Methods of treatment and prevention of bronchial asthma in children and adults: stepwise therapy of bronchial asthma. What is the secret of stepwise therapy of bronchial asthma Stages of treatment of bronchial asthma

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

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

Stepping asthma treatment is a process in which the number and dosage of drugs are increased if it is not possible to reduce the intensity of the manifestations of the disease and control the disease.

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

Thanks to an individual approach, it is possible to control the course of the disease using a minimum amount of medication.

In the process of taking medications, a continuous assessment of their effectiveness is carried out and prescriptions are adjusted according to indications. If the chosen tactics does not bring the desired results and the patient's condition worsens, the dosages are increased (go one step higher). This is done until the asthmatic's condition stabilizes or improves.

Step therapy goals

Components of the asthma treatment process:

1. Assessing disease control.
2. Therapy that aims to achieve control.
3. Patient observation.

In bronchial asthma, the goals of stepwise therapy are:

• reduction of bronchial obstruction;
• reduced need for bronchodilators;
• increasing the activity of patients and improving their quality of life;
• improvement of indicators of external respiration;
• seizure prevention;
• elimination of factors provoking an exacerbation of the disease.

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

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

Principles of stepwise treatment of bronchial asthma

With a stepwise approach to treatment, the doctor takes into account the patient's condition, the frequency of attacks, and then prescribes medication. If the appointments provide control over asthma, gradually reduce the amount of prescribed drugs or their dosages.

With partial control of pathology, consider increasing the doses of drugs or adding other drugs.

For patients with progressive asthma who have not previously received adequate treatment, the course begins with the second stage. If bouts of bronchospasm occur daily, asthma is shown to be treated immediately from the third stage.

At each stage of therapy, patients use emergency medicines, depending on the need, to quickly stop the symptoms of suffocation.

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

1. Light intermittent, or episodic. No more than two attacks of bronchospasm per month are observed only after exposure to provoking factors. During periods of remission, the person's health is satisfactory. The patient does not need long-term treatment. Medications are prescribed only to prevent seizures.
2. Light persistent. Attacks more than once a week. An asthmatic has bronchospasms at night (no more than 2 times a month). During exacerbations, physical activity decreases and sleep is disturbed.
3. Persistent moderate. Patients have daily attacks day and night (no more than 1 time per week). The activity of asthmatics is reduced. Constant control over pathology is necessary.
4. Persistent severe. Daily seizures during the day and at night (more than 1 time per week) with a deterioration in the quality of life. Exacerbations develop weekly.

Five steps of asthma therapy

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

Tactics are selected depending on the severity of the disease.

Stage 1

Assumes the use of emergency medicines only. Tactics are chosen for those patients who do not receive maintenance treatment and periodically experience symptoms of asthma during the day.

Usually exacerbation occurs no more than twice a month. Medications for asthma relief are fast-acting aerosolized β2-agonists. After 3 minutes, the funds stop the symptoms, expanding the bronchi.

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

If an asthma attack occurs against the background of physical exertion, short-acting or fast-acting inhalants are prescribed as a prophylaxis.

You can also use these medicines after exercise if you have symptoms of asthma. As alternative drugs, cromones are used - allergy medicines.

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

Stage 2

Tactics are selected for people with a mild persistent form of the disease. Asthmatics have to take daily medications to prevent bronchospasm and control the pathology.

First of all, the doctor prescribes anti-inflammatory corticosteroid drugs in low dosages for taking 1 time per day. To eliminate bronchospasm, fast-acting medications are used.

As an alternative, if the patient refuses hormones, antileukotriene drugs that relieve inflammation may be prescribed.

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

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

Step 3

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

1. inhaled glucocorticoids in small doses;
2. β2-agonist of prolonged action.

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

As an alternative treatment, patients are offered the following combination of medications:

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

If additional treatment with oral corticosteroids is required and symptoms worsen, proceed to the next step of therapy.

Step 4

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

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

An increase in the dosage of hormonal drugs is necessary as a temporary treatment. If after six months there is no effect, the dose is reduced due to the risk of developing undesirable effects.

The following combinations increase the effectiveness of treatment:

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

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

Step 5

Tactics are chosen for severe asthma. Most often, therapy is carried out in a hospital setting. Patients are prescribed the following drugs:

1. inhalation medicines for emergency care;
2. inhaled glucocorticoids in high doses;
3. β2-agonist of prolonged action;
4. antibodies to immunoglobulin E;
5. glucocorticoids in oral form (with and frequent exacerbations);
6. theophylline.

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

Then the doctor decides to reduce the number of drugs taken or reduce their dosage in order to establish a minimum amount of therapy.

Features of stepwise treatment of asthma in children

Gradual therapy of bronchial asthma of any form in adolescents and children practically does not differ from the treatment of adults. Therapy begins with the establishment of the severity of the course of the disease.

