Restoration of the drainage function of the bronchi

Restoration of the drainage function of the bronchi contributes to the rapid resorption of the inflammatory infiltrate in the lungs. For this purpose, expectorants and mucolytics are prescribed. These remedies are used when the cough becomes "wet". A solution of potassium iodide (drink with alkaline solutions, borjomi, milk), marshmallow root, mukaltin, acetylcysteine, bromhexine (bisolvon) have a good effect. Particular importance is attached to bromhexine, which stimulates the production of surfactant, an important component of the local bronchopulmonary protection system. Proteolytic enzymes are also used to thin sputum and cleanse the bronchi.

In severe acute pneumonia, a sharp violation of the drainage function of the bronchi or abscess formation, sanitation bronchoscopy is performed with a 1% dioxidine solution or a 1% furagin solution. Such activities are performed in the intensive care unit or unit.

Normalization of the tone of the bronchial muscles

Often in patients with acute pneumonia, pronounced bronchospasm is observed, which disrupts the ventilation function of the lungs, contributes to the development of hypoxemia, and delays the resorption of the inflammatory focus.

Bronchodilators are used to relieve bronchospasm. Eufimin is most often used intravenously, in candles, sometimes inside. In recent years, long-acting theophylline preparations have been widely used.

To stop an asthma attack, selective beta2-adrenergic receptor stimulants in the form of metered aerosols (berotek, ventolin, salbutamol, etc.) can also be used, some beta2-stimulants can also be used orally (alupent, etc.).

Restoration of the drainage function of the bronchi is one of the primary tasks in the treatment of diseases with chronic obstructive syndrome.

During the day, about 12,000 liters of more often polluted air passes through the lungs, while up to 70% of inhaled particles (mainly microorganisms) enter the distal respiratory tract.

The first barrier to the penetration of pathogenic substances into the body is the mucous membrane of the respiratory tract, which is represented by ciliated epithelium covered with a layer of mucus. The formation of bronchial secretions is a natural protective mechanism that provides humidification, warming of the air, evacuation of foreign particles, bacteria and viruses from the bronchi and lungs.

During the day, the body of a healthy person produces an average of 50-80 ml of bronchial secretions, which are secreted into the oral cavity and reflexively swallowed without causing a cough. Thanks to the work of the ciliated epithelium of a healthy person with normal bronchial secretion rheology, mucociliary clearance is ensured - the removal of excess mucus, foreign particles and microorganisms. In bronchopulmonary diseases, an increased amount of bronchial secretion is produced compensatory.

However, the mucous membrane of the bronchi in a significant number of people under the influence of smoking, environmental factors and chronic diseases changes pathologically. In smokers with COPD, the number and activity of the ciliated epithelium decreases very quickly, their metaplasia occurs, the number of goblet cells increases, and increased secretion production occurs. As a result of the inflammatory process, the goblet epithelium swells into the lumen, disrupting the patency of the small-caliber bronchi. Hyperplasia and hyperfunction of the secreting elements of the respiratory tract leads to hypercrinia (an increase in the amount of secretion) and dyscrinia (a change in its rheological properties). Due to the high viscosity, the speed of movement of the bronchial secretion is significantly slowed down.

In patients with severe forms of COPD, bronchial secretion can completely block the lumen of the bronchi, especially small ones, which leads to serious ventilation disorders. At the same time, the system of nonspecific components of local immunity, which has antiviral and antimicrobial activity: interferons, lactoferrin, lysozyme, is also disturbed. There is a decrease in the number of immunoglobulins, primarily immunoglobulin A. Favorable conditions are created for the colonization of microorganisms. If exposure to trigger factors, and primarily tobacco, continues, the number of neutrophils in the lung tissue increases, which are the main source of free radicals, due to which oxidative stress is formed. Under conditions of high concentration of neutrophils, the balance in the proteolysis-antiproteolysis system is disturbed.

Thus, it is obvious that a violation of the rheological properties of bronchial secretions, a violation of mucociliary clearance and a decrease in local immunity, which contributes to the colonization of bacteria and exacerbation of bronchitis, is one of the reasons for the exacerbation of the disease and its progression.

Expectorants and mucolytics.

Expectorants include drugs that stimulate expectoration and mucolytic drugs. Expectorants increase the activity of the ciliated epithelium and the peristaltic movement of the bronchi, promote the movement of sputum from the lower sections of the bronchi and its release.

One group of expectorants has a predominantly reflex effect - preparations of thermopsis, marshmallow, licorice, sodium benzoate, terpinhydrate, etc. The other group has a predominantly resorptive effect - mucolytic agents, which, acting on the physical and chemical properties of bronchial secretions, melt or thin it. This group is represented by enzymes and synthetic drugs (trypsin, chymotrypsin, acetylcysteine, mukaltin, bromhexine, etc.)

To date, there is no clear evidence of the high effectiveness of the use of mucolytics and mucoregulatory agents in the treatment of, for example, COPD. However, during the period of exacerbation, they are widely used. The purpose of any mucolytic agent depends on pathophysiological changes. So, at the beginning of the disease, the bronchial mucosa reacts to the impact of a pathological agent by developing local inflammation, increasing the activity of serous submucosal glands, which leads to an increase in the production of bronchial secretions with low viscosity and increased fluidity. Appointed during this period carbocysteine contributes to a change in the production of bronchial secretions, leads to the normalization of the ratio of acidic and neutral sialomucins, which improves its separation with cough. Under its influence, the pharmacological effects of xanthines and glucocorticoids prescribed in the treatment of such patients are also enhanced.

With a longer process, a restructuring of the mucous membrane of the tracheobronchial tree occurs. There is an increase in the number of goblet cells, the activity of mucus-forming cells increases, and the viscosity of sputum increases. With bacterial infections, sputum quickly transforms from mucous to mucopurulent. The activity of proteolytic enzymes of leukocytes and bacterial agents increases the adhesion of sputum, which impedes the movement of cilia of the ciliated epithelium. In this situation, mucolytic therapy should be preferred ambroxol, which increases the activity of serous submucosal glands, prevents the inactivation of a1-antitrypsin, reduces the viscosity of the tracheobronchial secretion, increases the production of surfactant, and stimulates the activity of the ciliary system. Ambroxol increases the penetration of amoxicillin, cefuroxime, erythromycin and doxycycline into the bronchial secretion when they are used together, which improves the effectiveness of antibiotic therapy. Perhaps the combined use of ambroxol and carbocysteine.

As an alternative therapy, it is possible to prescribe and acetylcysteine, which has a pronounced mucolytic effect, is an active antioxidant due to participation in the synthesis of glutathione. However, it should be remembered that with the simultaneous appointment of acetylcysteine ​​with tetracycline, ampicillin and amphotericin B, their interaction and a decrease in therapeutic efficacy are possible. It must also be remembered that if the patient has ventilation disorders associated with bronchospasm, these mucolytic agents do not find application points at all.

Enzyme preparations as mucolytics in chronic obstructive diseases are not used. Firstly, due to an increase in proteolytic and a decrease in the antiprotease activity of bronchial secretions during exacerbation of these diseases. Secondly, due to the high risk of developing such serious complications as hemoptysis, allergies, bronchoconstriction.

Education of patients with COPD

For COPD patients, education plays a role in improving skills and ability to cope with the disease. Education of patients to encourage smoking cessation has the greatest potential impact on the course of COPD. Education should cover all aspects of disease management and can take many forms: consultations with a doctor or other healthcare professional, home or out-of-home programs, and full-fledged pulmonary rehabilitation programs.

For patients with COPD, it is necessary to understand the nature of the disease, risk factors leading to the progression of the disease, understanding their own role and the role of the doctor in achieving the optimal result of treatment. Education should be adapted to the needs and environment of the individual patient, be interactive, easy to implement, practical and appropriate to the intellectual and social level of the patient and those who care for him and aimed at improving the quality of life. Recommended inclusion of the following components in training programs: smoking cessation; basic information about COPD; general approaches to therapy, specific treatment issues; self-management skills and decision-making during an exacerbation.

There are various types of training programs ranging from simple distribution of printed materials to educational sessions and seminars aimed at providing information about the disease and teaching patients special skills. Training is most effective when it is done in small groups. The cost-effectiveness of COPD education programs depends to a large extent on local factors that determine the cost of care.

