saqarTvelos respiraciuli asociacia
saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministro
mwvave bronqiti avtorebi: T.maRlakeliZe, k.vaWaraZe, i.CxaiZe, p.gvetaZe, n.yavlaSvili
eqspertebi: v.qacarava, q.Sarangia, T. lobJaniZe
Tbilisi 2006 1
gaidlainis aucilebloba. mwvave bronqiti traqeobronquli xis anTebiTi procesia, romlis sixSire gansakuTrebiT matulobs zamTris periodSi, infeqciebis
rodesac
gansakuTrebiT
ricxvi.
marto
aSS-Si
maRalia mwvave
mwvave
bronqitis
respiraciuli diagnoziT
12
milioni adamiani mimarTavs eqims, ris gamoc yovelwliurad 300.000 mln dolaris wamali iniSneba.
definicia mwvave bronqiti bronquli xis lorwovani garsis mwvave anTebaa, romelic grZeldeba 2-3 kviramde da romlis aucilebel simptoms warmoadgens xvela naxvelis gamoyofiT an mis gareSe.
epidemiologia mwvave bronqiti ojaxis eqimis mier erT-erTi yvelaze xSirad dasmuli diagnozia. is xSiria zamTris periodSi, rodesac Warbobs respiraciuli virusuli infeqciebi. bronqiti Sedis eqimTan vizitis uxSires mizezTa xuTeulSi. bronqiti Tanabrad gvxvdeba orive sqesis pacientebSi. yvelaze xSirad 5 wlamde asakis bavSvebi avaddebian. aseve maRalia misi sixSire 9-15 wlis bavSvebSi. mwvave bronqitis sixSire wlis
ganmavlobaSi
mosaxleze/kviraSi,
aSS-Si
xolo
saSualod
zamTris
87
periodSi
SemTxvevaa/100.000 misi
sixSire
150
SemTxvevaa/100.000 mosaxleze/kviraSi. britaneTSi skolis moswavleebSi bronqitis gavrceleba 20,7%-mdea. erT-erTi mizezi imisa, Tu ratom aris mwvave bronqiti ase xSiri, aris is, rom eqimebi am diagnozis qveS aerTianebian xvelis simptomiT mimdinare sxvadasxva daavadebebs, rogoricaa zemo sasunTqi gzebis daavadebebi, virusuli pnevmonia, asTma, sinusiti da sxv. saqarTvelos saministros erovnuli
Sromis,
daavadebaTa centris
2005
janmrTelobis kontrolis wlis
da
da
socialuri
samedicino
monacemebiT
dacvis
statistikis
saqarTveloSi
mwvave
bronqitis diagnoziT hospitalizebul iqna 3.214 avadmyofi, maT Soris 14 wlamde asakis 2.655 bavSvi. 100.000 mosaxleze maCvenebeli Seadgens 73.5-s. letalobis maCvenebeli 0,1%-ia.
etiologia mwvave virusebTan,
bronqiti
uxSiresad
rogoricaa
gaciebis
dakavSirebulia gamomwvevi
virusebi
respiraciul (rinovirusi, 2
koronavirusi), virusi,
gripis
martivi
virusi,
herpesis
adenovirusi,
virusi.
mwvave
rs-virusi,
paragripis
bronqitis
SedarebiT
umniSvnelo nawili ganpirobebulia sxva mizezebiT (Tumca maT Soris ufro xSiria baqteriuli gamomwvevebi: mikoplazma da qlamidia): baqteriebi: 1. Streptococcus Pneumoniae 2. Heamophilus Influenza 3. Moraxella catarrhalis 4. Bordetella pertusis (da parapertusis) atipuri gamomwvevebi 1. Mycoplasma pneumoniae 2. Chlamydophila pneumoniae 3. Legionella sokoebi: 1. Blastomyces dermatitidis 2. Candida albicans 3. Coccidiodes immitis 4. Cryptococcus neoformans 5. Histoplasma capsulatum garemos gamRizianeblebi 1. haeris dabinZureba 2. Tambaqos
boli
(15
wlamde
bavSvebSi
bronqitis
sixSire
korelirebs pasiur mowevasTan (mtkicebuleba IV) mwvave bronqitis gamomwvevTa asakobrivi da sezonuri Tavisebureba bavSvebSi aseTia: 1 wlamde: 1. respiraciul-sincitiuri virusi (zamTari-gazafxuli) 2. paragripis virusi (Semodgoma) 3. koronavirusi (zamTari-gazafxuli) 1-10 weli 1. paragripis virusi (Semodgoma) 2. enterovirusi (Semodgoma) 3. respiraciul-sincitiuri virusi (zamTari-gazafxuli) 3
4. rinovirusi (Semodgoma) 10 welze met asakSi 1. gripis virusi (zamTari-gazafxuli) 2. respiraciul-sincitiuri virusi (zamTari-gazafxuli) 3. adenovirusi. cxrilSi
moyvanilia
mwvave
bronqitis
uxSires
gamomwvevTa
epidemiologiis da klinikuri mimdinareobis Taviseburebani.
