Medicines for the treatment of asthma in the elderly. Bronchial asthma in the elderly - etiology, clinical presentation, treatment and care. Bronchial asthma in the elderly: features of the course, differential diagnosis, treatment
Over the last period of time, the percentage of morbidity in the elderly population bronchial asthma increased sharply. At the moment, this is 44% of the total number of patients with this disease. Three main factors contribute to all this:
- Increased level of allergic reactions.
- The polluted environment and advanced chemical production have increased exposure to allergens.
- Chronic diseases associated with the respiratory tract have become increasingly common.
What is bronchial asthma?
How does bronchial asthma manifest in the elderly?
Often, bronchial asthma in old people is chronic. It can be characterized by stable heavy breathing with a whistle. There is also shortness of breath, which is aggravated by strong physical exertion. In the process of exacerbations, asthma attacks may occur. Coughing up is one of the signs of bronchial asthma. Often accompanied by secretions in the form of mucous sputum. Choking attacks occur due to inflammatory and infectious lesions in the lungs. These include chronic bronchitis, ARVI.
A person who fell ill with bronchial asthma in his youth will not get rid of it until old age. It's just that the onset of seizures will be less pronounced. And due to the prescription of the disease, it will be possible to see how noticeably the respiratory organs and the heart have changed.
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How is bronchial asthma treated in the elderly?
Purines will help get rid of bronchial spasm during an attack, as well as between attacks. These include diprofillin, diaphyllin. They can be used internally and in the form of aerosols.
Let's try to compare it with adrenaline. The advantages in their appointment are expressed in the fact that their use has no contraindications for diseases such as atherosclerosis, ischemic disease hearts,. Plus, the use of drugs in this group helps to improve renal and coronary circulation. Thanks to all this, they are popular in practice.
The appointment of adrenaline promotes the rapid removal of bronchial spasm and the arrest of seizures. But, despite this, its purpose for non-young people should be done very carefully. This can be explained by the fact that old people are highly sensitive to the use of hormonal drugs. Adrenaline can be administered subcutaneously or intramuscularly only in extreme situations. When the seizure cannot be stopped with other medical means. The dosage is not more than 0.2-0.3 ml of a 0.1 percent solution. If the effect of adrenaline is absent, then it can be re-administered no earlier than 4 hours later at the same dosage. One more . Its use guarantees not such a quick, more long-lasting effect. We must not forget that this remedy cannot be prescribed to people with prostate adenoma.
Medicines such as novodrin, izadrin, orciprenaline sulfate have bronchodilator properties.
The use of such agents as trypsin and chymotrypsin in aerosols contributes to a better release of sputum from the human body. There is only one but. Can cause an allergic reaction. This is due, first of all, to the process of absorption of proteolysis substances. Previously, on the eve of their use and during all therapy, it is recommended to prescribe antihistamines. Bronchodilators are prescribed and used to improve the performance of the bronchial system.
Anticholinergics are considered excellent medicines. They provide assistance to the body, which does not accept ephedrine, izadrin. It also enhances the secretion of sputum. Combines with ischemic heart disease, which proceeds along with bradycardia. These include drugs such as troventol, atrovent, truvent.
In the treatment of bronchial asthma in combination with other drugs is used. Such as diazolin, suprastin, diphenhydramine, tavegil, diprazine.
For some patients, the use of novocaine is excellent. There are two types of novocaine administration - intramuscularly (5 cubes of a 2 percent solution) and intravenously (10 cubes of a 0.5 percent solution). To stop the attack, it will be useful to use unilateral novocaine blockade according to A.V. Vishnevsky. It is not advised to use a bilateral blockade. Because often from it, sick people have undesirable consequences. For example, blood circulation to the brain is impaired.
It is forbidden for old and elderly people to prescribe ganglion blockers. Due to the fact that a hypotensive reaction may occur. If, along with bronchial asthma, there is angina pectoris, then the use of inhalation is recommended for old people (nitrous oxide 70-75% and oxygen 25-30%).
When an attack occurs, cardiovascular drugs should be used all the time with bronchodilators. In an old person, during an attack, the cardiovascular system may fail.
An excellent result in the elimination and prevention of an attack is the use of hormonal therapy. These are analogs of cortisone and hydrocortisone. The introduction of these drugs to the elderly should be carried out strictly adhering to the dosages. Three times less than the dosage for young people. In the course of treatment, the lowest possible dose is set, which will give an effect. The duration of hormone therapy is no more than 3 weeks. As a side effect is possible. The use of glucocorticosteroids can be done together with bronchodilators. If you re-infection, corticosteroids are given in combination with antibiotics. However, even small doses of corticosteroids have side effects in older people. Because of this, this type of drug can only be used in the following conditions:
- The disease is severe. No other drugs help.
- The patient's condition deteriorated sharply due to intercurrent illness.
- The presence of an asthmatic condition.
A good effect is the use of aerosol glucocorticosteroids. With a small dose of the drug, it is possible to achieve a clinical effect. This reduces the frequency of side effects. In order to get rid of acute attacks, the use of hormonal agents occurs intravenously.
Crinoline sodium or intal is very popular in the treatment of bronchial asthma. It inhibits the de-granulation of mast cells. Does not allow media materials such as histamine and bradykinin to leave them. It is the presence of these substances that provoke inflammation and bronchospasm. This drug prevents asthmatic attacks from developing. It is prescribed in the form of inhalations at a dose of 0.02 g 4 times a day. As soon as the patient's condition improves, then it is necessary to reduce both the dose and the number of inhalations per day. A positive result can be achieved after 2-4 weeks. The course of treatment should be long.
In the process of treating bronchial asthma, an allergen can be found that is responsible for the disease. It should be eliminated and there is a need for specific desensitization to this substance. Elderly patients have low sensitivity to all allergens. Therefore, it is very difficult to correctly identify one or another type of allergen in them.
If an elderly person suffers from heart failure, then the appointment of diuretics, cardiac glycosides will be useful.
For restless patients, it is better to prescribe the tranquilizer trioxazine. And you can also use isoprotane, metami zil, diazepam, aminyl, meprobamate, chlordiazepoxide.
Expectorants prescribed for bronchial asthma include acetylcysteine and. Plus physical therapy.
Spicy and hot foot baths. Respiratory exercises and physiotherapy exercises can help older people get rid of bronchial asthma. Physical activity is assigned to everyone personally.
V last years the incidence of such a disease as bronchial asthma in the elderly has increased dramatically. This can be attributed to three main factors. First, allergic reactivity has increased. Secondly, due to the development of the chemical industry, pollution environment and other circumstances increase contact with allergens. Thirdly, chronic diseases of the respiratory tract are becoming more frequent, creating prerequisites for the development of bronchial asthma. The age structure of the disease has also changed. Currently, people of the elderly and senile age make up 44% of the total number of patients with this disease.