1 Stepwise increase in the volume of therapy depending on the severity of the course.

2. Patient education, exclusion of risk factors (level of evidence A).

3. Drug therapy is used to prevent and control symptoms, reduce the frequency of exacerbations, and improve exercise tolerance.

4. None of the available drugs for the treatment of COPD affects the long-term decline in lung function, which is the hallmark of this disease (Evidence A).

5. Bronchodilators are central to the symptomatic management of COPD (Evidence A).

7. Inhaled corticosteroids are indicated for symptomatic patients with FEV1< 50% от должной и повторяющимися обострениями (уровень доказательности А).

9. For patients with COPD at all stages of the course of the process, physical training programs are highly effective in increasing exercise tolerance and reducing dyspnea and fatigue (Evidence level A).

10. In severe respiratory failure, long-term oxygen therapy (more than 15 hours per day) is indicated (Evidence level A).

11.The choice of drug between anticholinergics, β2-agonists, theophylline, or a combination of these drugs depends on the availability and individual response to treatment in terms of symptom relief and the absence of side effects (Evidence A);

12. Xanthines are effective in COPD, but due to their potential toxicity, they are second-line drugs. Xanthines may be added to regular inhaled bronchodilator therapy for more severe disease (Evidence B).

Similar information.

Improving the drainage function of the bronchi is one of the most important conditions for the affective treatment of patients with pneumonia. Violation of bronchial patency in atom disease is due to several mechanisms:

A significant amount of viscous purulent exudate coming from the alma into the bronchi;

Inflammatory edema of the bronchial mucosa, draining the focus of inflammation of the lung tissue;

Damage to the ciliated epithelium of the bronchial mucosa and a violation of the mechanism of mucociliary transport;

An increase in the production of bronchial secretions due to involvement in the inflammatory process of the bronchial mucosa (hypercrinia);

A significant increase in the viscosity of sputum (discriia); . an increase in the tone of the smooth muscles of the small bronchi and a tendency to bronchus

hospasm, which makes it even more difficult to separate sputum.

Thus, violations of bronchial patency in large pneumonias are associated Tie only with the natural drainage of the focus of inflammation and the entry of viscous alveolar exudate into the bronchi, but also with the frequent involvement of the bronchi themselves in the inflammatory process. This mechanism is of particular importance in patients with bronchopneumonia of various origins, as well as in patients with concomitant chronic bronchial diseases (chronic obstructive bronchitis, bronchectomy, cystic fibrosis, etc.).

The deterioration of bronchial patency, observed in at least some patients with pneumonia, contributes to an even greater disruption of local processes, including immunological, protection, re-contamination of airborne pores and prevents the healing of an inflammatory focus in the lung tissue and the restoration of lung ventilation. A decrease in bronchial patency contributes to the aggravation of the modeling of ventilation and perfusion relations in the lungs and the progression of chronic insufficiency. Therefore, the complex treatment of patients with pneumonia includes the mandatory prescription of drugs that have expectorant, mucolytic and brocholytic effects.

It is known that the sputum present in the lumen of the bronchi in patients with pneumonia consists of two layers: the upper, more viscous and dense (gel), lying) share cilia, and the lower liquid layer (sol), in which the cilia seem to float and shrink. The gel consists of macromolecules of glycoproteins linked to each other by disulfide and hydrogen bonds, which gives it viscous and elastic properties. With a decrease in the water content in the gel, the viscosity of sputum increases and the movement of bronchial secretions along the right side *, and towards the oropharynx slows down or even stops. The speed of such movement becomes even less if you become thinner! a layer of liquid layer (sol), which to a certain extent prevents sputum from sticking to the walls of the bronchi. As a result, mucus and mucosal plugs are formed in the lumen of the small bronchi, which are removed with great difficulty only by a strong expiratory air flow during bouts of excruciating hacking cough.

Thus, the ability to unhindered removal of sputum from the respiratory tract is primarily determined by its rheological properties, the water content in both phases of the bronchial secretion (gel and sol), as well as the intensity and coordination of the activity of the cilia of the ciliated epithelium. The use of mucolytic and mucoregulatory agents is precisely aimed at restoring the ratio of sol and gel, thinning sputum, rehydrating it, and also stimulating the activity of ciliated epithelium cilia.

TACTICS OF RESTORATION OF PROTECTIVE AND CLEANING FUNCTIONS OF THE RESPIRATORY SYSTEM

At the very beginning of this part, we identified four main strategic tasks that need to be solved in the process of cleansing the lungs in order to restore their Lost physiological purity and health. Now the turn has come to decide how and by what means the tasks will be solved.

So, let's start in order.

1. Restoring the protective barriers of the upper respiratory tract

To restore the protective mechanisms of the upper respiratory tract, it is advisable to use water extracts that enhance the formation and secretion of a protective secret from MPC (medicinal plant materials) containing essential oils and phytoncides: infusion of birch buds, poplar, rosemary grass, heather, oregano, mint, lemon balm, thyme, eucalyptus leaves, sage, etc.; decoctions of rhizomes of calamus, rhizomes with elecampane roots, fruits of coriander, thyme, fennel, onion juice, garlic, honey and propolis can also be used.

To enhance the secretion of the resulting secret, you can use the juices of Kalanchoe, aloe and beets. They are diluted in boiled water 10-20 times and instilled with one drop in each nostril. They have a slight irritant effect and increase sneezing, contributing to the secretion.

2. Restoration of the drainage function of the bronchi

The drainage function of the bronchi is restored:
a) expectorant plants that provide sputum discharge - calamus, marshmallow, anise, veronica, elecampane, oregano, mullein, coltsfoot, lungwort, primrose, cyanosis, licorice, thermopsis, thyme, violet, etc .;
b) mucolytics, i.e., having the ability to dissolve mucus - marshmallow, wild rosemary, valerian, veronica, sweet clover, hyssop, istod, flax, Icelandic moss, pine buds, etc.

3. Infection control

The success of antimicrobial therapy is determined by the correct choice of agents to which the causative agent of an infectious disease is sensitive. Wherein:
a) combined, i.e. joint, use of medicinal plants with antimicrobial and antiviral properties is necessary;
b) combination of plants with various active substances, which not only allows to achieve a bactericidal effect, but also prevents the emergence of strains resistant (resistant) to herbal medicine;
c) for oral administration, it is advisable to use collections and rinses, a constant alternation of various groups of antimicrobial active substances that have been identified in calamus, geraniums, oregano, cinquefoil erectus, onions, raspberries (leaves), lemon balm, sage, garlic, eucalyptus.

4. Correction of anti-infective immunity

This direction is preferable to implement with the help of the following groups of medicinal plants:
a) interferon stimulators: coltsfoot, plantain, Icelandic cetraria;
b) alveolar phagocytic activity activators: mountain arnica, astragalus, borage, volodushka, stinging nettle;
c) local immunity stimulants: anise, arnica, shift, highlander bird, birch, sage, etc.

It should be noted that along the entire path of restoring the normal functioning of the respiratory system, it is necessary to constantly and purposefully use anti-inflammatory and antihypoxic agents of plant origin: linden leaves, calendula and chamomile flowers, string grass, horsetail, sage, etc.

From the first day of cleansing, it is also necessary to use highly effective vitamin complexes, since they contain enzymes and trace elements that significantly increase the bioavailability of vitamins. At the same time, medicinal plants rich in vitamins, which include lingonberries, cranberries, strawberries, blackberries, red ashberries, sea buckthorn, dandelion leaves, nettles, primroses, should be added to the main collection or taken additionally in the form of tea.
Given that effective cleansing is impossible without an increased water load, it is necessary to increase the amount of drinking up to 2.5-3 liters per day, unless, of course, there are contraindications from the cardiovascular and urinary systems.

And in conclusion of this chapter, I want to remind you once again that many diseases are much easier to prevent than to cure, therefore it is advisable to gradually increase the resistance of the respiratory organs to colds and infections by general hardening of the body and, if there is enough willpower and sanity, to refuse or at least stop abuse alcohol and tobacco. Both habits are closely related to breathing. After all, in addition to the general harmful effect on the body, causing deep dysfunctions of the nervous system and many other organs, alcohol has a detrimental effect directly on the tissue of the lungs and mucous membranes of the respiratory tract, because through them it and its oxidation products, aldehydes and ketones, are excreted from the body. This, by the way, explains the characteristic disgusting smell from the mouth after drinking alcoholic beverages.

