The drainage feature of the bronchi. Chronic bronchitis

Chronical bronchitis- a chronic inflammatory process in bronchi, accompanied by a cough with a wet separation at least 3 months a year for 2 years or more, while there are no diseases of the bronchopulmonary system and LOR organs that could cause these symptoms.

Therapeutic measures in chronic bronchitis are largely determined by the clinical form of the disease, the peculiarities of its flow. There is no generally accepted classification of chronic bronchitis. In practical medical activities, it is advisable to take advantage of the following.

Classification of chronic bronchitis

I. According to etiology - bacterial, viral, mycoplasma, from the effects of chemical and physical factors, dust.

II. By the nature of the inflammatory process:

Catarrhal;

Purulent; Catarist-purulent;

Fibrinous; hemorrhagic.

III. According to functional changes:

Unstructive;

Obstructive.

IV. With the flow:

Phase remission;

Phase of exacerbation.

V. By complications:

Respiratory (pulmonary) failure;

Lung emphysema;

Chronic pulmonary heart (compensated, decompensated);

Development of bronchiectasis.

Medical programwith chronic bronchitis (HB):

1. Elimination of etiological factors HB.

2. Inpatient treatment and bedding for certain indications (below).

3. Healing nutrition.

4. Antibacterial therapy in the period of exacerbation of purulent HB, including the methods of enlobronchial administration of drugs.

5. Improving the drainage function of the bronchi: expectorant means, bronchodylators, positional drainage, chest massage, phytotherapy, heparinotherapy, calcium treatment.

6. Disinfecting therapy in the period of exacerbation of purulent bronchitis.

7. Correction of respiratory failure: long-term low-flow hydraulic therapy, hyperbaric oxigation, elecorporal membrane blood oxygenation, inhalation of hydrated oxygen.

8. Treatment of pulmonary hypertension in patients with chronic obstructive bronchitis.

9. Immunomodulatory therapy and improvement of the function of the system of local bronchopulmonal protection.

10. An increase in non-specific resistance.

11. Physical Employee, LFK, Respiratory Gymnastics, Massage.

12. Sanatorium-resort treatment.

The elimination of etiological factors HB largely slows down the pro-combination of the disease, prevents the exacerbation of the disease and the development of complications.

First of all, it is necessary to categorically refuse smoking. Of great importance is attached to the elimination of the professional harm (various types of dust, vapor acids, alkali, etc.), a thorough sanitation of chronic infection foci (in the ENT organs, etc.). It is very important to create an optimal microclimate in the workplace and at home.

In the case of a pronounced dependence on the disease and subsequent exacerbations from adverse meteo conditions, it is advisable to move to the region with a favorable dry and warm climate.

Patients with the development of local bronchiectasis are often shown operational treatment. Elimination of a focus of purulent infection reduces the frequency of hb exacerbations.

Stationary treatment and bed mode are shown only to certain groups of patients with the following conditions:

Pronounced exacerbation of hb with increasing respiratory failure, despite active outpatient treatment;

Development of acute respiratory failure;

Acute pneumonia or spontaneous pneumothorax;

Manifestation or strengthening of worldwide failure;

The need for some diagnostic and therapeutic manipulations (in particular, bronchoscopy);

The need for surgical intervention;

Significant intoxication and pronounced deterioration of the overall state of patients with purulent bronchitis.

The rest of the sick hB is carried out outpatient treatment.

When HB with a separation of a large amount of sputum occurs, a loss of protein occurs, and with a decomposed pulmonary heart, an increased loss of albumin from the vascular bed in the intestinal lumen is noted. This patient shows the diet-enriched diet, as well as the transfusion of intravenously drip albumin and amino acid preparations (polyamine, nave-ramine, alvezin).

With a decompensulated pulmonary heart, diet No. 10 is prescribed with a limitation of energy value, salt and fluid and increased potassium content.

With pronounced hyperkapin, the carbohydrate load may cause acute respiratory acidosis due to the increased formation of carbon dioxide and the reduced sensitivity of the respiratory center. In this case, it is proposed to use a hypocalorial diet of 600 kcal with a limitation of carbohydrates (30 g of carbohydrates, 35 g of proteins, 35 g of fats) within 2-8 weeks. Positive results are noted in patients with excessive and normal body weight. In the future, the 800 kcal diet is appointed per day. Dietary treatment in chronic hypercapnia is quite effective (Tirlapur, 1984).

Antibacterial therapy is carried out in the period of exacerbation of the purulent HB for 7-10 days (sometimes with pronounced and long exacerbation for 14 days). In addition, antibacterial therapy is prescribed when developing acute pneumonia against the background of HB.

When choosing an antibacterial agent, the effectiveness of previously conducted therapy is taken into account. Efficiency criteriaantibacterial therapy in the period of exacerbation:

Positive clinical dynamics;

Mucous nature of sputum;

Reduction and disappearance of indicators of the active infectious inflammatory process (the normalization of the SE, the leukocyte blood formula, biochemical inflammation indicators).

The following groups of antibacterial agents can be used at hb: antibiotics, sulfonamides, nitrofurans, trichopol (metronidazole), antiseptics (dioxidine), phytoncides.

Antibacterial drugs can be assigned in the form of aerosols, inward, parenterally, endotracheal and endobrocial. The last two methods of applying antibacterial drugs are the most effective, as they allow you to penetrate the antibacterial substance directly into the focus of inflammation.

4.1. Antibernotac treatment

Antibiotics are appointed taking into account the sensitivity of the wet wets to them (the sputum must be examined by the method of a multiple or explore the flora and sensitivity to the antibiotic sputum obtained at bronchoscopy). To assign antibacterial therapy to obtaining the results of bacteriological research useful is a sputum microscopy with a painting gram. Typically, the aggravation of the infection-but-inflammatory process in bronchi is caused by a non-one infectious agent, but by the association of microbes, often resistant to most drugs. Often, there is a gram-negative flora among the pathogens, mycoplasma infection.

The right choice of antibiotic in chronic bronchitis is determined by the following factors:

Microbial spectrum of infection;

sensitivity of the infectious pathogen for infection;

The distribution and penetration of the antibiotic in the sputum, into the mucous membrane of the bronchi, bronchial glands, lung parenchyma;

Cytokineetics, i.e. The ability of the drug to accumulate inside the cell (it matters to treat infection caused by "intracellular infectious agents" - chlamydia, le-hyeellas).

Yu. B. Belousov et al. (1996) lead the following data on the etiology of the acute and exacerbation of chronic bronchitis (USA, 1989):

Haemophilus influenzae.50%

Streptococcus pneumoniae.14%

Pseudomonas Aeruginosas.14%

Moraxella (Neiseriaor Branhamella) Catarrhal 17%

Staphylococcus aureus.2%

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

Streptococcus Pneumoniae 30.7%

Haemophilus influenzae 21%

Str. haemolitjcus.11%

Staphylococcus aureus 13.4%

Pseudomonas Aeruginosae 5%

Mycoplazma.4,9%

HE detected pathogen 14%

Quite often, with chronic bronchitis, a mixture infection is revealed: Moraxella Catairhalis + Haemophilus Influenzae.

According to 3. V. Bulatova (1980), the proportion of a mixture in the exacerbation of chronic bronchitis is as follows:

Microbes of imikoplasm - in 31% of cases;

Microbes and viruses - in21% of cases;

Microbes, imikoplasm viruses - in 1%cases.

Infectious agents are released toxins (for example, N. influenzae -peptidoglycans, lipoligosaccharides; Str. Pneumoniae - Pneumolysin; R. Aeruginosae - Pyocianin, Ramnolypid), which damage the seating epithelium, slow down the cyiliary fluctuations and even cause the death of the bronchi epithelium.

When prescribing antibacterial therapy after establishing the type of pathogen, the following circumstances take into account.

N. influenzae is resistant to R-lacked antibiotics (penicillin and ampicillin), which is due to the development of the inventory theme-1, destroying these antibiotics. Inactive against N. Influenzae and Erythromycin.

Recently, a significant distribution of STR strains is reported. Pneumoniae resistant to penicillin and many other R-lactam antibiotics, macrolides, tetracycline.

M. Catarrhal is a normal saprophyte flora, but it can often be a reason for the exacerbation of chronic bronchitis. A peculiarity of Moraxella is the high ability of adhesion on Oro-Faringeal cells, and this is especially characteristic of persons over 65 years old with chronic obstructive bronchitis. Most often Moraxella is the cause of exacerbation of chronic bronchitis in areas with large air pollution (metallurgical and coal industry centers). Approximately 80% of Moraxella strains produce r-lactamases. The combined drugs of ampicillin and amoxycyl-lin with clavulanic acid and the Sulbactam are not always active against the R-lactamazoproduction strains of Moraxella. This. The speaker is sensitive to sepitime, Bactrim, Biseptol, and also highly sensitive to 4-fluoroquinolones, to erythromycin (however, 15% of Moraxella strains are not sensitive to it).

When mixed infection (Moraxella + hemophilic stick), producing β-lactamase, ampicillin, amoxicillin, ceflosporins (ceftriaxone, cefuroxime, cefriaxone) may not be effective.

