Bronchial asthma. Stepped therapy for bronchial asthma: principles and nuances of treatment Stepped basic therapy for bronchial asthma

Stepped therapy for bronchial asthma is a set of measures aimed at getting rid of the pathology and minimizing its symptoms. In total, therapy is divided into 5 levels, each of which plays a specific role. The advantage of this treatment is the control of the disease using a minimum of drugs.

Features of stepwise treatment of asthma

The disease can occur at any age and often becomes chronic. It cannot be completely cured, but you can reduce the symptoms and strengthen the patient’s immunity.

The basic principles of therapy include:

• choosing the best treatment regimen, while the doctor listens to the patient’s wishes;
• monitoring the course of the disease, monitoring the patient’s condition;
• adjustment of the course of therapy;
• moving to a higher level with zero therapeutic effect;
• move to a lower level if asthma can be controlled for at least 3 months;
• if the disease is of moderate severity and basic therapy has not been carried out, then the 1st stage is skipped and treatment begins with the 2nd;
• if asthma is uncontrollable, then it is necessary to start therapy from the 3rd stage;
• Emergency medications are used if necessary.

At each stage in the treatment of bronchial asthma, the patient must undergo certain diagnostic procedures in order to stop the manifestations of the disease and prevent the occurrence of complications. It is also necessary to determine the appropriate pharmaceutical drugs, because adverse reactions are likely to occur.

In adults

Since the adult body is more resistant to the active substances in asthma medications, the doctor increases the dosage in accordance with the standards. Of course, during pregnancy or the presence of contraindications, therapy is adjusted.

It is somewhat easier to treat adult patients, since they react to changes in their health and can notify the doctor in time. Moreover, in addition to drug treatment, the patient can be prescribed physiotherapeutic procedures: massages, acupuncture, thermotherapy.

In children

Pediatrics allows children to use drugs for adults. At the first stage of treatment, bronchodilators and short-acting agonists are used. At the second stage, inhaled glucocorticosteroids (ICS) are included in low dosages, but if relief does not come within 3 months, the dose is increased. For acute attacks of bronchial asthma, hormonal drugs are prescribed, but they are not taken for long.

At the third and fourth stages, the dosage of ICS is increased, and adrenergic stimulants are added to the nebulizer solution.

Adults should teach the child how to use the inhaler, since the device must be used regularly.

Five stages of treatment

To prescribe an appropriate course of therapy, the doctor needs to determine the level of disease control using the GINA table. The classification of bronchial asthma divides the disease into 3 types:

• Controlled. The patient experiences attacks a couple of times a week, with no exacerbations or disturbances observed.
• Persistent. Signs of asthma make themselves felt more often than once every couple of days, and they can also appear at any time of the day.
• Heavy. Attacks occur around the clock and quite often. Lung function is impaired and asthma worsens every 7–10 days.

In accordance with the classification, the doctor determines the level of therapy. In this case, emergency treatment drugs are used at any stage.

The patient’s condition is monitored every 3 months, and if exacerbations occur, the frequency is reduced to 1 month. The patient can be transferred to a lower level, but only from levels 2 and 3. At the same time, changes concern the quantity and dosage of drugs, but emergency aid remains unchanged.

It must be remembered that self-medication is prohibited, since only a doctor is competent enough to determine suitable medications. You need to follow the prescription given and monitor your own well-being.

First

Patients with mild asthma fall into this stage. Symptoms are episodic, and exacerbations are quite rare. The respiratory organs are functioning normally.

The main treatment methods at the first stage are as follows:

• It is necessary to avoid irritants and not come into contact with them.
• As a quick way to get rid of symptoms, inhalations of Salbutamol, Fenoterol, and Terbutaline are used.
• Before training or interaction with an allergen, you need to use Cromolyn sodium or short-acting P2-adrenergic agonists.

If symptoms become more severe, the doctor should consider transferring the patient to stage 2 of treatment for bronchial asthma.

Second

The course of the disease is also mild, but the frequency of exacerbations and symptoms increases: more than 1 time per week. The signs are constant, not very pronounced.

In accordance with a stepwise approach, the doctor prescribes the use of anti-inflammatory aerosols. Inhaled corticosteroids or Cromolyn sodium, which comes in powder form for dissolution, are suitable. He also prescribes Ketotifen for oral use.

If a therapeutic effect is not observed, then the dosage of corticosteroids is increased in the absence of contraindications from the patient, and the following medications are also included:

• bronchodilators: Volmax, Salmeterol;
• Theo-Dur, Theotard, Filocontin and other drugs of the 1st and 2nd generation, the main active ingredient of which is theophylline;
• Short-acting β2-adrenergic agonists for inhalation.

