Broncho-obstructive syndrome

Broncho-obstructive syndrome is the collective term including a symptom-complex of specificly outlined clinical implications of disturbance of bronchial passableness, having in the basis narrowing or an occlusion of respiratory tracts.

Clinically expressed syndrome of respiratory obstruction often enough meets at children, especially early age.

Occurrence and its development are influenced by various factors and, first of all, a respiratory virus infection contamination.

To number of viruses most often causing an obstructive syndrome carry a respiratory syncytial virus (about 50 %), then a parainfluenza virus, a pneumonia mycoplasma, is rarer - viruses of a flu and an adenovirus. In development of bronchial obstruction the certain role is played by the age features inherent to children of first three years of life. Bronchuses at small children have smaller diameter, than at adults. The narrowness of bronchuses and all respiratory apparatus considerably enlarge aerodynamic resistance. So, the edema mucous bronchuses of all on 1 mm causes rising of resistance to an air flow in a trachea more than on 50 %.

For children of early age the pliability of cartilages of the bronchial tract, an insufficient rigidity of osteal structure of the thorax, freely reacting an indrawing of compliant places on resistance rising in pneumatic pathes, and also features of position and a diaphragm constitution are characteristic.

Considerably burden flow a broncho-obstructive syndrome at children structural features of a bronchial side, such as a considerable quantity of the goblet cells mucifying and raised viscosity of a bronchial secret, bound to high level of sialine acid can.

Doubtless influence on functional disturbances of a respiratory organs at the small child such factors, as longer sleep render also, the frequent crying, primary stay on a back in the first months of life.

The early children's age is characterised by imperfection of immunologic mechanisms: interferon formation in the top respiratory tracts, a serumal immunoglobulin is considerably lowered And, a secretory immunoglobulin And, functional activity of T-system of immunodefence is lowered also. The majority of explorers influence of factors of a premorbidal background on development a broncho-obstructive syndrome admits. These are toxicoses of the pregnant women, the complicated labours, a hypoxia in sorts, a prematurity, the burdened allergological anamnesis, a hyperreactivity of bronchuses, a rachitis, a dystrophia, a thymus hyperplasia, a perinatal encephalopathy, the early artificial feeding, the tolerated respiratory disease at the age of 6-12 months.

Among factors of environment which can lead to development of an obstructive syndrome, especially the great value is given to passive smoking in monogynopaedium. Under the influence of a tobacco smoke there is a hypertrophy of bronchial mucous glands, the mucociliary clearance is broken, slime progression is slowed down. Passive smoking promotes a destruction of an epithelium of bronchuses. The tobacco smoke is an inhibitor of a chemotaxis of neutrophils. At long influence the tobacco smoke influences immune system, reduces activity of T lymphocytes, oppresses synthesis of antibodies of the basic classes, suscitates synthesis of immunoglobulins E, raises activity of a vagus nerve. Especially vulnerable in this plan children of 1st year of life are considered.

Certain influence renders also an alcoholism of parents. It is proved, that alcohol reduces rate of deducing of pathogenic microbes, causes an atony of bronchuses, development of protective inflammatory reaction inhibits.

Other important unfavorable factor is contamination of surrounding atmosphere by industrial gases: ammonia, chlorine, various acids, sulphurus gas, Carboneum oxide, ozone, phosgene, etc., an inorganic dust (coal, quartz, cement, etc.) an organic dust (cottonous).

In occurrence of bronchial obstruction various mechanisms - such as lay:

• a dystonia
• a hypertrophy of a muscular tissue
• a hypercrinia
• a dyscrinism
• mucociliary clearance disturbance
• an edema
• inflammatory infiltration
• a hyperplasia and a mucosa metaplasia
• a prelum, an obturation and deformation of bronchuses
• defects of aboriginal and system immunodefence, defects macrophage systems

On the basis of literature data it is possible to secure the following bunches of diseases accompanied by a syndrome of bronchial obstruction:

1. Diseases of a respiratory organs:
   • Infectious-inflammatory diseases (a bronchitis, a bronchiolitis, a pneumonia)
   • Allergic diseases (an asthmatic bronchitis, a bronchial asthma)
   • Bronchopulmonary dysplasia
   • Developmental anomalies of bronchopulmonary system
   • Tumours of a trachea and bronchuses
2. Foreign bodys of a trachea, bronchuses, an esophagus
3. Diseases of an aspiration genesis (or an aspiration obstructive bronchitis) - a gastroesophageal reflux, a tracheoesophageal fistula, developmental anomalies of a gastrointestinal tract, a phrenic hernia.
4. Diseases of cardiovascular system of the congenital and got character (a hypertensia of a small circle of a circulation, anomaly of pots, congenital not rheumatic cardites, etc.).
5. Diseases of the central and peripheric excitatory system.
6. Hereditary anomalies of an exchange.
7. The congenital and got immunodeficient conditions.
8. Rare diseases
9. Other conditions:
   • Traumas and combustions
   • Venenatings
   • Influences of various physical and chemical environmental factors
   • Prelum of a trachea and bronchuses out of a pulmonary parentage

From the practical point of view, depending on etiological pathogenetic mechanisms excrete 4 variants of a broncho-obstructive syndrome

• infectious, educing as a result of virus and (or) a bacteriemic inflammation in bronchuses and bronchioles
• allergic, educing owing to a spastic stricture and an allergic inflammation of bronchial structures with prevalence of the spastic phenomena over the inflammatory
• obturation, observed at a foreign body aspiration, at a prelum of bronchuses
• hemodynamic, arising at a heart failure on is left ventricular type

In pediatric practice most often there are first two clinico-pathogenetic variants of a broncho-obstructive syndrome.

On flow the broncho-obstructive syndrome can be acute, fixing, recurring and is continuous - recurring (in case of a bronchopulmonary dysplasia, a bronchiolitis, etc.).

On expression of obstruction it is possible to secure:

• easy degree of obstruction (1 degree)
• moderately severe (2 degree)
• serious (3 degree)

Broncho-obstructive syndrome of an infectious genesis

Acute broncho-obstructive syndrome at children of early age often takes place at virus and virusno-bacteriemic respiratory infections. In a genesis of bronchial obstruction at an ARD the mucosa edema, inflammatory infiltration, a hypersecretion has major importance. The mechanism of a bronchospasm which is caused or hypersensitivity of interoceptors of a cholinergic part (primary or secondary hyperactivity), or blockade ?-2-adrenoreceptors is to a lesser degree expressed.

Most often the broncho-obstructive syndrome of an infectious genesis meets at an obstructive bronchitis and a bronchiolitis. It is necessary to notice, that separation of an acute obstructive bronchitis and a bronchiolitis admits the world literature not all lung specialists.

Any viruses, and also pneumonia mycoplasma can cause an acute obstructive bronchitis. The clinical picture a broncho-obstructive syndrome does not depend on a virus kind, however, at adenovirus introduction, a pneumonia mycoplasma, and also at stratification of a bacteriemic infection contamination probably fixing flow broncho obstructions.

In most cases for an acute obstructive bronchitis the acute beginning, a fervescence to febrile digits, a rhinitis of mucous character, short dry tussis with fast transition in wet, presence of the phenomena of an intoxication - abandoning of a breast, depression of appetite, a bad sleep is characteristic, the child becomes flaccid, whimsical. For 2-4 day against already expressed catarral phenomena and a fervescence the broncho-obstructive syndrome educes: a dyspnea of expiratory character without the expressed tachypnea (40-60 respirations in a minute), an oral crepitation, sometimes remote rhonchuses in the form of noisy, rattling breath, a bandbox shade of a note, at auscultation - the extended expiration, dry droning rhonchuses, mixed wet rhonchuses from both parties. The broncho-obstructive syndrome proceeds within 3-7-9 and more days depending on character of an infection contamination and disappears gradually in parallel a subsiding of inflammatory changes in bronchuses. Application of antispasmodics (an Euphyllinum, NOSPANUM, adrenomimetic) or is noneffective, or gives small effect. The positive effect is observed gradually against the therapy enriching drainage function of bronchuses - inhalations with Mucolyticums, expectorants, physiotherapeutic treatment, massage, a postural drainage, tussic gymnastics. At the expressed respiratory insufficiency the oxygen therapy is shown. The approach to a prescription of antibiotics should be strictly individual. Following signs can be indications for appointment of antibacterial preparations: Long hyperthermia, absence of effect from spent therapy, presence of nonperishable fields of a hypoventilation in lungs and (or) an asymmetry of-physical data, toxicosis increase, signs of a hypoxia of a brain, appearance of a purulent sputum, irregular intensifying of a pulmonary drawing on the roentgenogram, in blood analysises - a leukocytosis, a neutrocytosis, an ESR acceleration, a sensibilization previous frequent SARS or the disease tolerated shortly before the present episode.

At repeated episodes the broncho-obstructive syndrome against SARS follows is differentiated to approach to an assessment of the causes of a recuring broncho to obstruction. At a part of children after tolerated unitary a broncho-obstructive syndrome the subsequent SARS proceed with the phenomena broncho obstructions, that is the broncho-obstructive syndrome accepts relapsing flow. To some extent burdened premorbidal background promotes it, as a rule: a prematurity, an alcoholic fetopathy, a rachitis, a dystrophia of a type of an oligotrophy, a perinatal encephalopathy. In these situations one more mechanism joins already known mechanisms of obstruction - a dystonia of a bronchial arbour on a hypotonic type

At some patients repeated episodes a broncho-obstructive syndrome can arise not only at a virus infection contamination, but also at influence of some nonspecific factors, such as a cold, an exercise stress, a hyperventilation, pungent smells and others irritant factors. In this case the broncho-obstructive syndrome is caused by a bronchospasm of a tonic type which is bound to development of nonspecific hyperactivity of bronchuses. In the literature specify various terms of duration of this phenomenon - from 7 till 3-8 months. Thus treatment should be referred on elimination of a disbalance of a vegetative nervous system

Acute bronchiolitis is observed mainly at children of the first half of the year of life, but can meet and later: till 2 years. It is is more often caused by a sintsitialno-virus infection contamination. At a bronchiolitis fine bronchuses, bronchioles and alveolar courses are amazed.

The clinical picture is defined by the expressed respiratory insufficiency: a perioral cyanosis, a Crocq's disease, a tachypnea to 60-80-100 respirations in minute, with a prevalence of an expiratory component, an "oral" crepitation, an indrawing of compliant places of a thorax. Percussionly: over lungs the bandbox shade of percussion tint is defined, at auscultation - set fine wet and rhonchuses on all fields of lungs on an inspiration and an expiration, the expiration is extended and complicated, at a shallow breathing the expiration can have usual duration with sharply reduced respiratory volume. The given clinical picture of disease educes gradually, within several days, less often acutely, against SARS and is accompanied by a sharp aggravation of symptoms. Thus there is a tussis of paroxysmal character, appetite decreases, there is a disturbing. Temperature more often febrile, sometimes, subfebrile or normal. At research of lungs the inflation of lungs, sharp intensifying of a bronchial drawing is taped at the big prevalence of these changes, high standing of a dome of a diaphragm, a horizontal locating of ribs.

Recurrence flow, 10-14 days and absence of repeated episodes is characteristic.

The broncho-obstructive syndrome at an acute pneumonia meets is rare and caused by bronchitis development. Thus the picture of bronchial obstruction also is combined with a clinicoradiological picture of a bronchopneumonia. Presence of an obstructive syndrome in early terms SARS allows to exclude a pneumonia with probability of exceeding 95 %.

Treatment of an acute bronchiolitis includes variety of the actions referred on struggle against respiratory insufficiency. An obligatory method of therapy is the oxygenotherapy in oxygen tent.

For a restore of loss of water at a hyperventilation application of a method of an oral rehydration which is considered less invasive in comparison with intravenous drop injection is desirable and gives possibility to spend a constant oxygen therapy. The best preparation used for this purpose - Rehydron. For struggle against a virus infection contamination interferon application is shown. The majority of modern writers, despite the virus nature of a bronchiolitis, consider necessary appointment of antibacterial therapy in the presence of symptoms of serious respiratory insufficiency and difficulties in an exception of a secondary bacteriemic infection contamination.

