Chronic obstructive pulmonary disease (COPD) is the most common pathology of the respiratory system, characterized by inflammation of the respiratory tract, which occurs under the influence of adverse environmental factors and is manifested partially reversible bronchial obstruction. Morphological changes in COPD are observed in the central and peripheral bronchi, lung parenchyma and blood vessels.
In recent years, international guidelines for the diagnosis, treatment and prevention of this disease (GOLD) have been developed, according to which COPD pharmacotherapy is aimed at preventing and controlling symptoms, reducing the frequency and severity of exacerbations, improving health and exercise tolerance. Frequent exacerbations of COPD significantly reduce the quality of life of patients, contribute to the progression of bronchial obstruction.
An exacerbation is understood as an acute, as compared with a stable condition of a patient, an increase in COPD symptoms that goes beyond their daily variability. The most frequent signs of exacerbation are the progression of dyspnea, increased cough, increased production of sputum and a change in its nature.
An effective modern drug for the treatment of COPD is tiotropium bromide (Spiriva, Boehringer Ingelheim) – an anticholinergic bronchodilator, which has a selective cholinolytic effect mainly on muscarinic receptors located in the smooth muscles of the bronchi (M3 receptors), which helps reduce the effect on bronchi of the bronchi, which helps to reduce the effect on bronchi of the bronchi Thus, tiotropium reduces the effects of four pathogenetic mechanisms of airflow obstruction due to parasympathetic innervation hyperreactivity airways: bronchospasm, bronchial hypersecretion of mucus by goblet cells, the activation of the vagus nerve afferent endings in tussogennyh zones swelling airway mucous membranes as a result of vasodilatation.
Siriva is available as a powder in a dose of 18 μg per capsule and is applied 1 time per day using an inhaler. The bronchodilator effect of the drug develops in about 30 minutes and lasts for 24 hours after application. With prolonged use of the drug tolerance does not develop. Numerous studies in recent years have shown that tiotropium significantly reduces the frequency of exacerbations, reduces the need for the use of short-acting b2-agonists, which helps to improve the quality of life of COPD patients. The advantages of the drug Spiriva are the absence of clinically significant adverse effects, good tolerability and safety.
In the city pulmonary center of the KGKB No. 17, the drug Spiriva has been used in the complex treatment of patients with COPD for more than two years. Good results are obtained when using this drug in clinical practice.
Clinical case number 1
Patient S., 67 years old, is currently not working. He first came to the clinic of the pulmonary center with complaints of paroxysmal cough (most often in the morning), with a small amount of gray sputum, shortness of breath with little exertion, wheezing in the chest.
Anamnesis of the disease. He considers himself to be sick for about 20 years, when after suffering pneumonia he began to get sick more often with colds. After a while, there was a feeling of lack of air during exercise, sometimes – wheezing in the chest. Treatment was usually symptomatic on an outpatient basis with a short-term improvement. After a few years, I began to feel shortness of breath during daily physical exertion – fast walking, climbing stairs. The patient was repeatedly treated in the therapeutic hospital with antibacterial, expectorant drugs, he was briefly prescribed the drugs Combivent, Ventolin, Berotek, however, no significant improvement in well-being was noted. Over the years, shortness of breath and wheezing in the chest have become more pronounced. During the exacerbation of bronchitis, the patient was sent to a pulmonary center.
Anamnesis of life. In childhood, suffered left-sided pleurisy, often suffered from colds. In my youth I smoked a lot – more packs a day, recent years – 5-6 cigarettes a day. For many years he worked in the production of plastic products.
Concomitant pathology. Chronic cholecystitis, urolithiasis. Coronary artery disease, arterial hypertension second stage. (identified 5 years ago).
Objective data. The patient has an asthenic constitution, breathing is audible from a distance. BH – 20 per minute. The chest is of the usual form, the intercostal muscles are involved in breathing. Percussion tone with boxed tone. Auscultation – breathing is hard, droning wheezes are heard bilaterally. Cardiac rhythmic activity, muted tones. HELL 160/70 mm RT. Art., HR – 86 beats / min.
X-ray data. The lungs are emphysematous, the roots are dilated, the diaphragm is located at the height of the ninth intercostal space, the sine on the left is veiled.
Spirometry Significant violations of the ventilation capacity of the lungs (VSL) of the restrictive type; sharp violations of AFL by obstructive type with impaired patency at all levels of the bronchi. ZHEL – 55,6%; FEV1 – 29.7%. Test with Berodual positive.
Diagnosis. COPD, aggravation. DN II-III Art. CHD, atherosclerotic cardiosclerosis. Hypertensive heart disease II. Heart failure І grad.
The patient was hospitalized in the pulmonary department. After 2 weeks discharged. Recommendations are made: Spiriva, 18 µg 1 time per day, Beclazon-eco, 2 breaths, 2 times a day, Berodual, as needed, Atma, 10 drops, 3 times a day. The patient was recommended to consult a pulmonologist after 6 months. All this time he was under the systematic supervision of the district therapist.
Improvement in the general condition was noted from the first month of treatment: cough, sputum and shortness of breath significantly decreased. After the first month of treatment, the patient was able to overcome without stopping one flight of the stairs. In the following months, a cough with a small amount of light sputum was observed only in the morning hours. In the spirogram, the increase in VC and FEV1 was observed (VEG – 57.8%; FEV1 – 34.6%). For all the time of treatment, the patient did not observe any undesirable effects of the drugs. After acute respiratory viral infections, some exacerbation of COPD in the form of increased cough and shortness of breath was noted, which did not require hospitalization. In the summer, the patient felt good, and therefore he reduced the frequency of using the drug Spiriva. Dyspnea slightly increased after hypothermia, sputum increased without worsening general well-being. The treatment was corrected: the initial dosage of the drug Spiriva was prescribed and the dose of Berodual was increased, expectorant preparations were prescribed; after that, the patient’s condition improved. A month later, the spirogram indicators were as follows: VC – 57.3%; FEV1 – 35.8%.
Thus, the given example of clinical observation shows that long-term complex treatment with the use of tiotropium bromide in patients with COPD of stage III. may reduce shortness of breath and severity of clinical symptoms, reduce the need for short-acting b2-agonists.
Clinical case number 2
Patient K., 55 years old, self-employed. He was taken by ambulance carriage to the KGKB No. 17 polytrauma department regarding spontaneous pneumothorax on the right. The patient underwent thoracoscopy, drainage of the pleural cavity. The lung cracked, however, severe shortness of breath remained with little exertion, cough with yellow sputum, weakness, and a feeling of heaviness behind the sternum. With these symptoms, the patient was transferred to the pulmonology department, where he received further treatment.
Anamnesis of the disease. Sick since 1997, when it was identified infiltrative tuberculosis of the upper lobe of the right lung in the stage of disintegration and seeding. He underwent inpatient chemotherapy for 10 months. As a result of treatment, residual changes in the form of calcifications in the roots of the lungs, fibrous focal changes in the upper lobes of both lungs, and the residual cavity of the upper lobe of the right lung remained. Since then, the patient began to grow short of breath, there was a feeling of lack of air during intense physical exertion. The patient did not seek medical care, did not receive treatment. Right-sided spontaneous pneumothorax developed on the background of physical exertion.
Anamnesis of life. Smokes for 30 years, 1.5 packs per day.
Concomitant pathology. Chronic hepatitis (viral hepatitis in 1976), cholecystitis, pancreatitis.
Objective data. Patient normostenicheskoy design, BH – 24 per minute. The chest is of the usual form, the intercostal muscles are involved in breathing. Percussion tone with boxed tone. Auscultation – breathing is hard, dry wheezing is heard bilaterally. Cardiac rhythmic activity, muted tones. HELL 155/90 mm RT. Art., HR – 100 beats / min.
X-ray data. Bilateral bullous emphysema of the lungs, fibrous focal shadows in the upper sections of the lungs, more to the right.
Fibroscopy Limited right-sided, slightly pronounced mucopurulent endobronchitis.
Spirometry Significant violations of the AFL restrictively; sharp violations of AFL by obstructive type with impaired patency at all levels of the bronchi. VC – 66.0%; FEV1 – 24.1%. Trial with Berodual, Zafiron positive.
Diagnosis. COPD, aggravation, severe course. Bullous emphysema. Spontaneous pneumothorax 11.03.08. NAM III st. Pulmonary hypertension. IHD, angina, atherosclerotic cardiosclerosis. Hypertensive heart disease II. Heart failure ІІА Art.
The following treatment was prescribed in the hospital: Baralgin, Asparkam, Mildronat, Lasolvan, Clexan, Nitrogranulong, Diakordin, Lipin, Preductal, Zilt, Naklofen, Prospan forte, Cordaron, Symbicort. A month later, the patient was discharged, his condition has improved significantly. It is recommended to continue treatment on an outpatient basis under the supervision of a district physician with the following drugs: Spiriva 1 time per day (long-term), Symbikort 1 breath 2 times a day, Preductal MR, Diakordin, Zilt, Kordaron, control spirogram after 1 month. During the second consultation with the pulmonologist, the patient noted a significant decrease in shortness of breath, improvement in the general condition. Cough is observed only in the morning with a small amount of light sputum. The patient reduced the number of cigarettes smoked to 5 per day. Spirogram indicators: VC – 67.8%; FEV1 – 32.0%. It was recommended to continue the prescribed treatment under the supervision of a district physician and cardiologist, followed by consultation with a pulmonologist after 4 months. Exacerbations of the process for the expired period were noted. The patient feels well, performs moderate physical exertion, overcomes without stopping one flight of stairs. Cough in the morning is preserved, not quit smoking. Against the background of good tolerability of drugs notes a slight dry mouth for several hours after the use of inhalers. Indicators spirogram: VC – 67.3%; FEV1 – 30.6%.
The given example of clinical observation also confirms that prolonged complex treatment using tiotropium (Spiriva) in patients with COPD can reduce shortness of breath and severity of clinical symptoms, improve the quality of life of patients, reduce the number of exacerbations.
