RU2717708C1 - Method of rehabilitation of patients with bronchial asthma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to pulmonology and restorative medicine, and is intended for use in medical rehabilitation of bronchial asthma patients at a health resort treatment stage. Rehabilitation of patients with bronchial asthma involves climatotherapy, therapeutic gymnastics, inhalation therapy, health trails in the open air and breathing exercises. Simultaneously with therapeutic gymnastics directly after inhalations of medicinal preparations, a New breath exercise breathing apparatus is applied additionally to achieve the following effects: increased volume of forced exhalation (FEV1) by at least 4 %, and/or increase of peak volume velocity (PVV) by not less than 8 %, and/or reduction of domain b4402 by at least 0.22 points, at that rehabilitation course 10–12 procedures.

EFFECT: method by recovering respiratory function, increasing pulmonary ventilation, increasing blood oxygenation and normalizing gas exchange enables improving exercise tolerance and increasing control of bronchial asthma.

1 cl, 2 tbl, 2 ex

Description

The method relates to medicine, namely to pulmonology and rehabilitation medicine, and can be used for medical rehabilitation of patients with bronchial asthma at the sanatorium stage.

Bronchial asthma (AD) is one of the most common chronic socially significant diseases, representing a serious medical and socio-economic problem [Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. Updated 2016 // http://www.ginasthma.org.].

Despite the significant success achieved during treatment and rehabilitation measures, AD therapy presents great difficulties, which is associated with the need for a comprehensive and long-term effect and, as a consequence, the development of a number of adverse reactions to medications, which significantly reduces the effectiveness of therapy. The listed disadvantages of drug therapy dictate the need to search for new non-drug effects that have a high pathogenetic orientation of the therapeutic effect and, at the same time, have a smaller spectrum of negative side effects, especially in the presence of irreversible changes in the bronchial tree.

Almost all pulmonological patients need medical rehabilitation [Mukharlyamov F.Yu., Sycheva MG, Rassulova MA, Razumov AN Pulmonary rehabilitation: modern programs and prospects // Pulmonology. 2013. No.6. S. 99-105.]. Conducting medical rehabilitation in the conditions of the climatic resort of the Southern Coast of Crimea (South Coast) increases its effectiveness, helps to lengthen the period of remission and maintain control of the disease.

Sanatorium-resort medical rehabilitation allows you to harmoniously combine both drug and non-drug methods of treatment, which should lead to the achievement of symptom control, long-term and stable remission of AD and the restoration of patient functions.

Traditionally, the complex of sanatorium-medical rehabilitation of patients with asthma includes climatotherapy, respiratory therapy, educational programs, various methods of physiotherapy and physiotherapy. Respiratory therapy includes inhalation of drugs, a variety of breathing exercises, including the use of various breathing simulators. Many models of such devices have been developed. Some of them make it difficult to breathe in atmospheric air with the help of special nasal masks, others are built on the principle of return breathing in small containers or use various gas mixtures.

There is a method of increasing the working capacity of patients with overweight bronchial asthma (Patent No. 2317057, application 2006129393, 08/14/2006). The method allows to increase the working capacity of patients with overweight bronchial asthma. The disadvantage is that for the implementation of the method it is necessary to take into account anthropometric data and the regulation of respiration is practiced in a static position. A significant disadvantage of this method is that it is effective at an early stage of rehabilitation treatment.

There are respiratory training devices designed in such a way that they can be used while walking, running and other exercises. However, such devices were not used in medical and rehabilitation practice in patients with AD.

There is also a known method for the treatment of bronchopulmonary diseases, based on the creation of resistance to exhalation using simulators such as "flutter". The principle of operation of such devices is to create a positive pressure on the exhale due to the rhythmic oscillation of the ball located at the outlet of the duct through which a person exhales with a certain effort. Positive pressure oscillations increase intrabronchial pressure, which reaches peripheral structures and has a broncho-expanding (dilatation) effect. The result of treatment is an improvement in sputum discharge, a decrease in the severity of bronchial obstruction, and an improvement in the well-being of patients. None of the flutter simulators was used during breathing exercises.

As a prototype, a method for the rehabilitation of children with asthma was chosen, which includes a rehabilitation course in breathing exercises using the PARI PEP2 simulator once a day for 4-5 minutes with a course of 10-14 procedures in addition to climatotherapy, diet, and exercise therapy and singlet oxygen therapy (Patent RU 164 286 U1 Method for the rehabilitation of children with bronchial asthma during remission / Tanaga V.A., Kobets T.V. - Application 2016121198/93, 05.27.2016).

Signs that coincide with the main features of the prototype are conducting rehabilitation treatment with the inclusion of non-drug methods of exposure to BA patients against the background of basic therapy and a complex of spa treatment - climatotherapy, diet and physiotherapy exercises.