If symptoms persist during sleep, the patient is transferred to level 3.

Third

Chronic asthma becomes moderately severe. Symptoms are observed every day, and the patient suffers from night attacks a couple of times a week.

In therapeutic measures, the doctor increases the daily dose of drugs to combat inflammation, however, when increasing the dosage, the patient must be constantly under the supervision of a doctor to avoid adverse reactions.

For nighttime symptoms, the patient is prescribed long-acting Theophylline preparations of the 1st and 2nd generation. P2-agonists also help, giving a prolonged effect. Troventol and Ipratropium Bromide are also used.

Fourth

Asthmatics whose disease has become severe with frequent exacerbations are transferred to this stage. During the day the symptoms are constant, but at night they appear from time to time.

Similar to the previous steps, the doctor increases the dosage of anti-inflammatory drugs. Medicines based on theophylline of the first and second generation of slow release are also used, but the dose of the drugs taken is not increased.

Inhaled and oral P2-adrenergic agonists combat night attacks: Volmax, Formoterol.

Fifth

At this stage, the same drugs are used as at the fourth stage, but the therapy includes systemic hormonal drugs for oral administration. They can relieve symptoms and improve well-being, but have a number of serious negative reactions. Anti-IgE antibodies are also needed in the form of injections administered subcutaneously.

Treatment of bronchial asthma is a complex procedure that requires an integrated and step-by-step approach. Thanks to a standardized method of step-by-step therapy, the patient can significantly alleviate the symptoms of the disease until they almost completely disappear. However, for a successful result, you must strictly follow the doctor’s recommendations and not take the initiative.

Relieving an attack of difficulty breathing. The goal is to achieve complete control of the disease with the help of basic drugs, so that short-acting drugs are used as rarely as possible. Only in this case the disease progresses favorably and has little effect on the patient’s quality of life.
Modern treatment of bronchial asthma depends on its severity, determined before the start of therapy. If the drugs at the selected stage are ineffective, the doctor adds new drugs, thus moving to the next stage. Once the disease has been overcome, a gradual reduction in the intensity of therapy to the optimal option begins.
So, the standards for the treatment of bronchial asthma include the so-called step therapy. At the same time, it is necessary to teach the patient how to use other devices, as well as tell him about the need to remove allergens (them) from the environment.

Treatment of bronchial asthma in adults

With a mild intermittent degree, that is, with rare symptoms and normal spirometry, it is enough for the patient to always have a drug from the group of short-acting β2-agonists (SABA) with him. The simplest example of such a medicine is salbutamol in aerosol form.

Spacer - a convenient device for patients with asthma

If symptoms of the disease occur more than once a week, then it is necessary to prescribe basic therapy, which is used daily. For mild cases of the disease, choose one of the following options:

• glucocorticosteroid hormones in inhalation form (IGCS) are the first choice;
• antileukotriene drug – in case of refusal from inhaled corticosteroids, side effects or contraindications to them.

For moderate severity of the disease (daily symptoms, moderate deterioration in external respiratory function), one of the following options is used:

• low doses of inhaled corticosteroids in combination with long-acting β2-agonists (LAAs);
• monotherapy with inhaled corticosteroids in medium or high dosage;
• combination of a low dose of inhaled corticosteroids with an antileukotriene drug;
• iGCS in combination with long-acting theophyllines.

In case of severe disease, a combination of three drugs is used, and in case of uncontrolled disease, the dosage of inhaled corticosteroids is increased to the maximum possible (2000 mcg per day). In this case, hormonal drugs are additionally prescribed orally in a minimal dosage. In addition, anti-IgE therapy is carried out with the drug Omalizumab.

Treatment of bronchial asthma in children

If a child becomes ill, it is necessary to monitor his height and weight annually and evaluate his height and weight at each visit using a questionnaire. In addition, the correctness of the inhalations is assessed, the compliance of the treatment with the planned one, and parent training is provided.

A nebulizer for children is often produced in the form of a toy.

In case of rare attacks, BACs are used to relieve them. If the need for them occurs more than 3 times a week, or the child begins to wake up at night due to coughing or choking, inhaled corticosteroids are used for continuous use. These drugs are prescribed to children starting with low doses, 1 – 2 times a day, depending on the control of the disease. Leukotriene receptor antagonists become reserve drugs.
If such therapy is ineffective, dietary supplements are added by inhalation, then the dose of inhaled corticosteroids is increased, Omalizumab is added, and low doses of oral prednisolone may be used.
If medications do not help at this stage, you should stop all medications, leaving the minimum dose of inhaled corticosteroids, and refer the child to a specialized hospital to find out the reasons for such a severe course of the disease.
In children under 5 years of age, cromones and the combination of dietary supplements and inhaled corticosteroids are not used.