When prescribing drugs, the doctor pays a special role to their side effects. Differences in the treatment of children are:

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

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

The complex of therapy includes inhalations using long-acting β2-sympathomimetics (1-2 times) and oral hormones. As emergency drugs, a combination of budesonide and formoterol can be used.

Inhalation therapy in newborns has the following features:

1. Using a jet sprayer with a compressor. With an attack, drugs containing fenoterol, salbutamol are used, for long-term therapy - drugs with budesonide, cromoglycic acid.
2. Use of metered-dose aerosols with spacer and mask.
3. With the development of hypoxia, an oxygen mask is shown.
4. In emergencies, β2-sympathomimetics are administered intravenously. With an increase in symptoms, epinephrine is injected subcutaneously and the baby is transferred to artificial ventilation of the lungs.

Medical treatment of children is supplemented with immunotherapy. Eliminate also potential sources of allergens.

Inhalation systems must meet the requirements of childhood. Children from 7 years of age can be transferred to a metered-dose aerosol.

Evaluation of the effectiveness of treatment

The criteria for effective treatment of bronchial asthma are:

1. Reducing the severity of symptoms.
2. Elimination of seizures at night.
3. Reducing the frequency of exacerbations of the disease.
4. Decrease in dosages of β2-agonists.
5. Increasing the activity of patients.
6. Complete disease control.
7. No side effects from drugs.

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

The basis of the stepwise approach to treatment is the determination of the minimum maintenance dose of drugs.

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

With an incomplete response to the action of the drug, oral hormones and inhalations with anticholinergics are included in the complex of therapy. If the answer is bad, call the doctor. The patient is taken to the intensive care unit.

Step down

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

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

Go to the next step in this way: reduce the dosage of the main drug or cancel the medication for maintenance therapy. In the course of changing treatment tactics, patients are monitored.

If there is no deterioration in the condition, monotherapy is prescribed - they switch to stage 2. In the future, a transition to the first stage is possible.

Finally

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

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

Thus, it is possible to significantly reduce the risk of exacerbations, prolong periods of remission, eliminate or alleviate symptoms.

»» No. 6 "98 »» New medical encyclopedia Modern views

Gleb Borisovich Fedoseev- head. Department of Hospital Therapy, St. Petersburg State Medical University. acad. I.P. Pavlova, Dr. med. Sciences, Professor, Honored. scientist of the Russian Federation
Maria Anatolyevna Petrova- Leading Researcher of the State Scientific Center for Pulmonology of the Ministry of Health of Russia, Dr. med. Sciences

Modern ideas about bronchial asthma
A fundamentally important provision of the modern concept of AD is the recognition of the leading link in the pathogenesis of the disease. chronic persistent inflammation of the airways(it dictates the need for early detection of these changes and anti-inflammatory treatment).
The peculiarity of inflammation in AD lies in the combination of immunological and non-immunological mechanisms of its occurrence.
According to most researchers, hereditary predisposition- a fundamental factor in the formation of BA. This pathology should be attributed to diseases with an additive polygenic type of inheritance with a threshold effect. In other words, multiple hereditary disorders form the disease under the influence of negative environmental factors.
Multifactorial diseases are characterized by the existence of clinical polymorphism of symptoms. At the same time, in the population there is a certain number of clinically healthy individuals with subthreshold level of violations. This provision is fully consistent with the concept we put forward earlier about "biological defects" as the first stage in the formation and development of AD.
A significant place in the etiology of the disease belongs to external factors:

• atmospheric pollution,
• professional aggressive influences,
• increased contact with allergens ("allergenic life"),
• viral infections,
• smoking (including passive) and others.

Significant role in the formation of BA play diseases of the extrapulmonary sphere: lesions of the upper respiratory tract (chronic rhinosinusopathy, polyposis) and skin (urticaria, eczema, atopic dermatitis), which have some common mechanisms of pathogenesis with BA. In a significant proportion of patients with this pathology, there is an altered sensitivity and reactivity of the bronchi, often among relatives there are those suffering from asthma.
Lesions of the extrapulmonary sphere in their isolated form can be considered as stage of pre-adjustment.
At present, the question of the causes of heterogeneity of BA at the stage of an already formed disease remains difficult.

