Рецепт. 2021; 24: 480-497
Ведение пациентов с бронхиальной астмой: GINA 2021
https://doi.org/10.34883/PI.2021.24.4.006Аннотация
Бронхиальная астма является широко распространенным гетерогенным заболеванием легких, характеризующимся хроническим воспалением дыхательных путей, наличием изменяющихся по времени и интенсивности респираторных симптомов с вариабельной обструкцией бронхов. В статье представлены современные рекомендации для врачей общей практики по диагностике и лечению бронхиальной астмы с позиций Глобальной инициативы по диагностике и лечению БА (Global Initiative for Asthma – GINA) пересмотра 2021 года. Изложены классификационные критерии степеней тяжести и уровней контроля астмы, основные механизмы патогенеза заболевания. Дано понятие фенотипов астмы. Предложены доступные, понятные и удобные для практического применения алгоритмы диагностики и ступенчатой терапии бронхиальной астмы. Перечислены характерные жалобы, данные анамнеза жизни и болезни, необходимый перечень лабораторного и инструментального обследования для установления правильного диагноза. Представлены спирографические критерии обратимого характера бронхиальной обструкции, дано понятие гиперреактивности бронхов и методов ее выявления. Определены основные цели и задачи в терапии астмы. Рекомендации по ступенчатому лечению заболевания изложены в виде схем-алгоритмов стартовой и персонализированной терапии с детальным рассмотрением всех ступеней. Отмечено, что с 2019 года монотерапия короткодействующими β2-агонистами (сальбутамол, фенотерол) для купирования приступов одышки/удушья при легкой бронхиальной астме более не рекомендуется. В изложении материала сделан акцент на предпочтительном использовании в лечении комбинированной терапии. Отмечено, что важным условием достижения контроля над астмой является высокий уровень взаимодействия врача с пациентом.
Список литературы
1. Avdeev S.N., Ajsanov Z.R., Belevskij A.S., Emeliyanov A.V., Kurbacheva O.M., Leshchenko I.V., Nenasheva N.M., Fassahov R.S. (2019) Putiuluchsheniya diagnostiki i lecheniya bol’nyh bronhial’noj astmoj vrachami pervichnogo zvena [Ways of improvement of diagnostics and treatment of patients with bronchial asthma by primary care physicians]. Pul’monologiya, no 29 (4), pp. 457–467. Available at: https://doi.org/10.18093/0869-0189-2019-29-4-457-467.
2. Baranovskaya T.V. (2018) Tyazhelaya bronhial’naya astma-2018. Soglasitel’nyj doklad ob”edinennoj gruppy ekspertov Associacii russkogovoryashchih specialistov v oblasti respiratornoj mediciny, Rossijskogo respiratornogo obshchestva, Rossijskoj associacii allergologov i klinicheskih immunologov [Severe bronchial asthma – 2018. Consensus report of the joint expert group of the Association of Russian-speaking specialists in the field of respiratory medicine, Russian respiratory society, Russian association of allergists and clinical immunologists]. Prakt. Pul’monologiya, no 3, pp. 52–64.
3. Bogush L.S., Davidovskaya E.I., Baranovskaya T.V. (2020) GINA 2019–2020: osnovnye izmeneniya i rol’vracha obshchej praktiki v vedenii pacientov s astmoj [GINA 2019-2020: main changes and role of general practitioner in management of patients with asthma]. Recept, no 5, pp. 732–749. Available at: https://doi.org/10.34883/PI.2020.23.5.0010.
4. Glinskaya T.N., Davidovskaya E.I., Shchaveleva M.V., Bogush L.S. (2020) Zabolevaemost’ vzroslogo naseleniya Respubliki Belarus’ boleznyami organov dyhaniya: 2008–2019 gody [Incidence of respiratory diseases in the adult population of the Republic of Belarus: 2008 2019]. Vopr. organizacii i informatizacii zdravoohraneniya, no 3, pp. 4–12.
5. Davidovskaya E.I., Skryagina E.M., Dubrovskij A.S. (2018) Ingalyacionnaya farmakoterapiya bronhoobstruktivnyh zabolevanij v Respublike Belarus’ – ot klinicheskih rekomendacij k real’noj klinicheskoj praktike [Inhaled pharmacotherapy of bronchial obstructive diseases in the Republic of Belarus – from clinical recommendations to real clinical practice]. Recept, vol. 21, no 2, pp. 248–254.
6. Leshchenko I.V. (2019) Bronhial’naya astma: prostye resheniya slozhnyh voprosov [Bronchial asthma: simple solutions of complicates problems]. Med. sovet, no 6, pp. 52–57.
7. Meshcheryakova N.N., Belevskij A.S. (2015) Vozmozhnosti primeneniya ekstramelkodispersnoj fiksirovannoj kombinacii beklometazona i formoterola v edinom ingalyatore v kachestve podderzhivayushchej i simptomaticheskoj terapii [Options of use of extrafine fixed combination of beclometasone and formoterol in a single inhaler as a supportive and symptomatic therapy]. Prakticheskaya pul’monologiya, no 1, pp. 88–92.
8. Avdeev S.N., Ajsanov Z.R., Belevskij A.S. (2019) Puti uluchsheniya diagnostiki i lecheniya bol’nyh bronhial’noj astmoj vrachami pervichnogo zvena [Ways of improvement of diagnostics and treatment of patients with bronchial asthma by primary care physicians]. Pul’monologiya, vol. 29, no 4, pp. 457–67. doi: 10.18093/0869-0189-2019-29-4-457-467
9. Saluhov V.V., Haritonov M.A., Zajcev A.A. (2020) Sovremennye predstavleniya o bronhial’noj astme [Modern ideas about bronchial asthma]. Vestnik Rossijskoj Voenno-medicinskoj akademii, no 2 (70), pp. 227–234.
10. Chuchalin A.G. (2019) Federal’nye klinicheskie rekomendacii po diagnostike i lecheniyu bronhial’noj astmy [Federal clinical recommendations on diagnostics and treatment of bronchial asthma]. M.: Ross. Respiratornoe obshchestvo, 97 p. (in Russian)
11. Dusser D., Montani D., Chanez P. (2007) Mild asthma: An expert review on epidemiology, clinical characteristics and treatment recommendations. Allergy, no 62 (6), pp. 591–604. doi: 10.1111/j.1398-9995.2007.01394.x
12. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. Updated 2021. Available at: http:ginasthma.org (accessed June 6, 2021).
13. Barnes P.J. (2012) Allergy Asthma Proc., vol. 33, p. 140.
14. Papi A. (2007) BEST Study Group. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N. Engl. J. Med., vol. 356, no 20, pp. 2040–2052.
15. Ducharme F.M., Ni Chroinin M., Greenstone I., Lasserson T.J. (2010) Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma. Cochrane Database Syst Rev., vol. 14 (4).
Recipe. 2021; 24: 480-497
Management of Patients with Bronchial Asthma: GINA 2021
https://doi.org/10.34883/PI.2021.24.4.006Abstract
Bronchialasthmaisawidespreadheterogeneouslungdiseasecharacterizedbychronicinflammation of the respiratory tract, the presence of time-varying and intensity-varying respiratory symptoms with variable bronchial obstruction. The article presents modern recommendations for general practitioners on the diagnostics and treatment of bronchial asthma from the perspective of the Global Initiative for asthma (GINA), 2021 revision. Classification criteria of the severity and asthma control levels, main mechanisms of the pathogenesis of the disease are described. The concept of asthma phenotypes is given. The simple, understandable and convenient algorithms for diagnostics and step-by-step therapy of bronchial asthma are proposed. The typical complaints, the anamnestic data of the life and case history, the necessary list of laboratory and instrumental examinations to make a correct diagnosis are listed. The spirographic criteria of the reversible nature of bronchial obstruction are presented; the concept of bronchial hyperreactivity and methods of its detection are provided. The main aim and objectives in the treatment of asthma are defined. Recommendations for step-by-step treatment of the disease are presented in the form of schemes-algorithms of initial and personalized therapy with a detailed consideration of all stages. It is noted that since 2019, the monotherapy with short-acting β2-agonists (salbutamol, fenoterol) for controlling wheezing attacks in mild bronchial asthma has no longer been recommended. The preferred use of fixed combinations in the treatment of the disease is emphasized. It is noted that an important condition for controlling asthma is the high level of interaction between the doctor and the patient.
References
1. Avdeev S.N., Ajsanov Z.R., Belevskij A.S., Emeliyanov A.V., Kurbacheva O.M., Leshchenko I.V., Nenasheva N.M., Fassahov R.S. (2019) Putiuluchsheniya diagnostiki i lecheniya bol’nyh bronhial’noj astmoj vrachami pervichnogo zvena [Ways of improvement of diagnostics and treatment of patients with bronchial asthma by primary care physicians]. Pul’monologiya, no 29 (4), pp. 457–467. Available at: https://doi.org/10.18093/0869-0189-2019-29-4-457-467.