Treatment of exacerbation of bronchial asthma

In children, treatment of asthma exacerbations in the absence of a normal response to bronchodilators is most often carried out in a hospital. A SABA and ipratropium bromide are given initially, either using a metered-dose inhaler and spacer or via a nebulizer. If the child is at home, and repeated inhalations of salbutamol up to 10 breaths do not have an effect, you should urgently call an ambulance. While waiting, a child older than 6 months can be inhaled with budesonide through a nebulizer.
Children with severe exacerbation are hospitalized. In the hospital, dietary supplements are usually discontinued, oxygen therapy is established if necessary, and prednisolone is administered orally for 3 to 14 days.
If inhalation therapy is ineffective, an intravenous infusion of salbutamol and then aminophylline is performed. The level of potassium in the blood must be monitored, since high doses of β2-agonists lead to the development of hypokalemia.
can be prescribed only for proven respiratory tract infection.
Adults with a severe asthma attack are not always hospitalized. If their respiratory function improves significantly after initial therapy, they can be released from the hospital emergency department to go home.
Treatment for exacerbations includes oxygen therapy, BAKA via nebulizer, ipratropium bromide, and oral prednisolone. In case of an intractable attack, the patient is transferred to the intensive care unit, where he is connected to a ventilator.

Treatment of severe asthma

Severe bronchial asthma is often combined with insufficient control. The therapy uses stage 4 or 5 - high doses of inhaled corticosteroids, BAKD via nebulizer, ipratropium bromide, extended-release theophyllines (theotard and others).

The partnership between doctor and patient is important

At the same time, such a patient should be examined by a therapist and other specialists to find the cause of the severe course of the disease. The patient should be taught the technique of performing inhalations and checked whether he performs them correctly. It is necessary to examine the patient frequently enough so as not to miss the deterioration of the condition requiring hospitalization.
A patient with a severe illness often requires the help of a psychologist. In any case, a trusting relationship must be established between the patient and his attending physician in order to avoid the patient withholding some important information (for example, refusing treatment for personal reasons, and so on).
In severe cases, the issue of prescribing oral glucocorticosteroids is always considered. Sometimes the benefits of using them outweigh the possible side effects. Such prescriptions should always be discussed with the patient.
So, the only method that has proven its effectiveness is drug therapy. Without daily use of basic anti-inflammatory drugs, the patient experiences more frequent exacerbations, increased respiratory failure, and complications of the disease.

Video on the topic “Treatment of bronchial asthma at different stages”

Stepped therapy for bronchial asthma is recognized as the most effective method of treatment and meets the approved international standard of therapeutic measures aimed at maintaining an adequate standard of living for patients. Bronchial asthma is one of the incurable diseases, and the main goal of treatment is to stop the development of asthma attacks, prevent the occurrence of status asthmaticus and severe complications of respiratory dysfunction. The range of prescribed drugs and the stages of bronchial asthma are closely interrelated. The peculiarity of step therapy is the long-term use of certain medications selected by the attending physician based on a detailed examination and determination of the current severity of bronchial asthma (BA).

In order for step-by-step therapy of bronchial asthma to achieve a positive result and significant improvement in the patient’s condition, it is necessary to accurately determine the severity of asthma development or the so-called stage of its development.

1. Clinical manifestations include a specified number of asthma attacks occurring during night sleep over a period of 7 days. The number of daily attacks that occurred during each day and the entire week is counted. Through constant observation, it is determined how significantly sleep is disturbed and whether there is a disruption in the patient’s physical activity.
2. Objective. FEV 1 (forced expiratory volume in 1 second) and PEF (peak expiratory flow) and their changes over 24 hours.
3. Medicines that help maintain the patient’s condition at the proper level.

The prescription and treatment of bronchial asthma in stages depends on the severity of the disease. To select the best-quality therapy, a table has been developed and compiled, with the help of which it is easier to determine the level of development of the disease.

1. Mild or episodic form of bronchial damage – stage 1. Harsh wheezing is rare. Perhaps once every three days, and at night, suffocation occurs once every 14 days.
2. 2 – nocturnal attacks 2-3 times a month, PEF fluctuations increase.
3. 3 – development of persistent BA. The condition is characterized as moderate.
4. 4 – severe form of persistent bronchial asthma. The quality of life is significantly reduced, the patient’s sleep is disturbed, and his physical activity is reduced.