The signs that limit the achievement of the expected result (increasing the efficiency of rehabilitation of patients with AD, improving the adaptive-compensatory capabilities of the body) is the use of the respiratory simulator "PARI PEP2", only at rest in a sitting position, not using during physical therapy and breathing exercises. The PARI PEP I, II system can be used both as an independent device for physiotherapy, and together with nebulizers (devices for inhalation, with ultra-small dispersed nebulization of drugs). In this method, as a surveyed contingent were children with BA.

The basis of the proposed method is the task of improving the prototype method by using the respiratory muscle simulator in the “New Breath” movement during breathing exercises in patients with AD by improving the function of the respiratory systems, activating metabolic processes, improving the oxygen-transport functions of the blood, and, in general, increasing the effectiveness of medical rehabilitation. It is proposed to evaluate the effectiveness of medical rehabilitation according to the criteria of the "International Classification of Functioning, Disability and Health" (ICF).

To solve the problem, BA patients underwent a course of sanatorium-resort medical rehabilitation, which included climatotherapy, medical gymnastics, inhalations, outdoor health paths, diet and in addition, patients of the main group received a course of respiratory medical gymnastics immediately after inhalation of drugs with a respiratory muscle simulator in the “New Breath” movement until effects are achieved: increase in oxygen saturation not less than 7% or increase in forced volume expiration (FEV1) of not less than 4% or increase of peak volumetric velocity (PIC) of not less than 8% or decrease of domain b4402 by not less than 0.22 points, with a rehabilitation course of 10 procedures, within 20 minutes daily.

The New Breath simulator is designed for respiratory training of athletes. The design of the simulator allows you to adjust the mechanical resistance and carry out low-frequency vibration of the flow of exhaled air and training the respiratory muscles when performing a complex of breathing exercises. This is its fundamental difference from other breathing simulators, the use of which is possible only at rest. The use of the respiratory simulator "New Breath" ensures the achievement of a number of targeted therapeutic and prophylactic effects: the training load on the respiratory muscles increases; the airways remain open in the expiratory phase, preventing the formation of air traps; inhale and exhale deepen; improves the drainage function of the bronchi; sections of the bronchopulmonary system with insufficient aeration are involved in the respiratory act; increased air flow at the end of the expiratory phase and increased lung capacity. The use of the “New Breath” simulator allows dosing of the parameters of the procedure (the intensity of the positive pressure effect at the end of exhalation, the intensity of physical activity, the rate of exercise and their sequence, duration of exercise, pulse rate). Respiratory gymnastics was carried out according to the usual program for AD patients, with the inclusion of special breathing exercises of a static and dynamic nature, maximally affecting the muscles involved in the breathing act, exercises with the pronunciation of certain sounds on the slow expiration to enhance sputum drainage. The problem is solved in that in the method of rehabilitation of patients with asthma simultaneously with therapeutic gymnastics after drugs, the respiratory muscle simulator “New breathing until effects are achieved: increase oxygen saturation by at least 7% or increase the volume of forced expiration (FEV1) not less than 4% or increase in peak volumetric velocity (POS) by no less than 8% or decrease in the b4402 domain by no less than 0.22 points, with a rehabilitation course of 10 procedures for 20 minutes daily. The proposed method allows to achieve high efficiency of medical rehabilitation due to the inclusion in the medical complex of medical respiratory gymnastics with a respiratory muscle simulator in the movement "New Breath", which ensures restoration of respiratory function, increased pulmonary ventilation, increased blood oxygenation, normalized gas exchange and eliminated cardiac vascular system and, as a result, improved tolerance to physical activity and increased control over the course of bronchial asthma.

The method is as follows. Patients with bronchial asthma, upon admission to the sanatorium-resort stage of medical rehabilitation, after a period of acclimatization, a complex including climatotherapy was prescribed, the basic therapy with pharmacological preparations and respiratory therapy, inhalation treatment and physiotherapy exercises, including a set of breathing exercises with a simulator, were adjusted, ” New breath ”, in the course of 10 lessons.

The study of the proposed method was carried out by the applicant in the climatic resort of the Southern coast of Crimea (Department of Pulmonology, GBUZ RK "ANII physical methods of treatment, medical climatology and rehabilitation"). The study involved 76 asthma patients aged 35 to 70 years who received a course of spa medical rehabilitation for 21 days.

The examination of patients included a clinical study, assessment of disease control according to ACT and ACQ questionnaires, laboratory tests (general and biochemical blood tests), functional studies (assessment of external respiration function by a flow-volume curve, electrocardiography, determination of blood saturation), a study of quality of life using a specialized AQLQ questionnaire. A comprehensive assessment of the condition of patients was carried out according to the ICF. The examination of patients was carried out upon admission to the clinic, and after completion of the course of basic treatment, before discharge. After the initial examination, the patients were divided into two groups: a control of 30 patients who were assigned a standard complex of spa treatment and the main group of 46 patients who were additionally prescribed a course of therapeutic breathing exercises with a respiratory muscle trainer in the movement “New Breath” 10-12 treatments.