gamomwvevi agenti
Tavisebureba
Influenza A
epidemiis dros avaddeba jgufis warmomadgeneli
Influenza B
avaddeba yvela warmomadgeneli
•
Parainfluenza 1–3
•
Adenovirus
S.Pneumoniae
Mycoplasma pneumonia
yvela
asakobrivi
asakobrivi
jgufis
erTeuli SemTxvevebi, epidemia iSviaTia
•
saSualo asakSi an moxucebSi
•
uecari dasawyisi
•
zemo sasunTqi simptomebi
•
epidemia 30 wlamde asakSi gvxvdeba
•
daavadebis daswyisSi damaxasiaTebelia zemo sasunTqi gzebis dazianebis simptomebi
•
mSrali xvela
gzebis
dazianebis
Bordetella pertussis
gaxangrZlivebuli xvela
Haemophilus influenzae
mwevelebSi an pirebSi qronikuli bronqitiT
Moraxella catarrhalis
qronikuli bronqiti, imunodeficiti
paTogenezi mwvave bronqitis dros viTardeba bronqis lorwovanis SeSupeba da lorwos hipersekrecia. xvela SeiZleba, erTi mxriv, gamowveuli iyos sasunTqi gzebis epiTeliumis destruqciiT, meore mxriv ki anTebis mediatorebis gamomuSavebiTa da mukociliuri aparatis dazianebiT, Tumca xvelis ganviTarebis meqanizmi bolomde naTeli ar aris. ufro 4
maRali
virulentobis
adenovirusi,
xvelis
mqone
virusebisaTvis,
mizezi
SeiZleba
rogoricaa
iyos
gripi
lorwovani
da
garsis
epiTeliumis daSla. ufro naklebi virulentobis mqone virusebisaTvis, rogoricaa
rinovirusi,
xvelas
SesaZloa
ganapirobebdes
anTebis
mediatorebis aqtivacia da bronqis mukociliaruli funqciis Secvla. bronqitis ganviTarebasa da simptomebis gamwvavebas xels uwyobs Tambaqos
boli
ganviTarebuli
da
haeris
anTebiTi
dabinZureba.
cvlilebebi
mwvave
bronqitis
gardamavalia,
dros
Tumca
xvela
SeiZleba gaxangrZlivdes 3 kviramde. mwvave bronqitis risk-faqtorebia: •
gadacieba;
•
cxviriT sunTqvis gaZneleba;
•
cxvir-xaxis qronikuli infeqciebi;
•
imunodeficituri mdgomareobebi;
•
bavSvTa da xandazmuli asaki;
•
Tambaqos moweva (pasiuric);
•
alkoholizmi;
•
refluqs-ezofagiti;
•
garemos dabinZureba.
klinikuri niSnebi mwvave bronqiti uxSiresad gamowveulia respiraciuli virusebiT, amitom
igi
iwyeba
Semcivneba,
saerTo
respiraciuli sisuste,
infeqciis
msubuqi
niSnebiT,
cxeleba
rogoricaa
(araumetes
3
dRis
ganmavlobaSi), cxviridan gamonadeni, yelis tkivili, kunTebis tkivili, xmis CaxleCa. ZiriTadi klinikuri niSani xvelaa, romelic daavadebis dawyebidan 2-4
dRis
Semdeg
iCens
Tavs.