The examination, measurement of FEV 1 and PEF make it possible to determine the severity of the disease and begin step-by-step therapy.

A condition such as status asthmaticus deserves special attention when choosing a treatment method and prescribing the most effective drugs. It is very dangerous not only for general health, but also for the life of the patient.

• anaphylactic – rapid;
• metabolic – gradual.

The danger of status asthmaticus lies in the fact that in the absence of timely, high-quality medical care, the patient’s life is threatened. The attack does not stop within several hours, despite the administration of strong anti-asthmatic drugs. As a result, a complete absence of bronchial conduction may develop.

The peculiarity of asthma is that this disease cannot be cured and accompanies the patient throughout his life, and the developed set of steps for the treatment of bronchial asthma makes it possible to keep the patient’s condition under control. With the help of step therapy, the attending physician is able to maintain the health of his patient at the proper level thanks to the scheme developed by the International Committee of the Global Strategy for the Treatment and Prevention of AD. A table compiled by experts will help you understand exactly how the quantity and quality of medications are determined depending on the severity of the disease.

In total, there are 5 stages of asthma treatment, and the first contains the minimum amount of drugs used.

1. The first is the use of bronchodilators, but doctors recommend doing this no more than once a day. Prescription of more effective medications is not required.

   The transition to the next level is carried out if there is no effect from the treatment and the dose of drugs needs to be increased.

2. The second part of therapy involves daily therapeutic activities. We are talking about the use of drugs introduced into the patient’s body by inhalation. At this stage, the use of glucocorticoids is permitted as a means of preventing the development of relapse of the disease.
3. Third, in addition to glucocorticoids and other inhaled drugs, patients are prescribed anti-inflammatory drugs. The dosage of substances increases noticeably. Reception is carried out daily, sometimes several times a day.
4. The fourth is therapy for severe bronchial asthma. Treatment is carried out in a hospital setting under the constant supervision of medical workers. This stage involves taking several medications (complex treatment), which is carried out daily.
5. Fifth - therapy for the most severe stage of the disease, carried out strictly in a hospital setting. Medications are taken multiple times, treatment is long-term, the use of inhalations is mandatory while taking anti-inflammatory drugs and antispasmodics.

If therapeutic measures at a certain stage have proven to be very effective, and the disease has been in remission for three months, a transition to a lower stage is possible.

The attending physician can change the treatment tactics if, as a result of the therapy, a positive effect was achieved and the disease went into remission at least three months ago. This allows for a transition to a softer, gentle treatment.

It is only possible to make a transition from the two lower steps if the patient took hormonal medications during the course of therapy.

The decision about the possibility of making the transition can only be made after a detailed examination carried out in a hospital setting. After completing the course of therapy, the doctor adjusts the medication intake, but he will only be able to decide to switch to another stage of therapy if remission lasts from three to six months.

1. Against the background of changing the use of medications, it is first necessary to take care of high-quality and effective prevention of the disease.
2. Reducing the dose and changing the method and regimen of taking medications is carried out under the strict supervision of the attending physician.
3. The slightest changes in the condition of a small patient should be reported to the attending physician immediately.

If the patient’s condition has stabilized, then a transition to a lower level of therapy is possible, which can be done under the supervision of physicians and very smoothly, gradually changing the doses of certain drugs (medicines) taken.

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Bronchial asthma is a serious disease that requires careful selection of treatment. In this case, the doctor takes into account the presence of suffocation, attacks, the severity and course of the disease. Stepped therapy for bronchial asthma allows you to take into account these aspects, as well as other associated health problems.

Bronchial asthma can occur in different ways. Regardless of the severity of the disease and what symptoms it manifests itself, it is classified as a disease of the respiratory system. Asthma is characterized by some symptoms of obstructive bronchitis and bronchial hyperactivity syndrome.

Depending on the stage of the disease, its severity varies. This is what influences the choice of therapy. A stepwise approach to treatment allows you to control the course of the disease.

For this method, a minimum dosage of drugs is used, increasing in cases of worsening the severity of the disease. If there is an improvement in the patient's condition and changes in treatment, the dose of drugs is reduced.

The stepwise therapy method helps control relapses of the disease and eliminates the factors that provoke them. This treatment is based on the use of anti-inflammatory medications. If the form of the disease is initial, attacks are sporadic, then nedocromil sodium or sodium cromoglycate is used. In more severe cases, a beta-2 agonist inhaler is used.