2. Baranovskaya T.V. (2018) Tyazhelaya bronhial’naya astma-2018. Soglasitel’nyj doklad ob”edinennoj gruppy ekspertov Associacii russkogovoryashchih specialistov v oblasti respiratornoj mediciny, Rossijskogo respiratornogo obshchestva, Rossijskoj associacii allergologov i klinicheskih immunologov [Severe bronchial asthma – 2018. Consensus report of the joint expert group of the Association of Russian-speaking specialists in the field of respiratory medicine, Russian respiratory society, Russian association of allergists and clinical immunologists]. Prakt. Pul’monologiya, no 3, pp. 52–64.
3. Bogush L.S., Davidovskaya E.I., Baranovskaya T.V. (2020) GINA 2019–2020: osnovnye izmeneniya i rol’vracha obshchej praktiki v vedenii pacientov s astmoj [GINA 2019-2020: main changes and role of general practitioner in management of patients with asthma]. Recept, no 5, pp. 732–749. Available at: https://doi.org/10.34883/PI.2020.23.5.0010.
4. Glinskaya T.N., Davidovskaya E.I., Shchaveleva M.V., Bogush L.S. (2020) Zabolevaemost’ vzroslogo naseleniya Respubliki Belarus’ boleznyami organov dyhaniya: 2008–2019 gody [Incidence of respiratory diseases in the adult population of the Republic of Belarus: 2008 2019]. Vopr. organizacii i informatizacii zdravoohraneniya, no 3, pp. 4–12.
5. Davidovskaya E.I., Skryagina E.M., Dubrovskij A.S. (2018) Ingalyacionnaya farmakoterapiya bronhoobstruktivnyh zabolevanij v Respublike Belarus’ – ot klinicheskih rekomendacij k real’noj klinicheskoj praktike [Inhaled pharmacotherapy of bronchial obstructive diseases in the Republic of Belarus – from clinical recommendations to real clinical practice]. Recept, vol. 21, no 2, pp. 248–254.
6. Leshchenko I.V. (2019) Bronhial’naya astma: prostye resheniya slozhnyh voprosov [Bronchial asthma: simple solutions of complicates problems]. Med. sovet, no 6, pp. 52–57.
7. Meshcheryakova N.N., Belevskij A.S. (2015) Vozmozhnosti primeneniya ekstramelkodispersnoj fiksirovannoj kombinacii beklometazona i formoterola v edinom ingalyatore v kachestve podderzhivayushchej i simptomaticheskoj terapii [Options of use of extrafine fixed combination of beclometasone and formoterol in a single inhaler as a supportive and symptomatic therapy]. Prakticheskaya pul’monologiya, no 1, pp. 88–92.
8. Avdeev S.N., Ajsanov Z.R., Belevskij A.S. (2019) Puti uluchsheniya diagnostiki i lecheniya bol’nyh bronhial’noj astmoj vrachami pervichnogo zvena [Ways of improvement of diagnostics and treatment of patients with bronchial asthma by primary care physicians]. Pul’monologiya, vol. 29, no 4, pp. 457–67. doi: 10.18093/0869-0189-2019-29-4-457-467
9. Saluhov V.V., Haritonov M.A., Zajcev A.A. (2020) Sovremennye predstavleniya o bronhial’noj astme [Modern ideas about bronchial asthma]. Vestnik Rossijskoj Voenno-medicinskoj akademii, no 2 (70), pp. 227–234.
10. Chuchalin A.G. (2019) Federal’nye klinicheskie rekomendacii po diagnostike i lecheniyu bronhial’noj astmy [Federal clinical recommendations on diagnostics and treatment of bronchial asthma]. M.: Ross. Respiratornoe obshchestvo, 97 p. (in Russian)
11. Dusser D., Montani D., Chanez P. (2007) Mild asthma: An expert review on epidemiology, clinical characteristics and treatment recommendations. Allergy, no 62 (6), pp. 591–604. doi: 10.1111/j.1398-9995.2007.01394.x
12. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. Updated 2021. Available at: http:ginasthma.org (accessed June 6, 2021).
13. Barnes P.J. (2012) Allergy Asthma Proc., vol. 33, p. 140.
14. Papi A. (2007) BEST Study Group. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N. Engl. J. Med., vol. 356, no 20, pp. 2040–2052.
15. Ducharme F.M., Ni Chroinin M., Greenstone I., Lasserson T.J. (2010) Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma. Cochrane Database Syst Rev., vol. 14 (4).
