Update: October 2018 Chronic Obstructive Pulmonary Disease
(COPD) – the actual problem of modern pulmonology, directly
associated with violations of the ecological well-being of mankind and,
first of all, with the quality of inhaled air. This pulmonary
pathology is characterized by continuing imbalance
air movement in the lungs with a tendency to progression and
involvement in the pathological process in addition to the lungs of other organs and
COPD is based on inflammatory changes in the lungs,
realized under the influence of tobacco smoke, exhaust gases and
other harmful impurities of atmospheric air.
The main feature of COPD is the ability to prevent it.
development and progression.
On сегодня по данным ВОЗ данное заболевание – четвертая по
frequency cause of death. Patients die from respiratory
failure of cardiovascular pathologies associated with
COPD рака легкого и опухолей иных локализаций.
In general, a person with this disease has an economic disadvantage.
(absenteeism, less efficient work, costs
hospitalization and outpatient treatment) is superior to the patient with
bronchial asthma three times.
Who is at risk for getting sick
In Russia, about every third man over 70 is sick
chronic obstructive pulmonary disease.
- On первом месте среди рисков для ХОБЛ стоит табакокурение.
- It is followed by harmful production (including high
dustiness of the workplace) and life in industrial cities.
- Also at risk are people older than 40 years.
To the predisposing factors of the development of pathology (especially in
young) are genetically determined formation disorders
connective tissue of the lungs, as well as prematurity of infants with
which the lungs lack surfactant providing them
full unwinding with the beginning of breathing.
Interesting are epidemiological studies of developmental differences and
course of COPD in urban and rural residents of the Russian Federation. For villagers more
characteristic more severe forms of pathology, purulent and atrophic
endobronchitis. У них chronic obstructive pulmonary disease чаще
It is combined with other severe somatic diseases.
The culprits of this are most likely insufficient.
availability of qualified medical care in the Russian
village and lack of screening studies (spirometry) among
wide sections of smokers over 40 years. With этом психологический
статус у жителей села, больных COPD не отличается от такового у
citizens that demonstrates how chronic hypoxic changes
in the central nervous system in patients with this pathology, regardless of where they live,
so and the overall level of depression of the Russian city and
Variants of the disease stage
There are two main types of chronic obstructive disease.
lungs: bronchitis and emphysematous. The first includes
mainly manifestations of chronic bronchitis. Second –
emphysema. Sometimes isolated and mixed version of the disease.
- With эмфизематозном варианте отмечается повышение воздушности
lungs due to the destruction of the alveoli, more pronounced
functional disorders that determine the drop in blood saturation
oxygen, decreased performance and manifestations of pulmonary
hearts. With описании внешнего вида такого пациента пользуются
the phrase “pink piper”. Most often it is smoking
a man about 60 years old with a lack of weight, pink face and
with cold hands, suffering from severe shortness of breath and cough with scanty
- Chronic bronchitis manifests itself with cough with sputum (on
three months over the past 2 years). Patient with such
A variant of the pathology is suitable for the phenotype “blue swell”. it
female or male about 50 years old with a tendency to corpulence, with
diffuse cyanosis of the skin, cough with copious mucopurulent
sputum, prone to frequent respiratory infections, often
suffering from right ventricular heart failure
With этом патология довольно долгий период времени может
to proceed without patient-recorded manifestations, developing and
Pathology has phases
stability and aggravation. In the first case, the manifestations are unchanged on
over the course of weeks or even months, the dynamics are monitored only when
observation throughout the year. Aggravation is marked by deterioration
symptoms for at least 2 days. Clinically significant
Frequent exacerbations are considered (from 2 to 12 months or exacerbations,
due to the severity of the condition of hospitalization), after which
patient comes out with reduced functionality
lungs. In this case, the number of exacerbations affects the duration
the lives of patients.
A separate option, highlighted in recent years, has become
ассоциация бронхиальная астма/COPD развившаяся у курильщиков,
previously suffered from asthma (the so-called overlap syndrome or
cross syndrome). With этом еще больше снижаются потребление
oxygen tissues and adaptive capacity of the organism.