Treatment of the disease occurs on an outpatient basis. Most often it does not reach hospital treatment. The only exception is the critical condition of the patient.

The main principles of this technique include:

• timely adjustment of therapy - dosage, medications, etc.;
• choosing the most appropriate drugs with the participation of the patient himself, as well as, if necessary, his relatives;
• constant monitoring of the patient’s condition and the course of the disease;
• if there is no visible effect or the patient’s condition worsens, move to a higher level of therapy;
• if the patient’s condition improves, remission is observed, the dosage is reduced, and a transition to a lower level of therapy;
• in the middle stage of the disease, treatment begins with the second stage of therapy - the basis;
• if the disease has not been observed and controlled previously, then therapy is started from the third stage;
• if necessary (attacks, suffocation) emergency medications are prescribed.

Each stage of therapy involves individual selection of medications, regular diagnosis of the condition, and a certain degree of control over the course of the disease.

Five steps of therapy

Treatment is selected according to the stage of the disease being diagnosed. If an exacerbation occurs unexpectedly, then prednisolone is included in complex therapy.

Depending on the severity of bronchial asthma, five stages of therapy are divided.

First stage

The first stage of therapy corresponds to the mildest stage of the disease. In this case, the use of heavy medications is not required. In some cases, it is recommended to take bronchodilators several times a day before attacks. These include Fenoterol, Salbutamol. In cases where the symptoms have increased and an increase in dosage is required, proceed to the next stage of treatment.

Second stage

At this stage, daily therapeutic effects occur. There is a daily intake of agonist-2-adrenergic receptors, antileukotrienes. Inhalers are also recommended for daily use. In case of relapses, therapy is supplemented with glucocorticoids. They prevent the patient’s condition from worsening, which is why they are prescribed at the beginning of the stage.

Third stage

In this case, basic therapy is used. Anti-inflammatory drugs and glucocorticoids are also used by inhalation. It is also possible to use Salmeterol or another analogue of a beta-adrenergic agonist for a long-term effect.

Fourth stage

This treatment tactic is used for severe disease. The dosage of glucocorticoids is quite high and is combined with bronchodilators. They are taken daily. In addition, the following may be prescribed: Theophylline, Prednisolone, Ipratropium bromide, Methylprednisolone. Since the dosages of medications are high, they are taken strictly under the supervision of a doctor.

Fifth stage

This stage is characterized by long and severe therapy. Short-acting glucocorticoid inhalations and long-acting bronchodilator inhalers are used. Without canceling the inhalation effects, Prednisolone is also taken regularly.

The nuances of moving one step lower

Each time you move to a lower level in this treatment regimen, a full medical examination is required. It includes a medical examination and a number of laboratory tests that will help assess the patient’s condition. If the patient is in remission for more than 3 months, then the level of therapy is reduced.

If treatment is started from stage 4 or 5, as well as when taking steroid hormonal drugs, a decrease in the degree of therapy may occur earlier. But at the same time, the patient must undergo stable therapy.

Features of stepwise treatment in childhood

A spencer is used to administer medications to a child. This device helps to spray the medicine more fully. In extremely severe cases, adrenergic stimulants in the form of inhalations or bronchodilators can be used. In order to prevent the occurrence of attacks, that is, as preventive measures, therapeutic actions must be carried out daily according to the regimen prescribed by the doctor.

In some cases, medications are prescribed in powder or liquid form.

The main initial goal in the treatment of bronchial asthma in children is to eliminate symptoms. For this, Prednisolone is used for 4-5 days.

In this case, you need to carefully monitor the dosage. Its increase can only occur as prescribed by a doctor if there is a visible deterioration in the condition of the small patient.

In cases where a child has severe or moderate bronchial asthma, small doses of glucocorticoids are prescribed in short courses. If attacks occur, it is recommended to inhale adrenergic stimulants through a nebulizer.

When the disease progresses to a mild form, quarterly diagnosis of the condition is required. To do this, every 3-4 months the patient must undergo a medical examination, based on the results of which the attending physician adjusts the dosage of medications. In cases of remission within 3 months, the patient is transferred to a lower level of therapy. A similar stepwise therapy strategy is carried out until remission or a stable good condition is achieved. In this case, you can completely stop taking medications, but only after consulting with your doctor. The only exception to this is preventive measures during seasonal exacerbations. During these periods, it is recommended to take sodium cromoglycate.

Also, for mild forms of the disease, the doctor may prescribe immunomodulators. They are offered to small specialists who have experienced a period of remission of more than 1 year.

