heart symptoms, as well as rebound syndrome (a condition in which, in the event of an overdose, the receptors for Salbutamol “close”). Therefore, they are recommended to use no more than 3 doses per hour (100 mcg for a child and 200 mcg for an adult). These include Salbutamol and its analogues.


2. Long-acting beta2-agonists. According to the mechanism of action, the drug is similar to Salbutamol, but lasts longer (up to 12 hours). These include Salmeterol and Formoterol.
3. Antileukotriene drugs. Montelukast, Zafirlukast, Pranlukast and their generics. They have an anti-inflammatory effect due to the inhibition of the action of leukotrienes, one of the mediators of inflammation in allergies.
4. Inhaled glucocorticosteroids. These are medications such as Flixotide, Beclazone, Budesonide, Mometasone. Most effective drugs those that have minimal side effects. Asthma is well controlled both as monotherapy and in combination with LABA. TO combination drugs include Seretide (fluticasone + salmeterol), Airtek (fluticasone + salmeterol) and Symbicort (budesonide + formoterol).
5. Systemic glucocorticosteroids. These include Prednisolone, Methylprednisolone, Polcortolone. These are drugs that have powerful anti-inflammatory and anti-edema effects that develop quickly, which is important in the fight against asthma attacks. In addition, the pronounced immunosuppressive effect is important in suppressing the synthesis of inflammatory cells, which, again, is important in this case.
6. Sustained release theophyllines. These include Aerophylline, Theophylline and others. This group of drugs has a bronchodilator effect and is also believed to have minimal anti-inflammatory effects. Valid for up to 12 hours.
7. Antibodies to immunoglobulin E. Currently introduced into clinical practice one such drug is Xolair (omalizumab). This drug is quite effective in patients with a proven immunoglobulin E-mediated disease mechanism (not all patients with asthma have high immunoglobulin E). The drug is quite expensive and has big amount side effects, and therefore is recommended only if all of the above groups of medications are ineffective.

Thus, a skillful combination of different groups of drugs, individual for each patient, will allow you to quickly achieve asthma control and improve the quality of life, as well as minimize possible side effects.

Evaluation of treatment effectiveness

Evaluation of the effectiveness of treatment, if the asthmatic’s condition does not worsen, is carried out at least 3 months after the start. In this case, every month it is necessary to monitor the current status of asthma by the attending physician and daily monitoring of the patient’s symptoms and peak exhalation flow. Patient in optimal option should keep a self-observation diary, where it is advisable to record all changes and symptoms that have occurred.

An example of a self-observation diary:

Keeping such a diary does not require much time, but it is of enormous importance for a doctor who can analyze the course of asthma. At the same time, if there is a deterioration in the condition and inhalation of short-acting β2-agonists is required, it is advisable to remember what preceded the attack. This way you can find out what triggers the attacks and avoid these events. If this is not possible, then immediately before this you need to inhale Salbutamol to prevent an attack.

If, after 3 months from the start of treatment, the doctor notes stabilization of the condition, he will change therapy. To make such a decision, it will be important to evaluate all those changes that were carefully noted in the self-observation diary. In addition, a study of the function of external respiration will be carried out in order to dynamically assess the changes that occurred during treatment. If the results of the spirogram are satisfactory, the treatment will be changed.

The stepwise approach to the treatment of asthma is now uniform throughout the world and copes well with its tasks, subject to the full cooperation of the doctor and the patient. Remember that the doctor wants to help, try to follow all the recommendations and then control of asthma will be achieved much faster.

Stepped therapy for bronchial asthma is a set of measures aimed at getting rid of the pathology and minimizing its symptoms. In total, therapy is divided into 5 levels, each of which plays a specific role. The advantage of this treatment is the control of the disease using a minimum of drugs.

Features of stepwise treatment of asthma

The disease can occur at any age and often develops chronic form. It cannot be completely cured, but you can reduce the symptoms and strengthen the patient’s immunity.

The basic principles of therapy include:

• choice the best scheme treatment, while the doctor listens to the wishes of the patient;
• monitoring the course of the disease, monitoring the patient’s condition;
• adjustment of the course of therapy;
• moving to a higher level with zero therapeutic effect;
• move to a lower level if asthma can be controlled for at least 3 months;
• if the disease is of moderate severity, and basic therapy was not carried out, then the 1st stage is skipped, and treatment begins with the 2nd;
• if asthma is uncontrollable, then it is necessary to start therapy from the 3rd stage;
• medications are used if necessary emergency care.