Tavidan
is
mSrali,
Semawuxebeli
xasiaTisaa, Semdeg produqtiuli xdeba. naxveli Tavidan lorwovania, mogvianebiT
SeiZleba
Cirqovani
gamowveulia
leikocitebis
gaxdes.
migraciiT
da
Tumca
Cirqovani
yovelTvis
ar
naxveli
miuTiTebs
baqteriuli infeqciis arsebobaze. adreuli asakis bavSvebi naxvels ylapaven, rasac SeiZleba mohyves Rebineba. dinamikaSi naxveli TandaTan Txierdeba
da
5-10
dReSi
xvela
gaivlis.
bronqitis
simptomebi
5
Cveulebriv 2 kviramde grZeldeba, Tumca iSviaTad SeiZleba xvela gaxangrZlivdes 4-6 kviramde.
obieqturi gamokvleva obieqturi gamokvlevis Sedegebi damokidebulia pacientis asaksa da daavadebis stadiaze. temperatura, rogorc wesi, normaluria, Tumca SesaZlebelia
subfebrilur
cifrebsac
aRwevdes.
adreul
etapze
SesaZloa gamoxatuli iyos nazofaringiti, koniunqtiviti da riniti. filtvebis auskultaciuri monacemebi am etapze ar aris Secvlili. daavadebis progresirebis da xvelis intensivobis matebasTan erTad filtvebis
auskultaciuri
monacemebi
icvleba,
sunTqviTi
xmianoba
xdeba mkvrivi, moismineba mSrali da sxadasxva yalibis sveli xixini. zog
pacientSi
damaxasiaTebeli
ismis
mstvinavi
lokaluri
sunTqva.
bronqitisaTvis
simptomatika:
lokaluri
ar
aris
krepitacia,
bronquli sunTqva, perkutoruli xmianobis moyrueba. aseT SemTxvevaSi gamosaricxia pnevmoniis arseboba. mikoplazmuri etiologiis bronqitis SemTxvevaSi SesaZlebelia kanze gamonayaris gaCenac.
garTulebebi •
pnevmonia (viTardeba pacientTa 5%-Si);
•
sunTqvis mwvave ukmarisoba.
simZimis Sefaseba mwvave bronqiti, rogorc wesi, mimdinareobs msubuqad an saSualo simZimiT, is ar saWiroebs hospitalizacias
hospitalizaciis Cvenebebi Cveulebriv
mwvave
bronqitis
mkurnaloba
ambulatoriulad
tardeba. hospitalizaciis Cvenebas warmoadgens: •
Tanmxlebi daavadebebi (gulis Tandayolili anomalia, filtvis qronikuli paTologia, nevrologiuri darRvevebi);
•
socialuri
problemebi
-
ojaxSi
movlis,
meTvalyureobis
deficiti, transportirebis saSualebis ararseboba (sarwmunoeba
IV, rekomendacia D); •
simptomebis 2-3 kviraze metad gaxangrZliveba;
•
toqsikozis niSnebi (saeWvoa baqteriuli traqeiti an pnevmonia);
•
sicocxlisTvis
saSiSi
niSnebis
arseboba
(sarwmunoeba
IV,
rekomendacia D,); 6
•
sakvebis da siTxis miRebis SeuZlebloba.
diagnozi daavadebis diagnostika tardeba klinikuri niSnebis safuZvelze. bronqitze eWvi unda iqnes mitanili im pacientebSi, romelTanac mwvave respiraciuli anamnezuri
infeqciis
gamokvleva
niSnebi
unda
asocirebulia
moicavdes
garemo
xvelasTan. aris
da
sruli
sigaretis
zegavlenis dadgenas, epidemiologiur monacemebs. sruli obieqturi gamokvleva aucilebelia, raTa gamoiricxos rogoricaa
kardiovaskuluri
daavadebebi
xvelis
sxva
mizezebi,
da
filtvis
parenqimis
ar
iZleva
daavadebis
dazianeba. sisxlis
saerTo
diagnostikis
da
(sarwmunoeba IV).
misi amitom
analizi
-
mkurnalobis ar
aris
gansazRvris
mizanSewonili
saSualebas
misi
rutinulad
Catareba (rekomendacia C). mwvave bronqitis dros SeiZleba gamovlindes leikopenia
an
leikocitozi,
limfocitozi,
Tumca
es
ar
aris
specifiuri am daavadebisaTvis. pulsoqsimetria,
Jangbadis
saturaciis
gansazRvra.