Currently, the ability to control the disease and improve the patient's quality of life are the main goals of treatment for bronchial asthma. This can be achieved by performing the following tasks:

1. elimination (elimination) or reduction of the impact of trigger factors on the body;
2. carrying out planned (basic) pharmacotherapy in a stable condition of the patient;
3. carrying out emergency pharmacotherapy during exacerbation of the disease;
4. using specific hyposensitization or immune therapy.

Completing the first and fourth tasks is especially important for the treatment of the allergic form of bronchial asthma. After all, if the main allergens and irritants that provoke exacerbations are removed from the patient’s environment, it will be possible to prevent the onset of symptoms of the disease and achieve long-term remission. Therefore, maximum efforts should be made to identify triggers - factors that cause exacerbation of the disease, primarily allergens. If you are allergic to pet hair, you need to remove these animals from the house or at least keep them out of the bedroom and wash them daily. If you are allergic to house dust and cockroaches, you should thoroughly and regularly clean the room and get rid of cockroaches. For frequent acute respiratory viral infections that aggravate the course of the disease, annual influenza vaccination and prophylactic administration of interferon locally to the nasal mucosa are necessary.

WORKING CLASSIFICATION OF THE DISEASE COURSE, BASIC TREATMENT
Currently, the pharmacotherapy of bronchial asthma is based on the recommendations of the International Consensus on Asthma (GINA, 2003), reflecting the general opinion of a working group of experts from WHO, the European Respiratory Society and the National Heart, Lung and Blood Institute (USA). The goals of long-term management of bronchial asthma, which are declared in international agreements (GINA, 2003), are:

1. achieving and maintaining symptom control;
2. prevention and effective elimination of exacerbations;
3. correction of pulmonary ventilation disorders and maintaining it at a normal level;
4. achieving a normal level of activity for patients, including physical activity;
5. elimination of side effects of disease therapy;
6. prevention of the development of irreversible bronchial obstruction;
7. preventing death from asthma.

In accordance with these recommendations, for the treatment of bronchial asthma, regardless of the causes that caused the disease, two groups of medications should be used: long-term anti-inflammatory therapy that ensures control of the disease (the so-called basic therapy), and symptomatic emergency therapy aimed at rapid elimination or reduction of acute symptoms.
Basic therapy includes drugs that act on certain pathogenetic links of the inflammatory process in the bronchi, reducing its clinical manifestations and preventing the progression of the disease as a whole. The optimal therapy is one that allows simultaneously influencing both main pathogenetic mechanisms of the disease - inflammation and dysfunction of bronchial smooth muscles. Medicines are used daily over a long period of time. These include inhaled and systemic corticosteroids, which are the most effective controllers of inflammation, as well as cromones (sodium cromoglycate and nedocromil sodium) and leukotriene modifiers. To some extent, prolonged forms of two groups of drugs - theophyllines and β2-agonists - have a moderate anti-inflammatory effect. The persistent bronchodilator effect of long-acting β2-agonists, which include salmeterol, is based on a fairly strong membrane-stabilizing effect.
The results of recent studies have shown that the goal of modern basic therapy is to achieve complete control not only over the symptoms of the disease, but also over its other signs. In contrast to previously accepted criteria, the following are considered signs of achieving control over the course of the disease:

1. absence or minimal manifestations of chronic symptoms, including nighttime ones;
2. no exacerbations or emergency calls;
3. minimal or no need for short-acting β2-agonists;
4. no signs of decreased patient activity, including physical activity, due to asthma symptoms;
5. daily variability of POS is less than 20%;
6. achieving the best FEV1 or POSV value for a particular patient, which should be close to normal;
7. absence of unwanted side effects that force changes in basic therapy.

