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40АЛЛЕРГИЧЕСКИЙ РИНИТ И БРОНХИАЛЬНАЯ АСТМА (обзор иностранной литературы)
Гуртовая М.Н.
ФГБОУ ВО «ТюмГМУМинздрава России», г. Тюмень
Прокопьев Н.Я.
ФГАОУ ВО «Тюменский государственный университет», г. Тюмень
Дуров А.М.
ФГАОУ ВО «Тюменский государственный университет», г. Тюмень
Губин Д.Г.
ФГБОУ ВО «ТюмГМУ Минздрава России», г. Тюмень
Назмутдинова В.И.
ФГАОУ ВО «Тюменский государственный университет», г. Тюмень
Фетисова Е.В.
ФГБОУ ВО «ТюмГМУ Минздрава России», г. Тюмень
ALLERGIC RHINITIS AND BRONCHIAL ASTHMA (Review of scientific foreign literature)
Gurtovaya M.N.
Prokopiev N. Ya. Durov A.M. Gubin D.G.
Nazmutdinova V.I.
Fetisova E. V.
АННОТАЦИЯ
В статье приводится обзор 295 источников иностранной литературы, отражающий современные взгляды на общее и различие аллергического ринита (АР) и бронхиальной астмы (БА) у взрослых и детей. Рассматриваются частота заболеваний и причины их возникновения в различных странах мира. Представлены возможные факторы риска появления АР и БА. Обсуждаются вопросы клинического применение и механизма действия различных лекарственных препаратов. Анализируются методы лечения и качество жизни больных АР и БА.
ABSTRACT
The article provides an overview of the 295 sources of scientific foreign literature reflecting modern views on the common and difference of allergic rhinitis (AR) and bronchial asthma (BA) of adults and children. It is presented the frequency of diseases and their causes in different countries, possible risk factors of AR and BA' emergence. It is discussed the problems of clinical use and mechanism of various drugs action. It is analyzed the methods of treatment and quality of life of patients with AR and BA.
Ключевые слова: аллергический ринит, бронхиальная астма.
Keywords: allergic rhinitis, bronchial asthma.
Аллергический ринит и бронхиальная астма -два наиболее часто встречающихся хронических аллергических заболевания у детей и взрослых. Проблема увеличивающегося распространения аллергических заболеваний и АР в частности и БА настолько масштабна, что было создано ряд обществ по их изучению: Международное Исследование Астмы и Аллергии у детей (ISAAC), Европейское Сообщество Обследование состояния здоровья (CCASHH), Международное Общество по изучению Зуда (International Forum for the Study of Itch), Всемирная Организация по Аллергии (WAO), Американская Академия Аллергии, Астмы и Иммунологии (AAAAI), Британское общество по аллергии и клинической иммунологии. Кроме того, была предложена классификация ARIA (аллергический
ринит и его влияния на астму - Allergic Rhinitis and its Impact on Asthma) [221].
На страницах специальной медицинской литературы регулярно проводятся систематические обзоры и анализы, касающиеся клиники, диагностики и лечения АР и БА [112, 257, 271, 286].
Знание анатомии и физиологии носа важно для того, чтобы понять АР. Три раковины каждой ноздри носа осуществляют фильтрацию, увлажнение и регулирование температуры вдыхаемого воздуха. Триада анатомических составляющих раковин носа, включающих в себя тонкий слой слизистой оболочки, реснички и волосы, осуществляет регулирование температуры вдыхаемого воздуха. Объем притока крови к каждой ноздре не только регулирует размер раковин, но и влияет на сопротив-
ление воздушному потоку. Многочисленные раздражители (например, пыль, сигаретный дым, холодный воздух, испарения бензина, запахи лаков и красок и т. д.) могут вызвать краткосрочный ринит. Однако аллергены вызывают каскад событий, которые могут привести как к более значительным по степени клинических проявлений, так и длительным воспалительным реакциям слизистой оболочки носа.