At each stage in the treatment of bronchial asthma, the patient must undergo certain diagnostic procedures to stop the manifestations of the disease and prevent complications from occurring. It is also necessary to determine suitable pharmaceutical drugs, because adverse reactions are likely to occur.

In adults

Since the adult body is more resistant to active substances As part of asthma medications, the doctor increases the dosage in accordance with the standards. Of course, during pregnancy or the presence of contraindications, therapy is adjusted.

It is somewhat easier to treat adult patients, since they react to changes in their health and can notify the doctor in time. Moreover, in addition to drug treatment The patient can be prescribed physiotherapeutic procedures: massages, acupuncture, thermotherapy.

In children

Pediatrics allows children to use drugs for adults. At the first stage of treatment, bronchodilators and short-acting agonists are used. At the second stage, inhaled glucocorticosteroids (ICS) are included in low dosages, but if relief does not come within 3 months, the dose is increased. At acute attacks For bronchial asthma, hormonal drugs are prescribed, but they are taken for a short time.

At the third and fourth stages, the dosage of ICS is increased, and adrenergic stimulants are added to the nebulizer solution.

Adults should teach the child how to use the inhaler, since the device must be used regularly.

Five stages of treatment

To prescribe an appropriate course of therapy, the doctor needs to determine the level of disease control using the GINA table. The classification of bronchial asthma divides the disease into 3 types:

• Controlled. The patient experiences attacks a couple of times a week, with no exacerbations or disturbances observed.
• Persistent. Signs of asthma make themselves felt more often than once every couple of days, and they can also appear at any time of the day.
• Heavy. Attacks occur around the clock and quite often. Lung function is impaired and asthma worsens every 7–10 days.

In accordance with the classification, the doctor determines the level of therapy. At the same time, drugs emergency treatment applied at any stage.

The patient’s condition is monitored every 3 months, and if exacerbations occur, the frequency is reduced to 1 month. The patient can be transferred to a lower level, but only from levels 2 and 3. At the same time, changes concern the quantity and dosage of drugs, but emergency aid remains unchanged.

It must be remembered that self-treatment prohibited, since only a doctor is competent to determine appropriate medications. You need to follow the prescription given and monitor your own well-being.

First

Patients with mild asthma fall into this stage. Symptoms are episodic, and exacerbations are quite rare. The respiratory organs are functioning normally.

The main treatment methods at the first stage are as follows:

• It is necessary to avoid irritants and not come into contact with them.
• As fast way To get rid of symptoms, inhalations of Salbutamol, Fenoterol, Terbutaline are used.
• Before training or interaction with an allergen, you should use Cromolyn sodium or short-acting P2-adrenergic agonists.

If symptoms become more severe, the doctor should consider transferring the patient to stage 2 of treatment for bronchial asthma.

Second

The course of the disease is also mild, but the frequency of exacerbations and symptoms increases: more than 1 time per week. The signs are constant, not very pronounced.

In accordance with a stepwise approach, the doctor prescribes the use of anti-inflammatory aerosols. Inhaled corticosteroids or Cromolyn sodium, which comes in powder form for dissolution, are suitable. He also prescribes Ketotifen for oral use.

If therapeutic effect is not observed, then the dosage of corticosteroids is increased in the absence of contraindications from the patient, and the following medications are also included:

• bronchodilators: Volmax, Salmeterol;
• Teo-Dur, Teotard, Filocontin and other drugs of the 1st and 2nd generation, mainly active substance which is theophylline;
• Short-acting β2-adrenergic agonists for inhalation.

If symptoms persist during sleep, the patient is transferred to level 3.

Third

Chronic asthma becomes moderately severe. Symptoms are observed every day, and the patient suffers from night attacks a couple of times a week.

IN therapeutic measures the doctor increases the daily dose of drugs to combat inflammation, however, when increasing the dosage, the patient must be constantly under the supervision of a doctor to avoid adverse reactions.

For nighttime symptoms, the patient is prescribed Theophylline drugs long acting I and II generations. P2-agonists also help, giving a prolonged effect. Troventol and Ipratropium Bromide are also used.

Fourth

Asthmatics whose disease has become severe with frequent exacerbations are transferred to this stage. During the day the symptoms are constant, but at night they appear from time to time.

Similar to the previous steps, the doctor increases the dosage of anti-inflammatory drugs. Medicines based on theophylline of the first and second generation of slow release are also used, but the dose of the drugs taken is not increased.

Inhaled and oral P2-adrenergic agonists combat night attacks: Volmax, Formoterol.

Fifth

At this stage, the same means are used as at the fourth stage, but the therapy includes hormonal medications systemic action for oral administration. They help relieve symptoms and improve well-being, but have a number of serious negative reactions. Anti-IgE antibodies are also needed in the form of injections administered subcutaneously.

Treatment of bronchial asthma is a complex procedure that requires an integrated and step-by-step approach. Thanks to a standardized method of step-by-step therapy, the patient can significantly alleviate the symptoms of the disease until they almost completely disappear. However, for a successful result, you must strictly follow the doctor’s recommendations and not take the initiative.

Stepped approach to treatment
bronchial asthma

Attention! Information provided
for informational purposes only.
Only a doctor should prescribe treatment.

Every major pharmaceutical company has its own line of drugs against asthma. In any medical institution there are usually several colorful advertising posters praising various medications. And it's no wonder that a common person may simply get confused in all this variety of anti-asthma drugs. How to treat? How to treat? What to do if the treatment is not effective? Perhaps someone has already encountered this problem. Someone might have heard about this from their relatives or friends. How to understand all the variety of drugs and treatment regimens for asthma?

The first stage includes minimal treatment, while the fifth stage includes the most strong drugs. Schematically, the stages of treatment for bronchial asthma look like this:

For example, at the first stage it is enough to use only a fast-acting adrenergic agonist. If this is not enough, then you need to move to the second step - add either inhaled GCS in a low dose or an anti-leukotriene drug

In most patients with symptoms of persistent asthma, treatment begins with step 2. However, if at initial examination If symptoms indicate a lack of asthma control, then treatment must begin at the third stage.

If the therapy the patient receives turns out to be ineffective, then you need to move to a higher level (for example, if the patient is at step 3 and the treatment does not give the desired effect, then you need to move to step 4). And vice versa, if good control over bronchial asthma is maintained for 3 months, then you can move to a lower level (under the supervision of a doctor, of course).

For the treatment of bronchial asthma in accordance with the international standard, you can contact (for residents of Rostov-on-Don and the Rostov region)

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To get rid of asthma symptoms, doctors select treatment regimens to achieve control over pathological processes. One approach is stepwise.

Thanks to this tactic, it is possible to alleviate the condition of an asthmatic and control the disease in the future.

Stepped treatment for asthma is a process in which the amount and dosage of medications is increased if the severity of the disease is not reduced and the disease is not controlled.

Initially, the doctor determines the severity of the pathology. Mild degree corresponds to the first stage of therapy, for severe pathological processes Treatment begins with the 3rd or 4th stage.

Thanks to individual approach it is possible to control the course of the disease using minimal amount medicines.

During the process of taking medications, their effectiveness is continuously assessed and prescriptions are adjusted according to indications. If the chosen tactics do not bring the desired results and the patient’s condition worsens, the dosage is increased (go to a higher level). This is done until the asthmatic’s condition stabilizes or improves.

Goals of step therapy

Components of the asthma treatment process:

1. Assessing disease control.
2. Therapy that aims to achieve control.
3. Monitoring the patient.

For bronchial asthma, the goals of stepwise therapy are:

• reduction of bronchial obstruction;
• reducing the need for bronchodilators;
• increasing patient activity and improving their quality of life;
• improvement of external respiration indicators;
• preventing seizures;
• elimination of factors that provoke exacerbation of the disease.

The condition of patients is assessed before the course of therapy to determine the dosage and regimen of medications. This is necessary to prevent asthma attacks.

If it is possible to achieve effective control of bronchial asthma for at least three months from the start of the course, the dosage is reduced.

Principles of stepwise treatment of bronchial asthma

With a stepwise approach to treatment, the doctor takes into account the patient’s condition, the frequency of attacks, and then prescribes medications. If prescriptions provide control of asthma, gradually reduce the amount of prescribed drugs or their dosage.

With partial control of the pathology, the issue of increasing the doses of medications or adding other drugs is considered.

For patients with progressive asthma who have not previously received adequate treatment, the course starts from the second stage. If bronchospasm attacks occur daily, the asthmatic is indicated for treatment immediately from the third stage.

At each stage of therapy, patients use rescue medications depending on their needs to quickly relieve symptoms of suffocation.

The effectiveness of treatment increases from step 1. The doctor selects tactics depending on the severity of bronchial asthma:

1. Mild intermittent or episodic. No more than two bronchospasm attacks per month are observed only after exposure to provoking factors. During periods of remission, a person’s well-being is satisfactory. The patient does not need long-term treatment. Medicines are prescribed only to prevent attacks.
2. Mild persistent. Attacks more often than once a week. An asthmatic experiences bronchospasms at night (no more than 2 times a month). During exacerbations it decreases physical activity and sleep is disturbed.
3. Moderately persistent. Patients experience daily attacks day and night (no more than once a week). The activity of asthmatics is reduced. Constant monitoring of pathology is necessary.
4. Persistent severe. Daily attacks during the day and at night (more than once a week) with a deterioration in the quality of life. Exacerbations develop weekly.

Five steps of asthma therapy

Treatment of bronchial asthma in stages allows you to eliminate the symptoms of the disease and increase the periods between attacks.

Tactics are selected depending on the severity of the disease.

Stage 1

Involves taking only emergency medications. This tactic is chosen for those patients who do not receive supportive treatment and periodically experience symptoms of asthma during the day.

Typically, exacerbations occur no more than twice a month. Medicines for the relief of suffocation are aerosolized β2-agonists with rapid action. Within 3 minutes, the drugs relieve symptoms, dilating the bronchi.

Possible alternative medications are oral β2-agonists or short-acting theophyllines, inhaled anticholinergic medications. But the effect of these drugs comes more slowly.

If an attack of suffocation occurs during physical activity, short-acting or rapid-acting inhalation agents are prescribed as prophylaxis.

You can also use these medications after exercise if symptoms of asthma occur. As alternative drugs Cromones are used as anti-allergy medications.

Patients are also advised to increase the duration of their warm-up before exercise to reduce the risk of bronchospasm. With the intermittent form, medications are not prescribed for long-term treatment. However, if the frequency of attacks increases, the doctor moves to the second stage.

Stage 2

Tactics are selected for people with a mild persistent form of the disease. Asthmatics have to take it daily medicines for the prevention of bronchospasms and control of pathology.

First of all, the doctor prescribes anti-inflammatory corticosteroid drugs in low dosages to be taken once a day. Fast-acting medications are used to eliminate bronchospasm.

As alternative means If the patient refuses hormones, anti-leukotriene drugs that relieve inflammation may be prescribed.

Such medications are also indicated for allergic reactions(rhinitis) and the occurrence unwanted effects from taking glucocorticoids. If shortness of breath occurs at night, one of the long-acting bronchodilators is prescribed.

It is possible to prescribe other drugs - theophyllines and cromones. However, their action is not enough for maintenance therapy. In addition, medications have side effects that worsen the patient's condition. If therapy is ineffective, move on to the next step.

Stage 3

For moderate illness, medications are prescribed to eliminate the attack and one or two drugs to control the course of the pathology. Usually the doctor prescribes the following combination:

1. inhaled glucocorticoids in small doses;
2. Long-acting β2-agonist.

With this combination, the patient receives hormonal drugs in lower dosages, and the effect of therapy is not reduced. If disease control was not achieved within three months of treatment, the dose of aerosol hormonal drugs increase.

As alternative treatment They offer patients the following combination of medications:

1. inhaled glucocorticoids in low doses;
2. antileukotriene drugs or low doses of theophyllines.

If you want to additional treatment oral corticosteroids, and symptoms worsen, proceed to next step therapy.

Stage 4

At stage 4, emergency medications and several medications for maintenance therapy are required. The choice of medications depends on the treatment in the previous stages. Doctors prefer the following combination:

1. inhaled glucocorticoids in medium or high doses;
2. inhaled long-acting β2-agonists;
3. one of the drugs as needed: slow-release theophylline, antileukotriene drugs, long-acting oral β2-agonist, oral corticosteroid.

Increasing dosages hormonal drugs needed as a temporary treatment. If after six months there is no effect, the dose is reduced due to the risk of developing undesirable effects.

The following combinations increase the effectiveness of treatment:

1. antileukotriene drugs with hormones in medium and small doses;
2. long-acting beta2-agonists with low-dose hormones with the addition of sustained-release theophyllines.

