SEVERE BRONCHIAL ASTHMA IN CHILDREN AND THE POSSIBILITY OF ACHIEVE CONTROL USING TARGET DRUGS

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Relevance: The goal of AD therapy is to achieve disease control and prevent exacerbations. Most patients achieve control by using the main drugs of basic therapy. However, a significant part (20-30%) has BA phenotypes that are difficult to treat, and it can take an uncontrolled course [2]. The use of monoclonal antibodies in the treatment of asthma allows for better control and reduces the risk of exacerbations.

Objective: to analyze the course of the disease and the experience of using targeted therapy in a 15-year-old patient with asthma.

Materials and methods: a retrospective analysis of anamnestic data, the course of the disease, laboratory and instrumental diagnostics, and treatment methods was performed in patients with bronchial asthma who were treated in 2021 in the specialized department of the State Budget Healthcare Institution "Children's Regional Clinical Hospital" of the Ministry of Health of the Krasnodar Territory (GBUZ "DKKB" of the Ministry of Health of the Krasnodar Territory) and received targeted therapy.

Results and discussion: the article presents a study of the use of targeted therapy for severe asthma in a 15-year-old patient who has been undergoing treatment in the specialized department of the State Medical Institution "DKKB" of the Ministry of Health of the Russian Federation since 2012. In November 2012, the child was admitted with complaints of coughing, mainly at night, as well as during physical exertion; distant wheezing, attacks of suffocation, a feeling of compression behind the sternum.

Medical history of the disease. According to the mother, the child has been ill since birth - pronounced manifestations of exudative-catarrhal diathesis with transformation into atopic dermatitis, after a year the skin rashes began to gradually fade, but frequent, prolonged laryngitis, tracheitis, bronchitis, pneumonia appeared; prolonged conjunctivitis in spring and August with pronounced itching of the orbits, rashes behind the ears, allergic reactions to insect bites (wasp, bee, mosquitoes) in the form of hyperthermia, swelling at the site of the bite, vomiting. He was examined and treated in the Central District Hospital at his place of residence, in November 2012 he was examined by a pulmonologist at the Children's Diagnostic Center in Moscow. Krasnodar, the diagnosis was made: "Allergic form of bronchial asthma, moderate severity, partially controlled course. Spring - autumn hay fever, remission phase. Allergic rhinitis", treatment was prescribed: pulmicort 250 mcg 3 times a day through a nebulizer, no effect was observed. 15.11.2012г. he was hospitalized with an exacerbation in a hospital at the place of residence, infusion therapy was performed: eufillin, prednisone, nebulizer inhalations of berodual and pulmicort, mucolytics, antihistamines, sedatives – the full effect was not achieved, he was sent to the pulmonology department of the State Medical Institution "DKKB" of the Ministry of Health of the KK for further examination, selection of therapy.

During an objective examination, nasal breathing is not difficult, nasal discharge is absent, the chest is cylindrical in shape, evenly participates in the act of breathing. When percussion is performed over the lungs, a box sound is detected, and there is no retraction of the intercostal spaces. During auscultation, breathing is carried out in all the pulmonary fields, hard, without wheezing. BH-28 in 1 min., exhalation is not changed, cough is wet with difficult-to-separate viscous sputum. Peak expiratory flow (PEF) - 180 l / min. (the norm is 220 l / min).

General clinical, biochemical, bacteriological, instrumental studies and consultations of specialists were conducted. It was found: in the general blood test, an increase in the level of red blood cells 4.78 10e12/l (norm 3.5-4.5), monocytes 9.61% (norm 1-6%), eosinophils 9.41% (norm 0.5-7%), basophils 1.82 % (norm 0-1%). In an enzyme-linked immunosorbent assay: an increase in the total IgE level to 759.5 MEd / ml (normal The study of pharyngeal mucus culture revealed bacteriologically: scanty growth of Staphylococcus aureus, moderate growth of Candida albicans, Haemophilus parainfluenzae, Streptococcus viridans. For spirometry: obstructive type of ventilation disorders: FEV1-102%; FVC-96%; PEF-85%.

Ultrasound of the abdominal cavity: echographic signs of an anomaly in the development of the gallbladder, indirect signs of gastritis.

Consultation with a gastroenterologist: abnormal bowel development? Chronic colitis, exacerbation. Intestinal dysbiosis? Chronic gastroduodenitis, exacerbation. Anomalies in the shape of the gallbladder - a bend in the bottom.

Dental consultation: acute chronic periodontitis.

ENT consultation: right-sided acute otitis media, right-sided cervical lymphadenitis. condition after tooth extraction. Recommendations are given.

Based on complaints, medical history, laboratory and instrumental examination data, a diagnosis is made:

Main: "Bronchial asthma is an allergic form, moderate severity, partially controlled course, exacerbation of moderate severity. DN 0 degrees. Spring - autumn hay fever, remission phase. Allergic rhinitis, incomplete remission. Insect allergy."

Concomitant: "Chronic periodontitis, exacerbation. Right-sided acute otitis media. Right-sided cervical lymphadenitis. Condition after tooth extraction. Chronic colitis, exacerbation. Chronic gastroduodenitis, exacerbation. Abnormal shape of the gallbladder-a bend in the bottom.".