В настоящее время АР страдает до 40% населения земного шара [35, 36, 37, 62], причем независимо от региона проживания [2, 3, 5, 8, 10, 11, 13, 14, 20, 23, 32, 43, 44, 45, 46, 52, 66, 73, 82, 88, 91, 93, 106, 118, 127, 130, 140, 144, 148, 153, 154, 164, 165, 171, 183, 195, 211, 228, 236, 240, 244, 251, 256, 262, 265, 270, 280, 293, 295].
Большую тревогу вызывает увеличение заболевания БА у детей различных стран мира. Бронхиальная астма - хроническое заболевание, в основе которого лежит аллергическое воспаление трахео-бронхиального дерева. Так, в частности, только в США более 15 миллионов человек, включая 5 миллионов детей, имеют эту опасную для жизни болезнь. Каждый год на больных астмой приходится почти 2 миллиона чрезвычайных посещений кабинетов врачей, 500 000 госпитализаций и более 5000 смертных случаев. Ежегодно экономические потери только на лечение БА обходится американскому обществу примерно в 4,5 миллиарда долларов.
Следует отметить, что, несмотря на огромный прорыв в изучении аллергии, на сегодняшний день нет достоверных сведений о частоте АР у больных БА (табл.).
Таблица
Авторы Страна, континент Число наблюдений % отношение ринита у астматиков
СеЫоп 1С. й а1. Китай 10009 6.2
Leynaert В. е! а1. Европа 90478 74-81
Leynert е! а1. Франция 850 78
Linneberg Л. et а1. Дания 743 100
Montnemery Р. et а1. Швеция 12079 46
Shamssain М.Н., Shamsian N. Англия 3000 53 у мальчиков 63 у девочек
Terreehorst I. et а1. Нидерланды 164 92
Статистика свидетельствует о том, что в распространении аллергии имеются различия между жителями сельских и городских районов, причем как в развитых, так и развивающихся странах [157, 193, 264, 268], возможно из-за различий в иммунной реакции [264].
Клиницисты отмечают, что АР и БА часто являются сопутствующими друг другу заболеваниями, что связано с их физиологическими, гистологическими и иммунопатологическими сходствами дыхательных путей [47, 48, 49].
Более 80% астматиков имеют АР [38], в то время как 10-40% людей с АР страдают БА [40, 192].
ЛР является фактором риска для больных БА [53, 129, 149, 231] и диагноз ЛР может предшествовать астме [212, 254].
Проведенные исследования у взрослых людей [115, 116, 257] и у детского населения [212] свидетельствовали о повышении риска развития астмы у людей с ЛР.
Достаточно трудно отличить АР от неаллергического ринита, так как они имеют сходные симптомы и даже могут сочетаться у одного и того же пациента [38, 39, 41]. Японскими специалистами сообщалось, что 44-68 % пациентов с БА страдают и АР [98, 184].
Существует также хронологическая связь АР и БА, что было многократно подтверждено в крупных исследованиях. Данные ВАМБЕ когорты (Швеция, 2012) показали, что в детском возрасте
астма часто сочетается с атопическим дерматитом (АД) и АР, в то время как ринит и АД чаще бывают изолированными [184]. Коморбидность возрастает с возрастом ребенка, так в возрасте 1 года астма сочеталась с ринитом и/или АД в 38 % случаев и показатель возрос до 67 % случаев к 12 годам. Развитие АД, АР и БА - это динамический процесс [16, 17, 119, 181].
В некоторых исследованиях показано, что есть связь между наличием ринита и тяжестью протекания астмы [50, 208, 252].
АР является проблемой глобального здравоохранения, которая затрагивает пациентов всех возрастов и этнических групп земного шара. АР оказывает существенное влияние на социальную жизнь человека, его сон, производительность на работе и учебу в школе [61, 223, 263, 274], и его экономическое воздействие является существенным [63, 121].
Воспаление слизистых оболочек и различные физические раздражители могут вызвать носовые нейрогенные рефлексы через сенсорные, парасимпатических и симпатических пути [38].