What causes bronchial asthma in the elderly?
In old and senile age, there is a predominantly infectious-allergic form of the disease. Bronchial asthma in the elderly occurs more often as a result of inflammatory diseases of the respiratory system (chronic pneumonia, chronic bronchitis, etc.). From this infectious focus, the body is sensitized by the decay products of its own tissues, bacteria and toxins. Bronchial asthma in the elderly can begin simultaneously with the inflammatory process in the lungs, more often with bronchitis, bronchiolitis, pneumonia.
How does bronchial asthma manifest in the elderly?
In most cases, bronchial asthma in the elderly has a chronic course and is characterized by constant wheezing and shortness of breath, aggravated by physical exertion (due to the development of obstructive pulmonary emphysema). Periodic exacerbations are manifested by the occurrence of attacks of suffocation. There is a cough with the separation of a small amount of light, thick, mucous sputum. Most often, infectious and inflammatory processes in the respiratory organs (acute respiratory viral infections, exacerbations of chronic bronchitis) play a dominant role in the occurrence of attacks of suffocation and exacerbation of the disease.
A bronchial asthma attack usually begins at night or early in the morning. This is primarily due to the accumulation of secretion in the bronchi during sleep, which irritates the mucous membrane, receptors and leads to an attack. An increase in the tone of the vagus nerve plays a certain role. In addition to bronchospasm, which is the main functional disorder in asthma at any age, in the elderly and old people its course is complicated by age-related pulmonary emphysema. As a result, in the future, heart failure quickly joins in pulmonary insufficiency.
Once it has arisen at a young age, it can persist in older people. In this case, the attacks are less acute. Due to the duration of the disease, there are pronounced changes in the lungs (obstructive emphysema, chronic bronchitis, pneumosclerosis) and the cardiovascular system (cor pulmonale - cor pulmonale).
During an acute attack, the patient has wheezing, shortness of breath, cough and cyanosis. The patient sits, leaning forward, leaning on his hands. All muscles involved in the act of breathing are tense. In contrast to young people, rapid breathing is observed during an attack, due to severe hypoxia. When percussion, a box sound is detected, sonorous buzzing, whistling rales are heard in large quantities, and wet rales can be detected. At the beginning of the attack, the cough is dry, often excruciating. After the end of an attack with a cough, a small amount of viscous mucous sputum is released. The reaction to bronchodilators (for example, theophylline, izadrin) during an attack in people of the older age group is delayed, incomplete.
Heart sounds are muffled, tachycardia is noted. At the height of the attack, acute heart failure may occur due to reflex spasm of the coronary vessels, increased pressure in the system pulmonary artery, reduced contractility of the myocardium, as well as in connection with concomitant diseases of the cardiovascular system (hypertension, atherosclerotic cardiosclerosis).
How is bronchial asthma treated in the elderly?
To relieve bronchospasm both during an attack and in the interictal period, purines (aminophylline, diaphyllin, diprofilpin, etc.) deserve attention, which can be administered not only parenterally, but also in the form of aerosols. The advantage of prescribing these drugs over adrenaline is that their administration is not contraindicated in hypertension, cardiac asthma, ischemic heart disease, cerebral atherosclerosis. In addition, aminophylline and other drugs from this group improve coronary and renal circulation. All this determines their widespread use in geriatric practice.
Although adrenaline usually provides quick withdrawal bronchospasm and, thereby, relief of an attack, it is necessary to prescribe it to the elderly and old people with caution due to their increased sensitivity to hormonal drugs. It is possible to resort to subcutaneous or intramuscular administration of adrenaline only if the attack cannot be stopped by any drugs. The dose of the drug should not exceed 0.2-0.3 ml of a 0.1% solution. In the absence of effect, the administration of adrenaline can be repeated in the same dose only after 4 hours. The appointment of ephedrine provides a less rapid, but more prolonged effect. It should be noted that ephedrine is contraindicated in prostate adenoma.
Bronchodilator properties are possessed by isopropylnoradrenaline preparations (izadrin, orciprenaline sulfate, novodrin, etc.).
When trypsin, chymotrypsin and other agents are used in aerosols to improve sputum discharge, allergic reactions are possible, mainly associated with the absorption of proteolysis products. Before their introduction and during therapy, antihistamines should be prescribed. To improve the patency of the bronchi, bronchodilators are used.
Anticholinergics are the drugs of choice. In case of intolerance to adrenergic agonists (izadrine, ephedrine), abundant sputum secretion and combination with coronary artery disease, proceeding with bradycardia, violation of atrioventricular conduction, anticholinergics (atrovent, troventol, truvent, berodual) are prescribed.
The complex therapy for bronchial asthma includes antihistamines (diphenhydramine, suprastin, diprazin, diazolin, tavegil, etc.).
In some patients, novocaine has a beneficial effect: intravenously 5-10 ml of a 0.25-0.5% solution or intramuscularly 5 ml of a 2% solution. To stop an attack, unilateral novocaine vagosympathetic blockade according to A.V. Vishnevsky. Bilateral blockade is not recommended, as it often causes side effects in such patients (violation cerebral circulation, breathing, etc.).
Ganglion blockers are not recommended for the elderly due to the occurrence of a hypotensive reaction.
If bronchial asthma in the elderly is combined with angina pectoris, inhalation of nitrous oxide (70-75%) with oxygen (25-30%) is indicated - at an injection rate of 8-12 l / min.
Along with bronchodilators during an attack, it is always necessary to use cardiovascular drugs, since an attack can quickly remove the cardiovascular system of an elderly person from a state of relative compensation.
Hormone therapy (cortisone, hydrocortisone and their derivatives) gives good effect stopping an acute attack and preventing it. However, in the elderly and old age, glucocorticosteroids should be administered in doses 2-3 times lower than those used for young people. When treating, it is important to establish the minimum effective dose. Hormone therapy for longer than 3 weeks is undesirable due to the potential for side effects. The use of glucocorticosteroids does not exclude the simultaneous administration of bronchodilators, which, in some cases, can be reduced. a dose of hormonal drugs. In a secondary infection, antibiotics are indicated, along with corticosteroids. Side effects are common in older people when treated with even low doses of corticosteroids. In this regard, glucocorticosteroids are used only under the following conditions:
- severe course, not treatable by other means;
- asthmatic condition;
- a sharp deterioration in the patient's condition against the background of an intercurrent disease.
The introduction of glucocorticosteroids in the form of aerosols is very promising, since at a lower dose of the drug, a clinical effect is achieved and thereby the frequency of side effects decreases. On the day of relief of an acute attack, hormonal drugs can also be administered intravenously.