Course and treatment of asthma
The nature of the course of asthma and its long-term prognosis are largely determined by the age at which the disease occurred.
In the vast majority of children with an allergic form of the disease, it proceeds relatively easily. However, in children receiving chronic hormonal therapy for BL (if it is insufficient), severe forms of BA, severe asthmatic statuses, and even death may occur.
The long-term prognosis of asthma, which began in childhood, is favorable. As a rule, by puberty, children "grow" out of asthma. However, they retain (sometimes asymptomatically) a number of pulmonary function disorders, bronchial hyperreactivity, and deviations in the immune status. There are indications in the literature about the unfavorable course of BA, which debuted in adolescence.
The nature of the development and prognosis of AD, which debuted in adulthood and old age, is more predictable. The severity of the course of the disease is determined, first of all, by its form. allergic asthma proceeds easier and is more favorable in the prognostic relation. "Pollen" asthma has a milder course than "dust". In elderly patients, a primary severe course is noted, especially in patients with "aspirin" BA.
As noted in the International Consensus, the adequacy of the treatment is certainly an important factor influencing the course of AD and its long-term prognosis. Currently, the so-called "stepwise" approach is used in the treatment of AD. Its goal is to achieve maximum control of the symptoms of the disease by selecting the optimal drugs for a given patient and their doses, which give a minimum of side effects. Schematically, this approach can be described as follows:
STAGE 1 - mild episodic course. In patients belonging to this group, the disease is characterized by the occurrence of rare, usually short-term, minimally pronounced asthmatic symptoms without significant functional impairment, which usually occurs in certain provoking situations.
Mild episodic asthma should be treated by proactively identifying triggers and addressing them. This approach, which is also significant for other groups of patients, is effective in some cases in patients with mild episodic asthma without the use of any additional therapeutic measures.
If it is not effective enough to relieve symptoms, they can be used short-acting beta 2 agonists, "on demand". These drugs or sodium cromoglycate are used prophylactically before physical activity or contact with an allergen.
STAGE 2 - mild persistent course. Asthma is characterized by mild but more distinct, clinically and functionally pronounced persistent symptoms that require active treatment of inflammation in the airways. For this group of patients, the drugs of choice should be inhaled anti-inflammatory drugs(mast cell membrane stabilizers). They are prescribed for a long time and are practically devoid of significant side effects.
Currently, an increasing place among anti-inflammatory drugs is given to leukotriene receptor blockers (acolate).
Short-term deterioration - attacks of suffocation or difficulty breathing - are stopped short-acting beta 2 agonists, which are prescribed no more than 3-4 times a day. Increasing demand for beta 2 agonists means that anti-inflammatory therapy needs to be stepped up.
STAGE 3 - for moderate severity. Asthmatic symptoms vary in frequency and severity, from relatively mild to severe. Functional indicators are very labile (FEV 1 (forced expiratory volume in the first second) and POS vyd. (peak expiratory volumetric flow rate) are 60-80% of the proper values, the daily variation is 20-30%).
Therapy of patients in this group should be individualized, using, in various combinations, almost the entire arsenal of anti-asthma drugs.
The main role is played anti-inflammatory drugs- including glucocorticosteroids (GCS), usually prescribed daily, for a long time, followed by selection of individual maintenance doses.
For the control of symptoms, especially at night, use is indicated. bronchodilator drugs(b 2 -agonists, methylxanthines, anticholinergics), predominantly prolonged action. The choice depends on the effectiveness of the drug and its tolerability.
STAGE 4 - severe course. The severe course of asthma is characterized by continuous recurrence of symptoms of the disease, leading to impaired physical activity and, often, disability of the patient. Given the significant severity of inflammatory changes, the leading place in the treatment of patients in this group belongs to inhaled corticosteroids in combination with minimal, individually selected doses of systemic corticosteroids administered orally.
The main task in the treatment of patients with severe BA is to reduce the consumption of corticosteroids, especially systemic ones. This is achieved by a reasonable combination of them with different groups. bronchodilators, mainly long-acting.
In some cases, the dose of corticosteroids can be reduced by using them with nedocromil sodium which has high anti-inflammatory activity.
In accordance with the stepwise approach to the treatment of asthma, when stable results are achieved and maintained (within several weeks or months), the intensity of drug therapy can be reduced to the level necessary to maintain disease control ("step down").
The transition to the "step up" (intensification of drug treatment) is necessary if it is impossible to control the disease at the previous stage, provided that the patient correctly fulfills the doctor's prescriptions.
According to the provisions of the International Consensus, the presented recommendations on drug therapy for patients with asthma are a scheme that reflects the modern, most common and effective approaches to the basic treatment of the vast majority of patients.
The inclusion of other drugs and non-drug methods in the arsenal of therapeutic measures is carried out in accordance with individual indications and contraindications.
Patients with asthma should be registered with a local doctor who, if necessary, consults them with a pulmonologist and other specialists (allergist, dermatologist, rhino-otolaryngologist, etc.), resolves issues of working capacity, hospitalization, and employment.
Regular exchange of information between the doctor, the patient and his family allows.

Stepwise therapy of bronchial asthma is recognized as the most effective method of treatment and complies with the approved international standard of therapeutic measures aimed at maintaining an adequate standard of living for patients. Bronchial asthma is one of the incurable diseases, and the main goal of treatment is to stop the development of asthma attacks, the inadmissibility of the occurrence of asthmatic status and severe complications of respiratory dysfunction. The range of drugs prescribed and the stages of bronchial asthma are closely interrelated. The peculiarity of stepwise therapy is the long-term use of certain drugs selected by the attending physician on the basis of a detailed examination and setting the currently existing severity of bronchial asthma (BA).

In order for gradual therapy of bronchial asthma to achieve a positive result and a significant improvement in the patient's condition, it is necessary to accurately determine the severity of asthma development or the so-called stage of its development.

There are criteria by which it is determined how severe this form of the disease is:

1. The number of clinical manifestations includes an established number of asthma attacks that occur during a night's sleep for 7 days. The number of daytime seizures that occurred during each day and throughout the week is counted. Through continuous monitoring, it is determined how much sleep is disturbed and whether there is a failure in the patient's physical activity.
2. Objective. FEV 1 (forced expiratory volume in 1 second) and PSV (peak expiratory flow rate) and their changes over 24 hours.
3. Medicines, thanks to which the patient's condition is maintained at the proper level.

The appointment and treatment of bronchial asthma in stages depends on the severity of the disease. To select the most high-quality therapy, a table has been developed and compiled, with the help of which it is easier to determine the level of development of the disease.

In accordance with this table, 4 degrees of severity of BA are distinguished:

1. Mild or episodic form of bronchial lesions - stage 1. Harsh wheezing is rare. Perhaps once every three days, and at night, suffocation occurs once every 14 days.
2. 2 - night attacks 2-3 times a month, fluctuations in PSV increase.
3. 3 - development of persistent BA. The condition is characterized as moderate.
4. 4 - severe form of persistent bronchial asthma. The quality of life is significantly reduced, the patient's sleep is disturbed, and his physical activity is reduced.

The survey, the measurement of FEV 1 and PSV allow you to determine the severity of the disease and begin therapy in steps.

Special attention when choosing a method of treatment and prescribing the most effective drugs deserves such a condition as status asthmaticus. It is very dangerous not only for general health, but also for the life of the patient.

There are two types of seizure development:

• anaphylactic - rapid;
• metabolic - gradual.

The danger of asthmatic status lies in the fact that in the absence of timely quality medical care, there is a threat to the patient's life. The attack does not stop within a few hours, despite the introduction of strong anti-asthma drugs. As a result, the development of a complete absence of bronchial conduction is possible.

The peculiarity of asthma lies in the fact that this disease cannot be cured and accompanies the patient throughout his life, and the developed complex of stages in the treatment of bronchial asthma makes it possible to keep the patient's condition under control. With the help of step therapy, the attending physician gets the opportunity to maintain the health of his patient at the proper level thanks to the scheme developed by the International Committee of the Global Strategy for the Treatment and Prevention of AD. The table compiled by specialists will help to understand exactly how the quantity and quality of drugs are determined depending on the severity of the disease.

In total, there are 5 stages of asthma treatment, and the first contains the minimum amount of drugs used.

The fifth is characterized by the appointment of the most powerful drugs that stop the development of asthma attacks and improve the general condition of the patient:

1. The first is the use of bronchodilators, but doctors recommend doing this no more than once a day. Prescribing more effective drugs is not required.

   The transition to the next level is carried out if there is no effect from the ongoing treatment and the dose of drugs needs to be increased.

2. The second part of therapy involves daily therapeutic measures. We are talking about the use of funds introduced into the patient's body by inhalation. At this stage, the use of glucocorticoids is allowed as a means that can prevent the development of a relapse of the disease.
3. Third - in addition to glucocorticoids and other inhaled drugs, patients are prescribed drugs for anti-inflammatory therapy. The dosage of substances increases markedly. Reception is carried out daily, sometimes several times a day.
4. The fourth is the treatment of severe bronchial asthma. Treatment is carried out in a hospital under the constant supervision of medical professionals. This stage involves taking several drugs (complex treatment), which is carried out daily.
5. Fifth - therapy of the most severe stage of the disease, carried out strictly in a hospital. Reception of drugs is repeated, treatment is long, the use of inhalations is mandatory against the background of anti-inflammatory drugs and antispasmodics taken.

If therapeutic measures at a certain stage turned out to be very effective, and the disease is in remission for three months, a transition to a lower stage is possible.

The attending physician can change the tactics of treatment if, as a result of the therapy, a positive effect was achieved and the disease went into remission at least three months ago. This allows you to switch to a softer sparing treatment.

Only from the two lower steps is it possible to make the transition if the patient has taken hormonal drugs during the course of therapy.

The decision on the possibility of making the transition can only be made after a detailed examination conducted in a hospital setting. After completing the course of therapy, the doctor adjusts the medication, but he can only decide to switch to another stage of therapy if the remission lasts from three to six months.

There are some features of the transition for children with bronchial asthma:

1. Against the background of a change in the intake of medicines, first of all, it is necessary to take care of high-quality and effective prevention of the disease.
2. Reducing the dose and changing the method and mode of taking drugs is carried out under the strict supervision of the attending physician.
3. The slightest change in the condition of a small patient should be immediately reported to the attending physician.

If the patient's condition has stabilized, then the transition of therapy to a lower level is possible, which can be done under the supervision of physicians and very smoothly, gradually changing the doses of certain drugs (drugs).

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Currently, the ability to control the disease and improve the quality of life of the patient is the main goal of the treatment of bronchial asthma. This can be achieved by performing the following tasks:

1. elimination (elimination) or reduction of the impact on the body of trigger factors;
2. carrying out planned (basic) pharmacotherapy in a stable condition of the patient;
3. conducting emergency pharmacotherapy in case of exacerbation of the disease;
4. using specific desensitization or immune therapy.

The fulfillment of the first and fourth tasks is especially important for the treatment of the allergic form of bronchial asthma. Indeed, if the main allergens and irritants that provoke exacerbations are removed from the patient's environment, it will be possible to prevent the onset of symptoms of the disease and achieve long-term remission. Therefore, maximum efforts should be made to identify triggers - factors that cause an exacerbation of the disease, primarily allergens. If you are allergic to pet hair, you should remove these animals from the house, or at least keep them out of the bedroom and wash them daily. If you are allergic to house dust and cockroaches, you should thoroughly and regularly clean the room, as well as get rid of cockroaches. With frequent acute respiratory viral infections that exacerbate the course of the disease, annual influenza vaccination is necessary, prophylactic administration of interferon locally on the nasal mucosa.

WORKING CLASSIFICATION OF THE COURSE OF DISEASE, BASIC TREATMENT
Currently, the pharmacotherapy of bronchial asthma is based on the recommendations of the International Consensus on Asthma (GINA, 2003), which reflects the common opinion of a working group of experts from WHO, the European Respiratory Society and the National Heart, Lung and Blood Institute (USA). The goals of long-term management of bronchial asthma, which are declared in international agreements (GINA, 2003), are:

1. achieving and maintaining symptom control;
2. prevention and effective elimination of exacerbations;
3. correction of violations of pulmonary ventilation and maintaining it at a normal level;
4. achievement of a normal level of activity of patients, including physical;
5. elimination of side effects of disease therapy;
6. prevention of the development of irreversible bronchial obstruction;
7. preventing death from asthma.

In accordance with these recommendations, for the treatment of bronchial asthma, regardless of the causes that caused the disease, two groups of medications should be used: long-term anti-inflammatory therapy that provides control of the disease (the so-called basic therapy), and symptomatic emergency therapy aimed at rapid elimination or reduction of acute symptoms.
The means of basic therapy include drugs that affect certain pathogenetic links of the inflammatory process in the bronchi, reducing its clinical manifestations and preventing the progression of the disease as a whole. The optimal therapy is one that simultaneously affects both main pathogenetic mechanisms of the disease - inflammation and dysfunction of the smooth muscles of the bronchi. Medicines are used daily for a long period of time. These include inhaled and systemic corticosteroids, which are the most effective controllers of inflammation, as well as cromones (sodium cromoglycate and sodium nedocromil) and leukotriene modifiers. To some extent, a moderate anti-inflammatory effect has a prolonged form of two groups of drugs - theophyllines and β2-agonists. The persistent bronchodilator action of prolonged β2-agonists, which includes salmeterol, is based on a fairly strong membrane-stabilizing effect.
The results of recent studies have shown that the goal of modern basic therapy is to achieve complete control not only over the symptoms of the disease, but also over its other signs. Unlike previously accepted criteria, the following are considered signs of achieving control over the course of the disease:

1. absence or minimal manifestations of chronic symptoms, including nocturnal ones;
2. lack of exacerbations and ambulance calls;
3. minimal or no need for short-acting β2-agonists;
4. lack of signs of a decrease in the patient's activity, including physical activity, due to asthma symptoms;
5. daily variability of POSvyd less than 20%;
6. achieving the best value for a particular patient FEV1 or FEV, which should be close to normal;
7. the absence of undesirable side effects that force a change in basic therapy.

The means of emergency therapy include drugs that quickly eliminate or reduce the effects of bronchospasm - short-acting β2-agonists, anticholinergics, short-acting theophyllines.
Medications can be administered to the body by inhalation, oral, rectal and injection routes. The advantage is given to the inhalation route, since it is this method of administration that ensures the creation of high therapeutic concentrations of drugs directly in the target organ with a minimum of systemic side effects. Currently, two dosage forms are used for this - aerosol metered dose inhalers (MDI) and dry powder inhalers (DPI), which come in various technical designs. Most often, these are gelatin capsules containing a single dose of the active substance in the form of a powder, complete with a special delivery device (HandiHaler type), which ensures the introduction of the drug into the bronchi with the force of the patient's inhalation. Recently, an improved device has appeared - a special inhaler containing a certain number of single doses of the active substance in the form of a powder (Discus type), the use of which during the patient's inhalation ensures the introduction of one therapeutic dose of the drug into the bronchi. It is recommended that aerosol metered dose inhalers be used together with a spacer, a special device that improves the delivery of medication directly to the lower respiratory tract without the need for strict coordination of inspiration and pressing the aerosol metered dose inhaler valve.
The attention of doctors and patients should be drawn to the fact that the success of treatment depends on how adequately the inhalation device is selected, how correctly the patient has mastered the technique of inhalation, and therefore how accurately he receives the dose of medicine prescribed by the doctor. Widely known studies have shown that patients accurately perform inhalations in 23-43% of cases when using an aerosol metered dose inhaler, in 53-59% of cases when using dry powder inhalers and in 55-57% of cases when using aerosol metered dose inhalers. inhalers along with a spacer. Therefore, medical personnel need to educate patients on the correct inhalation technique.
The International Consensus on Asthma (2003) recommended that physicians use the developed classification of bronchial asthma in their practical work, which is based on determining the severity of the course of the disease, taking into account the clinical manifestations and indicators of pulmonary ventilation at different stages of the disease (Table 11). The classification clearly regulates the amount of basic therapy required for a given severity of the course of the disease.
The approach to choosing drugs for basic therapy is unified and is used for all clinical forms of bronchial asthma (allergic and non-allergic). Before prescribing treatment, the doctor evaluates the frequency, strength and duration of asthma attacks, the patient's condition in the interictal period, the variability and reversibility of functional disorders of bronchial patency. Assessment of functional indicators to determine the severity of the course of the disease is carried out in the absence of episodes of expiratory dyspnea.

In accordance with this classification, intermittent and persistent course of bronchial asthma are distinguished. The intermittent (episodic) course is characterized by the absence of persistent symptoms of the disease and the presence of irregular attacks of breathlessness or their clinical equivalents less than once a week, mainly after contact with the allergen. There are often long asymptomatic periods. This course of the disease was conditionally called stage No. 1. The persistent course is characterized by the presence of persistent symptoms in the form of asthma attacks or their clinical equivalents once a week and more frequently. Depending on the frequency of symptoms of the disease, the degree of limitation of physical activity, indicators of bronchial obstruction, the persistent course of asthma is mild (stage No. 2), moderate (stage No. 3) and severe (stage No. 4). With the simultaneous presence of signs inherent in various stages of the disease, the patient is referred to the highest stage at which one of the existing symptoms occurs. With a change in the patient's condition, it is possible to move to a step higher or lower with a corresponding revision of the treatment.
If a good therapeutic effect is obtained at any of the classification levels and complete control of the disease is achieved, which lasts for at least 3 months, you can carefully move to a lower level in the classification, i.e., slightly weaken the therapy. In a situation where the control of symptoms and functional disorders in a patient is insufficient, one should move to a higher level and intensify therapy. However, first you should check whether the patient has followed all the doctor's prescriptions correctly. It is necessary to teach the patient to monitor their health, independently perform peak flowmetry, inform the doctor about the early symptoms of exacerbation.

In stage 1 (intermittent asthma), short-acting β2-agonists are most often used episodically when symptoms of the disease occur. Prophylactic use of cromones or leukotriene modifiers and/or short-acting β2-agonists is desirable before possible but unavoidable exposure to an allergen or before exercise.
Of the short-acting β2-agonists, two drugs are prescribed - salbutamol and fenoterol. In this case, the "gold standard" is salbutamol, which has the highest selectivity coefficient for β2-adrenergic receptors. It is believed that the higher this selectivity index, the less likely it is to develop undesirable side effects of β1-adrenergic stimulation. These drugs are available in the form of aerosol metered dose inhalers, one single dose of which contains 100 or 200 micrograms of the active substance. Drugs are used in a dose of 1-2 inhalations once for the relief of acute symptoms. Their action begins a few minutes after inhalation and lasts about 4-6 hours. Currently, dry powder forms of these drugs (DPI) have appeared, as well as solutions for nebulizer inhalation therapy - nebules.
Cromones are both means of preventive and basic anti-inflammatory therapy. The basis of their pharmacological action is the stabilization of the membranes of mast cells and basophils, which prevents the process of degranulation. The use of cromones is effective in the early stages of bronchial asthma, mainly of an allergic form. However, these drugs do not have enough effect on bronchial hyperreactivity and in some cases cannot fully control the course of the disease, starting from stage No. 2. It is advisable to use them to prevent the development of an asthma attack before the expected contact with the allergen or before physical activity.
Sodium cromoglycate is available in two dosage forms: in the form of a powder in capsules containing 20 mg of the substance, together with a delivery device - spinhaler, as well as in the form of an aerosol metered dose inhaler, a single dose of which contains 5 mg of the active substance. For the purpose of prevention, 10-20 mg of the drug is prescribed, and with continued contact with the allergen, the drug is inhaled at the same dose 4 times a day until the contact stops.
Nedocromil sodium the strength of the anti-inflammatory effect is several times greater than that of sodium cromoglycate. It is believed that the daily dose (8 mg) of nedocromil sodium is equivalent in strength to the anti-inflammatory effect of a dose of 400 μg of the reference inhaled GCS - beclomethasone. However, the use of nedocromil sodium is effective mainly in children and young people with manifestations of allergic bronchial asthma, as well as in the treatment of hay fever with asthmatic syndrome or occupational asthma. The drug form of the drug is an aerosol metered dose inhaler, a single dose of which contains 2 mg of the active substance. The bioavailability of the drug is low, side effects are observed very rarely in the form of nausea, headache, reflex cough. The prophylactic dose is 4 mg. With continued contact with the allergen, the drug is inhaled at the same dose 2-4 times a day until contact ceases.
At stage No. 2 (persistent asthma, mild course), permanent basic therapy is prescribed. In most cases, preference is given to inhaled corticosteroids in a daily dose of 200-500 mcg of beclomethasone or an equivalent dose of another drug. At this stage, the corresponding daily dose of fluticasone is 100-250 mcg, and mometasone is 200 mcg.
In children and young people with an allergic form of the disease, it is advisable to start treatment with the appointment of cromones. Most often, nedocromil sodium is used in a daily dose of 16 mg - 2 breaths 4 times a day until a clinical effect is achieved. Then the dose is reduced to 2 breaths 2 times a day. In case of ineffectiveness of cromones, they switch to treatment with inhaled corticosteroids.

Inhaled corticosteroids have the widest range of immunomodulatory, anti-inflammatory and anti-allergic properties. With the inhalation route of administration, a high therapeutic concentration in the bronchi is created with a minimum of systemic side effects. The possibility of side effects is determined by the dose of the drug and its bioavailability. When using inhaled corticosteroids at a daily dose of less than 1000 mcg, clinical systemic side effects are usually not observed.
Mometasone furoate with a Twisthaler delivery device and fluticasone propionate with a Diskus delivery device have the lowest bioavailability among inhaled corticosteroids. This determines their least systemic impact and the least number of side effects.
Of all inhaled corticosteroids, fluticasone and mometasone have the highest tropism (the ability to bind tissues) to the bronchi, which ensures the selectivity and prolongation of their action. It is believed that the activity and strength of the anti-inflammatory effect of fluticasone is twice that of the reference inhaled GCS - beclomethasone. Fluticasone is used 2 times a day in adults and children, starting from the first year of life. The ease of use of the drug is determined by the presence of its various drug forms - metered-dose aerosol inhaler, dry powder inhaler Discus, solution for nebulizer therapy.
Compared to other inhaled corticosteroids, mometasone furoate has the highest affinity for glucocorticosteroid receptors and is the strongest activator of anti-inflammatory gene transcription. Therefore, it can be used once a day. Its dose is approximately equivalent to that of fluticasone. However, mometasone is an order of magnitude more active than fluticasone in stimulating progesterone receptors, which leads to the possibility of additional side effects, especially in women of childbearing age.

A new approach in inhalation therapy, taking into account the environmental requirements for the propellant, is the use of hydrofluoroalkane-containing (HFA) aerosol metered-dose inhalers instead of chlorofluorocarbon-containing (CFC) drugs. Due to the smaller particle size of the new drug and the corresponding higher accumulation in the lungs, it is possible to achieve control of asthma symptoms with the use of half doses of inhaled corticosteroids. Thus, the transition of patients from chlorofluorocarbon-containing beclomethasone dipropionate to hydrofluoroalkane-containing beclomethasone dipropionate makes it possible to halve the inhalation dose of the drug.
Prolonged use of inhaled corticosteroids can lead to local side effects: candidiasis of the oral and pharyngeal mucosa, hoarseness or aphonia. Only thorough rinsing of the mouth and throat after inhalation of the drug prevents the occurrence of these complications, and the use of spacers and dry powder forms reduces their frequency.
In case of insufficient clinical effect of the basic treatment and incomplete control of the course of the disease at this stage, instead of increasing the dose of inhaled GCS, an additional prescription is given

The treatment of asthma is based on a stepwise approach. For this, five stages have been developed, where therapy strategies are defined depending on the clinical course, the presence of exacerbations or the possibility of their development, and the degree of control over the disease. The advantage of this approach is that it makes it possible to achieve a high degree of control over bronchial asthma, using drugs in a minimal amount.

Principles of stepwise treatment of bronchial asthma

Bronchial asthma is a chronic inflammation of the bronchi of allergic origin, which can occur at any age. Unfortunately, this disease cannot be completely cured, but it is possible to take it under control and live a full life. This is achieved through the elimination of provoking factors and the selection of optimal supportive treatment. It is to select the minimum amount of medications, their dosages with maximum control of symptoms and progression of pathology that stepwise therapy of bronchial asthma has been developed.