O2 saturaciis gansazRvra mizanSewonilia Cautardes Yyvela bavSvs, romelic hospitalizebulia sunTqvis mwvave ukmarisobiT (sarwmunoeba
II, rekomendacia C). rentgenologiuri
gamokvleva
– mwvave bronqitis dros
gulmkerdis rentgenograma normaluria an aRiniSneba bronqogenuri gaZliereba.
gulmkerdis
rentgenografia
ar
tardeba
rutinulad.
gulmkerdis rentgenografiis Cvenebebia: ¾ pacients aqvs cxeleba, magram ar aqvs zemo sasunTqi gzebis dazianebis simptomebi; ¾ pacients aqvs Tanmxlebi davadeba, romelic xels uwyobs pnevmoniis ganviTarebas – bronqoeqtazia, diabeti, gulis, RviZlis an Tirkmlis paTologia; ¾ anamnezSi pnevmonia (< 1 weli); ¾ anamnezSi tuberkulozis arseboba; ¾ daavadebis gaxangrZliveba an uCveulo mimdinareoba; ¾ eWvi pnevmoniaze.
7
etiologiuri
kvleva
- nazofaringuli sekretidan SeiZleba
virusis gamoyofa, Tumca es ar aris aucilebeli diagnostikis an mkurnalobisTvis. genezisaa,
ar
aris
mikroskopuli gamomwvevis
vinaidan
mwvave
rekomendebuli
kvlevis
Catareba.
(mikoplazmis,
bronqiti
ZiriTadad
naxvelis
mikrobiologiuri
serologiuri
qlamidiis)
virusuli
testiT
sawinaaRmdego
Tu
SeiZleba specifiuri
antisxeulebis dadgena. polimerazuli jaWvuri reaqciiT SesaZlebelia nebismieri etiologiuri faqtoris dadgena, Tumca es meTodi Zviria da stacionarSic ki rutinulad ar gamoiyeneba. filtvis daavadebul magram
funqciis
pacientebSi
spirografia
ar
Seswavla
dadgenilia aris
-
filtvis
rutinulad
mwvave funqciis
bronqitiT daqveiTeba,
rekomendebuli.
filtvis
funqciis Seswavla tardeba bronqul asTmaze eWvis dros. C-reaqtiuli
cila
–
kvlevebi
gviCveneben,
rom
es
testi
xasiaTdeba baqteriuli infeqciis mimarT maRali mgrZnobelobiT (80100%), da dabali specifiurobiT (60-70%). C-reaqtiuli cila SeiZleba gamoyenebul iqnas antibiotikoTerapiis kriteriumad hospitalizebul bavSvebSi
(rekomendacia B).
Tumca
dabali
C-reaqtiuli
cila
ar
gamoricxavs baqteriuli infeqciis arsebobas.
diferenciuliDdiagnozi diferencialuri diagnozi tardeba Semdeg daavadebebTan: ¾ pnevmonia; ¾ asTma; ¾ qronikuli bronqitis gamwvaveba; ¾ yivanaxvela; ¾ ucxo sxeulis aspiracia; ¾ mukoviscidozi; ¾ bronqioliti; ¾ zeda sasunTqi gzebis infeqcia; ¾ sinusiti; ¾ nazofaringiti; ¾ refluqs-ezofagiti; ¾ bronqis simsivne; ¾ atipuri mikobaqteriuli infeqcia; 8
¾ baqteriuli traqeiti. ¾ riniti da post-nazaluri wveTi.
prognozi prognozi
pacientTa
umravlesobaSi
keTilsaimedoa.