As for smoking, its harmful effect on the respiratory organs is perhaps even worse than alcohol, since, among other things, tobacco smoke inhibits the production of surfactant and thereby increases the surface tension of the alveoli. Because of this, the smoker, compared to non-smokers, has to make greater efforts to inhale.

But we have already talked about the dangers of smoking. Now it's time to talk about the main thing.

In a growing body age changes are mainly reduced to constant restructuring and growth of individual parts of the walls of the trachea and bronchi, and their differentiation occurs non-simultaneously and basically ends by 7 years (N. P. Bisenkov, 1955).

In the elderly age the processes of involution of the bronchial wall are revealed, consisting in atrophy, a decrease in the number of elastic and muscle fibers, calcification of cartilage. Such changes lead to a deterioration in the drainage function of the bronchi.

very characteristic sign in people older than 50 years, the distal trachea is shifted to the right by a sclerotic aortic arch, sometimes reaching a significant degree. The displacement of the trachea to the right can be combined with some narrowing of its lumen, which makes it difficult to examine the bronchi of the left lung during bronchoscopy.

Physiology of the bronchi. The tracheo-bronchial tree performs various functions. D. M. Zlydnikov (1959) considers the main functions of the bronchi to be ventilation, equatorial (drainage), secretory, speech, support, etc. Undoubtedly, the ventilation and drainage functions of the bronchi play a major role, the first being conducting air to the alveoli. is a direct appointment of the tracheobronchial system. The drainage function of the bronchi is a protective adaptation of the body developed in the process of evolution, which ensures the normal functioning of the broncho-pulmonary apparatus in various environmental conditions.

Tracheo-bronchial tree performs the function of an air duct between the external environment and the alveoli, in which gas exchange occurs. When air passes through the trachea and bronchi, it is warmed and moistened due to the secretion of the bronchial glands. Naturally, each violation of bronchial patency leads to the development of ventilation insufficiency. Diffuse impairment of the patency of small bronchi, leading to the appearance of obstructive respiratory failure (see Chapter I), and, after it, pulmonary heart failure, is especially hard on the function of external respiration.

Evidence of active participation bronchi in pulmonary ventilation are the physiological respiratory movements of the bronchi, which occur both as a result of contraction of the bronchial muscles, and as a result of the transmission of the respiratory movements of the chest wall and lungs to the bronchial tree. Among the most characteristic respiratory movements of the bronchi are expansion and narrowing, elongation and shortening, angular and torsional movements.

When inhaling the bronchi expanding, lengthen (the carina falls by 10-20 mm), the angles between them increase, and their external rotation occurs. When exhaling, reverse changes are observed. The question of the possibility of peristaltic movements of the bronchi in humans cannot be considered finally resolved.

In addition to respiratory movements, transmission pulsation is noticeable in the bronchi, more noticeable in areas of the tracheobronchial tree that are in direct contact with the heart and main vessels.

Decreased or increased respiratory and pulse mobility of the bronchi is an important sign of the pathological process in the bronchial tree, surrounding lung tissue or neighboring organs. So, the physiological movements of the bronchi completely disappear or are sharply limited in case of cancerous infiltration of the bronchial wall. Aortic arch aneurysms cause strong pulsation, especially noticeable in the left tracheobronchial angle.

Drainage function of the bronchi carried out due to the activity of the ciliated epithelium and the cough reflex. The cilia of the ciliated epithelium move continuously. Curving slowly like a swan's neck, they move back and then quickly straighten forward (Kassay). This continuous wave-like movement of the cilia, covered with a very thin layer of mucus, provides a constant flow of the latter towards the larynx and pharynx. Dust particles inhaled with air settle and float on the surface of ciliary waves, and the mucus layer carries dust particles through areas not covered by ciliated epithelium (vocal cords).

Arising from inflammatory processes metaplasia cylindrical ciliated epithelium into stratified squamous leads to a violation of the drainage function, stagnation of bronchial secretion, which is easily infected, which may be the cause of the development of secondary bronchiectasis.