Cromolyn sodium (intal) has found wide application in bronchial asthma. It inhibits the degranulation of mast cells (mast cells) and delays the release of mediator substances from them (bradykinin, histamine, and the so-called slowly reacting substances) that contribute to bronchospasm and inflammation. The drug has a preventive effect before the development of an asthmatic attack. Intal is used in inhalation of 0.02 g 4 times a day. After improving the condition, the number of inhalations is reduced by selecting a maintenance dose. The effect occurs in 2-4 weeks. Treatment should be long-term.
In case of bronchial asthma, in case of finding out the allergen responsible for the disease, it is necessary to exclude it, if possible, and carry out a specific desensitization to this substance. Elderly patients are less sensitive to allergens, so their correct identification is very difficult. In addition, they are polyvalently sensitized.
With the development of heart failure, cardiac glycosides, diuretics are prescribed.
For very restless patients, it is possible to use tranquilizers (trioxazine), benzodiazepine derivatives (chlordiazepoxide, diazepam, oxazepam), propanediol carbamide esters (meprobamate, isoprotane), diphenylmethane derivatives (aminyl, metamizil).
Bromhexine, acetylcysteine and physiotherapy are most often used as expectorants and secretolytic agents.
Appointment of mustard plasters, hot foot baths brings a well-known effect in an acute attack. Bronchial asthma in the elderly should also be treated with physiotherapy exercises, breathing exercises. The type and amount of exercise is determined individually.
Scientific studies have shown that older people with asthma often face extreme health risks. What is the reason for this and why exactly bronchial asthma in old age can cause many problems?
It turns out that bronchial asthma is especially dangerous not only for children. If a person develops asthma after age 65, they often have to go through a difficult battle for their own health.
The number of patients with asthma in the world is growing from year to year. Currently, the number of asthmatics has exceeded 300 million. Most often, children suffer from asthma. In addition, an increase in the incidence is noted among people aged 65 to 75 years. Previously, experts practically did not pay attention to this. However, now the number of people who die from bronchial asthma in old age is increasing.
One reason that is particularly challenging is that asthma is often misdiagnosed in adults. If an elderly person begins to suffer from shortness of breath, doctors often consider this a manifestation of age or a consequence of abnormalities in the work of the heart.
In addition, in old age, many people accumulate many other health problems, and this negatively affects the course of asthma. These problems include, first of all, cardiovascular diseases (angina pectoris, arrhythmia, hypertension, etc.) and diseases of the gastrointestinal tract. It aggravates asthma and its own long-term experience, since patients often need to adjust the dose of drugs, monitor pulmonologists, therapists, and cardiologists.
Causes of the disease
Heart failure.
Chronic course of obstructive pulmonary disease.
Acute respiratory diseases.
Pneumonia.
Complications after taking medications.
Systemic vasculitis.
Aging is an inevitable process characterized by the development of functional limitations of the reserves of the body, all its organs and systems, including the respiratory system. With age, a person changes the musculoskeletal frame of the chest, airways, a decrease in the cough reflex occurs, which disrupts the self-cleaning of the airways. Similar changes contribute to the development of chronic diseases of the broncho-pulmonary system.
In the absence of timely and competent treatment of bronchial asthma in old age, as a rule, there is a sharp deterioration in the patient's condition, and complications often arise.
Diagnosis of the disease
To diagnose an elderly patient with bronchial asthma, the doctor needs to pay attention to the following symptoms:
Wheezing;
Frequent cough;
Feeling of tightness in the chest;
Choking attacks.
The specialist should question the patient in detail about the symptoms, try to establish the possible causes of the development of the disease. Often, in older people, bronchial asthma occurs after acute respiratory infections.
An important part of the diagnosis is the increase in forced expiratory volume and expiratory flow rate. At the same time, the doctor should take into account that elderly patients cannot always correctly perform this test the first time, sometimes repeated attempts are required.
In some cases, for the final confirmation of the diagnosis, they resort to cytological analysis of sputum spontaneously secreted or induced by inhalation of a hypertonic solution.
Treatment of the disease
If a person from time to time has a feeling of difficulty breathing and tightness in the chest, wheezing, then regardless of age, he should consult with a specialist. If the person is elderly, it is especially important to see a doctor.
The main task of treating bronchial asthma in old age is to control the symptoms of the disease, as well as maintain normal lung function, prevent side effects of medication, as well as exacerbations.
Treatments for asthma are selected based on the severity of the disease. Older people should be vaccinated against influenza annually, as they are at risk due to age and the presence of bronchial asthma.
Asthma treatment should be rational and as gentle as possible, taking into account the diseases already in the patient. As a rule, this requires additional admission. medicines.
In the early stages of the disease, immunotherapy is effective. However, sometimes there are contraindications, and the older the patient, the higher the likelihood of their occurrence.
Most often, for bronchial asthma, complex therapy is prescribed, which includes anti-inflammatory drugs and bronchospasmolytics. In addition, long-term control of the disease requires the use of long-acting inhaled bb2-adrenergic receptor agonists. And to eliminate or prevent shortness of breath, cough, choking, inhaled b2-agonists of short action are used.
Asthma patients should remember that this disease is not a death sentence. With timely and competent treatment, it can be successfully controlled.
Academician of the Russian Academy of Medical Sciences N.R. Paleev, professor N.K. ChereiskayaMoscow Regional Research Clinical Institute. M. F. Vladimirsky (MONIKI), Moscow
Bronchial asthma (BA) can make its debut in childhood and young age and accompany the patient throughout his life. Less commonly, the disease begins in middle and old age. The older the patient, the more difficult it is to diagnose bronchial asthma, since the clinical manifestations are erased due to a number of features inherent in people of the elderly and old age (age-related morphological and functional changes in the respiratory system, multiple pathological syndromes, blurred and non-specific manifestations of diseases, difficulties in examination patients, depletion of adaptive mechanisms, including the hypothalamic-pituitary-adrenal system).
The course of most diseases in old age is characterized by a rapid deterioration of the condition, the frequent development of complications caused by both the disease and (often) and the treatment carried out in the absence of timely treatment. The choice of drugs for the treatment of bronchial asthma and associated diseases requires a special approach.
The inevitable processes of human aging are accompanied by a limitation of the functional reserves of all organs and systems, including the external respiration apparatus. Changes concern the musculoskeletal skeleton of the chest, airways, pulmonary parenchyma. Involutional processes in elastic fibers, atrophy of the ciliated epithelium, dystrophy of cells of the glandular epithelium with thickening of mucus and a decrease in secretion, weakening of bronchial motility due to atrophy of the muscle layer, a decrease in the cough reflex lead to impaired physiological drainage and self-purification of the bronchi. All this, combined with changes in microcirculation, creates preconditions for the chronic course of inflammatory diseases of the bronchopulmonary system. A decrease in the ventilation capacity of the lungs and gas exchange, as well as discoordination of ventilation-perfusion relations with an increase in the volume of ventilated, but non-perfused alveoli, contribute to the progression of respiratory failure.