Tu
xvela
gaxangrZlivda, saWiroa damatebiTi gamokvlevebi.
marTva mwvave
bronqitis
antibiotikoTerapia ormagi
brma,
ZiriTadi
ar
aris
gamomwvevia
naCvenebi.
randomizebuli
virusi,
amitom
placebo-kontrolirebadi,
kvlevebis
meta-analizis
Sedegad
naCvenebia, rom ar arsebobs mwvave bronqitis dros antibiotikebis gamoyenebis efeqturobis damadasturebeli monacemebi. antibiotikebi ar axdendnen
zegavlenas
baqteriuli
xvelis
infeqciebis
Semcirebaze,
ar
ganviTarebisagan
icavdnen an
meoradi
maTi
mZime
mimdinareobisagan. antibiotiki
(sarwmunoebis bronqitis
iniSneba,
done
I,
imisa,
saeWvoa
rekomendacia A).
diagnoscirebisas
miuxedavad
Tu
rom
eqimTa
baqteriuli dadgenilia,
50-79%
antibiotiks
niSnavs
sargebeli
infeqcia rom
mwvave
antibiotiks, ar
moaqvs.
antibiotikoTerapiaze unda vifiqroT, Tu: ¾ zogadi mdgomareoba uaresdeba; ¾ cxeleba grZeldeba erT kviraze met xans; ¾ aRiniSneba cxelebis meore talRa; ¾ aRiniSneba profuzuli da Cirqovani naxveli; ¾ epidemiologiuri
situaciidan
gamomdinare
eWvia
mikoplazmur,
qlamidiur infeqciaze an yivanaxvelaze; ¾ Tu mwvave bronqitis simptomebTan erTad aRiniSneba sinusiti an otiti; ¾ Tu
daavadeba
SeuZliaT
mimdinareobs gazardon
(imunodeficiti,
im
faqtorebis
pnevmoniis
alkoholizmi,
gulis
fonze,
romelTac
ganviTarebis qronikuli
riski
ukmarisoba,
filtvis qronikuli paTologia). mikoplazmur da qlamidiur infeqciaze eWvis dros rekomendebulia makrolidis gamoyeneba (sarwmunoebis done III, rekomendacia B). mkurnalobis principebi bavSvebSi 9
1. mSvidi, komfortuli garemo; 2. siTxeebis damatebiTi miwodeba; 3. antipiretuli saSualebebi; 4. amosaxvelebeli
saSualebebis
efeqturoba
da
sargeblianoba
bavSvebSi ar aris dadasturebuli; 5. bavSvebSi
xvelis
damTrgunvelebis
gamoyeneba
amasTan
ar
amcirebs
daavadebis
xangrZlivobas,
naxvelis
evakuaciis
daTrgunvam
SeiZleba xeli Seuwyos baqteriuli garTulebis
ganviTarebas; 6. bavSvebSi
ar
arsebobs
mwvave
bronqitis
β2-agonistebis
dros
efeqturobis damadasturebeli monacemebi; 7. antihistaminuri preparatebi ar aris rekomendebuli, radgan isini iwveven naxvelis gamoSrobas da SeiZleba gaaZlieron xvela. mSobels unda miewodos informacia, rom dauyovnebliv mimarTos eqims,
Tu
bavSvs
gaZnelebuli;
gamoexata
daewyo
Semdegi
FRebineba
niSnebi:
yoveli
sunTqva
kvebis
gaxda
ufro
ver
iRebs
Semdeg;
siTxeebs; gamoixata zogadi mZime mdgomareoba – daTrgunva, Zilianoba. mkurnalobis principebi mozrdilebSi 1. siTxeebis damatebiT miwodeba bronquli sekretis gamoSrobis Tavidan acilebis mizniT; 2. sigaretis mowevisagan Tavis Sekaveba; 3. antipiretuli saSualebebi; 4. xvelis damTrgunveli saSualebebi xSirad iniSneba bronqitis, gansakuTrebiT SeiZleba
Semawuxebeli
Seamciron
xvela,
xveliT magram
mimdinare,
maTi
miReba
dros. ar
maT
amcirebs
daavadebis xangrZlivobas. 5. amosaxvelebeli
saSualebebis
rutinuli
gamoyeneba
ar
aris
rekomendebuli. naxvelis gamaTxierebeli saSualebebis daniSvna SesaZlebelia
mxolod
webovani,
Znelad
gamosayofi
naxvelis
SemTxvevaSi; 6. bronqodilatatorebis
gamoyeneba
umniSvnelo
efeqts
iZleva
gaxangrZlivebuli xvelis dros;
10
7. kortikosteroidebis gamoyeneba ar aris rekomendebuli, vinaidan ar arsebobs kvleva, romelic daadasturebs maT efeqturobas mwvave bronqitis dros.
