News. Findings and events
Chronic obstructive pulmonary disease
Bronchial hyperreactivity (BHR) is one of the functional characteristics of chronic obstructive pulmonary disease (COPD) and is present in most patients with this disease. BHR has a negative modifying effect on the development of COPD, contributing to adverse prognosis and increased mortality compared to patients without bronchial hyperresponsiveness. The results of the evaluation of the impact of glycopyrronium bromide (GB) on BHR show a pronounced effect of the bronchoprotective broncholytic. The therapy by GB results in decrease in the level of BHR (p < 0.05), accompanied by a significant reduction of symptoms of COPD, improves tolerance to exercise and quality of life of patients in comparison with initial parameters (p < 0.05). Thus, BHR in patients with COPD appears to be an important criterion of therapeutic efficacy and decrease of the level of bronchial hyperresponsiveness has a significant clinical impact on the course of the disease.
The article considers key issues of the antibacterial therapy of exacerbations of chronic bronchitis and chronic obstructive pulmonary diseases. Etiology of exacerbations of the disease, indications for prescription of antibiotics, regimes of antimicrobial therapy are provided.
Relevance of work. Chronic obstructive pulmonary disease (COPD) is a subject of many international studies, which leads to permanent renewal of clinical recommendations and standards of diagnostics and therapy of this disease. The objective included evaluation of the clinical state of COPD patients, functional evaluation of data and peculiarities of their therapy in three pulmonologic departments of Kazan. Materials and methods. 100 COPD patients in conditions of inpatient department: 98 men (98%) and 2 women (2%), whose average age reached 65.14 ± 0.81 (8.14) years (median – 66 y.o.), only 23% were younger than 60 y.o.. The study was observational and non-interventional. Results. By classification GOLD-2007 patients were distributed in the following way: GOLD I (FEV1 80% and more) – in 4%, GOLD II (FEV1 50–79%) – in 22%, GOLD III (FEV1 30–49%) – in 49%, GOLD IV (FEV1 lower than 30%) – in 25%. By ABCD GOLD-2017 classification 1 patient was referred to Group C and 99 – to subgroup D. Combination of short term broncholytics and combination of iGCS/LABA was the most frequently used therapy. Only each third patient received long acting anticholinergic drugs. Conclusion. In the course of the study significant trends in therapy of COPD patients were detected. Prospects of improvement of rendering help to COPD patients were specified.
The article deals with the issues of differentiated approach to the appointment of bronchodilator therapy in COPD patients on the basis of a comprehensive assessment of the SGRQ quality of life questionnaire, CAT questionnaire, BODE prognostic index, and clinical and functional indicators (FEV1 and MRC index). Clinical examples of patient management are presented. The aim of the study was to study new approaches to the differentiated use of bronchodilator therapy. Material and methods: The study included 49 male patients treated in Regional Clinical Hospital No. 4 and the Pulmonary Center in Chelyabinsk in 2016-17. The analysis of drug therapy in all patients was conducted. The quality of life (QoL) was assessed using two questionnaires: the Russian-language version of the St. George Hospital (SGRQ) questionnaire, and the CAT universal questionnaire. The prognostic evaluation index BODE is calculated. Results and conclusions: 1. Combined preparation of glycopyrronium bromide / indacaterol 50/110 mcg is an effective and safe means for conducting bronchodilator therapy in patients with different variants of the course of COPD. 2. When double bronchodilator therapy is used, the increase in FEV1 by more than 60 ml is observed, especially in patients with a high risk of exacerbations and marked symptoms of the disease. 3. Application of quality of life questionnaires allows to be guided by correctness of the chosen medical tactics both in early, and in the remote periods of supervision of patients with COPD. 4. The use of prognostic indices in the selection of treatment tactics allows to evaluate the correctness of prescriptions at the early stages of patient management.
Bronchial asthma
The article is devoted to the concept of early treatment of patients with intermittent and slight course of bronchial asthma with the use of fixed combinations of inhaled corticosteroids and long-acting beta2-agonists. It describes the basic pathophysiological and molecular mechanisms of this therapy, and the synergy of its components and the local anti-inflammatory effects. Considerable attention is paid to the justification of different strategies for the prescription of steroid-containing combinations as initial therapy: regular prescription of fixed doses, use of a single inhaler for maintenance and symptomatic therapy, including ICS for patients with intermittent and mild BA, abandonment of regular therapy and use of combinations only for therapy on demand. It is emphasized that the basis for the application of such a strategy is low adherence to regular ICS therapy in patients with rare symptoms and undesirability of complete withdrawal of low dose ICS in patients with the light course of the disease because of the high risk of exacerbations. Current evidence suggests that the concept of early prescription of combinations on demand allows combining symptomatic and anti-inflammatory therapy as part of the start of treatment of patients with mild bronchial asthma.
In allergic asthma IgE plays a fundamental role in the development and maintenance of chronic inflammation, leading to remodelling of the airways, reduced lung function, development of fixed bronchial obstruction and resistance to therapy. Authors present literature data and clinical observation of the effectiveness of omalizumab-drug anti-IgE therapy in severe therapyresistant allergic asthma with fixed airflow obstruction.
Bronchial asthma (BA) is a common chronic disease heterogeneous in nature and variable in its course. Heterogeneity in asthma is manifested in relation to the age of the onset, triggers, pattern of inflammation, severity of clinical manifestations and response to therapy. Cysteinyl leukotrienes play an important role in the pathogenesis of asthma and allergic rhinitis (AR), therefore, antagonists of leukotriene receptors approved themselves as effective drugs in controlling asthma therapies, particularly for some phenotypes. This review article is devoted to the modern role of Montelukast in asthma treatment.
The review considers the importance of small airways in the development of the pathological process in bronchial asthma, the effect of dysfunction of small bronchi on the symptoms of asthma, the frequency of exacerbations, and disease control. The role of small airways as a target for anti-inflammatory therapy, the possibility of using fine-dispersed aerosols in the treatment of asthma, the features of clinical pharmacology, clinical effects and the safety of modern inhaled corticosteroid ciclesonides are discussed in detail.
Bronchial asthma is a chronic disease and this means that it will accompany the patient all his life and that’s why the aim of treatment is achievement and maintenance of control of BA symptoms (GINA 2016). One of the major control tools over the state of patients is use of peak flow meters and maintenance of peak flowmetry diaries. In respect of the nebulizer therapy the most important aspect is the correct choice of the situation of use. First of all, this type of therapy is used in a subjective situation of the patient control loss over symptoms of asthma or by changed peak flowmetry values.
Infections in pulmonology
Community-acquired pneumonia is one of the most prevalent infectious diseases and there are numerous diagnostic and therapeutic mistakes in relation to it. Prescription of the antibiotics to CAP patients remains a classic example of “educated guess”. Today one can find antibiotics active against a large range of intra- and extracellular causative agents able to prolong widely spread mechanism of resistance of major respiratory pathogens. The modern practice of clinical application of levofloxacin simultaneously demonstrates possibilities of modification of dosing regimes, safe reduction of the time of administration of the drug, minimization of the risk of selection of drug resistance of the disease causative agents, reduction of frequency and intensity of drug reactions.
Hospital-acquired pneumonia terminologically unites all types of pneumonia that arise in hospitalized patients: pneumonia in patients beyond artificial lungs ventilation (hospital pneumonia, medical aid-associated pneumonia) and hospital acquired pneumonia related to ALV (HAalv) or ventilator-associated pneumonia (VAP). A considerable difference of the hospital-acquired pneumonia from the community-acquired one is a different etiologic structure, which considerably complicates the choice of antibacterial drugs, at the stage of empirical therapy a necessity arises to use antibiotics active against community and hospital flora. The role of carbapenems, doripenem in particular, in therapy of hospital-acquired pneumonia is leading due to its high activity against the resistant flora.
The article describes peculiarities of community-acquired pneumonia on a background of non-epidemic influenza in 218 patients in the period from 2009 to 2016 at the age from 18 to 85 years. The diagnosis of community-acquired pneumonia was verified based on clinical and epidemiological data at the time of admission; radiological and laboratory diagnostic methods. Criteria of severity were: a degree of respiratory failure, severity of the intoxication syndrome, the amount of inflammatory infiltration, presence of complications, decompensation of co-morbidities. Pneumonia on a on the 6th day from onset of disease in women aged 21 to 49 years with premorbid background (overweight, obesity, hypertension, COPD, chronic pyelonephritis). The main clinical manifestations are: acute onset, fever at 38–41 °C, sore throat and pain at swallowing, chest pain, shortness of breath, cyanosis of the skin, decreased breath sounds auscultation. Community-acquired pneumonia on a background of non-epidemic influenza is characterized by unilateral lesion, predominantly in the right lung. Changes in the hemogram depended on the time of admission: leukopenia is diagnosed in the first days of the disease, with a later admission to hospital was dominated by leukocytosis, and thrombocytopenia, on the contrary, was identified at late admission to the inpatient hospital.
Pneumococcal infections (PI) is a group of acute antropozoonozes called pneumococcus that most often affects ENT organs, lungs and the central nervous system. A mechanism for transmission is air-borne – infection occurs during sneezing, coughing, conversation. The source is a sick man or a bacteria carrier. The Russian Federation is currently using pneumococcal vaccines for the prevention of PI. Polysaccharide vaccines operate under the T-independent immune response mechanism. This type of vaccine as an antigen contains the capsule polysaccharides activating the B-cell that launches the cloncal expansion of B- cells and their products of the IgM-class antibodies.
One of the important problems in pulmonology – lower respiratory tract infections that occupy a significant place in the structure of the pulmonary pathology. The major nosological entities at which this infection is the leading or the major ethiologic factor of the lower respiratory tract lesion is community-acquired pneumonia, exacerbations of the chronic obstructive lung disease, chronic bronchitis. The armamentarium of antibacterial drugs used for therapy of the lower respiratory tract infections azithromycin invariably retains leading positions. Depending on the nosological form it is used as the first line drug, an alternative drug or in a combination with other antibiotics. This is preconditioned by a number of exclusive peculiarities of azithromycin that makes it standing apart among other antibacterial drugs.
Pulmonologist school
Light Bronchial Asthma (BA) is the most prevalent form of the disease that, as a rule, is not inclined to progression to graver forms but involving development of exacerbations up to fatal ones. Inhalation glucocorticosterods (IGCS) form basis of the therapy of persistent BA. But IGCS even in case of regular administration can’t change the natural course of the BA and lead to cure. Patients with a light degree of BA are especially inclided to low adherenece and to independent transfer to intermittent administration of IGCS. Due to similar widespread real practice a number of studies evaluating the effect of intermittent therapy of IGCS on the course of light BA are conducted. On the whole, the study results demonstrate reduction of the exacerbations risk and insufficient control of symptoms and inflammation. Drugs targeted at symptomatic administration of fixed combinations IGCS/immediate action beta-2-agonists by patients with light BA.
Rational pharmacotherapy
A review of the foreign and Russian literature devoted to application of the herbal medicine Myrtol standardized, an original vegetative complex standardized by the content of three components: d-limonen, 1,8-cyneol, α-pinene. The clinical effectiveness of the standardized Myrtol was proved in the therapy of acute and chronic rhinosinusitis, acute and chronic bronchitis and chronic obstructive lung disease (COPD). The studies showed that the drug has a wide pharmacodynamic profile of action (mycolytic, secretolytic, secretomotor, antioxidant, anti-inflammatory and antibacterial effects) with high safety profie.
Community-acquired pneumonia (CAP) is a common and poorly diagnosed disease in the outpatient setting. The decision on hospitalization of the patient or treating him at home is the most important clinical conclusion made by the doctor in the course of the disease. Patients with non-severe course of CAP with the medical point of view are treated on an outpatient basis. Assessment of the severity of the patient CAP is based on the predictive Confusion-Respiratory rate – Blood pressure (CRB)-65 and criteria of systemic inflammatory response syndrome (SVR). CAP patients with a scale CRB 65 score 1 or more and/or syndrome SVR are hospitalized on an emergency basis. In accordance with the national guidelines for VAP amoxicillin is used to treat uncomplicated CAP as monotherapy (Group 1 included CAP patients). Amoxicillin is stable in an acidic environment and food intake doesn’t affect the drug absorption. Amoxicillin binds to plasma proteins by about 20% and easily permeates through histohematic barriers. The drug is active against aerobic gram-positive respiratory Staphylococcus spp. (except those strains producing penicillinase), Streptococcus pneumoniae and aerobic gram-negative respiratory organisms (Haemophilus influenzae, Escherichia coli, some strains of Klebsiella).
Influenza is an acute respiratory disease that harms human health and leads to huge economic losses. The fight against this disease is included in the priorities of healthcare in many countries and has important medical and social importance [1, 2]. In addition to vaccination as the main strategy in the fight against flu, the World Health Organization recommends the use of antiviral drugs. The development of such drugs began in the 60s of the last century, when the scientists became to understand the subtle processes of viral replication and the ability to suppress its individual stages, without exerting a significant effect on the cells metabolic processes.
In June 2017, in Reston, Virginia State (US) a conference was held devoted to maintenance ofp patients with coughing, American Cough Conference – 2017. The conference is the most respected site for discussion of new perspective methods of diagnostics and therapy of the most complex coughing forms.
CYSTIC FIBROSIS
Study objective: comparative evaluation of clinical status of patients with cystic fibrosis (CF) 6–9 years, the diagnosis of which was established before the start of neonatal screening (NS) for MV in the Moscow region and in same age group since the start of the NS according to the register 2012 and 2015. Patients and methods. The patients were divided into 2 groups: I – 45 children aged 6–9 years, diagnosed before the beginning of the NS, II – 86 children aged 6–9 years, identified after the start of the NS. Results. A comparative assessment of the age of diagnosis had a significant difference between groups I and II. The average age of diagnosis in group I was 2.29 (±2.29) years, in group II the average age of diagnosis – 0.66 (± 1.13) years (p = 0.0000). According to the microbiological status diagnosed according to the NS program (group II), chronic infection of the respiratory tract by Ps. aeruginosa was less frequent in this group (37.78% of patients in group I vs. 14,10 % in group II) (p = 0.0026). In the group of patients identified by the newborns screening program directed at newborns (group II) a statistically significant decrease of the ongoing intravenous (p = 0.0000) and inhaled antibiotic therapy (p = 0.0139) and reduced compared with group I patients receiving bronchodilators (p = 0.0322). Conclusion. A positive impact of neonatal screening for MV at the age of diagnosis and a number of important indicators of the disease was demonstrated.
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