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

1 group- Healthy first persons with post-regular bronchitis. In these patients, as a rule, a viscous purulent sputum is observed, antibiotics do not penetrate into the mucous membrane of the bronchi. This group of patients should be recommended to be abundant drinking, expectorant products, plant fees having bactericidal properties. However, in the absence of effect, antibiotics are used amoxicillin, ampicillin, erythromycin and other macrolids, tetracycles (doxycycline).

2 group- patients with chronic bronchitis, smokers. These include the same recommendations as for persons of the group 1.

3 group- patients with chronic bronchitis with concomitant severe somatic diseases and the high probability of the presence of resistant forms of pathogens (Moraxella, hemophilic stick). This group recommended R-lactamaz stable cephalosporins (cefaclor, zefisim), fluoroquinolones (ciprofloxacin, offloxacin, etc.), amoxicillin with clavulanic acid.

4 group- Patients with chronic bronchitis with bronchoexgas or chronic pneumonia that emit purulent sputum. Use the same drugs that were recommended for patients with 3 groups, as well as ampicillin in combination with Sulbactam. In addition, active drainage therapy is recommended, physiotherapy. With bronchiectases pleased

the frequent causative agent detected in the bronchi is the Haemophylus influenzae.

Many patients with chronic bronchitis, the aggravation of the disease is due to chlamydias, legionells, mycoplasmas.

In these cases, highly active macrolides and to a lesser degree-Dress Tsyuslin. Special attention deserves highly efficient macrolides azithromycin(Sumamedy) and roxitromycin(RULID), rovamicin(Spiramycin). These preparations after taking inside penetrate into the bronchial system, are continuously preserved in tissues in sufficient concentration, accumulate in polymorphic neutrophils and alveolar macrophages. Phagocytes deliver these * drugs to the place of the in-fec-inflammatory process. Roxitromycin (RULID) is prescribed 150 mg 2 times a day, azithromycin (Sumamed) - 250 mg 1 time per day, rovamycin (spiramsycin) - 3 million meters 3 times a day. The duration of the course of treatment is 5-7 days.

When appropriate antibiotics, individual tolerance of drugs should be taken into account, it applies to penicillin (it should not be prescribed with pronounced bronchospast syndrome).

Antibiotics in aerosols are currently applied rarely (an antibiotic aerosol can provoke bronchospasm, in addition, the effect of this method is not large). Most often, antibiotics are used inside and parenterally.

When detecting gram-positive cocking flora, the most efficient purpose of semi-synthetic penicillins, mainly combined (Ampioks.0.5 g 4 times a day intramuscularly or inside), or cephalosporins (Cefzol, Cephalexin, Kloforan1 g 2 times a day intramuscularly), in the fifteenth-negative cocking flora - aminag-licozov (Gentamicin0.08 g 2 times a day intramuscularly or aMICA-QIN0.2 g 2 times a day intramuscularly), carbenicidlin(1 g intramuscularly 4 times a day) or recent generation cephalosporins (Fortumempo1 g 3 times a day intramuscularly).

In some cases, antibiotics of a wide range of action can be effective macrolids(erythromycin of 0.5 g 4 times a day inside, olean-domicine at 0.5 g 4 times a day inward or intramuscularly, ericycline-community erythromycin and tetracycline - in capsules of 0.25 g, 2 capsules 4 times a day orally), tetracyclines,especially extended action (metacycline or rondomycin of 0.3 g 2 times a day, doxycycline or vibramicin in capsules of 0.1 g 2 times a day orally).

Thus, according to modern ideas, preparations of 1 row in the treatment of exacerbation of chronic bronchitis are ampicillin (amoxicillin), including in combination with P-lactamase inhibitors (Clavulanic acid Augmentin, Amoxiclav or Sulbactam Unasin, Sulacylin), oral cephalosporins II or III generation , fluorochyanolone drugs. If you suspected the role of mycoplasmas, chlahog, Legalonell in exacerbation of chronic bronchitis, it is advisable to use macrolide antibiotics (especially azithromycin - Sumamed, Roxitromycin - Rulid) or tetracycline (doxycycline, etc.). It is also possible to combine the use of macrolides and tetracyclines.

Dosage preparations in ch. "Treatment of acute pneumonia."

4.2. Sulfanimide drugs

Sulfanimide preparations are widely used in exacerbation of HB. They have chemotherapeutic activity when

gram-positive and non-negative flora. Usually prescribed preparations of extended action.

Biseptol.in the tablets of 0.48 g. They are prescribed inside 2 tablets 2 times a day.

Sulfatonvtablets at 0.35. On the first day, 2 tablets in the morning and in the evening are prescribed, in the next days 1 tablet in the morning and in the evening.

Sulfamonetoxinin the tablets of 0.5 g. On the first day they are prescribed 1 g in the morning and in the evening, in the following days of 0.5 g in the morning and in the evening.

Sulfadimetoxinon the meaningt. siajust like sulfamimetoxin.

Recently, the negative effect of sulfanimamides on the function of the fiscal epithelium has been established.

4.3. Nitrofuran drugs

Nsrofuran drugs have a wide range of action. Assigns predominantly furazolidon0.15 g 4 times a day after meals. Can also be applied metronidazole.(Trichopol) - the preparation of a wide range of action - in tablets of 0.25 g 4 times a day.

4.4. Antiseptics

Among the antiseptics of a wide range of action, dioxidine and furaciline deserve the greatest attention.

Dioxidin(0.5% solution of 10 and 20 ml for intravenous administration, 1% solution in ampoules of 10 ml for consuming and endobronchial administration) is a wide antibacterial preparation. We slowly intravenously introduced 10 ml of 0.5% solution in 10-20 ml of isotonic sodium chloride solution. Dioxidine is also widely used in the form of aerosol inhalations - 10 ml of 1% solution per inhalation.

4.5. Phyatshchzny drugs

Apply to phytoncides chlorofshlipt -the drug from eucalyptus leaves, which has a pronounced antistaphococcal effect. It is used inside a 1% alcohol solution of 25 drops 3 times a day. It is possible to introduce intravenously slowly 2 ml of 0.25% solution in 38 ml of sterile isotonic sodium chloride solution.

The phytoncides also applies garlic(in inhalations) or to receive inside.

4.6. Endobrocialism

Endesbronchial rehabilitation is made by endotracheal infusion and fibrobronchoscopy. Endotracheal infusion with the help of a gangny syringe or rubber catheter is the simplest method of endobronchial rejection. The number of injections is determined by the effectiveness of the procedure, the amount of sputum and the severity of its suppuration. Typically, a 30-50 ml of isotonic sodium solution of chloride heated to 37 ° C is poured into the trachea. After clearing the sputum introduces antiseptics:

furaticillina solution 1: 5000 - in small portions of 3-5 ml during the inhalation (only 50-150 ml);

solution or 0.5% solution;

kalanchoe juice in dilution 1: 2;

In the presence of bronchopgaz, you can enter 3-5 ml of the antibiotic solution.

Fibrobronchoscopy under local anesthesia is also effective. To sanitize the bronchial tree, it is used: a solution of furacilina 1: 5000; 0.1% Furagin solution; 1% solution of rivocheol; 1% chloro-phillipte solution in dilution 1: 1; Dimexide solution.

4.7. Aerosolherapy

Aerosolherapy with phytoncides and antiseptics can be carried out using ultrasound inhalers. They create homogeneous aerosols with the optimal particle size, which penetrate the peripheral departments of the bronchial tree. The use of drugs in the form of aerosols ensures their high local concentration and uniform distribution of the drug in the bronchial tree. With the help of aerosols, it is possible to ingiate furaticiline antiseptics, a rivochet, chloro-phillipte, bow or garlic juice (divorced 0.25% novocaine solution in a ratio of 1:30), infusion of fir, condensate for a lingonberry sheet, dioxi-din. After aerosol therapy, fast drainage is carried out, vibration massage.

In recent years, an aerosol preparation is recommended for the treatment of chronic bronchitis. bioparox(Locanbitala it contains one active component of Fuzanfungin - a drug of fungal origin, which has antibacterial and anti-inflammatory effect. Fusanfungin is active in relation to predominantly gram-positive cookers (staphylococci, streptococci, pneumococci), as well as intracellular microorganisms (mycoplasma, legionella). In addition, it has antifungal Activity. According to WHITE (1983), the counter-inflammatory effect of the Fusanfungin is associated with the suppression of the products of oxygen radicals by macrophages. Bioparox is used in the form of dosage inhalations - 4 inhales every 4 hours for 8-10 days.

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

To improve the drainage function of the bronchi, expectorant means are used, postural drainage, bronchodylators (with bronchospast syndrome), massage.

5.1. Expectorant products, phytotherapy

According to the definition of B. E. Visito, expectorant means are substances that change the properties of sputum and facilitating its sighs.

There is no generally accepted classification of expectorant means. It is advisable to classify them by the action mechanism (V. G. Kuzes, 1991).

Classification of expectorant means

I. Tools solurating expectoration:

a) preparations acting reflexively;

b) Preparations of resorbative action.

II. Mulitatic (or secretolithic) preparations:

a) proteodite preparations;

b) derivatives of amino acids with sh-group;

c) muggulators.