prevencia ¾ dty vaqcinacia; ¾ gripis sawinaaRmdego vaqcinacia; ¾ Tambaqos bolisgan Tavis arideba.
meTvalyureoba Semdgomi meTvalyureoba Cveulebriv ar aris saWiro, garda im SemTxvevebisa, roca: ¾ mdgomareoba uaresdeba an axali simptomebi Cndeba; ¾ xvela xangrZlivdeba >1 Tveze; ¾ simptomebi meordeba (>3 epizodze weliwadSi).
gaidlainis miRebis wyaro.
winamdebare
gaidlaini
warmoadgens
sxvadasxva gaidlainebis (ix. literatura) Sejerebis da adaptaciis Sedegs.
literatura: 1. Meza R, Bridges-Webb C, Sayer G, et al. The management of acute bronchitis in general practice: results from the Australian morbidity and treatment survey. Australian Family Physician, 1994; 23: 1550-1553. 2. Samuel Ong, MD, Visiting Assistant Professor, Department of Emergency Medicine, University of California at Los Angeles Medical Center-Olive View Bronchitis Last Updated: December 29, 2004, WEBMD, eMedicine 3. Guideline for The Management of Acute Bronchitis - developed by an Alberta Clinical Practice Guideline Working Group, 2006 Update. 4. Family Practice Notebook, 2000 5. Charles Callahan, DO, Professor, Deputy Chief of Clinical Services, Walter Reed Army Medical Center Bronchitis, Acute and Chronic Last Updated: January 30, 2006, WEBMD, eMedicine
11
6. DiFranza JR, Lew RA. Morbidity and mortality in children associated with use of tobacco products by other people. Pediatrics 1996; 97 (4); 560-568 7. Hamm R, Hicks R, Bemben D. Antibiotics and respiratory infections: are patients more satisfied when expectations are met? J. Family Practice, 1996; 43: 56-62. 8. O’Brien K, Dowell S, Schwartz B, et al. Cough illness/bronchitis – principles of judicious use of antimicrobial agents.Paediatrics,1998;101: 178-81. 9. Gonzales R, Barrett P, Steiner J. The relationship between purulent manifestations and antibiotic treatment of upper respiratory tract infections. J. General Internal Medicine, 1999; 14:151-6. 10. Gwaltney J. Acute bronchitis. In: Mandell G, Bennett J, and Dolin R (eds.). Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 5th edition, Churchill and Livingstone, Edinburgh, 2000. 11. Becker L, Glazier R, McIsaac W, et al. Antibiotics for acute bronchitis (Cochrane Review). In: The Cochrane Library, Issue 3, 1998. Oxford: Update Software. 12. Hueston W. Albuterol delivered by metered dose inhaler to treat acute bronchitis. J. Family Practice, 1994; 39(5): 437-440. 13. Irwin R, Curley F, Bennett F. Appropriate use of antitussives and protussives: a practical review. Drugs, 1993; 46: 80-91. 14. Hueston W. Antibiotics: neither cost effective nor ‘cough’ effective. J. Family Practice, 1997; 44(3): 261-5. 15. Clinical practice guideline for the diagnosis and management of acute bronchitis Inland empire health plan, San Bernandino, CA 2001 16. National Guideline Clearinghouse – Bronchitis, 2005 17. Gonzales R, Sande M. What will it take to stop physicians from prescribing antibiotics in acute bronchitis? Lancet, 1995; 345: 665-666. 18. Mainous A, Zoorob R, Hueston W. Current management of acute bronchitis in ambulatory care: the use of antibiotics and bronchodilators. Arch Fam Med, 1996; 5: 79-83. 19. National Guideline Clearinghouse – Use of antibiotics in pediatric care, 2002 20. Smuncy J, et al β2 agonists for acute bronchitis (Cochrane review) – The Cochrane Library, Issue 2, 2006 21. Acute Bronchitis - EBM Guidelines, 2004 22. Nelson - Textbook of pediatrics - 2005 23. Hueston W. J.,
Mainous A.G. Acute bronchitis. American Academy of Family
Physicians, 1998 12
mwvave bronqitis marTvis protokoli (pirveladi jandacvis rgolisaTvis) daavadebis definicia. mwvave bronqiti bronquli xis lorwovani garsis mwvave anTebaa, romelic grZeldeba 2-3 kviramde da romlis aucilebel simptoms warmoadgens xvela naxvelis gamoyofiT an mis gareSe.
simptomebi da niSnebi mwvave bronqiti uxSiresad gamowveulia respiraciuli virusebiT, amitom
igi
iwyeba
Semcivneba,
saerTo
respiraciuli sisuste,
infeqciis
msubuqi
niSnebiT,
cxeleba
rogoricaa
(araumetes
3
dRis
ganmavlobaSi), cxviridan gamonadeni, yelis tkivili, kunTebis tkivili, xmis CaxleCa. ZiriTadi klinikuri niSani xvelaa, romelic daavadebis dawyebidan 2-4
dRis
Semdeg
iCens
Tavs.
Tavidan
is
mSrali,
Semawuxebeli
xasiaTisaa, Semdeg produqtiuli xdeba. naxveli Tavidan lorwovania, mogvianebiT
Cirqovani
SeiZleba
gamowveulia
leikocitebis
gaxdes.
migraciiT
da
Tumca
Cirqovani
yovelTvis
ar
naxveli
miuTiTebs
baqteriuli infeqciis arsebobaze. adreuli asakis bavSvebi naxvels ylapaven, rasac SeiZleba mohyves Rebineba. dinamikaSi naxveli TandaTan Txierdeba
da
5-10
dReSi
xvela
gaivlis.
bronqitis
simptomebi
Cveulebriv 2 kviramde grZeldeba, Tumca iSviaTad SeiZleba xvela gaxangrZlivdes 4-6 kviramde. temperatura
normaluria
an
subfebriluri.
adreul
etapze
SesaZloa gamoxatuli iyos nazofaringiti, koniunqtiviti da riniti. daavadebis progresirebis da xvelis intensivobis matebasTan erTad moismineba mSrali da sxadasxva yalibis sveli xixini. zog pacientSi ismis
mstvinavi
lokaluri
sunTqva.
simptomatika:
perkutoruli
xmianobis
bronqitisaTvis lokaluri moyrueba.
ar
aris
krepitacia,
damaxasiaTebeli
bronquli
sunTqva,
aseT
SemTxvevaSi
gamosaricxia
mikoplazmuri etiologiis bronqitis
SemTxvevaSi
SesaZlebelia
pnevmoniis arseboba.
kanze gamonayaris gaCenac. 13
bronqitze eWvi unda iqnes mitanili im pacientebSi, romelTanac mwvave
respiraciuli
sruli
anamnezuri
infeqciis
gamokvleva
niSnebi unda
asocirebulia
moicavdes
xvelasTan.
garemo
aris
da
sigaretis zegavlenis dadgenas, epidemiologiur monacemebs. sruli obieqturi gamokvleva aucilebelia, raTa gamoiricxos xvelis sxva mizezebi,
rogoricaa
kardiovaskularuli
daavadebebi
da
filtvis
parenqimis dazianeba.
diagnostikur-laboratoriuli testebi sisxlis
saerTo
analizi
-
ar
iZleva
daavadebis
diagnostikis da misi mkurnalobis gansazRvris saSualebas. amitom ar aris mizanSewonili misi rutinulad Catareba. mwvave bronqitis dros SeiZleba
gamovlindes
leikopenia
an
leikocitozi,
limfocitozi,
Tumca es ar aris specifiuri am daavadebisaTvis. rentgenologiuri
gamokvleva
– mwvave bronqitis dros
gulmkerdis rentgenograma normaluria an aRiniSneba bronqogenuri gaZliereba.
gulmkerdis
rentgenografia
ar
tardeba
rutinulad.