Indications to antibioticotherapia appointment same, as at an obstructive bronchitis.

From preparations of spasmolytic action the greatest application in pediatric practice have received methylxanthine derivatives, sympathomimetics, an ethimizol and corticosteroid agents.

Methylxanthines. Most useful the Euphyllinum which it is necessary to use in a single dose of 4-6 mg on kg is. A preparation introduce inside or intramusculary, in cases of serious obstruction - intravenously. The effect from a preparation is observed at half of children with an obstructive bronchitis (more often at children is more senior 1 year and at 1 of 5 sick of a bronchiolitis). Preparation introduction (3-4 times a day in the same dose) is repeated expediently at effect reception on the first dose.

Ethimizol - a respiratory analeptic of the central action. In a dose of 0,1 ml on kg of 1,5 % of solution to children about one year and on 1,0-1,5 ml to children of 1-3 years, possesses broncholitic action, including at a part of children who are not reacting to an Euphyllinum.

Sympathomimetic - give a positive effect a little bit more often, than an Euphyllinum, however, they react usually quickly. There are observations about efficacyy of an alupent (orciprenaline) intramusculary in a dose of 0,3-1,0 ml 0,05 solutions at 80 children with obstructive forms SARS. Effect usually short-term (30-60 minutes). For long therapy the alupent can be used in a dose of 0,2-0,3 ml 2 times a day within 3-5 days.

Use of preparations inside (for example, Ventolinum on 0,1 mg on kg), as a rule, appears ineffective. Their application in the form of aerosols is more expedient.

Corticosteroids inside or a parenterally are used at obstructive forms SARS was rarely, practically unique form demanding their appointment, the adenoviral bronchiolitis with the expressed respiratory insufficiency is. The dose is inside equivalent 2 mg on Prednisolonum kg a day, a parenterally - in 3-5 times more (it is equivalent 6-10 mg on Prednisolonum kg a day) in view of fast deducing of a preparation at this path of introduction.

Other indication for application of corticosteroids is the suspicion on development of the asthmatic status against SARS, that it is not always easy to differentiate with a usual obstructive episode.

Aerosolic therapy is widely used. An aerosol refer under awning-tent ДКП-1 or under a cap (for children of the first months of life). Dispersion thus waters, isotonic solution of Sodium chloridum, 2 % of sodium of bicarbonate appears mucolytic action, promotes a discharge of a sputum and depression of losses of fluid. More expressed action acetyl-tsistein, Chymotrypsin etc. possesses, however, their application was rarely happens justified.

For calculation of a dose of medicinal material on one dispersion a single dose (age) multiply by an age loss factor: for children of the first half of the year - 5, at the age of 6 months - 3 years - 4, are more senior - 3. Volume of solution for inhalation - 50 100 ml, frequency of procedures 2-3 times a day.

The good spasmolytic effect at 50-80 % of patients is rendered by aerosols of sympathomimetics under awnings or through a mask. As a preparation solution of 1 ml on 10 ml physical solve can be used alupent (orciprenaline) of 0,05 % at rate of an air stream of 2-3 litres a minute or Веrоduаl (0,5 mg of Fenoterolum about 0,25 mg Ipratropium bromide in 1 ml) 4 drops on 10 ml solve.

Inhalations spend under an awning or through a facial mask within 10 minutes for children of 1st year of life and 15-20 minutes for more senior children.

Inhalations (1-2 times a day) can be spent by courses for 3-6 days.

Most powerful tools of remission of respiratory tracts from a secret is the postural drainage with vibratory massage. To begin this procedure it is possible about 2-3 days of disease, spending them against a summer residence spasmolytics, after carrying out of inhalations.

One of the basic components in treatment of children with disturbances of bronchial passableness at a broncho-obstructive syndrome is rising of efficacyy mucociliary escalatory systems. Medical actions should be referred on correction of leading pathogenetic parts: enriching of rheologic properties of a bronchial secret, adjustment of a bronchial drainage. These problems can be carried out by means of the preparations possessing various effects: fluidifying a bronchial secret and expectorating, reducing the intracellular myxopoiesis, suscitating a mucifying (transport), raising activity of the ciliary cells, suscitating production surfactant.

The agents suscitating an expectoration and mucolytic preparations concern the expectorating. Expectorating enhance physiological activity of a ciliary epithelium and peristaltic locomotion of bronchuses, promote moving of a sputum from the inferior parts of bronchuses and to its abjection. One bunch of the expectorating possesses mainly a reflex effect - preparations thermopsis, Althaea, Glycyrrhiza glabra, Natrium benzoicum, a terpin hydrate, etc. Other bunch possesses mainly resorptive action - mucolytic agents. The last, influencing physical and chemical properties of a bronchial secret, melt or fluidify it. The given bunch is presented by enzymes and synthetic preparations (Trypsinum, chymotrypsin, Acetylcysteinum, Mucaltinum, Bromhexinum and so forth)

The obliterating bronchiolitis differs frequent transition in chronic disease at which there is a widespread lesion of an epithelium of bronchioles to the subsequent organisation of an exsudate and granulomatous reaction, and then an obliteration of their lumen. An aetiology of an obliterating bronchiolitis mainly virus (an adenovirus, a virus of a whooping cough, a measles etc.). Children of first three years of life suffer basically.

The clinical picture of an obliterating bronchiolitis proceeds cyclically. In the first (acute) season against febrile temperature clinical signs, characteristic for an acute bronchiolitis, but with more expressed respiratory disorders are observed, is long remaining and even accruing during two weeks. On the roentgenogram "wadded" shades are defined. The expressed obstructive phenomena take place and after temperature normalisation. In the second season the state of health of the child is enriched, but there are expressed phenomena of obstruction, in lungs the mixed wet rhonchuses, whistling rhonchuses on an expiration are auscultated. The obstruction can periodically strengthen, sometimes reminding an asthmatic attack. In 6-8 weeks at some children the phenomenon of a "supertransparent" lung is formed. Treatment of an obliterating bronchiolitis represents the big difficulties in connection with absence of etiotropic agents.

Broncho-obstructive syndrome of an allergic genesis

The obstructive syndrome is observed at such forms of a respiratory allergosis as an asthmatic bronchitis and a bronchial asthma. The obstruction at the given diseases is caused mainly by a spastic stricture of fine bronchuses and bronchioles (a tonic type) and to a lesser degree - a hypersecretion and an edema. Appreciable difficulties are represented by the differential diagnosis between an asthmatic bronchitis and an obstructive bronchitis of an infectious genesis. In favour of an asthmatic bronchitis the heredity burdened on allergic diseases, burdened own allergological anamnesis (dermal implications of an allergy, "small" forms of a respiratory allergosis - an allergic rhinitis, a laryngitis, a tracheitis, a bronchitis, an intestinal allergosis), presence of communication of occurrence of disease with causally significant allergen and absence of such communication with an infection contamination, an elimination positive effect, a recuring of attacks, their uniformity of type testifies. For a clinical picture following signs are characteristic: Absence of the phenomena of an intoxication, remote whistling rhonchuses or "sawing" character of breath, expiratory dyspnea with participation of an auxiliary musculation, in lungs are auscultated mainly dry whistling rhonchuses and not numerous wet which quantity is enlarged after bronchospasm cupping. The attack arises, as a rule, in the first day of disease and is liquidated in short lines: during one - three days. In favour of an asthmatic bronchitis the positive effect on introduction broncospasmolytics (adrenaline, an Euphyllinum, Berotec, etc.) also testifies.

Cardinal sign of a bronchial asthma is the dyspnea attack. At children of early age it shows sharply expressed disturbing of the child (rushes about, does not find to itself a place), a thorax inflation, shoulder girdle bracing in an inspiratory phase, a tachypnea with insignificant prevalence of an expiratory component, disturbance of carrying out of breath in basal parts of the lungs, the expressed perioral cyanosis.