III. Regulators of the mucous secretary.

The sputum consists of bronchial secrets and saliva. Normally, bronchial mucus has the following composition:

Water with sodium ions dissolved in it, chlorine, phosphorus, calcium (89-95%); The consistency of sputum depends on the water content, the liquid part of the sputum is necessary for the normal functioning of mukiciliary transport;

Insoluble macromolecular compounds (highly and low molecular weight, neutral and acidic glycoproteins are mucins), which determine the viscous nature of the secret - 2-3%;

Complex plasma proteins - albumin, plasma glycoproteins, immunoglobulins of classes a, g, e;

Antiproyolatical enzymes - 1-antihatchin, 1-A-antitripsein;

Lipids (0.3-0.5%) -phospholipids surfactant from alveoli and bronchiole, glycerides, cholesterol, free fatty acids.

5.1.1. Tools stimulating expectoration

Reflex and acting drugs

Reflexively active drugs when taking inside have a moderate irritant effect on the gastric receptors, which reflexively excites the center of the vagauric nerve center in the oblong brain. This increases the secretion of the bronchi mucosa glazed, dilutes the bronchial secret, enhances the pelletic reductions of the bronchial muscles. There is also a slight excitation of a number of the vault center, which reflexively enhances the secretion of bronchial glands.

Since the effect of these drugs is a short, and raising a single dose causes vomiting, frequent methods of optimal doses are needed (every 2 h).

Preparations of this group contribute to the rehydration of bronchial mucus, strengthening the motor function of the bronchi and expectoration of the penaltical cuts of bronchial muscles, increasing the activity of the fibrous epithelium.

The current start of expectorant reflex remedies are alkaloids and saponins:

Infusion of grass thermopsisof 0.6-1 g per 200 ml of water, accepted by

1 tablespoon after 2 hours 6 times a day.

Infusion of root of Ipecakuanaof 0.6 g per 200 ml of water, it is accepted on 1 tablespoon every 2 hours 6 times a day.

The decoction of the root of the storyof 20.0 g per 200 ml of water, it is accepted on one tablespoon 5-6 times a day.

Infusion of the root of Sinaiof the 6-8 g per 200 ml of water, it is accepted on 3rd tablespoons a day after meals.

Liquorice rootit is used in the form of infusion from 6 g on 200 ml of water 1 tablespoon 6 times a day; It is part of the breast collection number 2 (1 tablespoon is brewed on 1 cup of boiling water, it is 30 minutes, it is accepted by \u003e D.glasses 4 times a day); Also also part of the chest elixir.

Glyciram. - the drug was obtained from the root of licorice, has an expectorant, anti-inflammatory and stimulating bark of adrenalities. It is applied in tablets 0.05. It is assigned to 1-2 tablets 4 times a day. Dilodic root preparations for overdose may cause an increase in blood pressure, sodium delay and water, the appearance of edema.

Root Alteain the form of infusion of 8 g on 200 ml of water 1-2 tablespoons 5-6 times a day. It is part of the breast collection number 1 (the root of Altea, mother-and-stepmother, soul grass). 1 tablespoon of collection is poured with 1 glass of boiling water, insist 30 minutes, take on "d" 7 times a day.

Mukaltin tablets containing a mixture of polysahares from altea grass. It is assigned to 3 tablets 4-6 times a day. One tablet contains 50 mg.drug.

Licarin -alkaloid contained in the plants of the Amaridi-owl family and Lilyna, strengthens the secretion of bronchial glands, distedsputum possesses broncholiticalaction. Produced in tablets of 0.0002 g, 1-2 tablets are prescribed 4 times a day.

Infusion of plantain leavesout of 10 g per 200 ml of water is accepted by

2 tablespoons 6 times a day.

Leaf leaf and stepmotherof 10 g per 200 ml of water, it is accepted on 1 tablespoon after 2-3 hours.

Decoration of the root of ninexilaof 20 g on 200 ml of water, 1-2 tablespoons are accepted 6 times a day.

Medicinal plants of this group are used most often in the treatment of chronic bronchitis and are part of various fees. S. S. Yakushin (1990) offered 3 types of prescription medicinal herbs for the treatment of HB.

Collection number 1 (dominant collection property - antiseptic)

Plane leaves 1 h.

The root of licorice is 1 h.

Sademy leaves 1 h.

Pine buds 2 h

Flowers of elderberry black 1 h.

From the collection number 1 is preparing an infusion or a decoction (1.5-2 tablespoons of the collection will prevent the enameled dishes, 200 ml of water are poured, closed with a lid and put on a boiling water bath. Infusion is heated for 15 minutes, the decoction is 30 minutes with a frequent stirring, then Focusing, the residue of the raw material is pressed, the finished extract is adjusted with boiled water up to 200 ml). Take 1 tablespoon after 1.5-2 h, i.e. 8-10 p; Z.in su-

tKI. Collection number 1 is appointed with the exacerbation of the HB of various degrees of activity, in the first silent, with purulent bronchitis and bronchiectases.

Collect number 2 (mainly browillating action)

Math-and-stepmother leaves 1 h.

Grass souls 1 h.

Licode root 2 h

Grass Big 2 h.

Collect No. 2 applies with mostly obstructive HB.

Collect number 3 (anti-inflammatory and expectorant)

"Nine root 1 h.

The root of Altea 2 h.

Grass souls 1 h.

Birch kidneys 1 h

Fees №2 and №3 are prepared and applied in the same way as the collection number 1. Collect No. 3 is used in patients with a non-rigorous exacerbation of HB and in the absence of exacerbation (as predominantly expectorant). These preparations of medicinal plants can be used throughout the duration of stay in the hospital, as well as for a long time after discharge from the hospital (2-3 months).

Two tablespoons of collection number 4 pour 500 ml of steep boiling water, to insist for about an hour, to use sips during the day.

For each patient, the collection must be selected individually. If the patient has a strong cough and phenomenon of bronchospasm, then the grass of Celebre, the grass of the chastard, mint, the root of Valerian, the soul is added. With a strong irritant cough with hem beams in the collection, the number of mucus-forming raw materials increases (Altea root, flowers of cowboy, leisure of mother-and-stepmother), bactericidal substances (pine buds, chamomile flowers) are added to the collection. The following fees can also be recommended:

Two tablespoons of collection number 5 Place in enameled dishes, close the lid, in water bath to boil, boil 15 minutes, cooling 45 minutes at room temperature, the remaining raw material is squeezed. The volume of obtained infusion to bring boiled water to 200 ml. Take on "/ ♦ glass 4 times a day (mainly with bronchitis, accompanied by bronchospasm).

Prepare as collecting number 5. Take on 4 cups 4-5 times a day after meals (mainly with asthmatic bronchitis).

Prepare as collected number 7. Take on 2 glasses 4 times a day.

2 tablespoons of collecting pour 500ml boiling water, insist 6 h, drinking on "/ 2 cups 4 times a day before eating in a warm form. Brew better in the thermos.

Two tablespoons of collection number 9 brew 200 ml of water, insist 40 min. Take % glasses 4 times a day.

Mix 4-6 tablespoons of collection, pour out in thermos (0.7-1 l), pour steep boiling water to the top. You can take in 2-3 hours, all infusion to drink in 3-4 receptions during the day.

Collection №11.

60 t.(3 tablespoons) crushed linen seed poured 1 l hot water, 10 minutes shake up, filter. In the resulting liquid, 50 g of licorice root, 30 g of anise fruits, 400 g of honey and mixed thoroughly are added. The mixture is adjusted to a boil, insist before cooling, filter and take on "/ g of a glass 4-5 times a day before meals (expectorant and softening painful cough action). Not recommended for honey intolerance.

Collect number 12 (antioxidant)

Olhi cones, three-color violet grass, grass. Black, grass of the sweaty, elderberry flowers, hawthorn fruits, immorteller flowers, black currant flowers, planting leaves for 50 g. Mix 10 g of a mixture, pour 300 ml boiling water on a water bath for 15 minutes , insist 45 minutes, squeeze. Take 100 ml 3 times a day 15 minutes before meals. The collection has an expectorant and antioxidant effect (inhibiting the onset oxidation of lipvdov).

Preparations of resorbative action

Preparations of resorbative action are absorbed in the gastrointestinal tract, then released by the mucous membrane of the bronchi, increase the bronchial secretion, dilute the sputum and make it easier for expectoration. Iodine-containing expectorant means together with leukocyte proteases also stimulate the splitting of sputum proteins.

Potassium iodide 3%solution, take 1 tablespoon 5-6 times a day, drinking milk or plenty of liquid. Duration of treatment 5-7 days, longer techniques can lead to phenomena of iodism (nasal congestion, runny nose, tear).

Sodium yodidavailable in a 10% solution of 10 ml in ampoules for intravenous administration. On the first day, 3 ml is introduced, in the second - 5 ml, in the third - 7 ml, in the fourth - 10 ml, then 10 ml 1 time a day for another 3 days, the course of treatment is 10-15 days. The intravenous method of introducing sodium iodide is better transferred than the oral intake of potassium iodide, not observed. Gives cumulation.

Grass Chabbreyvthe form of infusion of 15 g per 200 ml of water is accepted by 2 tablespoons 5-6 times a day.

Perstissin(Castabre extract - 12 parts, potassium Bromide - 1 part, sugar syrup - 82 parts, alcohol 80% - 5 parts), 2 tablespoons are taken 5-6 times a day.

Teremphydatvtablets of 0.25 g, 2 tablets are prescribed 4-5 times a day.

The fruits of Anisa B.the form of infusion 10 g per 200 ml of water, 2 tablespoons are accepted 4-6 times a day.

Summer-Anisovekipo Poons("Drops of the Danish King"). Composition: 2.8 ml Anise oil, 15 ml of ammonia solution, up to 100 ml of 90% alcohol. Take 15-20 drops 3-5 times a day.

Eucalyptus oil -10-20 drops for inhalations per 1 glass of boiling water.

Eucalyptus tincture -10-20 drops 4-6 times a day.

5.1.2. Mulitatic drugs

Multic drugs affect the physical and chemical properties of sputum and dilute it.

Proteolytic enzymes

Proteolytic enzymes tear the peptide connections of the sputum gel protein, it dilutes and easily flipped off.

TRIPSIN, KHOTRIPSIN -5-10 mg in 3 ml of isotonic sodium chloride solution for inhalations. Course of treatment 10-15 days.

Himopcin -25-30 mg in 5 ml of isotonic sodium chloride solution for inhalations. Inhalations are made 1-2 times a day, the course of treatment is 10-15 days.

Ribonuclease -25 mg in 3-4 ml of isotonic sodium chloride solution for inhalations 2 times a day, the course of treatment is 7-10 days.

Deoxyribonuclease -2 mg in 1 ml of isotonic sodium chloride solution for inhalation 3 times a day, a course of treatment - 5-7 days.

Profheseproteolytic preparation, obtained from the Culture of BACT. Subtilus is introduced endobronchial 0.5-1 g in dilution 1:10 (divorced by polyglyukine) 1 time in 5 days.

Territinethe proteolytic drug was obtained from asper-gillus fungus, the bottle 200 of the unit is dissolved in 5-8 ml of saline and inhaled 2 ml 1-2 times a day. It is combined with antibiotics and a dimexi house, can be used in the form of electrophoresis.

In the treatment of proteolytic enzymes there may be adverse reactions: bronchospasm, allergic reactions, pulmonary bleeding. Proteolytic enzymes are not prescribed during obstructive bronchitis.

Amino acids with sh-group "

The amino acids with the SH-group tear the disulfvdal bonds of sputum proteins, while macromolecules become less polymerized, the normalization of physical properties is very viscous mucus is accompanied by an acceleration of mucocyligar clearance.

Acetylcistein(Flower, Mukosiyshn) - 20% solution in inhalations 3 ml 3 times a day or inside 200 mg 3 times a day are used. During inhalation, bronchospasm is possible in patients with bronchial asthma, so before inhalation it is desirable to use bright -ulators.

In recent years, the protective properties of acetylcysteine, manifested in counteracting free radicals, reactive oxygen metabolites, which are responsible for the development of acute and chronic inflammation in the bronchopulmonal system.

Carbocysteine \u200b\u200b(Scholi)- The mechanism of action is close to acetylcy-steane. Produced in the form of a syrup for intake. Adults are prescribed inside 3 times a day at 15 ml (3 teaspoons), after improving the dose decreases: up to 10 ml (2 teaspoons) 3 times a day. There are also capsules at 0.375 g, the daily dose is 3-6 capsules. Children are appointed 1 teaspoon of syrup 3 times a day. Unlike acetylcysteine \u200b\u200bdoes not cause bronchospasm. The portability is good, rarely there are nausea, diarrhea, headache.

MistaBron.(Messen) - sodium salt 2-mercaptoethane sulfonic acid. The musolithic effect of the drug is similar to the action of acetylcysteine, but it is more effectively breaking the bisulfide bonds of macromolecular compounds of sputum, which reduces the viscosity of sputum. It is easily absorbed from the respiratory tract and quickly "is derived from the body unchanged. Available in ampoules for inhalations and for inside-bronchial injections.

Inhalation is carried out through the mouthpiece or mask with the help of appropriate devices under atmospheric conditions in a sitting position. Inhalation the contents of 1-2 ampoules without dilution or in dilution 1: 1 with distilled water or isotonic sodium chloride solution. Inhalation is carried out 2-4 times a day for 2-24 days.

Evdobronchially, the drug is introduced through the intracheactic tube every hour (1-2 ml together with the same volume of distilled water) until the wetting and removal of sputum. Usually this technique is used under intensive therapy. The drug cannot be used in conjunction with aminoglycosted antibiotics, as they reduce the activity of the Mistabron. In the inhalation use of mystabron, bronchospasm and cough are possible. The drug is contraindicated in bronchial asthma.

Mooregulators

Moorgulators are a new generation of musolithic drugs - derivatives of Visitsin. These drugs have a musolitic (secretolithic) and expectorant effect, which is due to the depolymerization and destruction of mukoprotein and wet mucopolysaccharides. In addition, they stimulate the regeneration of renewed cells of the focusing epithelium and increase its activity. The muffins also stimulate the synthesis of surfactant in the alveolar pneumocytes of type II and block its disintegration. Surfactant - an essential factor that supports the surface tension of the alveoli, positively affecting their functional properties, in particular, elasticity, extensibility and counter

the effective development of emphysema of the lungs. The surfactant is a hydrophobic borderline layer, lining alveoli, facilitates the exchange of non-polar gases, has an anti-ethical effect on alveoli membrane. It also participates in providing transport of alien particles from Alveol to the bronchial department, where Mukiciliary transport begins.

Bromgexin(Bisolvan) - is available in tablets of 0.008 g and in ampoules in 2 ml of 0.2% solution for intramuscular and intravenous administration, in a solution for oral and inhalation use with a content of 8 mg bromgexine in 4 ml of solution. In the body turns into AM-Broxol (below). It is used inside at 0.008-0.16 g (1-2 tablets) 3 times a day, intravenously at 16 mg (2 ampoules) 2-3 times a day or in the form of inhalation 4 ml 2 times a day.

The drug is well tolerated, side effects (skin rashes, gastrointestinal disorders) are rare. With chronic liver failure, the clearance of bromgexine falls, so it must be reduced by a dose. Comprehensively combined use inside and in inhalations. For inhalation, 2 ml of the solution is diluted with distilled water in a 1: 1 ratio. The effect is observed after 20 minutes and lasts 4-8 hours, 2-3 inhalation is carried out per day. In very severe cases, bromgexine is administered subcutaneously, intramuscularly or intravenously daily 2-3 times in 2 ml (4 ml). Course treatment - 7-10 days. In chronic recurrent diseases of the respiratory system, a longer use of the drug (3-4 weeks) is advisable. In these cases, the simultaneous use of situational drainage and vibration massage is shown.

LLCROKSOL.(Lasolvan) - is an active bromgexine metabolite. Available in 30 mg tablets in a solution for inhalation and internal use (2 ml contains 15 mg) and in ampoules for intravenous and intramuscular administration in 2 ml (15 mg).

At the beginning of treatment, they are prescribed inside of 30 mg (1 tablet or 4 ml of solution) 3 times a day for 5 days, then the dose is reduced by half, the maximum effect is observed to the 3rd day of treatment. Ambroxol can be used in the form of inhalations 2-3 ml of inhalation solution diluted with distilled water 1: 1. Before inhalation, it is advisable to use a broncholitic for the prevention of possible bronchospasm and the disclosure of the respiratory tract. Parenterally, the drug is applied subcutaneously and intravenously 2-3 ampoules per day (1 ampoule contains 15 mg of ambroxol), in severe cases, the dose can be increased to 2 ampoules (30 mg) 2-3 times a day. The drug can be administered intravenously drop in glucose solutions, ringer, as well as intramuscularly. With co-use with antibiotics, ambroxol increases penetration into amoxicillin, cefuroxine, erythromycin, doxycycline. Side phenomena are rare: nausea, abdominal pain, allergic reactions.

Lasolevan-retard -slow residual capsules containing 75 mg of ambroxol. The drug ensures that the uniform concentration in the blood has been maintained for 24 hours. It is used 1 time per day, the tolerability is good.

5.1.3. Regulators of the mucous secretary

The registers of the mucous secretary increase the aqueous component of sputum, it becomes less viscous and easier is cleared.

Alkaline mineral waters("Borjomi" and others) are accepted according to V 2 -L glass 4-5 times a day.

Sodium bicarbonateit is used as a 0.5-2% solution inhalation.

Sodium benzoateas a rule, added to expectorant medicine:

Infusion of grass Thermopsis of 0.8 g per 200 ml Take 1

Sodium bicarbonate 4 g tablespoon

Sodium benzoate 4 g 6-8 times a day.

Kaliiyeudida 4 g of thoracic elixir 30 g

Sodium chlorideapplied in the form of inhalation 2% solid.

The Best Expecting Tools for HB are considered to be Mucoregua Lanators: Bromgexin, lasolvan, with frequent and painful cough, you can combine expectorant with anti-kilk preparations (ch. "Treatment of acute pneumonia").

5.2. Bronchievous means

In detail in ch. "Treatment of bronchial asthma."

Bronchodulators are used in chronic obstruggable bronchitis.

Chronic obstructive bronchitis -chronic diffuse non-allergic inflammation of bronchi, leading to a progressive impaired pulmonary ventilation and gas exchange on obstructive type and manifested by a cough, shortness of breath and isolation of sputum, not related to the defeat of other organs and systems (consensus on chronic obstructive bronchitis of the Russian Congress of the Pulmonologists, 1995). In the process of the progression of chronic monstructive bronchitis, emphysema is formed, among the reasons for this - depletion and disruption of products of protease inhibitors.

Basic mechanisms of bronchial obstruction:

Bronchospasm;

Inflammatory edema, infiltration of the wall of the bronchus when aggravating the disease;

Hypertrophy of the muscles of bronchi;

Hypercreene (increase in the number of sputum) and discrimination (changing the rheological properties of sputum, it becomes viscous, thick);

Collapse of small bronchi in exhalation due to reducing the elastic properties of the lungs;

Fibrosis of the wall of the bronchi, obliterates their lumen.

Bronchodulators improve bronchial permeability by eliminating bronchospasm. In addition, methylxantins and p 2 -agonists stimulate the function of the fiscal epithelium and increase the sputum of sputum.

Bronchodulators are prescribed taking into account the daily rhythms of bronchial patency. Sympato-mimetic agents (P-adrenoreceptor stimulants), cholinolitic drugs, purine derivatives (phosphodiesterase inhibitors) - methylxantins are used.

SimszggheomimmesBeskev meansstimulate P-adrenoreceptors, which leads to an increase in the activity of adenyl cyclase, the accumulation of the CAMF and then the bronchoese effect. Used ephedrine(stimulates P-adrenergoregores, which provides bronchilation, as well as A-adrenoreceptors, which reduces the puffiness of the mucous membrane of the bronchi) by 0.025 2-3 times a day, combined drug teofedrineby U 2.tablets 2-3 times a day, broncholitin(The combined drug, 125 of which contains glaucine 0.125 g, ephedrine 0.1 g, sage oil and citric acid at 0.125 g) 1 tablespoon 4 times a day. Broncholi-TIN causes bronchorated, antitussive and expectorant effect.

Ephedrine, Theofedrine, Broncholitin is especially important to prescribe in the early morning hours, since at this time there are peak bronchial obstruction.

In the treatment with these drugs, side effects associated with stimulation of both P\u003e (tachycardia, extrasystole) and A-adrenoreceptors (arterial hypertension) are possible.

In this regard, the greatest attention is paid to selective FI R adrenostimulantors(selectively stimulate p 2 -adrenoreceptors and practically do not affect the PG of adrenoreceptors). Usually used sal-Butamol, Terbutalin, Ventoline, Berretk,as well as partially p 2-delegive stimulator astmopent.These drugs are used in the form of dosage aerosols of 1-2 inhale 4 times a day.

With long-term use of stimulants of P-adrenoreceptors, tachofilaxia develops - a decrease in the sensitivity to the bronchi them and a decrease in the effect, which is explained by the decrease in the number of P 2 -adrenorezep-tori on the membranes of the smooth muscles of the bronchi.

In recent years, began to be applied pG Long-term adrenostimulants(duration of about 12 hours) - salmetterol, formathersthe form of dosage aerosols 1-2 inhale 2 times a day, ™ ™0.02 mg 2 times a day inside. These drugs are less likely caused to-chifilaxia.

Purnic derivatives(methylxantins) inhibit phosphodiestera-memory (this contributes to the accumulation of CAMF) and adenosine bronchi receptors, which causes brightness.

With pronounced bronchial obstruction assign eufimine10 ml of 2.4% solution in 10 ml of isotonic sodium solution chloride intravenously very slowly, intravenously drip to lengthen its action -10 ml of 2.4% of the solution of euphilline in 300 ml of isotonic sodium chloride solution.

In chronic bronchial obstruction, it is possible to use the preparations of euphilline in tablets of 0.15 g 3-4 times a day inside after meals or in the form of alcoholic solutions, which are better absorbed (euphilline - 5 g, ethyl alcohol 70% - 60 g, distilled water - up to 300 ml, take 1-2 tablespoons 3-4 times a day).

Of particular interest are drugs extended theophyllinewhich operate 12 hours (accepted 2 times a day) or 24 hours (accepted 1 time per day). Theodore, Thewong, Teobilong, Teotard are prescribed by 0.3 g 2 times a day. Unifillain provides a uniform level of theophylline in the blood during the day and is assigned to 0.4 g 1 time per day.

In addition to bronchhalytic action, the theophyllins of extended action during bronchial obstruction also cause the following effects:

Reduce pressure in the pulmonary artery;

Stimulatesmucciliary clearance;

Improve the contractile ability of the diaphragm and other respiratory muscles

Stimulate derency alternatelukocorticov;

Diuretic action is provided.

The average daily dose of theophylline for non-smokers is 800 mg, for smokers - 1100 mg. If earlier the patient did not take theophylline preparations, then the treatment must begin with smaller doses, gradually (after 2-3 days) increasing them.

5.2.1. Holytalithic means

Peripheral M-cholinolites are used, they block the ace-tilcholine receptors and thereby contribute to the brightness. Preference is given to the inhalation forms of cholinolithics.

The arguments in favor of wider use of cholinolithics in chronic obstructed bronchitis are the following circumstances:

Anticholinergic agents are provocated to the same as stimulants P g of adrenoreceptors, and sometimes even more pronounced;

The effectiveness of cholinolithics is not reduced even with prolonged use;

With an increase in the age of the patient, as well as the development of emphysema of the lungs, the number of p 2 -adrenoreceptors in bronchops decreases and, therefore, the effectiveness of stimulants p 2 -adrenororeceptors decreases, and the sensitivity of the bronchi to the bronchial cholinolithic effect is preserved.

Applied jipratropium bromide(Atrovant) - in the form of a dosage aerosol 1-2 inhale 3 times a day, oxytropium bromide(Coloring, vein-tilat) - cholinolitics of long-term action, is prescribed at a dose of 1-2 inhale 2 times a day (usually in the morning and before bedtime), in the absence of effect - 3 times a day. Preparations are practically devoid of side effects. They show a bright effect after 30-90 minutes and are not intended to relocate choking vocapa.

Cholinolites can be assigned (in the absence of an armored effect) in combination with P g adrenostimulants. Combination of Atro-Vent with p 2 -adenostimulator fenoterol(Berotecom) produced in the form of a dosage aerosol berodalawhich is used for 1-2 doses (1-2 inhars) 3-4 times a day. The simultaneous use of cholinolithics and ragonists enhances the effectiveness of browillating therapy.

In chronic obstructive bronchitis, it is necessary to individually select basic therapy with bronchus preparations in accordance with the following principles (L. N. Tsarakov, V. A. Ilchenko, 1991):

Achievement of maximum brightness for the entire time of day, basic therapy is selected taking into account the circadian rhythms of bronchial obstruction;

In the selection of basic therapy is guided by both the subjective and objective criteria for the effectiveness of bronchodylators: the volume of the forced exhalation for 1 C or peak rate of exhalation in L / min (is measured using an individual picoflorometer);

With moderately pronounced bronchial obstruction, it is possible to improve the bronchial permeability by a combined drug. theofed rin(In addition to which, along with other components, theophile lin, belladonna, ephedrine) in g 1 tablet 3 times a day or reception of the powders of the following composition: ephedrine0.025 g platimism0.003 g eufil Ling0.15 g, papaverine0.04 g (1 powder 3-4 times a day).

First row preparations are jipprety Bromide(Atrovant) or oxytropium bromide,in the absence of the effect of treatment with inhalation cholinolithics, stimulants p 2 -adrenoreceptors are added (Fenoterol, Salbutamolet al.) or a combined drug is applied berodal.In the future, in the absence of effect, it is recommended to consistently add to the previous steps of prolonged teo Phillinovthen inhalation forms of glucocorticov (most effective and safe ingakort.(hemihydrate floanolide), when it does not apply bekotideand finally, with the ineffectiveness of the previous stages of treatment - short courses for receiving glucocorticoids inside. O. V. Alexandrov and 3. V. Vorobyov (1996) consider the effective diagram to be effective: prednisone is prescribed with a gradual increase in dose to 10-15 mg for 3 days, then 5 days applied to the reached dose, then it gradually decreases for 3-5 days . Prior to the phase of the purpose of glucocorticoids, it is advisable to connect anti-inflammatory agents (intorta, tillage) to the bronchylasting agents, which reduce the swelling of the bronchi wall and bronchial obstruction.

The purpose of glucocorticoids inside, of course, is undesirable, but in cases of severe bronchial obstruction, in the absence of an effect from the foregoing, armored therapy, it may be necessary to apply.

In these cases, it is preferable to apply short-acting drugs, i.e. Prednisolone, urbazon, try to use small daily doses (3-4 tablets per day) Not long (7-10 days), with the transition further on supporting doses, which are appropriate to be prescribed in the morning in a discontinuous method (double-supported dose every other day). A portion of the maintenance dose can be replaced with a becotide inhalation, ingakort.

Stages of treatment of chronic obstruction bronchitis are represented by 5.

It is advisable to carry out differentiated treatment of chronic obstructive bronchitis, depending on the degree of violation of the fencission of external respiratory.

There are three severity of chronic obstructive bronchitis depending on the volume of the volume of forced exhalation in the first second (FEV,):

Easy - FEV, equal to less than 70%;

Average - FEV, in the range 50-69%; Heavy-phv, less than 50%.

In tab. 23 shows the therapy of chronic obstructive bronchitis, depending on the degree of severity (E. I. Shemelev et al., 1996)

5.3. Positioning drainage

Positional (overall)drainage is the use of a certain body position for the best "Caressputum. Positioning drainage is performed in patients with chronic bronchitis (especially with purulent forms) when reducing kashlevoyreflex or too viscous sputum. It is also recommended after endotrachealthe infusion or introduction of expectorant means in the form of an aerosol.

It is performed 2 times a day (in the morning and evening, but it is possible and more often) after prior reception bronchodlatatorsand expectorant means (usually infusion of thermopsis, mother-and-steph, richness, plantain), as well as hot lime tea. After 20-30 minutes, after this, the patient alternately occupies the provisions that contribute to the maximum empty from the sputum of certain lung segments under the action of gravity and "Stacking"to kashlevreflexogenic zones. In each position, the patient first performs 4-5 deep slow respiratory movements, inhaling the air through the nose, and exhausted through compressed lips; Then, after a slow deep breath produces 3-4-fold shallow cuffs 4-5 times. A good result is achieved with a combination of drainage provisions with various methods of breast vibration over drainaged segments or its compression with hands on exhalation, massage done quite vigorously.

Postural drainage is contraindicated in heaming, pneumothorax and occurrence during the procedure of considerable shortness of breath or bronchospasm.

5.4. Massage

Massage is included in the complex therapy HB. It promotes sneakeniesputum possesses bronchodassablayeraction. Classic, segmental, point massage is used. The last type of massage can cause significant bronchodassabareffect.

5.5. Heparinotherapy

Heparin warns degranulationfat cells, increases the activity of alveolar macrophages, has an anti-inflammatory effect, antitoxic and diuretic effect, reduces the pulmonary plastergepromotes festivalsputum.

The main testimony for heparin at HB are:

The presence of reversible bronchial obstruction;

Legogypertension;

Respiratory failure;

Active inflammatory process in bronchi;

DVS Syvdrom;

Significant increase in sputum viscosity.

Heparin is prescribed by 5000-10,000 Elf3-4 times a day under the skin of the abdomen. The drug is contraindicated in hemorrhagic syndrome, hemoptia, peptic ulcer.

The duration of treatment with heparin is usually 3-4 weeks, followed by a gradual cancellation by reducing a single dose.

5.6. Using Calcithonin

In 1987, V. V. Peda, the treatment of hb was proposed calccenin(Calcitrine is an injection dosage form of sketchgonia). It has an anti-inflammatory effect, inhibits the release of mediators from the fat cells, improves bronchial permeability. It is used in the obstruggable HB in the form of an aerosol inhalation (1-2 units in 1-2 ml of water for 1 inhalation). Course treatment - 8-10 inhalations.

With a deshokloxyction purposes in the period of exacerbation of purulent bronchitis, an intravenous drip flow of 400 ml of hemodesa is used (contraindicated allergy, bronchospastic syndrome), isotonic sodium chloride solution, ringer solution, 5% glucose solutions. In addition, it is recommended to drink abundant drink (cranberry juice, rhythmnik, lime tea, fruit juices).

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

Chronic respiratory failure -this is a state of the body, in which due to damage to the external respiratory system is either maintained by the normal gas composition of blood, or it is achieved primarily by inclusion of compensatory mechanisms of the external respiratory system itself, a cardiovascular system, a blood transport system and metabolic processes in tissues (O. V. Alexandrov, 3. V. Vorobyeva, 1996).

Therapeutic tactics in chronic respiratory failure depends on its stage and is presented in Table. 24.

With chronic respiratory failure I Art. It is successfully applied hydoxherapy.It has the following positive mechanisms of action:

Increases blood pressure in the pulmonary artery system, which leads to an increase in perfusion of pulmonary capillaries, improving the ventilation of the alveoli and, ultimately, to an increase in the partial pressure of oxygen in the blood;

Intensifying the body mechanisms to hypoxia, it causes the development of tissue and cellular reactions that increase resistance to hypoxia.

The patient breathes atmospheric air with reduced to 11-12 about. % oxygen content for 5 minutes, and then 5 minutes breathes with atmospheric air with a normal oxygen content. For one session, 6 such cycles are performed. Every day spend 1 session. The course of treatment lasts 15-20 days.

V.P. Silvestrov et al. (1996) showed high efficiency of pulsed hypoxygherapy using helium with chronic non-structural bronchitis. A gas mixture was used containing 10% oxygen and 90% helium. Helium has a higher than nitrogen, diffusion ability, lesser density and more pronounced antiatesk-tatical effect.

Prior to the beginnings of hypoxyterapics, samples are performed for hypoxia tolerance, during which the reaction of the cardiovascular, respiratory and central nervous system is estimated, the saturation of hemoglobin oxygen. Hypoxyterability is effective in 89-90% of patients with chronic ne-structural bronchitis: chronic symptoms of the disease are reduced, the hemoglobin content and the number of erythrocytes in the blood increase increase the indicators of the function of external respiration.

Oxygen therapy significantly improves the overall condition of the patient, reducing hypoxemia, preventing the progression of pulmonary hypertension and hygown damage to organs and tissues.

One of the most important methods of oxygen therapy - long-flow oxygen therapy.Indications for its purpose:

Severe hypoxemia at rest (RA0 2 50-55 MMRT. Art.) And hypercaps (more than 50 mm. RT. Art.);

RA0 2 from 55-90 mmm. Art. Alone in cases of the following complications:

a) pulmonary hypertension with worldwide failure;

b) resistant polishhemia;

c) cerebral disorders that are corrected by oxygen therapy;

d) the frequent panty of angina, the rhythm of the heart, the refractory left-oscillatory failure of blood circulation, decreasing with oxygen inhalations;

Night excitement, anxiety, nightmares that are a consequence of heavier hypoxsemia developing during sleep (RT0 2 decreases to 50-55 mm Hg. Art.) And decreasing oxygen inhalation;

A pronounced shortness of breath that limits the usual domestic activity of a person, which is a consequence of heavier hypoxemia during exercise (decrease in RA0 2 below 55-50 mm Hg. Art.).

Oxygen is supplied through the nose using a Y-shaped tube in an amount providing RA0 2 above 65 mm Hg. Art. Alone and warning its decline below 55 mm Hg. Art. With load.

The oxygen flow usually does not exceed 3 l / min. At rest and 5 l / min with a load, which approximately corresponds to 32% and 40% oxygen-air mixture. At night, the flow of oxygen is increased by 1 l / min compared to those in the rest of the daytime.

As a source of oxygen at home, cylinders with compressed oxygen or hubs, portable devices for obtaining oxygen from room air using molecular sieves, the greatest distribution among which were obtained zeolites, selectively absorbing air nitrogens.

The duration of low-threaded oxygen therapy is at least 18 hours per day.

In the case of a very pronounced hypoxemia and chronic hypercapinia, a hypercapnic coma is possible in connection with alveolar hypoventilation, which arises due to the depression of a normal reaction to hypercapno. Such patients are prescribed oxygen-and-therapy of 24-28% oxygen-air mixture (corresponds to a flow of oxygen 1-2 l / min).

Exciting respiratory center (Cordiamine);

Stimulating respiratory muscles (prozerne);

Protecting the surfacgant from the damaging effect of oxygen (essentially);

Overwhelming lipid peroxidation and the formation of free-radical compounds damaging the bronchopole monoal system (antexhaoxidan - vitamin E, vitamin C);

Normalizing the rheological properties of blood (heparin, chief);

Lowering pulmonary panttenzia(Nitrates, calcium antagonists).

Longmalcotional oxygen therapy increases the duration of the life of patients for 5-7 years.

In recent years, reported on the favorable effect of the new respiratory analeptics ashitrina(VEKERION).It reduces the shortness of breath, stimulates peripheral hemorecaptors,increases oxygen voltage in arterial blood. Taking 100 mg of almitrine inside is equivalent to the effect of administration of 1 l oxygen through the nose for 1 min. The preparation is used by 150 mg 2 times a day.

In addition to long-term oxygen therapy, currently being developed membrane (extracorporeal) oxygenblood. The blood of the patient is skipped through specialdevices where she coming into contact with special Oxygenizesmembranes are enriched with oxygen and then returns to the body of the patient. Duration oxygenationranges from 1 to 3 hours.

With the impossibility of performing low-throat hydrochiotherapy, inhalation of hydrated oxygen through the nasal catheters is carried out.

To correct respiratory failure, it is also applied aerionotherapy(at the stage I, 12 billion aeroimes for a session, at stage II - 8 billion aeroimes per session), is carried out at 1 session per day, the course of treatment lasts 15-20 days. Aerionotherapy has an antioxidant effect.

In recent years, extracorporeal methods have been used to treat severe chronic respiratory failure - hemosorption and erythrocytopheresis followed hemodulition.In hemosorption, the sorbents remain functionally weakened under the influence of long hypoxemiaerythrocytes incapable of gas exchange. Activation of hemolysis on sorbents stimulates the formation of functionally full-fledged erythrocytes. Using erythrocythererzezaerythrocytes with a modified membrane are removed and then repelted in the blood circuit gljin, hemodez. Hemosorptionand the red blood celliforez has a positive effect on the microcirculation system, improve ventilation-perfusionrelations.

Chronic hypoxemiapermanent increase in respiratory deepening lead to fatigue and further to fibrous changes in respiratory muscles, which, naturally, aggravates respiratory failure. To improve the operation of the respiratory muscles, a protein diet is used, physical training in the amount not exceeding the level of fatigue. To improve the diaphragm function, special diaphragm stimulants are used (ESD-2P, ESD 2N-LC, etc.). The duration of one stimulation session is 30 minutes, the course of treatment is 20-30 sessions.

With particularly severe chronic respiratory failure, the radical method of treatment is the lung transplantation. Two-year survival after operation is 60-70% of cases. Usually use the transplant of both lungs, but the transplant of one lung is also successfully applied.

In the treatment of pulmonary hypertension at HB, it is based on the following provisions (L. N. Tsarakov, V. A. Ilchenko):

Pulmonary hypertension is caused by Gapoxemia, which dictates the need for adequate continuous basis therapy of the broncho-processing syndrome;

In the early stages, pulmonary hypertension is reversible, therefore, continuous therapy should be carried out, aimed at reducing the functional component of pulmonary hypertension already at the initial stage of its development.

To combat pulmonary hypertension with III functional classes, according to V. P. Sylvester, most appropriate to accept calcium antagonists - Foridon, Corinthar, Cordafenpo0.02 g 4 times a day for 4 weeks.

With III-IV functional classes of pulmonary hypertension (actually decompensated pulmonary heart against the background of chronic obstruction bronchitis) nitrates are recommended. They reduce the pulmonary vascular resistance and pressure in the pulmonary artery, reduce the venous influx to the heart and reduce the load on the right hearts. This group of drugs can remove vasoconstriction in poorly ventilated zones and aggravate hypoxemia, reduce the impact volume of the heart. That is why treatment with these means is advisable to conduct under the control of hemodynamics of small and large circles of blood circulation and gas composition indicators.

It is recommended from nitrates nitrosorbid.0.02 g 4 times a day for 3-4 weeks. Similar to the nitrosorbide action has moxido-min.(Corvaton), is used in the initial dose of 0.002 g 4 times a day, followed by an increase in the dose to 6-8 mg 3 times a day. Treatment continues for about 3 weeks, followed by a transition to supporting doses of 4-6 mg per day.

Treatment of a decompensated pulmonary heart, developing in patients with chronic obstructive bronchitis, in ch. "Treatment of chronic pulmonary heart."

Immunomodulatory (immunocorrorizing) therapy normalizes the operation of a system of general and local immunity (ie, the bronchopulmonal immune protective system). This therapy is most appropriately carried out after a preliminary study of the immune status, phagocytosis, the function of the function of local bronchopulmonal protection. The same indicators should be checked during immunocorrorizing therapy.

Indicationsconducting immunocorrorizing therapy for hB are protracted exacerbations, often recurrent and purulent forms of chronic bronchitis.

Dese(Levamizol) - enhances the function of T-suppressors and T-helpers, the activity of natural killers and phagocytosis. It is assigned to 100-150 mg per day for 2-3 days with a subsequent 4-day break, only 8-12 cycles. In the treatment of levamizol, leukopenia, agranulocytosis may develop (more often in individuals with HLAB 27 antigen).

T-activin -timus preparation, reinforces the function of T-lymphocytes, phagocytosis, interferon products, stimulates the function of T-killers. It is assigned 100 μg subcutaneously once a day for 3-4 days.

Ttalintimus preparation, has the properties of T-activin. It is prescribed for 10-20 mg intramuscularly for 5-7 days.

Dioucecra -increases the activity of T-helpers and T-suppressors, as well as natural killers. Appointed in tablets of 0.1 g 3 times a day by courses for 5 days (only 2-4 courses).

Catergen -increases the activity of natural killers, is an antioxidant and hepatoprotectory. It is assigned to 0.5 g 3 times a day during meals for 2 weeks.

Prodigiosan -bacterial polysaccharide, stimulates phagocytosis, T-lymphocyte function. It is assigned to gradually increasing doses from 25 to 100 μg intramuscularly with an interval of 3-4 days, the course of treatment - 4-6 injections (in the phase of remission of HB).

Sodium nucleinate -received from yeast, it is assigned to 0.2 g 3 times a day 2-4 weeks. The drug enhances phagocytosis, the function of T- and B-lymphocytes, the products of interferon, increases the content in Lizozyme bronchi.

Ribominyl -it consists of a complex of ribosomal fractions of four bacteria, which is most often causing the infectious-inflammatory process of the upper respiratory tract and the bronchopulmonal system (Klebsiella Pneumoniae, Diplococcus Pneumoniae, Streptococcus Pyogenes, Haemophilus Influenzae). To enhance the immunogenic effect of ribosomes, proteoglycans of the cell wall K1 are added as an adjuvant. Pneumoniae. Ribomunyl normalizes the phagocytic immunity system, the level of immunoglobulins in the bronchial secrete, improves the functional state of the local immune bronchopulmonal system (R. M. Khaitov et al monitor; 1995). The drug is produced in tablets of 0.00025 g and is used inside the following scheme: 3 tablets in the morning on an empty stomach every 4 days for 3 weeks of the first month, then 3 tablets for the first 4 days of each month for 5 months. As a result of treatment, Ribo Munil decreases the frequency of exacerbations of chronic bronchitis and they proceed most easily. The most favorable period for treatment with ribominyl is the phase of remission of chronic bronchitis, which is associated with the vaccine-like action of Ribominyl. The tolerability of the drug is good.

Echinacin -a vegetable immunomoduator, which is the juice of the above-ground parts of the blooming Red Rudbecia (Echinacea Purpurea). The preparation has antibacterial (bacteriostatic), immunostimulating and wound-healing effects. Echinacin stimulates phagocytosis, the activity of natural killers, the function of T-lymphocytes, prevents the aggravation of chronic bronchitis and lengthens the phase of remission, and is also effective in the protracted flow of pneumonia, it can be used as a means of immunoprophylaxis at the first signs of acute respiratory disease (A. V. Karaulov, 1995) . The drug is used by 20 drops 3 times a day inside to 8 weeks, then a break is taken for 2-4 weeks. Side effects of Echinacin are not installed.

Likopid -new immunomodulator, M-acetylglucosamin-N-acetylmural l-alanyl-o-isoglutamin (GMDP). The GMDP is a general repeating fragment of the peptidoglycan of the cell wall of all known bacteria. It affects almost all populations of the cells of the immune system (macrophages, β- and T-lymphocytes), which is associated with the presence of specific intracellular receptors.

Licopid stimulates phagocytosis (due to the increase in the synthesis of cytokines - the tumor necrosis factor, interleukin-1), leukopoese, antitumor immunity, suppresses the synthesis of pro-inflammatory cytokines and has an anti-inflammatory effect, increases the number of T-lymphocytes, natural killers. The drug can be used at HB both in the remission phase and in the aggravation phase. A. In Nikitin (1996) recommends appointing a lycopid in a daily dose of 1 mg in chronic diseases of the bronchopulmonal system in the aggravation phase and unstable remission. In the sluggish, often recurrent inflammatory processes in the bronchopulmonal system, the use of liquid in a daily dose of 10 mg is most appropriate.

Oxymetacil -the pyrimidine derivative (2, 4-dioxy-5-hydroxy-6-methyl-1,2,3,4-tetrahydropymidine) is an immunomodulator and has anti-inflammatory activity, increases resistance to infections and the effectiveness of antibacterial therapy, stimulates phagocytosis. In addition, the preparation has an antioxidant effect, reduces bronchospasm. Oxymetacyl is prescribed in tablets of 0.25 g of 1 tablet 3 times a day after eating for 3-4 weeks. According to A. M. Bova (1995), oxymetacil can be applied in patients with chronic bronchitis both in the aggravation phase and in the remission phase. The best clinical effect is noted in a complex with antibacterial therapy in the aggravation phase of the bronchopulmonal inflammatory process. Side Effects Oxymetacil does not have.

Immunocorrorizing properties also possess plachaferz, UFO blood(increases the phagocytic function of neutrophils, enhances the bactericidal effect of the blood, normalizes the function of T- and B-lymphosi-TOV), laser blood irradiation(increases the activity of the phagocytic neutrophil system, normalizes the function of T- and B-lymphocytes).

In order to normalize the function of the system of local bronchopulmonal protection, techniques of introduction into bronchi culture of alveolar macrophages, immunoglobulins, interferon, which makes it possible to quickly stop the aggravation of the inflammatory process in bronchi and warn it.

To improve the function of bronchopulmonal protection, you can recommend vitamins E, A.

Non-specific organism resistance rises by applying adaptogen - eleuteococcal extract40 drops 3 times a day, ginseng tincture30 drops 3 times a day, tincture of Aralia, Ro-diol pink, Pantokrinin the same doses saparala0.05 g 3 times a day. The effect of these drugs is multifaceted: they have a positive effect on the work of the immune system, exchange processes, increase the body's resistance to adverse effects of the external environment and infectious factors influences.

Physiotherapy is used in patients with chronic bronchitis in order to suppress the inflammatory process, improving the drainage function of the bronchi.

In the HB, inhalation aerosolherapy is widely assigned. This treatment method is carried out with the help of individual (domestic) inhalers (AIP-1, Mist, Musson, Geyser-6, UZI-70 TIR, etc.) or in hospital and sanatorium inhalers.

The surface of the mucous membrane of the affected bronchial tree in chronic diseases of the bronchi is from 10 to 25 m 2, and the diameter of the bronchi small and medium caliber is from 10 to 4 mm. Therefore, only sufficiently large volumes of aerosol with small particles are able to penetrate into the hard-to-reach places of respiratory tract and to provide therapeutic effect on the bronchi mucosa.

The solution to this problem is under the power of only therapy with the help of individual ultrasound inhalers generating dense and highly dispersed (with particle size of 5-10 μm) aerosols in large volumes in a short period of time.

According to V. N. Solopova, the correction of bronchial obstruction under the broncho-structured diseases is inhalation of expectorant and powerful antiseptic drugs. At the same time, combinations of several expectorant means are used, for example, at the beginning of thinning wets (acetylcisgein, mystabrons), and then stimulating itching (hypertensive solutions of potassium and sodium iodide, sodium bicarbonate, mixtures thereof). The duration of one course of treatment is -2-3 months. Inhalations are prescribed 2 times a day. V. N. Solopov offers the following inhalation program for a patient with obstructive or Gaoino-obstructive bronchitis:

1. Bronchyolitic mixture with adrenaline:

adrenaline solution 0.1% - 2 ml of atropine solution 0.1% - 2 ml of diploma solution 0.1% - 2 ml of 20 drops by 10-20 ml of water.

You can also use the other inapplication:

euphillin solution 2.4% - 10 ml of a solution of adrenaline0.1% - 1 ml of diploma solution 1.0% - 1 ml of sodium solution of chloride 0.9% - up to 20 ml of 20 ml per 1 inhalation.

2. 20% acetylcysteine \u200b\u200bsolution is 5 ml per 20 ml of isotonic sodium chloride solution.

3. Alkaline expectorant mixture:

sodium bicarbonate - 2 g of sodium tetraborate - 1 g sodium chloride - 1 g of distilled water - up to 100 ml of 10-20 ml per 1 inhalation.

You can take advantage of words

sodium bicarbonate - 4 g of potassium water - 3 g of distilled water - up to 150 ml of 10-20ml to 1 inhalation

sodium Bicarbonate - 0.4 g

sodium citrate - 0.1 g

copper sulfate-0.001 g

1 Powder on 20 ml of water to 1 inhalation.

4. 1% dioxland solution - 10 ml per inhalation.

You can also use in words

furatcilina solution 1: 5000- 400 ml

sodium citrate - 2 g

sodium bicarbonate- 16g

copper sulfate - 0.2 g

10-20 ml per 1 inhalation.

Criteria for the effectiveness of treatmentit is an improvement in spilinking sputum, the lack of difficulty breathing, the disappearance of purulent sputum. If purulent sputum continues, it is possible to try instead of antiseptic solutions to introduce into the respiratory pathways of the wide spectrum of action (aminoglycosis, cephalosporins) in the form of a fine powder.

Aerionotherapy with negative ions is also very helpful.

In recent years, an endobronchial ultrasonic spraying of antibiotics with a low-frequency ultrasound (S. I. O-Charenko, 1991) has been developed.

UHF currents for 10-12 min on the area of \u200b\u200bthe roots of the lungs in an hour in an oligothermal dosage;

microwave therapy (decimeter waves by the Wave-2 apparatus) into the area of \u200b\u200bthe roots of the lungs daily or every other day, 10-15 procedures (improves the permeability of small bronchi);

Ivdukghotermia or shortwave diathermy for an inter-opacker region for 15-25 minutes, daily or every other day (only 10-15 procedures);

With an abundant amount of sputum - UHF in alternation with calcium electrophoresis of chloride on the chest, with dry cough -electrophoresis of potassium iodide;

In the presence of bronchospasm - Potassium electrophoresis Iodida SinducTo-Termey, spasmodic electrophoresis - papaverine, magnesium sulfate, euphilline;

All patients showing electrophoresis with heparin on the chest;

Sinusoidal modulated currents (improve chalk
kih bronchi).

With a thorough exacerbation of HB, you can apply the appliques of dirt, ozokerite, paraffin on the chest, UFO in the warm season in the phase close to remission; coniferous, oxygen baths; Warming circular compresses.

Therapeutic physical culture (LFC) is a mandatory component of the treatment of HB. Use traditional LFCs with a predominance of static and dynamic exercises against the background of general connoisseurs. In the presence of purulent bronchitis, drainage exercises are included.

LFC is contraindicated in acute respiratory and cardiovascular failure.

O. F. Kuznetsov proposed in the middle of the main period of the LFC, during the peak period, individual exercises are not performed 3-6 times, as usual, and repeat repeatedly for 1-3 minutes at a temperature of 12-18 movements in min with deep breath and reinforced exhale. After each such cycle, a pause of a fixed active recreation should be 1.5-2 minutes. The optimal load at hB is 2 cycles of exercise with two recreation intervals. The duration of intense gymnastics is 25-35 minutes. It is performed 2 times a week (only 4-8 times) against the background of daily classes with generally accepted medical gymnastics.

The most preferred form of exercise for most patients is walking. Patients HB can under the guidance of an instructor to engage in gymnastics of yogis.

With severe respiratory disorders due to bronchial obstruction, exercises associated with the deepening of breathing, elongation of the exhalation phase after a deep breath (the ratio of the duration of inhale and exhalation 1: 3), with additional resistance to the breath (slow exhalation, through compressed lips) alone and When loading, as well as training aperture and aperture breathing when the auxiliary respiratory muscles of the neck and shoulder belt are turned off. For patients with bronchial obstruction, exercises are necessarily included, creating positive pressure on exhalation, which improves ventilation and bronchial drainage. For this purpose, respiratory regulators are used (ch. "Treatment of bronchial asthma").

Be sure to temper the body that should be started in July-August with gradual buildup of cold load. Hardening makes it possible to increase the resistance of the patient to the sharp temperature drops, the hypoints.

Sanatorium-resort treatment increases the nonspecific resistance of the body, has an immunocorrigating effect, improves the respiratory function and the drainage function of the bronchi.

The main therapeutic factors of the resort treatment:

Purity and ionization of air with negative ions; bactericidal properties of ultraviolet irradiation;

Balneological factors;

Terrencours; aerosolherapy;

LFK, massage;

Breathing exercises;

Physiotherapy.

Balneotherapy is actively used in the resorts. The hydrogen sulfide baths have an anti-inflammatory effect, carbon dioxide enhance the bronchial patency.

Resorts with seaside climate (south coast of Crimea, Anapa, Gelendzhik, Lazarevka);

Resorts with a mountain climate (Kislovodsk, Issyk-Kul);

Local suburban resorts (Ivanteevka, Sestroretsk, Slav
Gork and others).

In the Republic of Belarus - Sanatorium "Belarus" (Minsk region),
"BUG" (Brest region)

Patients are sent to the resorts in the phase of remission with the initial phenomena of respiratory failure or without it.

1. Chronic abstruse bronchitis with rare exacerbations (no more than 3 times a year) in the absence of pulmonary failure.

Patients are inspected by therapist 2 times a year, an ENT doctor, a dentist 1 time per year, a pulmonologist - according to the testimony.

Common blood test, sputum and sputum analysis on Koch bacillos is produced 2 times a year, ECG, bronchological examination - by testimony.

Purchase therapy is carried out 2 times a year, as well as with sharp respiratory viral infections. It includes:

Inhalation aerosol therapy; polyvitamino therapy;

Recedeagedophenes;

The use of expectorant means;

Physiotherapeutic treatment;

LFK, massage;

Charging, sports; Sanation of foci of infection;

Spa treatment; to give up smoking;

Employment.

2. Chronic unstructive bronchitis with frequent exacerbations in the absence of respiratory failure.

Therapist examinations are recommended 3 times a year, general blood tests - 3 times a year, spirography - 2 times a year, fluorography and biochemical blood test - 1 time per year. Anti-terrain treatment is carried out 2-3 times a year, the volume is the same, but the immunocorgryrigi-routing is turned on.

3. Chronic obstructivebronchitis with respiratory failure.

Therapist examinations are held 3-6 times a year, other surveys are the same for the same time. , what in the 2nd group.

Anticondizabletreatment is carried out 3-4 times a year, the treatment program is the same, with purulent bronchitis, is shown evdobronchialsanation, in addition apply bronchodulators.