What is heard in the lungs in bronchial asthma. Auscultation for bronchial asthma

Bronchial asthma is a chronic respiratory disease. Inflammatory processes occurring in the bronchi disrupt normal breathing, while the general condition of the patient is significantly deteriorating.

Auscultation is of great importance. The doctor, listening to the patient's chest, may hear wheezing or whistling sounds. They have a wide variety of origins and can be heard both on inhalation or exhalation, and when holding the breath.

Correct interpretation of what the doctor hears during the auscultation process helps in the diagnosis and treatment of AD.

Auscultation refers to the diagnostic methods used in bronchial asthma. With it, the doctor listens to the patient, identifying and classifying the murmurs in the lungs.

Two methods of auscultation are practiced:

1. Straight. Listening to the lungs is carried out without any devices. Most often, the doctor simply puts his ear to the patient's chest.
2. Indirect. This method requires a special device - a stethoscope.

In modern medicine, only the second method is used, considering the first insufficiently reliable.

Auscultation, the doctor is able not only to make a preliminary diagnosis, but also to determine the severity of the disease.

Features of auscultation

In modern medicine, the indirect method of auscultation is used. The attending physician carefully listens to the patient's breathing both on inhalation and exhalation and analyzes what he hears.

The results must be entered into the patient's outpatient card. For a more complete picture, the procedure is performed while standing and sitting.

In some cases, when the patient is unable to stand or sit for health reasons, the procedure can be performed in the supine position. Since it is in any case important to listen to all areas of the chest, the patient should take deep, full breaths in and out.

In some cases, normal listening is not enough. For such situations, there is a special technique - bronchophonia. The essence of this method lies in the fact that the patient whispers words, which include the sounds "R" and "H".

If the doctor clearly distinguishes the spoken words through the statoscope, it means that the patient has a certain seal in the lung area. It also suggests a cavity in the lungs. These signs make it possible to diagnose bronchial asthma.

In the case of listening to a healthy patient, the doctor is not able to distinguish any words (only some hissing sounds).

After completing the procedure, the doctor systematizes what he heard and draws conclusions based on the following criteria:

• compares the same noise in both lungs at symmetrical points;
• determines the type of noise, according to the accepted classification;
• detects the presence of extraneous noises uncharacteristic for BA.

Despite the fact that modern medicine has such modern diagnostic methods as radiography, bronchography, etc., auscultation is mandatory. And all other examinations are assigned only according to its results.

Breathing noises and wheezing in bronchial asthma

Auscultatory data obtained by the doctor during the initial examination of the patient, as well as when they are of great diagnostic value.

There are three types of noise:

• main:
• side;
• noises due to friction of the pleura.

Basic noises

These are noises from breathing. In medicine, there are 2 types of breathing:

• bronchial;
• vesicular.

In order to assess bronchial breathing, the following zones should be listened to:

• above the larynx;
• over the trachea;
• over the bronchi;
• in the area of ​​the seventh cervical vertebra.

In the presence of bronchial asthma, harsh sounds are heard on auscultation. For a correct diagnosis, it is important to listen to it both on inhalation and exhalation. In this case, the exhalation is always coarser and takes longer.

If you listen to other areas, the sound has a different timbre. It corresponds to vesicular respiration. The air entering the alveoli straightens their walls with a characteristic sound.

A single clinical picture can be distinguished for BA. If there is a weakening of respiratory sounds during an attack, this means that acute emphysema or pneumothorax of the lungs has developed.

"Silent lung" (in any of the departments there is no breathing) indicates a large mucous plug or severe bronchospasm, requiring urgent resuscitation.

If wheezing is monotonous, equally distributed over the entire surface of the lungs, this indicates bronchospasm.

A combination of high and low wheezing indicates prolonged exacerbation.

If the patient has a mild stage of obstruction, the noises are clearly audible only on exhalation. As the condition worsens, they begin to listen on inhalation.

Side noise

Auscultation of bronchial asthma produces crepitus and wheezing.

Wheezing, in turn, is also usually classified:

1. Dry. Arise due to narrowing of the lumen of the bronchi. This occurs with bronchial asthma, pneumonia and other inflammatory diseases. Dry wheezing may appear or disappear. They are heard both on inhalation and exhalation.
2. Wet. Occur in the case of excessive accumulation of sputum. Moist wheezing is an indicator of the presence of fluid in the lungs. It occurs when air passes through it. That is why such a noise resembles a gurgle. These wheezing sounds are best heard during inhalation, but an experienced doctor can hear them at any stage of breathing.

By tonality, there are:

1. High. They are characteristic of small bronchi.
2. Low. They arise in large and medium bronchi.

Wheezing can be heard only on inhalation or only on exhalation. In some cases, they can be heard even without the aid of any instruments. For example, with a bronchial attack, they are heard at a distance of several meters from the patient.

By localization, point is distinguished (for example, with tuberculosis) and spread throughout the cavity (bronchial asthma).

Crepitation should be singled out separately. It occurs in the alveoli when a specific fluid accumulates there, which is formed during inflammatory processes. Crepitation is well audible on inspiration. After coughing, it does not disappear.

Noises arising from friction of the pleura

The pleura in its normal state is a flat surface. If breathing is not complicated by any pathologies, the pleural sheets easily and soundlessly slide over each other.

In the presence of inflammation, a different picture arises. Irregularities are formed on the surface of the pleura. On auscultation of the lungs, the doctor will hear a crackling sound caused by the friction of these irregularities against each other.

Very often bronchial asthma develops with toxic damage to the pleura. It becomes dry and leaf nodules form on the surface.

The noise generated by them is easily audible both during inhalation and exhalation. With this type of pathology, the patient may experience pain.

There are several main differences between pleural friction and wheezing:

1. The more the statoscope is pressed against the patient's body, the more clearly the crackling sound is heard.
2. If the patient coughs frequently, wheezing changes its strength and tone. In the event of friction, the sound remains unchanged.

For a clear differentiation, doctors use a special technique: first, they ask the patient to breathe in deeply and hold the air, and then strongly stick out the stomach, imitating abdominal breathing. In this case, there is friction between the pleural petals.

The difference between asthma and other pathologies in the auscultatory picture

Through auscultation, the physician can distinguish bronchial asthma from other diseases associated with airway inflammation.

For bronchial asthma, uniform, localized rales are characteristic of the entire surface. And, for example, with tuberculosis, their localization is pointwise.

During the period of pneumonia, high-pitched noises are clearly heard. During bronchial breathing (which indicates the presence of voids in the lung), a low tone and low volume noise is possible.

In acute emphysema, a decrease in noise is noted. The wheezing is moist, the breathing is weakened.

Bronchitis is characterized by vesicular breathing with dry wheezing and crepitus.

With pleurisy, the main distinguishing feature is the noise that occurs when the pleura is rubbed. If the disease is exudative, vesicular respiration may be present.

Despite the fact that with the help of auscultation it is possible to determine the pathology that has affected the airways, the final diagnosis is made only after other, more informative modern studies.

Finally

Auscultation in bronchial asthma is of great diagnostic value. Any other study (X-ray, bronchography, and so on) is prescribed only after listening to the patient.

The characteristic wheezing and type of breathing allow the doctor to make a preliminary diagnosis and begin timely treatment.

Bronchial asthma is an infectious and allergic disease, the main signs of which are attacks or periodic states of expiratory suffocation caused by pathological hyperreactivity of the bronchi.

Classification
There is no generally accepted classification of bronchial asthma. In the classification of A.D. Ado and P.K.Bulatov, adopted in the USSR since 1968, two main forms are distinguished: atopic and infectious-allergic. In most countries of Europe and America, bronchial asthma is divided into caused by external factors and associated with internal factors.

According to modern concepts, the first corresponds to the concept of non-infectious-allergic, or atopic, bronchial asthma, the second includes cases associated with acute and chronic infectious diseases of the respiratory system, endocrine and psychogenic factors.

Each of the forms is divided into stages for pre-asthma, stage of attacks and stage of asthmatic conditions.

According to the severity of the course, mild, moderate and severe asthma are distinguished.

Infectious-dependent bronchial asthma is formed and exacerbated in connection with bacterial and especially often viral infections of the respiratory system. It is interesting that in addition to allergens, the etiological factor of the first attack of suffocation can also be psychogenic; its importance especially increases with the further course of the disease (it often provokes a recurrence of an attack of suffocation). Physical activity, as well as climatic factors (cooling, insolation), can also trigger the development of asthma.

The role of hereditary burden is also significant, primarily in atopic bronchial asthma inherited in a recessive manner with 50% penetrance. There is an opinion that the development of bronchial asthma is also promoted by some endocrine disorders and dysfunction of the pituitary gland - adrenal cortex; known, for example, exacerbation of the disease in menopause in women. Probably, the cold, damp climate, as well as air pollution, should be attributed to the predisposing factors.

The pathogenesis of bronchial asthma is complex and not fully understood. It is assumed that it consists in the formation of bronchial hyperreactivity, manifested by spasm of bronchial muscles, edema of the bronchial mucosa (due to increased vascular permeability) and mucus hypersecretion, which leads to bronchial obstruction and the development of suffocation.

Bronchial obstruction can occur both as a result of an allergic reaction and in response to exposure to nonspecific irritants - physical (inhalation of cold air, dust, etc.), chemical (ozone, sulfur dioxide), weather changes, strong odors, physical or emotional overload.

Pathological anatomy
Macroscopically, signs of emphysema, obstruction of the bronchi with mucous or mucopurulent plugs, and total bronchospasm are almost always found. Sometimes complicating pneumonia is recorded in varying degrees of severity. Microscopically, an increase in the number of goblet cells, their replacement of ciliated epithelial cells, an increase in the number of mucous glands, desquamation of the epithelium, thickening of the basement membrane, as well as a significant number of eosinophils in the walls of the bronchi, mucus and mucous plugs are found.

Clinical picture
In the pre-asthma stage, in many patients, the examination reveals polyposis, or allergic, rhinosinusitis. The manifestations of pre-asthma itself include paroxysmal cough (dry or with the release of a small amount of mucous viscous sputum), which is not relieved by conventional antitussive drugs and is eliminated by means of treating bronchial asthma. Coughing fits usually occur at night or in the early morning hours. Most often, the cough remains after suffering a respiratory viral infection or exacerbation of chronic bronchitis, pneumonia. The patient does not yet experience significant breathing difficulties.

With auscultation of the lungs, sometimes hard breathing is determined, rarely dry wheezing with forced expiration.

Eosinophilia is found in the blood and sputum. When examining the function of external respiration (FVD) before and after inhalation of adrenergic agonists, a significant increase in the expiratory power can be detected, which indicates latent bronchospasm.

In the subsequent stages of development of bronchial asthma, its main manifestations are asthma attacks, and in severe cases, also states of progressive asthma, called "asthmatic status".

Bronchial asthma attack
The atopic form is characterized by sporadic development of an attack of suffocation upon contact with an allergen. The termination of contact also determines the termination of the attack.

Asphyxiation, as a rule, is preceded by an aura, characterized by a pronounced polymorphism of manifestations (vasomotor rhinitis with abundant discharge of watery secretions, urticaria, itching of the skin, migraine, Quincke's edema, etc.). This type of attack is typical against the background of a short analysis, mainly in young people.

Attacks with an infectious-allergic form of bronchial asthma have the following distinctive features: they develop against the background of acute respiratory diseases, bronchitis or pneumonia, more often in the autumn-winter period; predominantly middle age groups are affected. The aura is mainly expressed by coughing. Asthma attacks, as a rule, are of moderate or severe degree, are prolonged, often resistant to conventional therapy, and are often transformed into an asthmatic state. The most commonly detected sensitivity to staphylococcal toxin and streptococcus.

The main clinical symptoms of an attack of suffocation are expiratory shortness of breath against the background of a sharp restriction of chest mobility (low standing of the diaphragm), wheezing, scattered dry wheezing and buzzing wheezing, constantly changing its intensity and localization, moist fine bubbling wheezing (in the presence of foci of inflammation).

The patient always takes a forced position: he sits, resting his hands on the edge of the table, bending forward significantly. The skin is pale, the accessory muscles are tense, there is tachycardia, deafness of heart sounds, the boundaries of cardiac dullness are not determined due to emphysema.

The appeared wheezing in the chest, which at first is felt only by the patient himself (or the doctor who listens to his lungs), soon become audible at a distance (distant wheezing). At the height of the attack, the patient experiences severe suffocation, difficulty not only exhaling, but also inhaling.

In the case of an infectious-allergic form of bronchial asthma, the attack ends with the discharge of a significant amount of viscous mucopurulent sputum. If the attack is delayed, then a pronounced depressive state of the patient is noted, pallor is replaced by warm cyanosis of the skin of the face and limbs.

Due to a significant increase in pressure in the small circle system, the right ventricle of the heart has to overcome significant resistance against the background of insufficient oxygen supply, which can lead to heart pains caused not by myocardial infarction, but by deep tissue hypoxia.

With percussion of the chest at this time, a box sound is determined, the lowering of the lower border of the lungs and the restriction of the respiratory mobility of the diaphragm, which is confirmed by X-ray examination, which also reveals a significant increase in the transparency of the pulmonary fields (emphysema). Other complications include functional bronchiectasis, segmental, less often lobar atelectasis, pneumonia, thrombosis; during a severe attack, fractures of those ribs may occur, to which the anterior scalene and external oblique muscles are attached. Occasionally, the formation of a spontaneous pneumothorax is possible.

When examining peripheral blood, eosinophilia and basophilia are often detected.

Urinalysis can reveal mild hematuria and albuminuria, which are the result of increased pressure in the renal circulatory system due to hypoxia.

Electrocardiographic studies often show signs of right heart overload.

X-ray examination, in addition to the above emphysema, can show depletion of the peripheral vasculature, expansion of the roots due to the central branches of the pulmonary artery. Depending on the severity of the attack, the X-ray symptoms of pulmonary hypertension and cor pulmonale may be more pronounced: bulging of the pulmonary artery, flattening of the heart waist, "drip heart".

During bronchoscopy, predominantly endobronchitis of varying severity is detected, in the case of infectious-allergic asthma - a significant number of mucopurulent plugs obstructing the lumen of the bronchi.

In the study of the function of external respiration in patients at the height of the asthma attack, a decrease in VC is recorded, the residual volume and functional residual capacity (FRC) significantly increase. The process of gas miscibility is impaired.

Distinguish between ineffective hyperventilation - with mild and medium degrees of asthma attacks and hypoventilation - with severe. According to pneumotometry indicators, pronounced disorders of bronchial conduction are revealed; in this case, the expiratory power is predominantly impaired. Oxygen consumption is dramatically increased, but its use is difficult, which reflects impaired ventilation and blood flow.

A prolonged course of an attack of suffocation can turn into a qualitatively new state of the body, designated as asthmatic status.

Asthmatic status
Status asthma is defined as a life-threatening increasing bronchial obstruction with progressive impairment of ventilation and gas exchange in the lungs, which is not relieved by bronchodilators, which are usually effective in this patient.

There are 3 options for the onset of status asthmaticus:

The rapid development of coma (sometimes observed in patients after the withdrawal of glucocorticoids),

The transition to the asthmatic status of a prolonged asthma attack,

Slow development of progressive suffocation, most often in patients with infectious-dependent bronchial asthma.

According to the severity of the patient's condition and the degree of gas exchange disturbances, there are 3 stages of status asthmaticus.

The first stage is characterized by the appearance of persistent expiratory dyspnea, against the background of which attacks of suffocation often occur, forcing patients to resort to repeated inhalations of adrenomimetics, but the latter only briefly relieve suffocation, without completely eliminating expiratory dyspnea, and after a few hours this effect is also lost. The patients are somewhat agitated.

Percussion and auscultation reveal changes similar to those in an attack of bronchial asthma, but dry wheezing is usually less abundant and high-pitched wheezing prevails. As a rule, tachycardia is determined, especially pronounced with intoxication with adrenergic agonists, when tremors of the fingers of the hands, pallor, increased systolic blood pressure are also detected; sometimes extrasystole, dilated pupils. There may be a tendency to hypocapnia in the blood.

The second stage of status asthmaticus is characterized by a severe degree of expiratory suffocation, fatigue of the respiratory muscles with a gradual decrease in the minute volume of respiration, and increasing hypoxemia. The patient is in a forced position: reclining or sitting, leaning on the edge of the bed. Excitement begins to give way to apathy. The skin of the face and trunk is cyanotic. Breathing is quickened, but less deep than in the first stage. Percussion is determined by the picture of acute swelling of the lungs, auscultatory - weakened hard breathing, in places not audible at all - zones of the "silent" lung. The number of dry wheezing decreases; abundant and quiet wheezing predominates. From the side of the cardiovascular system - tachycardia, often - extrasystole; ECG shows signs of pulmonary hypertension. Decompensated respiratory acidosis and hypercapnia develop.

The third stage is the formation of a hypoxemic coma. Clinically marked diffuse cyanosis, rapid or slow loss of consciousness with the extinction of all reflexes, "silent" lung syndrome, cardiac arrhythmia, frequent and small pulse, hypotension, collapse. The lethal outcome occurs due to paralysis of the respiratory center.

Differential diagnosis
It is carried out most often between infectious-dependent bronchial asthma and chronic obstructive bronchitis, the manifestations of which may be similar.

Eosinophilia of blood and sputum, the presence of allergic and polypous rhinosinusitis, a positive test for detecting latent bronchospasm, and the therapeutic effect of antihistamines testify in favor of bronchial asthma.

The same criteria, as well as the results of an allergic examination, are used for the differential diagnosis of bronchial asthma with asthma-like bronchospasm in lung cancer, systemic mastocytosis, when trachea or bronchi are irritated by a foreign body, when they are compressed by a tumor, enlarged lymph nodes, aortic aneurysm.

The asthma attack in bronchial asthma should be distinguished from cardiac asthma (left ventricular failure). In the case of the latter, the disease preceding the attack - cardiac etiology, the nature of shortness of breath - inspiratory, with auscultation - moist rales, mainly in the lower parts of the lungs; there are swelling of the lower extremities and an increase in the liver; therapeutic effect - from heart and urinary remedies.

Forecast
The long course of the disease usually leads to severe disability. The prognosis is especially unfavorable in older age groups. However, with properly carried out complex treatment, adequate supportive therapy, the allergic process subsides. Desensitization is especially important in atopic bronchial asthma; in the case of infectious-allergic genesis of the disease, prevention of exacerbation of chronic infectious processes in the patient's body is of great importance.

Treatment
Treatment should be long-term, persistent and complex. Most often, it is aimed at achieving remission of the disease and preventing its exacerbations, preventing asthma attacks. Methods of treating bronchial asthma can be conditionally divided into specific, used for atopic bronchial asthma, and nonspecific, used for all forms of asthma, including drug therapy, physiotherapy, spa treatment, psychotherapy, acupuncture, exercise therapy.

Specific treatment methods, used mainly by allergists, are aimed at limiting or stopping contact with identified allergens and desensitization by specific immunotherapy.

Nonspecific drug therapy of patients with bronchial asthma should be carried out very carefully. It is known that some drugs are absolutely contraindicated in this disease, as they can provoke an attack of suffocation. These include cholinomimetics (even pilocarpine in eye drops), cholinesterase inhibitors (physostigmine), B-blockers (anaprilin, obzidan, etc.); undesirable - rauwolfia preparations; opiates; penicillin - the latter often provokes allergies. Really effective drugs used in bronchial asthma include: bronchodilators (these are B-adrenomimetics and xanthine derivatives: aminophylline, caffeine), as well as intal and glucocorticoids. Basic treatment for asthma patients usually involves the use of drugs from one or two of these groups.

For relief of mild attacks of suffocation, alupent, berotek are often used, as well as atrovent, berodual, salbutamol, contained in manual metered-dose inhalers. So, if attacks occur at night, they can be prevented by evening inhalation of a bronchodilator immediately before bedtime.

In case of mild, but frequent attacks during the day, it is recommended to use inhalations of these drugs, 1-2 doses from 3 to 6-8 times a day without medical supervision. Often prescribed adrenomimetics tablets or rectally (in enemas or suppositories), which allows you to lengthen the time of action of drugs that prevent an attack by 2-3 hours.

Ephedrine, theofedrine, antasman, oral aminophylline (in powders, mixtures, tablets), prolonged theophylline preparations are widely used.

Expectorants are auxiliary used: potassium iodide, bromhexine, mucosalvin, which increase the effectiveness of bronchial drainage. Intal, which stabilizes mast cells, is prescribed in order to achieve remission during bronchial asthma, although it does not have the ability to stop an attack that has arisen. For the same purpose, ketotifen (zaditek) is prescribed, which has an even wider spectrum of action.

When stopping severe attacks of bronchial asthma, intravenous administration of aminophylline is most often prescribed, which, in addition to bronchodilator, also has a hypotensive effect in the system of the pulmonary circulation.

To correct the tachycardia caused by aminophylline, especially in patients with concomitant pulmonary heart failure, the introduction of cardiac glycosides (korglikon, strophanthin) is used. If the therapy is unsuccessful, glucocorticoids are prescribed in patients with severe asthma attacks.

When the need arises for the first time to use them, for example, in connection with asthmatic status, one should strive to cancel them in the next 3-5 days, regardless of the value of the initial daily dose, since the formation of a hormone-dependent course of bronchial asthma and the likelihood of known side effects is determined not so much by the daily and course doses, how much by the duration of their use.

Treatment of an attack of bronchial asthma - with a mild course, it is carried out by the patient himself according to the previously received doctor's recommendations: inhalation of adrenomimetics (alupent, salbutomol, berotek, etc.) or a combined drug (berodual, berotek, atrovent). Without the supervision of a doctor, inhalations are allowed no more than 8 times a day. For a moderate to severe attack, a doctor provides emergency assistance. Begin with the introduction of 5-10 ml of a 2.4% solution of aminophylline into a vein.

At the same time, to obtain an expectorant and enhance the bronchodilator effect, the patient is given 2-3 glasses of hot milk with the addition of Borjomi 1: 1 or sodium bicarbonate (1/2 tsp per glass), tea from breast herbal preparations. In some cases, the resolution of seizures is facilitated by simple means of reflex therapy: placing hands and feet in hot water, rubbing the skin of the limbs and chest, using mustard plasters, etc.

Attention should be paid to the mental state of the patient, to calm him down, to instill confidence in the early resolution of the attack, since often there is a state of "respiratory panic" - an irrational increase in the frequency and dysrhythmia of breathing, aggravating the impairment of ventilation of the lungs. In the absence of positive dynamics with ongoing drug therapy (after the first injection of aminophylline, inhalation is given 1-2 times, epinephrine or ephedrine subcutaneously), 60 ml of prednisolone (or 8 ml of dexamethasone) is administered intravenously and the patient is hospitalized with suspicion of developing status asthmaticus.

Treatment of status asthmaticus, and, if necessary, all resuscitation measures are carried out only in a hospital.

In stage I, these are glucocorticoids administered orally and parenterally; intravenous drip - aminophylline; to improve bronchial drainage - 3% solution of potassium iodide, 20 ml every 3-4 hours - 2-3 days; on isotonic sodium chloride solution, a 5.5% glucose solution, polyglucin, rheopolyglucin is injected, vibration massage of the chest is performed.

In stage II, additional measures are taken to eliminate hypoxemia. Inhalation of the helium-oxygen mixture is used. If the obstruction of the bronchi still grows, sometimes bronchoscopic lavage is used, that is, washing the bronchial tree with saline sodium chloride under anesthesia. In stage III - against the background of artificial ventilation of the lungs, the bronchial tree is washed and cleaned through the endotracheal tube in combination with an active shock massage of the chest.

The aim of the study is to determine the height of the apexes of the lungs in front and behind, the width of the Kroenig fields, the lower borders of the lungs and the mobility of the lower border of the lungs. Topographic percussion rules:

percussion is carried out from the loud-sounding organ to the dull-sounding organ, that is, from clear to dull;

the finger-plessimeter is located parallel to the defined boundary;

the border of the organ is marked on the side of the plessimeter finger facing the organ giving a clear pulmonary sound.

Determination of the upper boundaries of the lungs is performed by percussion of the pulmonary tops in front of the clavicle or behind the spine of the scapula. In front, a plessimeter finger is placed over the clavicle and percussed upward and medially until the sound dulls (the tip of the finger should follow the posterior edge of the sternocleidomastoid muscle). Behind percussion from the middle of the supraspinatus fossa towards the VII cervical vertebra. Normally, the height of the apex of the lungs is determined in front by 3-4 cm above the clavicle, and behind it is at the level of the spinous process of the VII cervical vertebra. The patient is in a standing or sitting position, and the doctor is standing. Percussion is carried out with a weak beat (quiet percussion). Topographic percussion begins with determining the height of the tops and the width of the Kroenig fields.

Diagnosis of bronchial asthma: basic methods

Bronchial asthma is a chronic disease of the respiratory system associated with increased bronchial reactivity to certain environmental factors. Diagnosis of bronchial asthma is an important task in the daily practice of a general practitioner, since correct treatment can ensure control over the disease and the complete absence of symptoms of suffocation in patients.

Physical examination

First of all, the doctor must interview the patient, collect anamnesis, and use the methods of auscultation and percussion of the chest organs to make a preliminary diagnosis.

Taking anamnesis

• As a rule, the disease begins at a young or childhood age, genetic prerequisites for the development of the disease can be traced. Blood relatives have other allergic diseases or bronchial asthma.
• The attack can be associated with the impact of a specific provoking factor (or factors), it develops sharply, there is shortness of breath with difficult exhalation, a feeling of congestion in the chest. Such a factor (trigger) can be physical effort, cold air, pollen, animal hair and skin, bird feathers, house dust, mold, certain foods and much more.
• Patients assume a forced position. which facilitates the participation of the auxiliary muscles in the breathing process. Wheezing, shortness of breath is heard from a distance. The attack can last from several minutes to several hours, after inhalation of a bronchodilator, normal breathing is restored very quickly. The attack ends with the discharge of a large amount of light vitreous sputum, which brings relief to the patient.

Patient examination

At the initial stages of the disease, examination of the patient does not give any special findings in terms of confirming the diagnosis of bronchial asthma. However, with a prolonged course of the disease and frequent attacks, a symptom such as a "barrel chest" develops. Indeed, due to difficulty in exhaling, emphysema of the lungs gradually develops, their volume increases, the chest expands.

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Treatment for bronchial asthma should be selected individually, taking into account the course of the course,

Bronchial asthma

Bronchial asthma is a chronic disease that occurs with relapses, with a predominant lesion of the respiratory tract, which is based on chronic allergic inflammation of the bronchi, accompanied by their hyperreactivity and recurrent attacks of shortness of breath and suffocation as a result of widespread bronchial obstruction, which is caused by bronchospasm, hypersecretion of mucus, edema bronchial walls.

There are two forms of bronchial asthma - immunological and non-immunological - and a number of clinical and pathogenetic variants: infectious-allergic, atopic, autoimmune, adrenergic imbalance, dyshormonal, neuropsychic, primary altered bronchial reactivity, cholinergic.

Etiology and risk factors for bronchial asthma in children: atopy, bronchial hyperreactivity, heredity. Causes (sensitizing): household allergens (house dust, house dust mites), epidermal allergens of animals, birds, and other insects, fungal allergens, pollen allergens, food allergens, drugs, viruses and vaccines, chemicals.

The general pathogenetic mechanism is the altered sensitivity and reactivity of the bronchi, the determination of bronchial patency by reaction in response to the influence of physical, chemical, and pharmacological factors.

Topographic chest percussion

Using topographic percussion of the lungs, the following is determined:

a) the lower borders of the lungs;
b) the upper boundaries of the lungs, or the height of the standing of the tops of the lungs, as well as their width (Krenig fields);
c) the mobility of the lower edge of the lungs.

The volume of one or both lungs in various diseases can increase or decrease. This is detected during percussion by a change in the position of the pulmonary edges compared to normal. The position of the edges of the lungs is determined by normal breathing.

Rice. 30. Determination of the boundaries of the lungs:
a, b, c - lower front and back and its diagram;
d, e, f - top front, back, and its measurement.

The lower boundaries of the lungs are set as follows. They overkut by moving the finger-plessimeter along the intercostal spaces from top to bottom (starting from the II intercostal space) until the clear pulmonary sound is replaced by an absolutely dull sound. In this case, as noted, weak percussion is applied. It is carried out along all the identification vertical lines from two sides, starting from the peristernal and ending with the paravertebral (Fig. 30, a, b). On the left mid-clavicular, and sometimes along the anterior axillary lines, the lower edge of the lung is rather difficult to determine, since here it borders on the stomach containing air. Having determined the position of the lower edge of the lung along all lines and marking this place with points at the level of each of them, the latter are connected with a solid line, which will be the projection of the lower edge of the lung onto the chest (Fig. 30, c). The lower edge of the lung in a healthy person with percussion in an upright position passes along the perusternal line on the right - along the upper edge of the VI rib, on the left - along the lower edge of IV (here is the upper border of the absolute dullness of the heart), as well as along the right and left mid-clavicular lines - along the lower edge of the VI rib, along the anterior axillary - on the VII rib, middle axillary - on the VIII, posterior axillary - on the IX, scapular - on the X rib and along the paravertebral lines at the level of the spinous process of the XI thoracic vertebra.

Medical Textbook / Propedeutics of Internal Diseases / Bronchial Asthma

Expiratory shortness of breath, characterized by sharply obstructed exhalation, while inhalation is made short, and exhalation is elongated; suffocation attacks that occur at any time of the day, especially in frosty weather, in strong winds, during the flowering period of some flowers, etc. paroxysmal cough with the discharge of a scant amount of viscous glassy sputum. Asthma attacks last from several hours to 2 or more days (status asthmaticus).

Anamnesis in a patient with an infectious-allergic form of bronchial asthma: indications of previous diseases of the upper respiratory tract (rhinitis, sinusitis, laryngitis, etc.), bronchitis and pneumonia, the occurrence of the first attacks of suffocation after them. Find out the frequency of occurrence of asthma attacks in subsequent years, their relationship with cold and damp weather, acute respiratory diseases (influenza, bronchitis, pneumonia). The duration of the onset and interictal periods of the disease, the effectiveness of treatment in outpatient and inpatient conditions, the use of medications, corticosteroid drugs are assessed. From complications, the formation of pneumosclerosis, pulmonary emphysema, the addition of respiratory and pulmonary heart failure is possible.

Anamnesis of a patient with atopic form of bronchial asthma: exacerbations of the disease are seasonal, accompanied by rhinitis, conjunctivitis; patients have urticaria and Quincke's edema, intolerance to certain foods (eggs, chocolate, oranges, etc.), drugs, odorous substances, a hereditary predisposition to allergic diseases is noted.

Interview a patient with bronchial asthma and identify complaints:

expiratory shortness of breath, characterized by sharply obstructed exhalation, while the inhalation is short and the exhalation is elongated; suffocation attacks that occur at any time of the day, especially at night or in the early morning, in frosty weather, in strong winds, during the flowering period of some plants and lasting from several hours to 2 or more days (asthmatic condition), paroxysmal cough with scant discharge the amount of viscous, vitreous sputum that occurs after physical exertion, when inhaling allergens, aggravated at night or upon awakening; the appearance of episodes of wheezing or a feeling of compression in the chest under the above conditions.

Take a history of the patient with an infectious-allergic form of bronchial asthma: indications of the transferred diseases of the upper respiratory tract (rhinitis, sinusitis, laryngitis, etc.), bronchitis and pneumonia; the occurrence of the first attacks of suffocation after them; a cold that "descends into the chest" or lasts more than 10 days. In subsequent years, the frequency of occurrence of asthma attacks, their relationship with cold, damp weather, acute respiratory diseases (influenza, bronchitis, pneumonia). The duration of the onset and inter-onset periods of the disease. The effectiveness of treatment and its results in an outpatient, inpatient setting. The use of medications, corticosteroid drugs. The presence of complications - the formation of pneumosclerosis, pulmonary emphysema, the addition of respiratory and pulmonary heart failure.

Take a history of the patient with atonic form of bronchial asthma: exacerbations of the disease are seasonal, accompanied by rhinitis, conjunctivitis; patients have urticaria, Quincke's edema, intolerance to certain foods (eggs, chocolate, oranges, etc.), drugs, odorous substances, a hereditary predisposition to allergic diseases is noted.

Conduct a general examination of the patient. Assess the patient's condition (which may be difficult), position in bed: during an attack of bronchial asthma, the patient takes a forced position, usually sitting in bed, resting his hands on his knees or the back of a chair. The patient breathes loudly, often, with a whistle and noise, the mouth is open, the nostrils are flared. When you exhale, swelling of the neck veins appears, which decreases with inhalation. Spilled diffuse cyanosis is noted.

Identify the symptoms of bronchial asthma in a patient by examining the respiratory system: when viewed from the chest of an emphysematous form, during an attack it expands and takes an inspiratory position (in the position of maximum inspiration). The auxiliary muscles, the muscles of the shoulder girdle, back, and abdominal wall are actively involved in breathing. On palpation, a rigid chest is determined, a weakening of vocal tremors in all sections due to increased airiness of the lung tissue. With comparative percussion, the appearance of a boxed sound over the entire surface of the lungs is noted, with topographic percussion: displacement of the boundaries up and down, an increase in the width of the Kroenig fields, limitation of the mobility of the lower pulmonary margin. During auscultation of the lungs against the background of weakened breathing, a large number of dry wheezing rales are heard, often heard even at a distance. Bronchophonia is weakened over the entire surface of the lungs.

Identify the symptoms of bronchial asthma when examining the cardiovascular system: on examination, the apical impulse is not detected, swelling of the cervical veins is noted. On palpation, the apical impulse is weakened, limited or undetectable. The boundaries of the relative dullness of the heart during percussion are determined with difficulty, and the absolute one is not determined due to acute distension of the lungs. On auscultation, the heart sounds are weakened (due to the presence of pulmonary emphysema), the accent of the II tone over the pulmonary artery, tachycardia.

In laboratory research a patient with bronchial asthma in the peripheral blood is characterized by the appearance of eosinophilia and moderate lymphocytosis. When examining sputum, it is a vitreous, viscous mucous membrane; microscopic examination finds many eosinophils, often Kurshman's spirals and Charcot-Leiden crystals.

Identify the symptoms of bronchial asthma in a patient with a chest x-ray: there is an increase in the transparency of the pulmonary fields and limitation of the mobility of the diaphragm.

Assess the function of external respiration: for bronchial asthma is characterized, first of all, by a decrease in the parameters of bronchial patency (FEV I of the Tiffno test). Bronchial obstruction is reversible. There is an increase in RO and OEL.

Differentiate an attack of bronchial asthma from an attack of cardiac asthma(see table 6) and bronchial asthma from chronic obstructive bronchitis(see Table 7).

Is a chronic non-infectious disease of the respiratory tract of an inflammatory nature. An attack of bronchial asthma often develops after precursors and is characterized by a short, sharp breath and a noisy prolonged exhalation. It is usually accompanied by a cough with viscous phlegm and loud wheezing sounds. Diagnostic methods include the assessment of spirometry data, peak flowmetry, allergy tests, clinical and immunological blood tests. In the treatment, aerosol beta-adrenomimetics, m-anticholinergics, ASIT are used; in severe forms of the disease, glucocorticosteroids are used.

ICD-10

J45 Asthma

General information

Over the past two decades, the incidence of bronchial asthma (BA) has increased, and today there are about 300 million asthmatics in the world. This is one of the most common chronic diseases to which all people are susceptible, regardless of gender and age. Mortality among patients with bronchial asthma is quite high. The fact that in the past twenty years the incidence of bronchial asthma in children has been constantly growing, makes bronchial asthma not just a disease, but a social problem, to combat which maximum efforts are directed. Despite its complexity, bronchial asthma responds well to treatment, thanks to which a persistent and long-term remission can be achieved. Constant control over their condition allows patients to completely prevent the onset of asthma attacks, reduce or eliminate the use of drugs for stopping attacks, as well as lead an active lifestyle. This helps to maintain lung function and completely eliminate the risk of complications.

Causes

The most dangerous provoking factors for the development of bronchial asthma are exogenous allergens, laboratory tests for which confirm a high level of sensitivity in BA patients and in those at risk. The most common allergens are household allergens - house and book dust, food for aquarium fish and animal dander, plant allergens and food allergens, which are also called nutritional allergens. In 20-40% of patients with bronchial asthma, a similar reaction to drugs is revealed, and in 2% the disease is obtained as a result of working in hazardous industries or, for example, in perfumery stores.

Infectious factors are also an important link in the etiopathogenesis of bronchial asthma, since microorganisms and their metabolic products can act as allergens, causing sensitization of the body. In addition, constant contact with the infection maintains the inflammatory process of the bronchial tree in the active phase, which increases the body's sensitivity to exogenous allergens. The so-called haptenic allergens, that is, allergens of a non-protein structure, entering the human body and binding with its proteins also provoke allergic attacks and increase the likelihood of AD. Factors such as hypothermia, aggravated heredity and stressful conditions also occupy one of the important places in the etiology of bronchial asthma.

Pathogenesis

Chronic inflammatory processes in the respiratory organs lead to their hyperactivity, as a result of which, upon contact with allergens or irritants, bronchial obstruction instantly develops, which limits the air flow rate and causes suffocation. Asthma attacks are observed with different frequency, but even in the stage of remission, the inflammatory process in the airways persists. At the heart of the violation of the patency of the air flow in bronchial asthma are the following components: obstruction of the airways due to spasms of the smooth muscles of the bronchi or due to edema of their mucous membranes; blockage of the bronchi with secretion of the submucous glands of the respiratory tract due to their hyperfunction; replacement of muscle tissue of the bronchi with connective tissue during a long course of the disease, which causes sclerotic changes in the wall of the bronchi.

At the heart of the changes in the bronchi is sensitization of the body, when antibodies are produced during allergic reactions of an immediate type, proceeding in the form of anaphylaxis, and when an allergen is encountered again, an instant release of histamine occurs, which leads to edema of the bronchial mucosa and hypersecretion of the glands. Immunocomplex allergic reactions and delayed sensitivity reactions proceed similarly, but with less severe symptoms. An increased amount of calcium ions in human blood has recently also been considered a predisposing factor, since an excess of calcium can provoke spasms, including spasms of the muscles of the bronchi.

In the pathological examination of the dead during an attack of suffocation, there is a complete or partial blockage of the bronchi with viscous thick mucus and emphysematous expansion of the lungs due to difficulty in exhaling. Tissue microscopy most often has a similar picture - it is a thickened muscle layer, hypertrophied bronchial glands, infiltrative bronchial walls with desquamation of the epithelium.

Classification

BA is subdivided according to etiology, severity of the course, level of control and other parameters. Allergic (including professional asthma), non-allergic (including aspirin asthma), unspecified, mixed bronchial asthma are distinguished by origin. According to the severity, the following forms of asthma are distinguished:

1. Intermittent(episodic). Symptoms occur less than once a week, and exacerbations are rare and short.
2. Persistent(constant flow). Divided into 3 degrees:

• mild - symptoms occur from 1 time per week to 1 time per month
• average - daily seizure frequency
• severe - symptoms persist almost constantly.

During asthma, exacerbations and remission (unstable or stable) are distinguished. Whenever possible, control over asthma seizures can be controlled, partially controlled and uncontrolled. A complete diagnosis of a patient with bronchial asthma includes all of the above characteristics. For example, "Bronchial asthma of non-allergic origin, intermittent, controlled, in the stage of stable remission."

Symptoms of bronchial asthma

The asthma attack in bronchial asthma is divided into three periods: the precursor period, the peak period and the period of reverse development. The period of precursors is most pronounced in patients with an infectious-allergic nature of BA, it is manifested by vasomotor reactions from the nasopharynx organs (abundant watery discharge, incessant sneezing). The second period (it can start suddenly) is characterized by a feeling of tightness in the chest, which does not allow breathing freely. The inhalation becomes sharp and short, and the exhalation, on the contrary, becomes long and noisy. Breathing is accompanied by loud wheezing, a cough with viscous, difficult to expectorate sputum appears, which makes breathing arrhythmic.

During an attack, the patient's position is forced, usually he tries to take a sitting position with the body tilted forward, and find a fulcrum or rests with his elbows on his knees. The face becomes puffy, and during exhalation, the cervical veins swell. Depending on the severity of the attack, the involvement of muscles can be observed, which helps to overcome the resistance on exhalation. In the period of reverse development, a gradual discharge of sputum begins, the number of wheezing decreases, and the attack of suffocation gradually fades away.

Manifestations in which the presence of bronchial asthma can be suspected.

• high-pitched wheezing wheezing on exhalation, especially in children.
• repeated episodes of wheezing, shortness of breath, tightness in the chest, and cough that gets worse at night.
• seasonality of deterioration of health on the part of the respiratory system
• the presence of eczema, allergic diseases in history.
• worsening or onset of symptoms upon contact with allergens, taking medications, upon contact with smoke, with sudden changes in ambient temperature, acute respiratory infections, physical exertion and emotional stress.
• frequent colds "descending" in the lower respiratory tract.
• improvement after taking antihistamines and anti-asthma drugs.

Complications

Depending on the severity and intensity of asthma attacks, bronchial asthma can be complicated by pulmonary emphysema and the subsequent addition of secondary cardiopulmonary insufficiency. An overdose of beta-adrenostimulants or a rapid decrease in the dosage of glucocorticosteroids, as well as contact with a massive dose of an allergen, can lead to status asthmaticus, when asthma attacks follow one after another and are almost impossible to stop. Status asthma can be fatal.

Diagnostics

The diagnosis is usually made by a pulmonary clinician based on complaints and symptoms. All other research methods are aimed at establishing the severity and etiology of the disease. With percussion, the sound is clear boxed due to the hyper-airiness of the lungs, the mobility of the lungs is sharply limited, and their boundaries are shifted down. During auscultation over the lungs, vesicular breathing is heard, weakened with a prolonged expiration and with a large number of dry wheezing rales. Due to the increase in lung volume, the point of absolute dullness of the heart decreases, the heart sounds are muffled with an accent of the second tone over the pulmonary artery. From instrumental research is carried out:

• Spirometry... Spirography helps to assess the degree of bronchial obstruction, to find out the variability and reversibility of the obstruction, as well as to confirm the diagnosis. In BA, forced expiration after inhalation with a bronchodilator increases by 12% (200 ml) and more in 1 second. But to obtain more accurate information, spirometry should be performed several times.
• Peak flowmetry... Measurement of peak expiratory activity (PEF) allows monitoring the patient's condition by comparing the indicators with those obtained earlier. An increase in PSV after inhalation of a bronchodilator by 20% or more from PSV to inhalation clearly indicates the presence of bronchial asthma.

Additional diagnostics include allergen tests, ECGs, bronchoscopy, and chest x-rays. Laboratory blood tests are of great importance in confirming the allergic nature of bronchial asthma, as well as monitoring the effectiveness of treatment.

• Blood test... Changes in the KLA - eosinophilia and a slight increase in ESR - are determined only during an exacerbation. A blood gas assessment is needed during an attack to assess the severity of DN. A biochemical blood test is not the main diagnostic method, since the changes are general in nature and such studies are prescribed to monitor the patient's condition during an exacerbation.
• General sputum analysis... Microscopy in sputum can detect a large number of eosinophils, Charcot-Leiden crystals (shiny transparent crystals that form after the destruction of eosinophils and have the form of rhombuses or octahedrons), Kurshman spirals (formed due to small spastic contractions of the bronchi and look like casts of transparent mucus in the form of spirals). Neutral leukocytes can be found in patients with infectious-dependent bronchial asthma in the stage of an active inflammatory process. The release of Creole bodies during an attack is also noted - these are rounded formations consisting of epithelial cells.
• Study of the immune status... In bronchial asthma, the number and activity of T-suppressors decreases sharply, and the amount of immunoglobulins in the blood increases. The use of tests to determine the amount of immunoglobulins E is important if allergy tests are not possible.

Treatment of bronchial asthma

Since bronchial asthma is a chronic disease, regardless of the frequency of attacks, the fundamental point in therapy is the exclusion of contact with possible allergens, adherence to elimination diets and rational employment. If it is possible to identify an allergen, then specific hyposensitizing therapy helps to reduce the body's response to it.

For the relief of asthma attacks, beta-adrenergic agonists are used in the form of an aerosol in order to quickly increase the lumen of the bronchi and improve the outflow of sputum. These are fenoterol hydrobromide, salbutamol, orciprenaline. The dose in each case is selected individually. The drugs of the m-anticholinergic group - aerosols of ipratropium bromide and its combination with fenoterol - also relieve attacks well.

Xanthine derivatives are very popular among patients with bronchial asthma. They are prescribed to prevent asthma attacks in the form of prolonged-release tablets. In the past few years, drugs that inhibit the degranulation of mast cells have had a positive effect in the treatment of bronchial asthma. These are ketotifen, sodium cromoglycate and calcium ion antagonists.

In the treatment of severe forms of asthma, hormonal therapy is used, almost a quarter of patients need glucocorticosteroids, 15-20 mg of Prednisolone is taken in the morning along with antacids that protect the gastric mucosa. In a hospital setting, hormonal drugs can be administered in the form of injections. The peculiarity of the treatment of bronchial asthma is that it is necessary to use drugs in the minimum effective dose and to achieve an even greater reduction in dosages. For better sputum discharge, expectorant and mucolytic drugs are indicated.

Forecast and prevention

The course of bronchial asthma consists of a series of exacerbations and remissions, with timely detection, a stable and long-term remission can be achieved, the prognosis depends to a greater extent on how carefully the patient treats his health and complies with the doctor's prescriptions. The prevention of bronchial asthma is of great importance, which consists in the rehabilitation of foci of chronic infection, the fight against smoking, as well as in minimizing contact with allergens. This is especially important for people who are at risk or have a history of family history.