Increasing the frequency of dosing with budesonide also increases the chances of achieving disease control. If there are side effects of beta2-agonists, an anticholinergic agent containing ipratropium bromide is prescribed.

Level 5

Tactics are chosen for severe asthma. Therapy is often carried out in a hospital setting. Patients are prescribed the following medications:

1. emergency inhaled medications;
2. inhaled glucocorticoids in high doses;
3. Long-acting β2-agonist;
4. antibodies to immunoglobulin E;
5. glucocorticoids in oral form (for frequent exacerbations);
6. theophylline.

For all 5 stages of treatment for bronchial asthma, it is mandatory to maintain control over the disease for three months.

The doctor then decides to reduce the number of medications taken or reduce their dosage in order to establish a minimum amount of therapy.

Features of stepwise treatment of asthma in children

Step-by-step therapy for bronchial asthma of any form in adolescents and children is practically no different from the treatment of adults. Therapy begins with establishing the severity of the disease.

When prescribing medications, the doctor pays special attention to their side effects. The differences in treatment in children are:

1. In the persistent form without growth retardation, long-term therapy with anti-inflammatory drugs is carried out.
2. At mild stage diseases are prescribed inhaled glucocorticoids in doses that do not cause side effects The child has. As an alternative, preparations containing ipratropium bromide are offered in an age-appropriate form.
3. Second-line drugs are cromones (antiallergic drugs).
4. For moderate pathology, dosed inhaled glucocorticoids are prescribed. It is recommended to use spacers. Another treatment option is a combination of hormones with long-acting inhaled β2-agonists (allowed for children from 4 years of age).
5. To prevent seizures, a child under 4 years of age is prescribed an oral β2-agonist in the evening.

In severe cases of the disease, when symptoms bother the child regularly, sleep quality is disturbed and emphysema develops, treatment with inhaled hormones is prescribed.

The complex of therapy includes inhalations using long-acting β2-sympathomimetics (1–2 times) and oral hormones. A combination of budesonide and formoterol can be used as emergency medications.

Inhalation therapy in newborns has the following features:

1. Using a jet sprayer with a compressor. During an attack, medications containing fenoterol and salbutamol are used; for long-term therapy, medications containing budesonide and cromoglycic acid are used.
2. Use of metered aerosols with a spacer and mask.
3. If hypoxia develops, an oxygen mask is indicated.
4. IN emergency conditionsβ2-sympathomimetics are administered intravenously. If symptoms increase, adrenaline is administered subcutaneously and the baby is transferred to artificial ventilation lungs.

Drug treatment for children is supplemented with immunotherapy. Potential sources of allergens are also eliminated.

Inhalation systems must comply with the requirements childhood. Children from 7 years of age can be switched to a metered dose aerosol.

Evaluation of treatment effectiveness

Criteria effective therapy bronchial asthma are:

1. Reduced severity of symptoms.
2. Elimination of attacks at night.
3. Reducing the frequency of exacerbations of the disease.
4. Reduce the dosage of β2-agonists.
5. Increased patient activity.
6. Complete control over the disease.
7. No unwanted effects from drugs.

The doctor monitors the patient after the appointments and evaluates the body's response to the prescribed dose of medication. If necessary, the dosage is adjusted.

The stepwise approach to treatment is based on determining the minimum maintenance dose of drugs.

A good response to the use of β2-agonists during an attack is their effect for 4 hours.

In case of incomplete response to the action of the drug, the complex of therapy includes oral hormones and inhaled anticholinergic drugs. If the answer is poor, a doctor is called. The patient is taken to the intensive care unit.

Moving down a step

To make the transition to a lower level, the effectiveness of therapy is reviewed every six months or 3 months. If control over the pathology is maintained, the volume of prescriptions can be gradually reduced.

This reduces the risk of side effects of drugs in patients and improves susceptibility to further therapy.

They proceed to the next step in this way: reduce the dosage of the main drug or discontinue medications for maintenance therapy. Patients are monitored as treatment tactics change.

If there is no deterioration of the condition, monotherapy is prescribed - go to step 2. In the future, a transition to the first stage is possible.

Finally

The treatment offered for asthma at each stage is not general for all patients.

To achieve control over the disease, it is necessary to draw up an individual plan for everyone, taking into account age, characteristics of the disease, and concomitant pathologies.

In this way, you can significantly reduce the risk of exacerbations, prolong periods of remission, and eliminate or mitigate symptoms.