Classification of the stages of this the disease was canceled by the committee
экспертов GOLD в 2011 году. New degree assessment
severity combined not only indicators of bronchial patency
(according to spirometry, see Table 3), but also clinical manifestations,
registered in patients, as well as the frequency of exacerbations. See tab. 2
For risk assessment use questionnaires, see Table 1
The formulation of the diagnosis of chronic obstructive pulmonary disease
looks like that:
- chronic obstructive pulmonary disease
- (bronchitis or emphysema variant),
- light (moderate, severe, extremely severe) degree
- severe clinical symptoms (the risk of the questionnaire is greater or
равен 10 баллам), невыраженные симптомы (<10),
- rare (0-1) or frequent (2 or more) exacerbations,
In men, COPD is statistically more common (due to
adherence to smoking). In this case, the frequency of professional
options for the disease is the same for both sexes.
- In men, the disease is better compensated by respiratory
gymnastics or physical training, they are less likely to suffer
aggravations and more highly appreciate the quality of life during
- Women are characterized by increased bronchial reactivity, more
severe shortness of breath, but the best indicators of tissue oxygenation
with the same bronchial patency with men
Early manifestations of the disease include complaints of coughing and
(or) shortness of breath.
- Cough more often appears in the morning, with this or
a different amount of mucous sputum. There is a connection cough and
periods of upper respiratory tract infections. Since the patient is more likely
associates cough with smoking or adverse effects
air, it does not pay due attention to this manifestation.
and rarely examined in more detail.
- The severity of dyspnea can be assessed on a scale of British
Medical Council (MRC). It is normal to feel shortness of breath with strong
- Graduated dyspnea, grade 1, is forced breathing during fast
walking or climbing a gentle hill.
- Moderate severity and grade 2 – shortness of breath, forcing on level
terrain to walk slower than a healthy person.
- Severe dyspnea of grade 3 is recognized as the patient’s condition.
suffocating during the passage of a stometrovka or after a few minutes
walking on flat ground.
- Very severe dyspnea of grade 4 occurs while dressing or
undressing, also when leaving the house.
- Graduated dyspnea, grade 1, is forced breathing during fast
The intensity of these manifestations varies from stability to
aggravation, which increases the severity of shortness of breath,
sputum volume and cough intensity increases, viscosity changes and
the nature of the discharge of sputum. The progression of pathology passes
uneven, but gradually the patient’s condition is getting worse,
extrapulmonary symptoms and complications join.
Like any chronic inflammation, chronic obstructive
pulmonary disease has a systemic effect on the body and causes
to a number of disorders not related to the physiology of the lungs.
- Dysfunction of skeletal muscles involved in breathing (intercostal),
- Damage to the inner vascular lining and development
atherosclerotic lesions, an increase in propensity to
- Loss resulting from previous circumstances
cardiovascular system (arterial hypertension, ischemic
heart disease, including acute myocardial infarction). At the same time for
persons with arterial hypertension on the background of COPD is more characteristic
left ventricular hypertrophy and dysfunction.
- Osteoporosis and the associated spontaneous fractures of the spine and
- Renal dysfunction with reduced glomerular speed
filtration, reversible reduction of the amount of urine.
- Emotional and mental disorders are expressed in
disability, tendency to depression, reduced
emotional background, anxiety. In this case, the greater the degree
the severity of the underlying disease, the worse the correction
emotional disorders. Also, patients are recorded
sleep disorders and sleep apnea. Patients with moderate to severe COPD
degree often demonstrates cognitive impairment (suffer
memory, thinking, ability to learn).
- In the immune system, an increase in phagocytes, macrophages,
in which, however, activity and ability to
absorption of bacterial cells.