Аллергенная сенсибилизации организма человека является важным фактором риска в развитии всех атопических заболеваний, включая АР и БА [217]. Выполненные [145] исследования показали, что простое воздействие вдыхаемых аллергенов не является фактором риска для возникновения БА в будущем.
В этиологии АР придается большое значение домашней пыли и клещам [33, 89, 145, 173, 174, 237, 253, 269], домашним животным [29, 150, 151, 152, 206, 207, 272, 281, 290], пыльце трав [69, 155, 234], профессиональным вредностям [67, 110, 137, 175, 258, 261, 276, 277, 278], курению (в том числе пассивному, особенно у подростков) [9, 298], продуктам питания [30, 161, 162, 218], бытовому газу [289], керосину как топливу в домашних условиях [266], загрязнениям внутреннего и наружного воздуха окружающей среды [86, 99, 100, 294].
По данным журнала Electromagnetic Biology and Medicine миру грозит эпидемия техногенного недуга - электрогиперчувствительности и к 2017 году ею будет страдать каждый второй человек планеты.
Продолжается накопление и анализ клинической оценки тяжести клинических симптомов АР [97, 108, 135, 141, 146, 245, 255] и факторов риска развития БА [42, 126, 147].
Дискуссионным остается вопрос влияния АР на течение БА [70, 124, 172, 199, 200, 247], в том числе на функциональные возможности бронхов и легких [22].
Изучается влияние климатических условий на распространенность симптомов астмы, АР и атопи-ческой экземы у детей [214, 283].
Пациенты с БА с установленным диагнозом сопутствующего АР требуют больших затрат на лечение по сравнению с пациентами, которые имеют только астму [202].
Исследования E. Groot и соавт. [114] показали, что пациенты с БА в сочетании с АР имели достоверно более выраженный воспалительный процесс, чем пациенты АР.
Систематически осуществляются публикации научных обзоров и крупномасштабных исследований, а также клинических рекомендаций по современным вопросам, связанных с изучением и лечением АР и астмы [60, 107, 138, 168, 177, 190, 191, 197, 213, 232, 238, 249], в том числе у спортсменов [31].
Предлагаются опросники по изучению АР и БА [18, 259]. Так, в частности, шведскими исследователями [115, 116] разработана и апробирована на большом числе населения карта исследования больных с АР и БА.
В Швеции проведено когортное исследование по изучению индекса массы тела у призывников с аллергическим риноконьюнктивитом и БА [43, 44, 45].
Вызывает интерес обследование близнецов, а также братьев и сестер по изучению у них распространенности аллергических заболеваний [166]. Изучаются вопросы развития аллергии и астмы у младенцев и маленьких детей до возраста 7 лет с АД, причем наметились некоторые перспективы решений [117, 189].
Показано, что клинические проявления АР весьма разнообразны, ибо он может поражать глаза [54, 105, 134, 188, 194].
Изучаются клинические особенности астматических больных и роль хронического гиперпластического риносинусита и полипоза носа [122].
Ведутся исследования о состоянии женщин, больных БА во время беременности [139] и влияние сезонного АР на менструальный цикл [250].
В последние годы разрабатываются научно-методологические подходы к проблемам оценки качества жизни в различных разделах сферы деятельности человека, в том числе и медицины. Всё большее внимание обращается на экономическое развитие общества и качество жизни больных АР и БА [6, 68, 125, 132, 133, 142].
Подчеркивается, что низкий социально-экономический статус является фактором риска для лечения АР и БА [6].
Исследования свидетельствуют о том [115, 116], что АР является независимым фактором риска для развития кашля помимо простуды среди взрослых. В этом направлении [239] проведено продольное исследование по изучению АР к появлению у человека рецидивирующего кашля и храпа во время сна.
Накапливаются сведения об изменении состава крови у больных с аллергическими заболеваниями [109, 215, 285], а также роли тучных и стволовых клеток на рецепторный аппарат слизистой оболочки носа [216].