Emergency treatment includes drugs that quickly eliminate or reduce bronchospasm - short-acting β2-agonists, anticholinergic drugs, short-acting theophyllines.
Medications can be administered into the body by inhalation, oral, rectal and injection routes. Preference is given to the inhalation route, since it is this method of administration that ensures the creation of high therapeutic concentrations of drugs directly in the target organ with a minimum of systemic side effects. Currently, two dosage forms are used for this - aerosol metered dose inhalers (MDI) and dry powder inhalers (DPI), which come in different technical designs. Most often, these are gelatin capsules containing a single dose of the active substance in powder form, complete with a special delivery device (HandyHeiler type), which ensures that the medicine is administered into the bronchi by the patient’s inhalation force. Recently, an improved device has appeared - a special inhaler containing a certain number of single doses of the active substance in the form of a powder (Discus type), the use of which, during the patient’s inhalation, ensures the introduction of one therapeutic dose of the drug into the bronchi. It is recommended to use aerosol metered dose inhalers in conjunction with a spacer - a special device that improves the procedure for delivering medication directly to the lower respiratory tract without the need for strict coordination of inhalation and pressing the valve of the aerosol metered dose inhaler.
Doctors and patients should be aware that the success of treatment depends on how adequately the inhalation device is selected, how correctly the patient has mastered the inhalation technique, and therefore, how accurately he receives the dose of medication prescribed by the doctor. Widely known studies have shown that patients accurately perform inhalations in 23-43% of cases when using an aerosol metered dose inhaler, in 53-59% of cases when using dry powder inhalers, and in 55-57% of cases when using aerosol metered dose inhalers. inhalers together with a spacer. Therefore, medical personnel need to train patients in the correct inhalation technique.
The International Consensus on Asthma (2003) recommended that doctors in their practical work use the developed classification of bronchial asthma, which is based on determining the severity of the disease, taking into account the clinical manifestations and indicators of pulmonary ventilation at different stages of the disease (Table 11). The classification clearly regulates the amount of basic therapy required for one or another severity of the disease.
The approach to the selection of basic therapy drugs is unified and is applied to all clinical forms of bronchial asthma (allergic and non-allergic). Before prescribing treatment, the doctor assesses the frequency, strength and duration of asthma attacks, the patient’s condition during the interictal period, the variability and reversibility of functional disorders of bronchial obstruction. Assessment of functional indicators to determine the severity of the disease is carried out during the absence of episodes of expiratory dyspnea.

In accordance with this classification, intermittent and persistent courses of bronchial asthma are distinguished. The intermittent (episodic) course is characterized by the absence of constant symptoms of the disease and the presence of irregular attacks of suffocation or their clinical equivalents less than once a week, mainly after contact with an allergen. However, there are often long asymptomatic periods. This course of the disease is conventionally called stage No. 1. The persistent course is characterized by the presence of constant symptoms in the form of attacks of suffocation or their clinical equivalents once a week or more often. Depending on the frequency of symptoms of the disease, the degree of limitation of physical activity, and indicators of bronchial obstruction, the persistent course of asthma can be mild (step No. 2), moderate (step No. 3) and severe (step No. 4). If there are simultaneous presence of signs inherent in various stages of the disease, the patient is assigned to the highest stage at which any of the existing symptoms occurs. As the patient's condition changes, it is possible to move to a higher or lower level with a corresponding revision of the treatment.
If at any of the classification levels a good therapeutic effect is obtained and complete control of the disease is achieved, which persists for at least 3 months, you can carefully move to a lower level in the classification, i.e., slightly weaken the therapy. In a situation where the control of symptoms and functional disorders in the patient is insufficient, one should move to a higher level and intensify therapy. However, you should first check whether the patient followed all the doctor’s instructions correctly. It is necessary to teach the patient to monitor his health, perform peak flowmetry independently, and inform the doctor about the early symptoms of an exacerbation.

At stage No. 1 (intermittent bronchial asthma), short-acting β2-agonists are most often used occasionally when symptoms of the disease occur. Prophylactic use of cromones or short-acting leukotriene modifiers and/or β2-agonists is advisable before possible but inevitable exposure to an allergen or before physical activity.
Of the short-acting β2-agonists, two drugs are prescribed - salbutamol and fenoterol. In this case, the “gold standard” is salbutamol, which has the highest selectivity coefficient for β2-adrenergic receptors. It is believed that the higher this selectivity index, the less likely it is to develop unwanted side effects of β1-adrenergic receptor stimulation. These drugs are available in the form of aerosol metered-dose inhalers, one single dose of which contains 100 or 200 mcg of active substance. The drugs are used in a dose of 1-2 inhalations at a time to relieve acute symptoms. Their action begins a few minutes after inhalation and lasts about 4-6 hours. Currently, dry powder forms of these drugs (DPI) have appeared, as well as solutions for nebulizer inhalation therapy - nebulas.
Cromones are both preventive and basic anti-inflammatory therapy. The basis of their pharmacological action is the stabilization of the membranes of mast cells and basophils, preventing the process of degranulation. The use of cromones is effective in the early stages of bronchial asthma, mainly of the allergic form. However, these drugs do not sufficiently affect bronchial hyperreactivity and in some cases cannot completely control the course of the disease, starting from step No. 2. It is advisable to use them to prevent the development of an attack of suffocation before expected contact with an allergen or before physical activity.
Sodium cromoglycate is available in two dosage forms: as a powder in capsules containing 20 mg of the substance, along with a delivery device - spinhaler, as well as in the form of an aerosol metered-dose inhaler, a single dose of which contains 5 mg of the active substance. For the purpose of prevention, 10-20 mg of the drug is prescribed, and if contact with the allergen continues, the drug is inhaled in a similar dose 4 times a day until contact ceases.
Nedocromil sodium The anti-inflammatory effect is several times greater than the effect of sodium cromoglycate. It is believed that a daily dose (8 mg) of nedocromil sodium is equivalent in strength to its anti-inflammatory effect to a dose of 400 mcg of the reference inhaled corticosteroid, beclomethasone. However, the use of nedocromil sodium is effective mainly in children and young people with manifestations of allergic bronchial asthma, as well as in the treatment of hay fever with asthmatic syndrome or occupational asthma. The medicinal form of the drug is an aerosol metered dose inhaler, a single dose of which contains 2 mg of the active substance. The bioavailability of the drug is low, side effects are observed very rarely in the form of nausea, headache, reflex cough. The prophylactic dose is 4 mg. If contact with the allergen continues, the drug is inhaled in the same dose 2-4 times a day until contact stops.
At stage No. 2 (persistent asthma, mild course), constant basic therapy is prescribed. In most cases, preference is given to inhaled corticosteroids in a daily dose of 200-500 mcg of beclomethasone or an equivalent dose of another drug. At this stage, the appropriate daily dose of fluticasone is 100-250 mcg, and mometasone is 200 mcg.
In children and young people with an allergic form of the disease, it is advisable to begin treatment with the appointment of cromones. Most often, nedocromil sodium is used in a daily dose of 16 mg - 2 puffs 4 times a day until a clinical effect is achieved. Then the dose is reduced to 2 breaths 2 times a day. If cromones are ineffective, they switch to treatment with inhaled corticosteroids.

Inhaled corticosteroids have the widest range of immunomodulatory, anti-inflammatory and antiallergic properties. The inhalation route of administration creates a high therapeutic concentration in the bronchi with a minimum of systemic side effects. The possibility of side effects is determined by the dose of the drug and its bioavailability. When using inhaled corticosteroids in a daily dose of less than 1000 mcg, clinical systemic side effects are usually not observed.
The lowest bioavailability among inhaled corticosteroids is found in mometasone furoate with the Twistheiler delivery device and fluticasone propionate with the Discus delivery device. This determines their lowest systemic impact and the fewest side effects.
Of all inhaled corticosteroids, fluticasone and mometasone have the highest tropism (the ability to bind to tissues) to the bronchi, which ensures selectivity and prolongation of their action. It is believed that the activity and strength of the anti-inflammatory effect of fluticasone is twice as great as that of the standard inhaled corticosteroid, beclomethasone. Fluticasone is used 2 times a day in adults and children, starting from the first year of life. The ease of use of the drug is determined by the presence of its various medicinal forms - a metered-dose aerosol inhaler, a dry powder Discus inhaler, a solution for nebulizer therapy.
Compared to other inhaled corticosteroids, mometasone furoate has the highest affinity for glucocorticosteroid receptors and is the most powerful activator of anti-inflammatory gene transcription. Therefore, it can be used once a day. Its dose is approximately equivalent to that of fluticasone. However, mometasone is an order of magnitude more active than fluticasone in stimulating progesterone receptors, which raises the possibility of additional side effects, especially in women of childbearing age.

A new approach in inhalation therapy, taking into account environmental requirements for the propellant, is the use of hydrofluoroalkane-containing (HFA) aerosol metered-dose inhalers instead of chlorofluorocarbon-containing (CFC) drugs. Due to the smaller particle size of the new drug and the corresponding higher accumulation in the lungs, it is possible to achieve control of asthma symptoms with the use of half doses of inhaled corticosteroids. Thus, switching patients from chlorofluoro-carbon-containing beclomethasone dipropionate to hydrofluoroalkane-containing beclomethasone dipropionate allows the inhalation dose of the drug to be halved.
Long-term use of inhaled corticosteroids can lead to local side effects: candidiasis of the oral mucosa and pharynx, hoarseness or aphonia. Only thorough rinsing of the mouth and throat after inhalation of the drug prevents the occurrence of these complications, and the use of spacers and dry powder forms reduces their frequency.
In case of insufficient clinical effect of basic treatment and incomplete control of the course of the disease at this stage, instead of increasing the dose of inhaled GCS, additionally prescribed