In everyday clinical practice, a doctor is faced with two groups of elderly patients with bronchial asthma: those who are suspected of having this disease for the first time, and those who are sick for a long time. In the first case, it is necessary to decide, in particular, whether the clinical picture (cough, shortness of breath, physical signs of bronchial obstruction, etc.) is a manifestation of bronchial asthma. With a previously confirmed diagnosis, complications of long-term bronchial asthma and the consequences of its therapy are possible, as well as concomitant diseases that aggravate the patient's condition or treatment for these diseases. Taking into account age characteristics in patients of both groups, there is a great threat of a rapidly advancing decompensation of all organs and systems in the event of even a mild exacerbation of one of the diseases.
Bronchial asthma that first appeared in the elderly is considered to be the most difficult to diagnose, due to the relative rarity of the onset of the disease at this age, the weariness and nonspecificity of the manifestations, a decrease in the severity of the symptoms of the disease and low requirements for the quality of life in the elderly. The presence of concomitant diseases (primarily of the cardiovascular system), which are often accompanied by a similar clinical picture (shortness of breath, cough, decreased exercise tolerance), also complicates the diagnosis of bronchial asthma. It is also difficult to objectively confirm transient bronchial obstruction in the elderly due to the difficulty in performing diagnostic tests for spirometry and peak flowmetry.
To establish the diagnosis of bronchial asthma in elderly patients greatest value have complaints (cough, usually paroxysmal, asthma attacks and / or wheezing). The doctor should actively question the patient, seeking maximum full description the nature of these manifestations and the probable causes of their occurrence. Often, asthma in the elderly debuts after an acute respiratory infection, pneumonia.
Atopy is not decisive in the occurrence of bronchial asthma in the elderly. At the same time, it is necessary to clarify information about all concomitant diseases of allergic and non-allergic genesis, such as atopic dermatitis, Quincke's edema, recurrent urticaria, eczema, rhinosinusopathy, polyposis of various localization, the presence of bronchial asthma in relatives.
To exclude drug-induced bronchial obstruction, it is necessary to clarify which medications the patient has been taking recently.
Exclusively essential have physical signs of bronchial obstruction and the effectiveness of bronchospasmolytics, which can be assessed directly at the doctor's appointment with the appointment of a b2-agonist (fenoterol, salbutamol) or its combination with an anticholinergic drug (berodual) in the form of inhalation through a nebulizer. In the future, the presence of bronchial obstruction and the degree of its variability are clarified when examining the function of external respiration (spirometry or monitoring the peak expiratory flow rate using peak flowmetry). It is considered diagnostically significant to increase the forced expiratory volume in 1 second by 12% and the peak expiratory flow rate by 15% of the initial values. However, it should be emphasized that elderly patients are far from always able to correctly perform such studies the first time, and a number of patients are generally not able to carry out the recommended breathing maneuvers. In these cases, it is advisable to evaluate the effectiveness of short-term symptomatic (bronchospasmolytics) and prolonged pathogenetic (glucocorticosteroids - GCS) therapy in combination with symptomatic anti-asthma.
The results of skin testing are not of great diagnostic value, since the occurrence of bronchial asthma in the elderly is not associated with specific allergic sensitization. Due to the high risk of complications in elderly patients, provocative drug tests (with obzidan, methacholine) should be avoided.
It should also be remembered that broncho-obstructive syndrome (ie, violation of bronchial patency) can be caused by various reasons: a mechanical obstacle inside the bronchus; compression of the bronchus from the outside; violation of pulmonary hemodynamics due to left ventricular failure, thromboembolism in the pulmonary artery system (Table 1).
Thus, the list of nosological forms and syndromes with which it is necessary to differentiate the newly emerging bronchial asthma in the elderly is quite large.
In old age, the line between bronchial asthma and chronic obstructive pulmonary disease (COPD) is largely blurred. In this case, a trial course of treatment (1-3 weeks) is carried out with GCS at a dose of 30-40 mg / day in terms of prednisone. With bronchial asthma, there is a significant improvement in the patient's well-being and condition, the need for bronchodilators decreases, and the speed indicators of spirometry improve. In the future, the patient is selected for basic therapy, which should be based on inhaled glucocorticoids (ICS).
Certain difficulties arise in the differential diagnosis of bronchial asthma with stenosis of the upper respiratory tract. Stenosis is characterized by stridor breathing, a predominant increase in aerodynamic resistance in the inspiratory phase, changes in the flow-volume loop specific to extrathoracic obstruction. At the same time, there are no clinical, laboratory and instrumental signs of true bronchial obstruction. Timely consultation with an otorhinolaryngologist in such cases is especially important.
Tracheobronchial dyskinesia (or functional expiratory stenosis) of the trachea, a syndrome characterized by pathological extensibility and weakness of the membranous wall of the trachea with its prolapse into the lumen of the trachea and partial or complete overlap (expiratory collapse), can become a common cause of paroxysmal coughing and choking in the elderly. Cough and choking with this syndrome often occur with laughter, loud speech. The discrepancy between complaints and physical data, the lack of effect during trial therapy with bronchospasmolytics and GCS, pathological mobility of the membranous wall of the trachea during tracheoscopy can clarify the diagnosis.
In the differential series, GERD should be considered as the cause of paroxysmal cough and transient bronchial obstruction, especially in the elderly, since this disease, like many others, is associated with age. If there is a suspicion of a connection between cough and bronchospasm with reflux esophagitis, endoscopic examination is indicated, as well as daily pH-metry and esophageal manometry in parallel with monitoring of bronchial patency by the method of peak flowmetry. Adequate treatment GERD can lead to a complete regression or a significant reduction in all its manifestations, including bronchopulmonary.
It should be borne in mind that in bronchial asthma, some medications can affect the functional state of the lower esophageal sphincter. So, one of the side effects of theophylline is relaxation of the lower esophageal sphincter, which naturally aggravates its failure in GERD. Prescribing these drugs to elderly patients with bronchial asthma, especially at night, can increase the nighttime symptoms of bronchial asthma. Other drugs, as well as foods that cause or aggravate gastroesophageal reflux, are presented in table. 2.
It is appropriate to propose several rules that should be followed when clarifying the diagnosis and treatment of elderly people: to doubt more, to carefully examine the patient in the early stages of the disease, to cancel drugs with unwanted side effects, to optimize nutrition if there is a suspicion of reflux-induced cough or bronchial obstruction. According to indications, trial therapy with diuretics is recommended for congestive heart failure, proton pump inhibitors, antacids, prokinetics, etc. with GERD, bronchospasmolytics and GCS with probable bronchial asthma.
In recent years, the number of patients with a combination of chronic respiratory diseases and coronary artery disease has been increasing. In a typical course of ischemic heart disease, history data, physical examination in conjunction with the results instrumental research(ECG, echocardiography - EchoCG, Holter monitoring, etc.) make it possible to diagnose ischemic heart disease in more than 75% of cases, although it is recognized that in patients with bronchial asthma and COPD it is more frequent than in the general population (66.7 and 35 -40%), is atypical, i.e. without angina pectoris. This is especially true for patients with severe bronchial asthma and COPD, when the symptoms of bronchopulmonary disease and their complications determine the clinical picture, leaving coronary heart disease in the shadows. According to our data, with such a combined pathology in 85.4% of patients with coronary artery disease occurs without angina pectoris.
The goal of treating bronchial asthma, regardless of the patient's age, should be the complete elimination or significant reduction of symptoms, the achievement of the best indicators of the function of external respiration, a decrease in the number and severity of exacerbations, optimization of the therapy of the disease itself and its complications, as well as concomitant diseases, and rational use of drugs.
To achieve the best control over the course of bronchial asthma in the elderly, it is important to provide not only the patient, but also (most importantly) his relatives and loved ones with the necessary information about the disease, methods of control at home, the rules for using drugs, especially inhalers. It should be noted that the efficiency educational programs in Asthma schools in the elderly is lower than in patients of young and middle age, due to psychoemotional, behavioral characteristics. Difficulties may arise in regularly attending classes (if the patient is not in the hospital), etc. Therefore, priority is given to individual sessions conducted by both a doctor and nursing staff (if necessary, at home). An elderly patient needs systematic and more careful observation. For the elderly and the elderly, it is necessary to draw up detailed memos on the regimen of taking and dosing drugs, monitor the correctness of the inhalation technique, and evaluate the speed indicators of inspiration. For the elderly, the use of a spacer is especially important.
Immunotherapy (specific hyposensitization) in the elderly and the elderly is practically not carried out, since it is most effective in the early stages of the disease and has certain contraindications, the likelihood of which increases with age.
Most elderly patients with bronchial asthma are shown complex, individually selected basic drug therapy, including anti-inflammatory and bronchospasmolytic drugs. As drugs for long-term control of bronchial asthma, preference should be given to ICS. Long-acting inhaled bb2-adrenergic receptor agonists can be added to the basic therapy in case of high, despite the optimal doses of ICG, the need for short-acting bronchospasmolytics.
Prolonged theophyllines, taking into account the known side effects (arrhythmogenic, gastrointestinal, etc.), have limited use in the elderly. Their appointment is justified in case of insufficient therapy, intolerance of b2-agonists, as well as in patients who prefer oral administration (in the absence of GERD).
Short-acting inhaled b2-agonists are used to relieve or prevent episodes of shortness of breath, choking, or paroxysmal cough in the elderly. If undesirable effects occur (stimulation of the cardiovascular system, tremors of skeletal muscles, etc.), their dose can be reduced by a combination with anticholinergic drugs, which are recognized as alternative bronchodilators for the relief of asthma attacks in the elderly. In the period of exacerbation of bronchial asthma in elderly patients, it is preferable to transfer to the use of bronchospasmolytics through a nebulizer.
Therapy for bronchial asthma in the elderly should be rational (minimizing the amount of drugs without reducing the effectiveness of treatment) and as gentle as possible (excluding drugs that can cause Negative influence on the course of bronchial asthma), taking into account concomitant diseases, as a rule, requiring additional medicines. General principles of management of the elderly suffering from asthma are presented in Table. 3.
When prescribing topical anti-inflammatory therapy to the elderly, it should be borne in mind that all known and most frequently used IGCs have anti-inflammatory activity sufficient for a clinical effect. The success of treatment is mainly determined by the patient's adherence to the doctor's recommendations, the optimal route of drug delivery (inhaler, spacer) and the inhalation technique, which should be convenient and not burdensome for the patient.
The number of patients who strictly follow the doctor's recommendations varies widely (from 20 to 73%). When using conventional metered-dose aerosol inhalers (MDIs), approximately 50% of patients (even more among the elderly) cannot synchronize inhalation with the activation of the inhaler can, as a result of which the effectiveness of treatment decreases. Ineffective use of the inhaler creates conditions under which ICS are used in uncontrolled, more often suboptimal doses, causing systemic side effects mainly associated with an increase in the oropharyngeal fraction of the drug, and also increases the cost of treatment.
It is known that the volume of the respirable fraction is important in both efficacy and safety of treatment; in turn, the distribution of the drug in the respiratory tract is highly dependent on the inhalation device. The use of inspiratory-activated MDIs (Beklazon Eco Light Breathing®) does not require the patient's inhalation to be synchronized and the inhaler activated. In a study by J. Lenney et al. It has been demonstrated that 91% of patients correctly perform the inhalation technique with the inhalation-activated Light Breath® PIM.
Undoubtedly, the inhalation technique, which is simple for the patient, with the help of inhalation-activated PAI Light Breath® promotes an increase in mutual understanding between the doctor and the patient, the implementation of the doctor's recommendations on the treatment regimen and, as a result, more effective treatment of patients with bronchial asthma, especially the elderly. The inspiratory rate when using the inhalation-activated AID (Beklazon Eco Light Breathing® or Salamol Eco Light Breathing®) can be minimal (10 - 25 l / min), which, even with severe bronchial asthma, is under the force of most patients and ensures the delivery of the drug into the respiratory tract, significantly improving the quality of inhalation therapy.
There is no doubt that GCS are the most effective, pathogenetically substantiated means of treating bronchial asthma, and most patients are shown to use them for many years. The frequency of complications of long-term therapy with GCS (Table 4) has been decreasing in recent years due to the predominantly inhalation method of their administration. At the same time, the number of elderly patients with bronchial asthma in our country who receive systemic GCS for a long time is still quite large. Especially relevant in this regard is the problem of osteoporosis - steroid-induced in combination with senile. Timely transfer of patients to ICS therapy, dynamic monitoring of the state of bone tissue (densitometry), drug prevention and treatment of osteoporosis greatly improves the quality of life of patients.
The most common pathology in old age is the pathology of the cardiovascular system, primarily ischemic heart disease and hypertension. General practitioners, cardiologists, pulmonologists quite often have to decide how to treat these conditions in patients with bronchial asthma. Difficulties in combined pathology are due to the increasing risk of iatrogenic effects. The urgency of the problem is emphasized by the fact that certain drugs prescribed for coronary artery disease and hypertension are undesirable or contraindicated in patients with bronchial asthma. Conversely, drugs for the treatment of bronchial asthma can have a negative effect on the cardiovascular system. In the literature, there are conflicting data on the effect of b2-agonists on the myocardium in isolated COPD, as well as in combination with coronary artery disease. In practice, preference is given to drugs with the highest selectivity, in particular albuterol (Salamol Eco Light Respiration®, Ventolin, etc.).
According to most researchers, the selectivity of β2-agonists is dose-dependent. With an increase in the dose of the drug, b1-receptors of the heart are also stimulated. This, in turn, is accompanied by an increase in strength and heart rate, minute and stroke volume. At the same time, b2-agonists are recognized as the most powerful bronchospasmolytics, the most important drugs for the treatment of COPD; with the correct dosage regimen, they do not cause an arrhythmogenic effect and do not aggravate existing cardiac arrhythmias.
A certain group of drugs can induce a cough in patients without COPD, or cause an exacerbation of bronchial asthma or COPD. We are talking about drugs that are most often used in elderly patients. In the treatment of coronary artery disease, hypertension, heart failure, b-blockers, ACE inhibitors are successfully used.
B-blockers in recent years occupy a leading position in the treatment of hypertension. However, due to the blockade of b2-adrenergic receptors, there is a high likelihood of a side effect in the form of bronchospasm, which can pose an immediate threat to life, especially with an already existing bronchial obstruction syndrome, including in patients with bronchial asthma. When prescribing cardioselective b-blockers - such as betoprolol, atenolol, bisoprolol, carvedilol, the likelihood of such a formidable side effect is much lower. However, it is better not to prescribe drugs of this subgroup in the absence of special indications (intolerance or ineffectiveness of other drugs).
One of the most common (up to 30%) side effects during treatment with ACE inhibitors is a persistent dry cough that occurs at different (!) Periods from the start of treatment. The mechanism of the development of cough is associated with the effect of drugs of this group on the synthesis of prostaglandins, as a result of which the activity of the bradykinin system increases. As a rule, after the abolition of ACE inhibitors, the cough disappears. These drugs are not contraindicated in patients with bronchial asthma, however, in about 4% of patients, they can cause an exacerbation of the disease. Careful observation is necessary when taking drugs of this group and their withdrawal in case of the appearance or intensification of cough. In some patients, cough does not occur in response to all drugs in this group, therefore, in some cases, it is possible to replace one drug with another from the same group. In recent years, a new generation of antihypertensive drugs has appeared - angiotensin II receptor antagonists, which are devoid of such a side effect.
It should be borne in mind that intolerance to b-blockers and ACE inhibitors can manifest itself in patients who have been taking them for a long time, during or shortly after an acute respiratory illness, pneumonia.
Currently, out of 7 groups of antihypertensive drugs (b-blockers, diuretics, calcium antagonists, ACE inhibitors, angiotensin II receptor antagonists, b-blockers, central sympotolytics) for the treatment of hypertension in elderly patients with bronchial asthma, first-line drugs are recognized as calcium antagonists ...
Most elderly and old people have diseases of the musculoskeletal system, in which arthralgias become the leading ones, and NSAIDs are the main treatment. In patients with aspirin asthma, these drugs can lead to a severe exacerbation of the disease, up to and including death. In all other cases, when prescribing these drugs, patients must be carefully monitored.
Individual approach to the treatment of hypertension and ischemic heart disease in patients with bronchial asthma suggests:
1.exclusion of some drugs (non-selective b-blockers);
2. careful monitoring of the tolerance of all drugs, especially selective b-blockers (in case of special indications for their appointment), ACE inhibitors, NSAIDs;
3. consistent inclusion of drugs in the treatment regimen when indicated for combination therapy.
Thus, the management of elderly patients with bronchial asthma presupposes the physician's knowledge of a wide range of disciplines of internal medicine, and treatment requires an integrated approach, taking into account all concomitant diseases.
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The prevalence of bronchial asthma (BA) in old and senile age ranges from 1.8 to 14.5% in the population. In most cases, the disease begins in childhood. In a smaller number of patients (4%), symptoms of the disease first appear in the second half of life.
AD in old age has important features currents associated with involutive changes in the respiratory system and morphological features of the disease itself. Elderly patients have a poor quality of life, are hospitalized and die more often than young people. Difficulties in diagnosing asthma are caused by multimorbidity and a decrease in the patient's perception of the symptoms of the disease. In this regard, it is important to study lung function with a test for reversibility of obstruction. AD underdiagnosis is one of the reasons for its inadequate treatment. In the management of patients, their education, taking into account comorbidities, drug interactions and side effects of drugs plays an important role. The article presents the reasons for BA underdiagnosis, the most common reasons respiratory symptoms in elderly patients, diagnostics and treatment of asthma in elderly and senile patients are discussed in detail. Special attention is paid to combination drugs that increase the effectiveness of therapy for severe asthma.
Keywords: bronchial asthma, elderly and senile age, diagnosis and treatment of patients.
For citation: Emelyanov A.V. Features of bronchial asthma in elderly and senile age // BC. 2016. No. 16. P. 1102–1107.
For citation: Emelyanov A.V. Features of bronchial asthma in elderly and senile age // BC. 2016. No. 16. S. 1102-1107
Features of asthma in elderly patients
Emelyanov A.V.
North-Western State Medical University named after I.I Mechnikov, St. Petersburg
The prevalence of bronchial asthma (BA) in elderly and senile patients ranges from 1.8 to 14.5%. In most cases, disease manifestation is observed in childhood. First appearance of symptoms in the second half of life is observed in few patients (4%),
BA in elderly patients has important features associated with involutive changes of the respiratory system and morphological features of the disease. Elderly patients have poorer quality of life, are hospitalized and die more often than young people. BA diagnostic difficulties are caused by multimorbidity and decrease of perception of symptoms. So it is important to assess pulmonary function with test for reversibility of obstruction. BA underdiagnosis is one of the reasons for its inadequate treatment. BA management includes important parts - patients teaching, assessment of comorbidity, drug interactions and side effects. The paper presents reasons for BA underdiagnosis, most common causes of respiratory symptoms in elderly patients, diagnosis and treatment of BA in elderly patients. Special attention is paid to combined preparations, increasing the efficiency of treatment of severe forms.
Key words: bronchial asthma, elderly and senile patients, diagnosis and treatment of patients.
For citation: Emelyanov A.V. Features of asthma in elderly patients // RMJ. 2016. No. 16. P. 1102–1107.
The article highlights the features of the course of bronchial asthma in old and senile age.
Introduction
In various countries of the world, about 300 million people suffer from bronchial asthma (BA). Its prevalence in the elderly (65–74 years) and senile (75 years and older) age ranges from 1.8 to 14.5% in the population. According to our data, in St. Petersburg this disease affects 4.2% of men and 7.8% of women over 60 years old. In most cases, AD begins in childhood or young age (early asthma). Its manifestations may persist in the elderly or disappear. In a smaller number of patients, symptoms of the disease appear in old (~ 3%) and senile (~ 1%) ages (late asthma).
The risk of death in older patients with asthma is higher than in younger patients. Among 250 thousand patients who die annually in the world from AD, people over 65 prevail. As a rule, most of the deaths are due to inadequate long-term asthma treatment and errors in the provision of emergency care when exacerbations develop.
Diagnostics of the bronchial asthma
Diagnosis of asthma arising in old and senile age is often difficult. In more than half of patients, this disease is diagnosed late or not diagnosed at all. Possible reasons for this are shown in Table 1.
Perception of AD symptoms in elderly patients is often diminished. This is probably due to a decrease in their sensitivity of inspiratory (mainly diaphragmatic) proprioceptors to changes in lung volume, chemoreceptors to hypoxia, as well as impaired sensation of increased respiratory load. Paroxysmal shortness of breath, paroxysmal cough, tightness in the chest, wheezing are often perceived by the patient and the attending physician as signs of aging or other diseases (Table 2). More than 60% of patients do not have classic attacks of expiratory suffocation.
It has been shown that almost 75% of elderly patients with BA have at least one concomitant chronic disease. The most common ischemic heart disease (CHD), arterial hypertension, cataracts, osteoporosis, respiratory infections. Concomitant diseases often alter the clinical picture of asthma.
Of great importance for the correct diagnosis is a carefully collected anamnesis of the patient's illness and life. Attention should be paid to the age of the onset of the disease, the reason for the appearance of its first symptoms, the nature of the course, burdened heredity, occupational and allergic history, smoking, taking medications for concomitant diseases (Table 3).
Due to the difficulty of interpreting clinical symptoms when making a diagnosis, the results of an objective examination are of great importance, which make it possible to establish the presence of signs of bronchial obstruction, pulmonary hyperinflation, concomitant diseases and assess their severity.
Mandatory research methods include spirography with a test for the reversibility of obstruction. Signs of impaired bronchial patency are a decrease in the forced expiratory volume in 1 second (FEV1<80% от должного) и соотношения ОФВ1/форсированная жизненная емкость легких (ФЖЕЛ) (менее 70%). Обструкция обратима, если через 15–45 мин после ингаляции бронхолитика наблюдается прирост ОФВ1 на 12% и 200 мл и более по сравнению с исходным .
It has been shown that elderly patients, in comparison with young patients, often have more pronounced bronchial obstruction, its less reversibility after inhalation of a bronchodilator and disturbances at the level of the distal bronchi. In some cases, this complicates the differential diagnosis of asthma and chronic obstructive pulmonary disease (COPD).
To assess the variability of violations of bronchial patency, peak flowmetry is used. Due to a decrease in visual acuity and memory impairment, its implementation by elderly and senile patients may be difficult.
In addition to the reversibility of bronchial obstruction, additional tests for the differential diagnosis of BA and COPD include the determination of the diffusion capacity of the lungs. It has been shown that in patients with COPD, in contrast to patients with asthma, its decrease is observed.
In patients with characteristic clinical symptoms and normal lung function, detection of nonspecific bronchial hyperreactivity (to methacholine, histamine, dosed physical activity, etc.) allows confirming the diagnosis of asthma. At the same time, along with high sensitivity, these tests have an average specificity. It has been shown that bronchial hyperreactivity occurs not only in patients with asthma, but also in healthy people in old age, smokers, patients with COPD and allergic rhinitis. In other words, its presence does not always allow differentiating asthma and other respiratory diseases.
In a population study, it was shown that an objective assessment of lung function when diagnosing asthma is performed in less than 50% of elderly and senile patients. The frequency of its use is reduced to 42.0, 29.0 and 9.5% in patients aged 70–79, 80–89 and 90–99 years, respectively. At the same time, several studies have shown that the vast majority of elderly patients, under the guidance of experienced medical personnel, can perform high-quality and reproducible maneuvers in spirography and assessment of the diffusion capacity of the lungs.
To confirm the diagnosis of asthma, in some cases, cytological analysis of sputum and the concentration of non-invasive markers of inflammation in the exhaled air (nitric oxide, etc.) are used. It was found that sputum eosinophilia (> 2%) and the level of FeNO as a marker of eosinophilic inflammation of the airways have a high sensitivity, but an average specificity. Their increase can be observed not only with asthma, but also with other diseases (for example, with allergic rhinitis). Against, normal values these indicators can be observed in smokers, as well as in patients with non-eosinophilic asthma.
Thus, the results of studies of markers of airway inflammation in the diagnosis of AD should be necessarily compared with clinical data.
It has been shown that the severity of bronchial hyperreactivity to methacholine, the level of FeNO, eosinophils and neutrophils in sputum and blood in BA patients older and younger than 65 years does not differ significantly. Elderly patients were characterized by more pronounced signs of bronchial wall remodeling (according to computed tomography) and signs of dysfunction of the distal bronchi (according to the results of pulse oscillometry and FEF 25–75). It is assumed that these changes are associated with both aging of the lungs and morphological disorders associated with asthma.
Allergic examination of patients is important to assess the role of exogenous allergens in the development of asthma. It has been shown that atopic asthma occurs less frequently in the elderly than in the young. This reflects the age-related involution of the immune system.
At the same time, it has been shown that 50–75% of patients over 65 years of age have hypersensitivity to at least one allergen. The most common sensitization to allergens from house dust mites, cat hair, molds and cockroaches. These data indicate the important role of allergological examination (history, skin tests, determination of allergen-specific immunoglobulin E in the blood, provocative tests) in elderly patients for identifying possible triggers of asthma exacerbations and their elimination.
To diagnose concomitant diseases (see Table 2) in elderly and senile patients, a clinical blood test, an X-ray examination of the chest cavity organs in 2 projections and paranasal sinuses, an electrocardiogram (ECG), and echocardiography, if indicated, should be performed.
The main factors that complicate the diagnosis of asthma in old and senile age are shown in Table 4.
The course of bronchial asthma
The peculiarity of BA in the elderly is that it is more difficult to control. Patients are more likely to seek medical help and have more high risk hospitalization compared with young patients (2 or more times). The disease significantly reduces the quality of life and can be fatal. It is known that about 50% of deaths in asthma are observed in elderly and senile patients. Depression is one of the reasons for the unfavorable course of asthma in this group.
Approximately half of the elderly with asthma, who usually have a history of smoking, have concomitant COPD. Computed tomography of the chest reveals pulmonary emphysema and, in contrast to patients with isolated COPD, more often (52%) hypersensitivity to inhalation allergens and a high level of FeNO are noted.
Treatment of bronchial asthma
The goal of asthma treatment in old age is to achieve and maintain symptom control, normal activity levels (including physical activity), indicators of lung function, prevention of exacerbations and side effects of drugs and mortality.
Education of patients and their families is of great importance. Every patient should have written plan treatment. When meeting with a patient, it is necessary to assess the severity of the symptoms of his illness, asthma control, medications used, and the implementation of recommendations for the elimination of exacerbation triggers. Several studies have shown that inhaler errors increase with age and the perception of correctness decreases with age. In this regard, the assessment of inhalation technique and, if necessary, its correction should be carried out during each visit of elderly patients to the doctor.
Pharmacotherapy involves the use of drugs for the long-term control of asthma and the rapid relief of its symptoms. Stepwise treatment of asthma in old and old age does not differ from that in young people. The elderly are characterized by comorbidities, the need to take several drugs at the same time, and a decrease in cognitive function, which reduces adherence to treatment and increases the number of errors when using inhalers.
In the treatment of elderly patients with asthma, the leading place is given to inhaled glucocorticosteroids (ICS), the sensitivity to which does not decrease with age. These drugs are indicated if the patient uses quick-acting bronchodilators 2 or more times a week.
ICS reduce the severity of asthma symptoms, improve the quality of life of patients, improve bronchial patency and hyperreactivity of the bronchi, prevent the development of exacerbations, and reduce the frequency of hospitalizations and mortality. The most common side effects in elderly patients are hoarseness, oral candidiasis, and less often the esophagus. High doses of ICS can contribute to the progression of osteoporosis present in old age. For prevention, the patient should rinse his mouth with water and eat after each inhalation.
Prevent the development of side effects using large volume spacers and powder inhalers. Patients receiving high doses of ICS are advised to take calcium supplements, vitamin D3 and bisphosphonates for the prevention and treatment of osteoporosis.
An important method of preventing side effects is also the use of the lowest possible dose of ICS. The combination of them with β2-agonists allows to reduce the dose of ICS long acting(LABA): formoterol, salmeterol and vilanterol. The combined use of these drugs in elderly patients with asthma provides effective asthma control, reduces the frequency of hospitalizations and deaths to a greater extent than monotherapy with each of these drugs separately. In recent years, fixed combinations have been created (Table 5). They are more convenient, improve adherence of patients to treatment, and guarantee the intake of ICS together with bronchodilators. Clinical studies, which also included elderly patients, have shown the possibility of using the ICS / Formoterol combination both for maintenance therapy (1-2 inhalations 1-2 times a day) and for relief of asthma symptoms on demand. Such a dosage regimen prevents the development of exacerbations, reduces the total dose of ICS and reduces the cost of treatment.
Caution is needed when using β2-agonists in elderly and senile patients with concomitant diseases of the cardiovascular system. These drugs must be prescribed under the control of blood pressure, pulse rate, ECG ( Q-T interval) and serum potassium concentration, which may decrease.
In recent years, convincing evidence has been obtained that LABA (salmeterol, formoterol, etc.) should be used in BA patients only in combination with ICS.
Antileukotriene drugs (zafirlukast and montelukast) have anti-inflammatory activity. They are inferior to ICS in terms of their effect on asthma symptoms, the frequency of exacerbations and lung function. Some studies have shown that the therapeutic efficacy of zafirlukast decreases with age.
Leukotriene receptor antagonists, although to a lesser extent than LABA, increase the effect of ICS. It has been shown that montelukast, prescribed together with ICS, improves the results of treatment of the elderly with asthma. A distinctive feature of antileukotriene drugs is a good safety profile and high adherence to treatment.
The combination of ICS / antileukotriene receptor antagonists can be an alternative to ICS / LABA in elderly patients with concomitant diseases of the cardiovascular system and a high risk of side effects when LABA is prescribed (cardiac arrhythmias, hypokalemia, prolongation of the Q – T interval on the ECG, etc.) ...
The only long-acting anticholinergic agent for the treatment of severe asthma, currently registered in the Russian Federation, is tiotropium bromide. It has been shown that its appointment in addition to ICS / LABA increases the time to the first exacerbation and has a moderate bronchodilator effect. It has been shown that tiotropium bromide improves lung function parameters and reduces the need for salbutamol in patients with COPD in combination with asthma receiving ICS.
Registration clinical trials included patients 12 years of age and older, including the elderly with concomitant diseases. The good safety profile of the drug indicates the possibility of its use in the treatment of asthma in elderly people.
Omalizumab is a humanized anti-immunoglobulin E monoclonal antibody approved for the treatment of severe atopic AD. Prescribed in addition to ICS / LABA and other therapy, this drug reduces the frequency of exacerbations, hospitalizations and emergency calls, reduces the need for ICS and oral glucocorticoids. The efficacy and safety of omalizumab in people younger and older than 50 years was the same, which indicates the possibility of its use in elderly patients.
Recently reported monoclonal antibodies against interleukin (IL) 5 (mepolizumab and reslizumab) are indicated in the treatment of severe eosinophilic AD. The efficacy and safety of these agents in patients older and younger than 65 years old was similar. The data obtained indicate the potential for their use in elderly and senile patients without additional dose adjustment.
Among the drugs for relieving asthma symptoms in the elderly, inhaled bronchodilators (β2-agonists and short-acting anticholinergics) occupy the main place. Taking tabletted theophyllines and oral β2-agonists (salbutamol, etc.) can lead to the development of side effects (Table 6). Due to the potential toxicity, they should not be prescribed to elderly and senile patients.
With insufficient bronchodilator activity, β 2 -adrenomimetics of rapid action (salbutamol, etc.) are combined with anticholinergics.
The choice of an inhalation dosing device is of great importance in elderly and senile patients. It has been established that the probability of errors in the use of inhalers increases with the age of the patient, with insufficient training and non-compliance with the instructions for use.
Often, due to arthritis, tremors and other neurological disorders in the elderly, coordination problems occur, and they cannot properly use conventional metered-dose aerosol inhalers. In this case, inhalation-activated devices are preferable (for example, turbuhaler, etc.). If the patient is unable to use them, it is possible to use nebulizers for long-term treatment of asthma and its exacerbations at home. It is important that the patient himself and his family members know how to handle them correctly.
Annual influenza vaccination is recommended to prevent respiratory infections and reduce mortality from them.
Unfortunately, the wrong treatment for AD is frequent problem in elderly and senile patients. Several studies have shown that 39% of patients do not receive any therapy and only 21–22% use ICS. Most often, drugs were not prescribed in the group of patients who were observed by general practitioners and family doctors, in contrast to those who were treated by pulmonologists and allergists. Many elderly and senile patients reported problems in communicating with doctors.
Thus, AD is often found in elderly patients and has important features of its course associated with involutive changes in the respiratory system and morphological features of the disease itself. Elderly patients have a poor quality of life, are hospitalized and die more often than young people. Difficulties in detecting AD are caused by multimorbidity and a decrease in patients' perception of the symptoms of the disease. In this regard, it is important to study lung function with a test for reversibility of obstruction. AD underdiagnosis is one of the reasons for inadequate treatment. In the management of patients, their education, consideration of comorbidities, drug interactions and side effects of drugs play an important role.
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