The results of symptom control tests, laboratory and functional examination methods at admission and at discharge in the main and control groups are presented in table 1.

The table shows that the patients' condition improved after a course of sanatorium-resort medical rehabilitation in both the main and control groups. Significantly increased control over the course of the disease (according to the ACT, ACQ questionnaires), normalized cardiovascular (BH, BP) activity, significantly increased indices of the function of external respiration FEV1 and FVC), and oxygen saturation in the blood SpO2. When comparing the changes in the main and control groups, a statistically significant difference was found, in the main group there were more significant changes in the increase in the ACT questionnaire and a more significant decrease in the ACQ questionnaire, which indicates a more pronounced achievement of asthma control in patients of the main group. Significant differences were found in the indicators of the function of external respiration, FVC, FEV1 increased more in the main group compared with the control. The value of 6MShT (six-minute step test, expressed as a percentage in the main group increased more than in the control, which indicates an increase in exercise tolerance.

It is possible to objectively evaluate the result of medical rehabilitation of asthma patients according to ICF criteria. The following set of domains was used: b4301 - oxygen transport functions of blood, b4303 - coagulation functions of blood, b4402 - functions related to the volume of lung expansion during breathing, b4408 - other respiration functions, specified, b450 additional respiratory functions, b455 - functions of tolerance to physical load, b460 - sensations associated with the functioning of the cardiovascular and respiratory systems, b530 - functions of maintaining body weight.

Table 2 reflects the dynamics of the condition of patients before and after spa treatment for the analyzed domains.

The domain indices b4301 and b4303 describing blood coagulation and oxygen transport functions did not change significantly. At the same time, the parameters of domains characterizing respiratory functions and exercise tolerance statistically significantly changed, and in all patients in both observation groups. With the exception of domain b4402, which includes data on the main indicators of the spirometric study of FEV1 and FVC, its level significantly decreased only in the group of patients with the inclusion of exercises with the New Breath simulator.

Example 1

Patient V., 59 years old, was admitted to the pulmonology department with a diagnosis of persistent asthma, moderate, uncontrolled course, hypertension, stage II stage II, risk II. From the anamnesis it is known that she’s been sick since childhood, had a severe course at the onset of the disease, was undergoing systemic glucocorticosteroid therapy (prednisolone per os) for a long time, and since 2004 she has used long-acting inhaled glucocorticosteroids and beta2-agonists as the basic therapy (Seretide, Zenhale) . Allergic history is burdened - mom and grandmother had urticaria. Suffers from a polyvalent allergy - medication, pollen, household. On admission, she complained of a paroxysmal cough with scanty white sputum, shortness of breath with little physical exertion, the use of salbutamol several times a week, ACT 16 points, ACQ 2.28 points. The examination revealed signs of obstructive syndrome (scattered dry wheezing in the lungs), with spirometry - OFV1 71%, FVC 83%, FEV1 / FVC 0.7, OBO + 3%, overweight (BMI 34.8 kg / m2) in the general blood test - a slightly increased ESR of 18 mm / h, in the biochemical analysis - increased cholesterol - 7.8 mmol / l, β-lipoproteins - 73 units, CRP - 25 mg / l. Other indicators are within normal limits. The patient was prescribed the standard SCR complex (clinical nutrition, climatotherapy - fresh air paths, chest massage, nose cure, pharynx No. 3, 4% soda inhalation, miramistin), the same basic therapy (Zinhale 200/5 mcg). In addition to traditional respiratory gymnastics, a course of respiratory muscle trainers in motion (TDMD) was prescribed. During treatment, the patient's condition improved, shortness of breath, coughing decreased, attacks of labored breathing began to occur much less frequently, she did not practically use salbutamol. ACT 19 points, ACQ 1.42 points. Dry wheezing in the lungs disappeared. Spirometric indices of FEV1 79%, FVC 85%, FV1 / FVC 0.74, OBO + 12%, overweight (BMI 33.9 kg / m2) increased, in the general blood test - ESR decreased to 12 mm / h, in biochemical - increased cholesterol decreased to 6.9 mmol / L, β-lipoproteins to 65 units, CRP to 18 mg / L.