- Acute respiratory failure
- Pulmonary hemorrhage
- Pulmonary hypertension complicates up to 25% of moderate cases
легочной обструкции и до 50% тяжелых форм diseases. Her numbers
slightly lower than with primary pulmonary hypertension and not
exceed 50 mm Hg Often it is the increase in pressure in the pulmonary
artery becomes the culprit of hospitalization and mortality
- Pulmonary heart disease (including decompensation with a pronounced
circulatory failure). Formation of pulmonary heart
(right ventricular heart failure) undoubted effect
has the experience and volume of smoking. Smokers with forty years of experience
pulmonary heart is an almost obligatory accompaniment of COPD. With
this formation of this complication does not differ for
bronchitis and emphysematous variants of COPD. It develops
or progresses as the main pathology progresses. Withмерно у
10–13 percent of patients have pulmonary heart decompensation. Nearly
always pulmonary hypertension is associated with an extension of the right
ventricle, only in rare patients the size of the right ventricle remain
The quality of life
Для оценки данного параметра используются Вопросники SGRQ и
HRQol, Pearson χ2 and Fisher tests. The age of onset is taken into account.
smoking, number of packs smoked, duration of symptoms,
stage of disease, degree of dyspnea, level of blood gases, amount
exacerbations and hospitalizations for the year, the presence of concomitant
chronic pathologies, the effectiveness of basic treatment, participation in
- One factor to consider when evaluating
quality of life of patients with COPD becomes smoking experience and
the number of cigarettes smoked. Research confirms. What with
the increase in smoking experience in patients with COPD is significantly reduced
social activity, and increasing depressive manifestations,
responsible for reducing not only performance, but also
социальной адаптированности и статусности the sick.
- The presence of concomitant chronic pathologies of other systems
reduces the quality of life due to the mutual complication syndrome and
increases the risk of death.
- Older patients have worse functional performance and
opportunities for compensation.
Diagnostic Methods for Detecting COPD
- Screening method for detecting pathology becomes
spirometry. The relative cheapness of the method and ease of implementation
diagnostics allows them to cover a fairly wide masses
patients of the primary therapeutic and diagnostic level. Diagnostically
Significant signs of obstruction are difficulty breathing out.
(reduction of the ratio of forced expiratory to forced
lung capacity less than 0.7).
- In persons without clinical manifestations of the disease to alarm
may change the expiratory part of the curve “flow-volume”.
- Additionally, when revealing difficulties with exhalation are held
inhalation drug tests
bronchodilators (Salbutamol, Ipratropium bromide). it
allows to separate patients with reversible bronchial disorders
patency (bronchial asthma) from patients with COPD.
- Less often use daily monitoring of respiratory function with
to clarify the variability of disorders depending on time
day load, the presence of harmful factors in the inhaled
With выборе стратегии ведения пациентов с данной патологией
urgent tasks are improving the quality of life (first
turn by reducing the manifestations of the disease, improving
exercise tolerance). In the long run
you need to strive to limit the progression of bronchial obstruction,
reduce possible complications and ultimately limit the risks
Primary tactical measures should be considered
non-pharmacological rehabilitation: reducing the effects of harmful
factors in inhaled air, patient education and
потенциальных жертв COPD ознакомление их с факторами риска и
methods to improve the quality of inhaled air. Also for patients with
a slight course of pathology shows physical activity, while
severe forms – pulmonary rehabilitation.
All patients with COPD should be vaccinated against the flu, as well as against
The scope of drug provision depends on the severity
clinical manifestations, stage pathology, the presence of complications. On
Today, preference is given to inhaled forms of drugs,
received by patients as from individual dosage
inhalers, and using nebulizers. Inhalation route
introduction not only increases the bioavailability of drugs,
but also reduces the systemic effects and side effects of many groups
- With этом следует помнить, что пациент должен быть обучен
use inhalers of various modifications, which is important when
replacing some drugs with others (especially with a preferential
drug provision, when often pharmacies are not able to
supply patients with the same dosage forms constantly
and requires a transfer from one drug to another).
- Patients themselves should read the instructions carefully.
spinchallers, turbuhallers and other dosing devices before
start therapy and feel free to ask doctors or pharmacists about
proper use of the dosage form.
- You should also not forget about the phenomena of bounce, relevant to
many bronchodilators, when exceeded
dosing, the drug ceases to help effectively.
- Not always when replacing combination drugs with a combination
individual counterparts achieved the same effect. With снижении
efffektivnosti treatment and renewal of symptoms worth
inform your doctor, and not try to change the dosage regimen
or the multiplicity of admission.
- Use of inhaled corticosteroids requires constant
prevention of a fungal infection of the oral cavity, therefore
forget about hygienic rinses and limiting use
local antibacterial agents.
- Bronchodilators are assigned either continuously or in
needs. Long-term inhalation forms are preferred.
- Long beta-2 agonists: Formoterol (aerosolized or
powder inhaler), indacaterol (powder inhaler),
- Short acting agonists: salbutamol sprays or
- Short-acting anticholinergic dilatators – aerosol
Ipratropium bromide, long-term – Tiotropium powder inhalers
bromide and glycopyrronium bromide.
- Combined bronchodilators: Fenoterol aerosols plus
Ipratropium bromide (Berodual), Salbutamol plus Ipratropium bromide
- Long beta-2 agonists: Formoterol (aerosolized or
- Glucocorticosteroids in inhibitors have low systemic and
a side effect, well increase bronchial passability.
They reduce the number of complications and improve the quality of life. Aerosols
Beclamethasone dipropionate and fluticasone propionate powder
- Combinations of glucocorticoids and beta2-agonists can reduce
mortality, although it increases the risk of pneumonia in patients.
Powder inhalers: Formoterol with budesonide (Symbicort
Turbuchaller, Formisonide, Spiromax), Salmeterol, aerosols:
Fluticasone and Formoterol with Beclomethasone Dipropionate
- Methylxanthine Theophylline in low doses reduces the frequency
- Phosphodiesterase-4 inhibitor – Roflumilast reduces exacerbations
severe forms of the bronchitis disease.
Dosing regimens and regimens
- For mild and moderate COPD with unexpressed
symptomatology and rare exacerbations are preferred salbutamol,
Fenoterol, Ipratropium bromide in “on demand” mode. Alternative
– Formoterol, Tiotropium bromide.
- With тех же формах с яркими клиническими проявлениями Форотерол,
Indacaterol or Tiotropium bromide, or combinations thereof.
- Moderate and severe course with a significant decrease
forced expiratory volume with frequent exacerbations, but
unexpressed clinic requires the appointment of Formoteroli or
Indacaterol in combination with budesonide, Beclametoazon. I.e
more often use inhaled combination drugs
Symbicort, Foster. An isolated appointment of Tiotropium is also possible.
bromide. Alternative – назначение длительных бета-2 агонистов и
Tiotropium bromide in combination or Tiotropium bromide and
- Moderate and severe with severe symptoms –
these are Formoterol, budesonide (Beclamethasone) and Tiotropium bromide or
The exacerbation of COPD requires not only increasing the dose of the main
drugs, but also to connect glucocorticosteroids (if previously
they were not intended) and antibiotic therapy. Heavyweight
patients often have to be transferred to oxygen therapy or
artificial ventilation of the lungs.
Onрастающее ухудшение кислородного обеспечения тканей требует
additional oxygen therapy in constant mode while reducing
oxygen partial pressure of 55 mm Hg and saturation less
88%. Relative indications are pulmonary heart,
blood clots, swelling.
However, patients who continue to smoke are not receiving
drug treatment or not tuned to oxygen therapy,
This type of assistance is not provided.
The duration of treatment takes about 15 hours a day with
breaks no longer than 2 hours. The average feed rate of oxygen from
1-2 to 4-5 liters per minute.
An alternative in patients with less severe impairment of ventilation.
prolonged home ventilation of the lungs becomes. She assumes
use oxygen respirators at night and several
hours in the afternoon. The selection of ventilation modes is carried out in a hospital or
Contraindications to this type of therapy are low.
motivation, patient agitation, swallowing disorders,
the need for long-term (about 24 hours) oxygen therapy.
Other methods of respiratory therapy include percussion
bronchial drainage (small amounts of air are supplied
into a bronchial tree with a certain frequency and under a certain
pressure), as well as breathing exercises with forced expiration
(ballooning, mouth breathing through a tube) or breathing
Pulmonary rehabilitation should be carried out for all patients. beginning
with 2 degrees of severity. It includes breathing exercises.
and exercise, if necessary – skills
oxygen therapy. Also provides psychological help.
sick, they are motivated to change their lifestyle,
обучение распознаванию признаков ухудшения заболевания и
skills for quick access to medical care.
Thus, at the present stage of development of medicine
chronic obstructive pulmonary disease, лечение которой
quite elaborated, is a pathological process,
which can not only be corrected, but also prevented.