Prescribed treatment: table: hypoallergenic; antibacterial therapy: cefuroxime; inhaled glucocorticosteroids: pulmicort 250 mcg through a nebulizer 2 times a day, bronchodilator therapy: berodual 10 drops through a nebulizer for an attack of asthma; leukotriene receptor antagonists: montelukast; antihistamine therapy: suprastinex; nootropic drug: phenibut; symptomatic therapy; physiotherapy treatment, therapeutic gymnastics, massage.

The child was discharged from the department with improvement, the condition is moderate in terms of the disease. PEF at discharge: 210 l / min (the norm is 220 l / min). Recommendations for disease control are given:

Medical supervision in a polyclinic; hypoallergenic lifestyle; hypoallergenic diet. Monitoring of the DDC pulmonologist with referral after 3 months.

Basic asthma treatment:

• Combined bronchodilator 2 times a day for 3 months.

• Daily peak flowmetry with registration.

In August 2013, the child was re-admitted to the pulmonology department of the State Medical Institution "DKKB" of the Ministry of Health of the KK on a planned basis. After the prescribed basic therapy in 2012, remission periods are short (no more than two weeks), asthma symptoms resume, and systemic glucocorticosteroids (prednisone IV) are often used. The last exacerbation since April 2013, when rhinoconjunctival and bronchoobstructive syndrome worsened against the background of flowering plants, berodual was prescribed through a nebulizer 12 drops 3-4 times a day, pulmicort 500 mcg through a nebulizer 2 times a day, prednisone 5 mg 7.00-3 tablets (15 mg) after a meal; 11.00-2 tablets (10 mg) after a meal-complete drug control cannot be achieved. On objective examination, nasal breathing is not difficult, and there is no nasal discharge. When percussion is performed over the lungs, a box sound is detected. During auscultation, breathing is carried out in all the pulmonary fields, hard, and wheezing is heard. BDD-24 in 1 min., exhalation is prolonged, cough with hard-to-separate viscous sputum.

General clinical, biochemical, and instrumental studies were performed. It was found: in the general blood test, eosinophilia was 9.52 % (norm 0.5-7%). In an enzyme-linked immunosorbent assay: an increase in the total IgE level to 851.8 MU / ml (normal Honey / ml). For spirometry: peak expiratory flow (PEF)- 230 l / min (norm 250-300 l / min)

Based on complaints, objective examination, laboratory and instrumental research methods, a clinical diagnosis is made:

Main: "Bronchial asthma is an allergic form, severe severity, uncontrolled course, exacerbation of severe severity. DN of the 2nd degree. Allergic rhinitis, a phase of incomplete remission. Hay fever, spring-autumn, remission phase".

Concomitant: "Chronic colitis, remission stage. Chronic gastroduodenitis, remission stage. An anomaly in the shape of the gallbladder – a bend in the bottom."

The child is sent for a medical and sanitary examination to consider the appointment of stage 5 therapy. Given the severe, torpid course of asthma, the lack of complete drug control of symptoms of bronchospasm and obstruction against the background of combined high-dose inhaled steroid therapy, Also, after a course of systemic steroid therapy with prednisone for 1 month, it was decided to transfer the child to stage 5 asthma therapy with monoclonal antibodies-Xolar (omalizumab) - 300 mg subcutaneously 1 time per month.

The patient has been receiving targeted therapy for 8 years to date. In the course of dynamic observation, the patient's condition is stable with improvement, there is no cough, difficulty breathing; there is no wheezing; there is a decrease in the level of IgE-from 851.8 MEd / ml to 380 MEd / ml, improvement in spirometry indicators: reF with 230 l / min (standard 250 - 300 l / min) up to 520 l / min. (the norm). Bronchial asthma became medically controlled. Basic therapy for asthma currently includes: xolar (omalizumab) – 300 mg subcutaneously 1 time per month, formoterol/budesonide (capsules with powder for inhalation combined) 12/400 mcg through an aerolizer 2 times a day constantly; for bronchial obstruction: ipratropium bromide / fenoterol solution through a nebulizer; for exacerbation of rhinitis: mometasone furoate (nasal spray) 1 dose 1-2 times per day for 10 days, during remission cromogexal nasal spray 1 dose 3 times a day for 10 days monthly; antihistamines in courses: cetirizine 10 mg in the morning 1 month 1 time per quarter; antileukotriene drugs: montelukast 5 mg at night 1 month 1 time per quarter; daily peak flowmetry with registration (morning-evening, patient's diary).

Thus, when targeted therapy is included in the treatment of severe asthma, the patient has a significant reduction in exacerbations of the disease, an improvement in lung function (REF-520 l / min), as well as a reduction in the dose of inhaled and elimination of systemic glucocorticosteroids.

Conclusion: The study of the pathogenesis and treatment of bronchial asthma is constantly developing and improving. The introduction of targeted therapy significantly improves the course of severe bronchial asthma and has a significant impact on the quality of life.

About the authors

Julia Pisotskaya

Federal State Budgetary Educational Institution of Higher Education "Kuban State Medical University" of the Ministry of Health of the Russian Federation

Email: ms.pisotskaya2017@gmail.com
ORCID iD: 0000-0002-0674-7194
SPIN-code: 3634-0055

resident doctor of the Department of Pediatrics №2

Russian Federation, 350063, Russia, Krasnodar Territory, Krasnodar, st. Sedina 4

Diana Vsevolodovna Ustuzhanina

Кубанский государственный медицинский университет

Author for correspondence.
Email: lilicolin@mail.ru
ORCID iD: 0000-0002-3580-5816
SPIN-code: 3293-0548

References