The 5 Steps of GINA Asthma Treatment

The main principles of this approach to treatment:

• selection of optimal drug treatment together with the patient and his relatives;
• continuous assessment of the clinical course of the disease, the level of its control;
• timely correction of therapy;
• in the absence of a clinical effect - the transition to a higher level;
• with complete control over the disease for 3 months. – transition to a lower level;
• if there was no basic therapy in the moderate course of bronchial asthma, then treatment begins from the 2nd stage;
• with uncontrolled disease, start with the 3rd stage;
• if necessary, emergency drugs are used at any stage of treatment.

At each level, a therapeutic cycle is performed, which includes an assessment of the degree of control over the disease, a course of therapeutic measures aimed at achieving high control and monitoring of the condition to maintain a period of remission.

Five steps of asthma therapy

Before starting therapy, the specialist determines the level of disease control based on the data of an objective examination, analysis of complaints, the frequency of exacerbations, and the results of functional diagnostic methods. Thus, bronchial asthma can be:

• controlled - daytime attacks no more than 2 times a week, with the optional use of emergency therapy, no exacerbations, lung function is not impaired, no exacerbations;
• partially controlled (persistent) - symptoms of the disease occur more than 2 times a week, including at night, require emergency treatment, exacerbations at least 1 time per year, lung function is reduced, activity is moderately impaired;
• uncontrolled (severe) - attacks occur day and night, can be repeated, activity is reduced, lung function is impaired, exacerbations occur every week.

Based on the degree of control, a certain level of therapy is selected. Each stage contains a variant of the basic treatment and an alternative one. At any stage, the patient may use short-acting or long-acting rescue medications.

First stage

This level is suitable for patients with controlled asthma. Treatment includes the use on demand (with the development of an asthma attack) of beta2-agonists of rapid action in inhaled form. Alternative treatments include inhaled anticholinergics or oral short-acting beta2-agonists or theophyllines.

The same treatment approach is used for exercise-induced bronchospasm. Especially if this is the only manifestation of the disease. To prevent an attack, the drug is inhaled before the load or immediately after it.

Second step

Patients at this level and beyond need regular supportive care and emergency relief for seizures. At any age, the appointment of low-dose hormonal agents in inhalation form is acceptable. If their administration is not possible due to patient rejection, severe side effects, or chronic rhinitis, antileukotriene drugs are prescribed as an alternative.

Third step

Adult patients are given a low-dose combination of a low-dose inhaled glucocorticosteroid (IGCS) and a long-acting beta2-agonist. The drugs can be used individually or as part of a combined dosage form. The combination of Budesonide and Formoterol is also suitable for the relief of an acute asthma attack.

Another treatment option is to increase the dosage of ICS to the average values. At the same time, it is recommended to use spacers for better drug delivery and reduce side effects. In addition, for maintenance therapy, it is possible to use inhaled corticosteroids in conjunction with antileukothiens or slow theophylline.

Fourth step

If control over the disease is not established at the previous level, then a complete examination of the patient is necessary with the exclusion of another disease or the establishment of a form of bronchial asthma that is difficult to treat. It is recommended, if possible, to contact a specialist who has extensive positive experience in the treatment of this disease.

To establish control, combinations of inhaled hormones and long-acting beta2-agonists are chosen, while ICS are prescribed in medium and high dosages. As an alternative, antileukotrienes or medium doses of slow theophylline can be added to ICS at medium doses.

Fifth step

At this level, oral hormonal preparations of systemic action are added to the previous treatment. This choice helps to improve the patient's condition, reduce the frequency of seizures, but causes severe side effects, which the patient should be informed about. Anti-immunoglobulin E antibodies can be used as a therapy option, which significantly increases the level of control over severe asthma.

Step down

Monitoring of the course of the disease should be carried out regularly at regular intervals. After the appointment of therapy, control is carried out after 3 months, and in case of exacerbation after 1 month. During a visit to the doctor, the patient's condition is assessed and the issue of the need to change the therapeutic stage is decided.

Going one step lower with a high probability is possible from levels 2-3. At the same time, the dose of drugs is gradually reduced, their number (within 3 months); in the absence of deterioration, they switch to monotherapy (stage 2). Further, with a good outcome, only the emergency drug is left on demand (level 1). It takes 1 year to move down a step, during which the level of disease control remains high.

Features of stepwise treatment of asthma in children

In children of any age, therapy begins with the use of low-dose ICS (stage 2). If there is no effect within 3 months, a gradual increase in the dosage of drugs (stage 3) is recommended. To stop an acute attack, the administration of systemic hormonal agents in a short course in the minimum allowable doses is used.

For effective control of bronchial asthma in children, it is necessary to carefully approach the education of the child (from 6 years old) and parents on the technique of using inhalers. In childhood and adolescence, the disease can be completely cured, so monitoring and dose adjustment should be carried out at least once every six months.

Conclusion

Stepwise therapy of bronchial asthma allows to achieve high control over the disease by prescribing a minimum amount of drugs and constant monitoring of the patient's condition. It is important that the basic principles of this approach to treatment be observed by both the specialist and the patient.