The dynamics of the ICF domains was as follows: b4402 - functions associated with the volume of lung expansion during breathing (includes data from the main indicators of spirometric studies of FEV1 and FVC), the indicator decreased from 1.5 to 1.0 points, b4408 - other breathing functions, specified (includes the frequency of suffocation attacks and the use of BDKD, objective examination indicators - the nature of breathing, characteristics of wheezing in the lungs) the indicator decreased from 1.1 to 0.64 points, b450 additional respiratory functions (the domain describes the main complaints - cough and sputum) spruce decreased from 2.2 to 0.6 points, b455 - functions of exercise tolerance (data of a 6-minute step test and physical activity in the daytime), the indicator decreased from 2.0 to 1.5 points, b460 - sensations associated with the functioning of the cardiovascular and respiratory systems (the degree of dyspnea on physical exertion and complaints of difficulty breathing), the indicator decreased from 1.0 to 0.5 points and b530 - the function of maintaining body weight from 2.0 to 1.5 points.

Example 2

Patient I., 60 years old, was admitted to the department of pulmonology with a diagnosis of Bronchial asthma, persistent, moderate, uncontrolled course. From the anamnesis it is known that she suffers from bronchial asthma from 32 years old, the course of the disease progressed, she received therapy only during exacerbations, for the last 5 years she began to regularly receive basic therapy with Symbicort 80 / 4.5 mcg 2 times a day. On admission, she complained of coughing with sputum in the morning, shortness of breath during active physical exertion (climbing the mountain, brisk walking), daily breathing difficulties, stopped on her own or with the use of salbutamol, asthma control tests ACT 10 points, ACQ 2 points. The examination revealed signs of obstructive syndrome (weakened breathing, single dry rales in the lungs with forced breathing), with spirometry - FEV1 52%, FVC 73%, FEV1 / FVC 0.60, OBO + 40%, in the general analysis of blood - eosinophils 6 %, in biochemical - increased cholesterol - 7.5 mmol / l, β-lipoproteins - 57 units, total bilirubin - 37.4 μmol / l. On the ECG, common changes in the myocardium, incomplete blockade of the right leg of the bundle of His, signs of hypertrophy of the right ventricle. Other indicators are within normal limits. Cytological analysis of sputum - leukocytes up to 50 in the field of view, of which 90% are eosinophils. The patient was prescribed the standard SCR complex (clinical nutrition, climatotherapy - fresh air paths, morning exercises, chest massage, KUV nose, throat No. 3, inhalation of 4% soda, pulmicort 250 mcg, singular 10 mg), basic therapy in the same volume (Symbicort 160 / 4.5 mcg), in addition, the patient was prescribed a course of exercise therapy using a respiratory muscle simulator in the movement "New Breath", 10 procedures.

During treatment, the patient's condition improved, shortness of breath, cough decreased, she did not practically use salbutamol. ACT 20 points, ACQ 1.28 points. Dry wheezing in the lungs disappeared, breathing is better. Spirometric indices of FEV1 71%, FVC 85%, FV1 / FVC 0.71, OBO + 22%, in the general blood test, the eosinophils remained at the same level, in the biochemical analysis, the cholesterol level decreased to 6.9 mmol / l, bilirubin to 15.9 μmol / L. Cytological examination of sputum revealed a decrease in eosinophils to 10%.

The dynamics of the ICF domains was as follows: b4402 - the functions associated with the volume of lung expansion during breathing decreased from 1.5 to 1.0, b4408 - other respiration functions, adjusted from 0.47 to 0.38 points, b450 additional respiratory functions with 1.4 to 1.2 points, b455 - exercise tolerance functions did not change 1.0 before treatment and 1.0 after treatment, b460 - sensations associated with the functioning of the cardiovascular and respiratory systems from 1.0 to 0, 5 points and b4303 - oxygen-transport functions of blood from 2.0 to 1.0 points.

The use of the proposed method can improve physiological functions and reduce the severity of manifestations of bronchial asthma. This is especially important in light of the implementation of the strategy and tactics of prevention, treatment and sanatorium-resort rehabilitation. It also has a positive effect on the functioning parameters of the main physiological systems.

There were no cases of deterioration and the development of negative reactions under the influence of the exposure.

This method allows to achieve high overall effectiveness of medical rehabilitation of patients with AD without causing adverse reactions.

A method of treating AD patients is aimed at improving the effectiveness of rehabilitation treatment of this patient population and can / can be applied in sanatorium-resort and rehabilitation institutions.

Claims (1)

A method of rehabilitation of patients with bronchial asthma, including climatotherapy, therapeutic gymnastics, inhalation therapy, outdoor health path and breathing exercises, characterized in that, simultaneously with therapeutic gymnastics immediately after drug inhalation, the respiratory muscle simulator “New breath” is additionally used in motion until achievement of effects: increase in forced expiratory volume (FEV1) by at least 4%, and / or increase in peak volumetric velocity (POS) by at least 8%, and / and whether the reduction of the B4402 domain is not less than 0.22 points, while / the course is 10-12 procedures.