Для уменьшения выраженности АР во время природного воздействия пыльцы растений и трав предлагается использовать специальные маски -«носовые фильтры» и очки [111, 187].
Даются рекомендации путешественникам по их поведению и методам защиты при природном воздействии аллергенов [7, 94, 95, 96].
Широко обсуждаются вопросы клинического применение и механизма действия различных лекарственных препаратов на больных, страдающих АР [1, 12, 15, 21, 25, 55, 56, 57, 58, 59, 74, 76, 84, 90, 92, 120, 136, 143, 156, 176, 178, 185, 196, 205, 219, 246, 267, 287, 284, 203, 204, 222, 233, 273], в том числе применённых сублингвально [19, 26, 83, 123, 128, 158, 182, 186, 288, 102, 103, 159, 229], а также в комбинации сублингвально и подкожно [101, 179, 180, 282].
В лечении АР и БА широко используется специфическая иммунотерапия [4, 27, 28, 65, 75, 77, 78, 79, 80, 104, 113, 160, 163, 169, 170, 220, 230, 235, 248, 260, 275, 279].
Обращается внимание на то, что использование водного назального спрея мометазона у детей с многолетним АР не вызывает замедления роста [224]. В то же время Skoner D.P. с соавт. сообщают [242], что обнаружили подавление роста детей во время интраназального применения беклометазона дипропионата.
Для лечения сезонного АР предлагается использование акупунктуры [51, 210, 292].
Значительная часть исследований проводится по изучению сезонной изменчивости бронхиальных клеток, состояния верхних и нижних дыхательных путей и мокроты у больных, как АР, так и БА [24, 34, 48, 64, 71, 81, 85, 167, 201, 225]. Приводятся
сведения о функциональном состоянии легких на фоне АР [72].
Рассматриваются причины наследственной расположенности к аллергическим заболеваниям [189].
Особого внимания заслуживают исследования роли уровней IgE человека с аллергическими заболеваниями [87, 131, 209, 226, 241, 291].
Таким образом, следует признать, что АР и БА, несмотря на несомненно достигнутые успехи в их диагностике и лечении, имеют весьма высокую тенденцию к распространению в различных странах мира, отличаются полиморфизмом клинических проявлений, высокой долей экономических потерь на лечение и смертностью.
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НЕЙРОАНЕСТЕЗИЯ В ДЕТСКОМ ВОЗРАСТЕ
Цветанова К. Т.
д-р мед. наук,
УМБАЛ „Д-р Г. Странского " ООО- г. Плевна, " Клиника по анестезиологии и интенсивного лечения " Медицински университет, г. Плевна
NEUROANESTHESIA IN CHILDHOOD
Tsvetanova K.
PhD
UMHAT "Dr. G.Stranski" Ltd.-city of Pleven, ClinicinAnaesthesiologyandIntensive Care, MedicalUniversity - city of Pleven
MedicalUniversity - city of Pleven
АННОТАЦИЯ
Заболевания, связанные с пораждением нервной системы и требующие хирургического вмешательства, многочисленны и разнообразны. Особенности детской патологии ставят более высокие требования к детскому анестезиологу, который должен не только осуществить анестезию для хирургического вмешательства, но и поддерживать в норме основные жизненные показатели ребёнка, и в конечном итоге привести операцию к наиболее благоприятному исходу для маленького пациента.
ABSTRACT
Diseases which are associated with affection of the nervous system and require surgical treatment arevarious. Specifics of childhood pathology set high requirements in front of the children anesthesiologist, who must maintain the main vital signs and finally to care about the best result for the little patient.
Ключевые слова: нейроанестезия, педиатрические пациенты.
Keywords: neuroanesthesia, pediatric patients.
Введение: Нейрохирургические операции пе-диатричных больных представляют собой профессиональный вызов не только для нейрохирурга, но
и для анестезиолога в связи с анатомическими и физиологическими (связанными с возрастом) особен-ностя мималеньких детей.
Анатомо-физиологические особенности:
