Chronic obstructive pulmonary disease is today one of the socially significant diseases, and its treatment remains a major medical problem.

Currently, the main goals of treating patients with COPD are: eliminating symptoms and improving the quality of life, preventing exacerbations and reducing future risks, slowing the progression of the disease and reducing mortality.

The article presents a clinical case from the practice of a patient with COPD who received tiotropium bromidi as monotherapy. The patient had significant impaired airway patency during spirometry, a decrease in exercise tolerance. The patient was assigned a new representative of combination preparations with a 24-hour action – Anoro Ellipta® (Vilanterol + Umeklidiniy) 22/55 mcg, with a new drug delivery vehicle. After 6 months of therapy with Anoro Ellipt®, the patient has increased exercise tolerance, improved pulmonary function, as well as quality of life. 

Although there is now much evidence that COPD is a more complex systemic disease than airway and lung disease, a comprehensive approach to early diagnosis and more accurate assessment of the disease is far from complete. The most common co-morbidities with COPD are cardiovascular disease, diabetes mellitus, osteoporosis, depression, anemia, etc. The problem of diagnosis and treatment of COPD patients with osteoporosis is currently topical and insufficiently studied. In this review the peculiarities of osteoporosis in COPD are considered: its prevalence, the influence of the severity of bronchial obstruction on the bone mineral density (BMD), clinical manifestations (frequency of vertebral body compression fractures (VBCF) and hip fractures), the influence of risk factors (glucocorticosteroids, low body weight, vitamin D deficiency, smoking, impaired lung ventilation, sedentary lifestyle, etc.) on the development of osteoporosis. Data of researches on studying bone formation markers and bone resorption in patients with COPD are given. Full understanding of the mechanisms of development, early diagnosis of osteoporosis in COPD patients will allow to choose the most effective therapeutic tactics, which will correspond to the modern concept of personalized medicine.

Chronic obstructive pulmonary disease (COPD) is a chronic, environmentally mediated disease manifested by broncho-obstructive syndrome, which is not completely reversible.

The purpose of this review was to summarize the latest changes in the management of these patients, which occurred in international and domestic guidelines.

Methods. The analysis of work on the problem of COPD, available in the E-Library and PubMed electronic libraries, was carried out.

Results. The year 2019 was marked by the renewal of global GOLD initiatives and the implementation of national guidelines for the diagnosis and treatment of COPD in practice. The most significant provisions are the following: double long-acting bronchodilators are the main treatment for stable COPD; specific indications are needed for the administration of ICS and they are not universal in the treatment of COPD; not all double bronchodilators are the same – their evidence base is not yet equivalent. The analysis of real practice shows that the use of shortacting bronchodilators, ICS and triple therapy remains excessive.

Conclusion. Understanding of COPD is improving, identifying the most vulnerable points, problems, the solution of which will make it possible to take new steps to improve the quality of life of these patients and reduce mortality. 

Severe asthma along with the impact on the quality of life of those suffering from this disease leads to significant medical and social damage. Studies of the last decade indicate the leading role of eosinophilic inflammation of the bronchi as the basis of the pathogenesis of the T2 phenotype of bronchial asthma, which led to the development of targeted therapy. The most effective in this direction were preparations of humanized monoclonal antibodies directed against the main pro-inflammatory cytokines involved in respiratory tract inflammation in bronchial asthma, one of the most significant among which is interleukin 5. Refinement of the definition of severe asthma, selection of these patients among patients with difficult to treat bronchial asthma allows to clearly determine the contingent with a predicted positive effect these highly effective drugs precision therapy. On clinical examples, the difference between difficult to treat and severe bronchial asthma is discussed. The stages of clinical trials of the preparation of monoclonal antibodies against interleukin 5 Mepolizumab are analyzed in detail, the search for effective prognostic biological markers available in normal practice, allowing to select patients suitable for the treatment of patients with severe eosinophilic bronchial asthma. The effectiveness of the approach based on the allocation of two threshold values of the number of eosinophils in the peripheral blood is convincingly confirmed by the results indicating a significant reduction in the number of exacerbations, improved of lung function and an increase of the quality of life in patients, including with steroiddependent bronchial asthma, obtained not only in randomized clinical studies, but also in studies in real clinical practice.

Mild bronchial asthma (BA) occurs in 50–75% of patients with this disease. It is characterized by clinical symptoms that are controlled by low doses of inhaled glucocorticoids (IGCS) or anti-leukotriene drugs. Mild BA reduces the quality of life of patients, is accompanied by the development of severe, in some cases fatal exacerbations, and is characterized by a significant cost of treatment. One of the main problems in the management of patients with this disease is their low adherence to IGCS treatment and the excessive use of short-acting 2-adrenomimetic agents. Several clinical studies have shown that the use of a combination of budesonide/formoterol (Symbicort® Turbuhaler®) in an «as needed» mode reduces the incidence of severe exacerbations of mild BA as well as low doses of budesonide, and is characterized by a lower cumulative dose of this glucocorticoid. The results obtained were the basis for the creation of a new treatment concept, which gives preference to the combination of IGCS / formoterol «as needed» in mild BA as a supporting therapy, and for the management of symptoms of the disease.

The article describes a modern approach to the use of anti-IgE therapy for allergic bronchial asthma and conditions associated with this disease. The humanized monoclonal anti-IgE antibody, Omalizumab (Xolar®), is a promising treatment for allergic diseases mediated by IgE. Much evidence has been obtained of the effectiveness of Omalizumab in allergic bronchial asthma and chronic spontaneous (idiopathic) urticaria, on the basis of which global meta-analyzes have been carried out confirming the effectiveness and safety of this therapeutic strategy. Recent scientific articles actively discuss the possibility of expanding indications for the medical use of Omalizumab. Clinical studies have been published on the efficacy and safety of Omalizumab for allergic rhinitis, allergic keratoconjunctivitis, chronic rhinosinusitis, nasal polyps, chronic idiopathic urticaria, food allergies, allergen-specific immunotherapy, atopic dermatitis, allergic bronchopulmonary aspergillosis – in cases of comorbidity with asthma. The clinical effect of Omalizumab in patients with allergic bronchial asthma is the most studied and proven. Currently, a number of clinical studies evaluate the long-term results of prolonged use of Omalizumab or the condition after its cancellation in patients with allergic bronchial asthma and various comorbidity.

This article is devoted to the main characteristics of severe bronchial asthma (SBA) and its heterogeneity, in particular, T2 asthma is characterized and the role of the main cytokines forming T2-inflammation is presented. The main emphasis is made on the role of the IL-4 and IL-13 in the pathogenesis of AD as the key cytokines in the initiation and maintenance of T2-inflammation, as well as on a new biological molecule – monoclonal antibody – dupilumab, directed to the α-subunit of IL-4 receptor, thus blocking the pathways of IL-4 and IL-13. Dupilumab has recently been registered in our country for the treatment of moderate and severe BA, as well as moderate and severe atopic dermatitis. The article presents the clinical efficacy and tolerability of dupillumab in patients with moderate and severe BA.

Patient compliance describes the degree, to which a patient follows treatment regimen. At present, non-compliance with medical recommendations is one of the key problems for outpatient practice. Even in case of respiratory infections, patients often violate the prescribed treatment regimen, which leads to growth of ineffective treatment cases, complications, and is also accompanied by a high risk of selection of drug-resistant infectious organisms and rise in expenditures for managing patients. The most common mistakes made by patients include the change by patients of the prescribed antibiotic dosing regimen and premature termination of antimicrobial therapy. Factors affecting patient compliance are extremely diverse. Among them are factors associated with treatment and a disease, patient-associated factors of «doctor - patient» contact, and demographic predictors of low compliance, drug dosage frequency. The most important factors affecting adherence to treatment are duration of therapy; drug tolerance/safety; dosage forms (tablets, syrup, sachet); patient confidence in medical recommendations (presence of «doctor - patient» relationship); severity of the disease; patient age and sex; social activity/employment of the patient; social status of the patient, level of education; marital status; presence of a concomitant pathology in the patient; presence of bad habits (smoking, alcohol) in the patient. The main factor affecting the compliance with therapy is the drug dosage frequency. It is known that compliance is highest, if a patient is required to take a single dose of the drug per day. Duration of therapy is another important factor affecting the patient compliance. For instance, pharmacotherapy for 7 days is characterized by better compliance compared to longer antibiotic treatment regimens. Methods of improving compliance with antimicrobial therapy: reduction in the drug dosage frequency; short courses of antibiotic therapy; favourable safety profile; the cost of the drug; a patient-friendly form of antibiotic dosage form; patient education, clear information of the patient; monitoring the treatment process (repeat visits, phone contacts, etc.). The most effective way to increase compliance is to use an antibiotic drug 1-2 times per day. The use of short antibiotics courses (less than 7 days) is also a good way to increase adherence to treatment. The use of antibiotics with a good safety profile is another important approach to improving the compliance. The article also discusses other ways to enhance the patient compliance with the treatment for respiratory infections.

It is known that the use of medicinal plants, including as part of comprehensive therapy, significantly enhances therapeutic capabilities and allows you to achieve better clinical results. WHO called on all governments to make traditional medicine using medicinal herbs a part of public health systems. Cough medicines for respiratory diseases are subject to the following requirements: the drug should relieve inflammation of the respiratory tract, ensure their release through secretolytic, secretomotor action, and at the same time facilitate coughing, combat the cause of the disease and its complications, providing a comprehensive etiopathogenetic approach to treatment. The preparation possessing secretolytic, expectorant and anti-inflammatory action due to extracts of medicinal plants contained in its structure: thyme, ivy and primrose meets these requirements. Thyme has anti-inflammatory, antiviral and antibacterial medicinal effect, blocking the growth of various strains of bacteria and fungi. The antiviral effect of thyme against influenza, parainfluenza and rhinosyncytial virus was demonstrated in the test of neutralization of viral plaque formation. These properties have also been proven to a certain extent for ivy leaf extracts. The mechanism of action has only recently been studied. Antibiotic effects have been studied in detail in vitro, which also confirmed the antiviral and antifungal effects. Ivy also has an antibacterial effect, and extracts of primrose roots showed antifungal activity. The main mechanism of action of the phytopreparation includes normalization of mucous viscosity, anti-inflammatory and broncholytic effects. There are certain groups of patients (children, elderly) in whose therapy the use of the phytopreparation is particularly appropriate. 

The drug under consideration is produced in two main dosage forms: a syrup containing liquid extracts of thyme herb and ivy leaves, and tablets (Bronchipret TP) containing dry extracts of thyme and primrose roots. In the process of production of the preparation highly effective technologies of extraction of extracts from plant raw materials are applied, in particular, gentle lowtemperature vacuum extraction in a closed cycle, which allows to prevent quantitative and qualitative changes of active components as much as possible. 

Community-acquired pneumonia is still the cornerstone of practical public health care due to high morbidity and mortality. Streptococcus pneumoniae (30-50%), Haemophilus influenzae, Staphylococcus aureus and Klebsiella pneumoniae remain the main cause of community-acquired pneumonia (3-5%). In recent years, the spread of strains resistant to macrolide antibiotics (~30:) and isolates with reduced sensitivity to β-lactams among pneumococci has been a topical problem. On the pages of international recommendations, biological markers of inflammatory response are of great importance in the diagnosis of community-acquired pneumonia. Thus, in patients with an uncertain diagnosis of «community-acquired pneumonia» in case of concentration of C-reactive protein ≥ 100 mg/l its specificity in confirming the diagnosis exceeds 90%, at a concentration of < 20 mg/l the diagnosis of pneumonia is unlikely. All hospitalized patients with community-acquired pneumonia should use the IDSA/ATS criteria or SMART-COP scale to assess severity, predict and determine admission to intensive  care  unit. When planning antimicrobial therapy tactics in hospitalized patients, it is advisable to categorize patients taking into account risk factors for ineffective therapy. In the absence of such, choice of antibiotics are inhibitor-proof aminopenicillins (amoxicillin/clavulanate, etc.), ampicillin; the alternative therapy mode involves the use of respiratory fluoroquinolones.

In patients with comorbidities and other risk factors for infection with resistant microorganisms, the drugs of choice are inhibitorproof aminopenicillins (amoxicillin/clavulanate, etc.), III generation cephalosporins (cefotaxime, ceftriaxone), respiratory fluoroquinolones, and ceftaroline and ertapenem may be used in certain categories of patients. With regard to ceftaroline, it is worth noting that its use is currently an attractive strategy due to its wide range of activities, including resistant strains of pneumococcus and S. aureus. Special attention in the publication is paid to antimicrobial therapy modes in case of severe community-acquired pneumonia, the criteria of efficacy assessment and duration of antibiotics application are reflected. 

Acute respiratory disease (ARD) is a common pathology. Untimely diagnosis and treatment, co-morbidities, old age and children under 1 year of age, pregnancy can increase the severity of the condition and lead to complications and death. According to IDSA recommendations, vaccination is an effective way to prevent complications and fatal influenza cases. Vaccination is primarily for people at risk of serious illness. In cases of suspected influenza, molecular diagnostics is recommended. At the same time, treatment of suspected influenza should be prescribed immediately, without waiting for laboratory confirmation of the diagnosis. Etiotropic treatment aimed at suppressing virus replication should be the first priority in the treatment of acute respiratory viral infections. Bacterial agents may be the primary cause of respiratory diseases or may complicate viral diseases. In the presence of a bacterial pathogen, antibacterial agents are prescribed. ARD symptoms worsen the quality of life of patients. Complex treatment of respiratory diseases includes the prescription of symptomatic therapy: antipyretics, antitussives, vasoconstrictor drugs in rhinorrhea. Cough is the most common respiratory symptom. In various diseases, cough has its own peculiarities, which allows you to carry out differential diagnosis. The American Thoracic Society has proposed schemes of differential search for acute and chronic coughs, which allow rational diagnosis of diseases. The use of antitussive drugs has its own peculiarities: when the cough is non-productive, drugs are prescribed to suppress cough, when the cough is productive - drugs are aimed at facilitating the evacuation of sputum. One of the preparations possessing expectorant, mucolytic and antispasmodic action, is Hedelix syrup on the basis of ivy.

The use of a combination of the inhaled glucocorticosteroid budesonide and beta2-selective long-acting adrenergic agonist formoterol is recommended for both bronchial asthma (BA) and chronic obstructive pulmonary disease (COPD), however, indications for their use have changed significantly over the past 20 years. In BA, there was a transition from regular dosing to the tactics of a single drug – regularly and on demand, to the last recommendation – to apply as necessary at all stages of BA treatment. In COPD, this combination was a universal drug for the treatment of severe COPD with frequent exacerbations or in combination with BA, and now not only the severity and frequency of exacerbations, but also the level of blood eosinophilia is taken into account. The combination of budesonide / formoterol, which is important for practical health care, has become more accessible in recent years thanks to the advent of a domestic reconstituted drug with an original capsule powder inhaler. The drug went through comparative studies with the original drug both in clinical efficacy and in the properties of the delivered particles.

This article discusses the main aspects of the nebulizer therapy used to treat respiratory diseases. The basic principle of operation of all types of nebulizers is based on the generation of aerosol containing particles comprising an active substance. Currently, there are three types of nebulizers: jet, or compressor (which uses the energy of a gas jet), ultrasonic (which uses oscillation energy of the piezoelectric element) and membrane (Mesh nebulizers). The jet nebulizers are the most common, because they have affordable cost, are easy to use, however, using this type of nebulizers is accompanied by quite large losses of the drug (more than 50%), and they are quite noisy due to the compressor. Among the advantages of ultrasonic nebulizers are virtually silent operation, fast aerosol production and shorter inhalation times compared to compressor devices, small size and weight, and operation from the batteries. However, one of the most important disadvantages of ultrasonic nebulizers is the limited range of drugs that can be used for inhalation, which significantly limits their use in pulmonological practice. In particular, they are not suitable for inhalation of suspensions (glucocorticosteroids) due to the impossibility of homogeneous nebulization, in addition, part of the GCS molecules are destroyed by ultrasound. In recent years, the greatest prospects have been associated with the use of a new generation of nebulizers created using the so-called Vibrating Mesh Technology. Membrane nebulizers have a number of advantages compared to the compressor and ultrasonic devices. Among them are a small residual volume, noiseless operation, high mobility due to the small size, weight and ability to operate using battery.