gulmkerdis rentgenogramis Cvenebebia: ¾ pacients aqvs cxeleba, magram ar aqvs zemo sasunTqi gzebis dazianebis simptomebi; ¾ pacients aqvs Tanmxlebi davadeba, romelic xels uwyobs pnevmoniis ganviTarebas – bronqoeqtazia, diabeti, gulis, RviZlis an Tirkmlis paTologia; ¾ anamnezSi pnevmonia (< 1 weli); ¾ anamnezSi tuberkulozis arseboba; ¾ daavadebis gaxangrZliveba an uCveulo mimdinareoba; ¾ eWvi pnevmoniaze.
mkurnaloba mwvave
bronqitis
antibiotikoTerapia
ar
ZiriTadi aris
gamomwvevia
naCvenebi.
virusi,
antibiotikoTerapiaze
amitom unda
vifiqroT, Tu: ¾ zogadi mdgomareoba uaresdeba; ¾ cxeleba grZeldeba erT kviraze met xans; ¾ cxeleba Tavidan iwyeba; ¾ aRiniSneba profuzuli da Cirqovani naxveli; 14
¾ epidemiologiuri
situaciidan
gamomdinare
eWvia
mikoplazmur,
qlamidiur infeqciaze an yivanaxvelaze; ¾ Tu mwvave bronqitis simptomebTan erTad aRiniSneba sinusiti an otiti; ¾ Tu
daavadeba
SeuZliaT
mimdinareobs gazardon
(imunodeficiti,
im
faqtorebis
pnevmoniis
alkoholizmi,
fonze,
romelTac
ganviTarebis
gulis
qronikuli
riski
ukmarisoba,
filtvis qronikuli paTologia). mikoplazmur da qlamidiur infeqciaze eWvis dros rekomendebulia makrolidis gamoyeneba. mkurnalobis principebi bavSvebSi 1. mSvidi, komfortuli garemo; 2. siTxeebis damatebiTi miwodeba; 3. antipiretuli saSualebebi; 4. bavSvebSi
xvelis
damTrgunvelebis
gamoyeneba
amasTan
naxvelis
ar
amcirebs
daavadebis
xangrZlivobas,
evakuaciis
daTrgunvam
SeiZleba xeli Seuwyos baqteriul garTulebas;
5. bavSvebSi ar arsebobs mwvave bronqitis dros β2-agonistebis efeqturobis damadasturebeli monacemebi; 6. antihistaminuri preparatebi ar aris rekomendebuli, radgan isini iwveven naxvelis gamoSrobas da SeiZleba gaaZlieron xvela. mSobels unda miewodos informacia, rom dauyovnebliv mimarTos eqims,
Tu
bavSvs
gaZnelebuli;
gamoexata
daewyo
Semdegi
FRebineba
niSnebi:
yoveli
sunTqva
kvebis
Semdeg;
gaxda
ufro
ver
iRebs
siTxeebs; gamoixata zogadi mZime mdgomareoba – daTrgunva, Zilianoba. mkurnalobis principebi mozrdilebSi 1. siTxeebis damatebiT miwodeba bronquli sekretis gamoSrobis Tavidan acilebis mizniT; 2. sigaretis mowevisagan Tavis Sekaveba; 3. antipiretuli saSualebebi; 4. xvelis damTrgunveli saSualebebi xSirad iniSneba bronqitis dros. maT SeiZleba Seamciron xvela, magram maTi miReba ar amcirebs daavadebis xangrZlivobas. 15
5. amosaxvelebeli saSualebebis rutinuli gamoyeneba ar aris rekomendebuli.
naxvelis
gamaTxierebeli
saSualebebis
daniSvna SesaZlebelia mxolod webovani, Znelad gamosayofi naxvelis SemTxvevaSi; 6. bronqodilatatorebis gamoyeneba umniSvnelo efeqts iZleva gaxangrZlivebuli xvelis dros;
7. kortikosteroidebis gamoyeneba ar aris rekomendebuli. reabilitacia da dakvirveba Semdgomi meTvalyureoba Cveulebriv ar aris saWiro, garda im SemTxvevebisa, roca: ¾ mdgomareoba uaresdeba an axali simptomebi Cndeba; ¾ xvela xangrZlivdeba >1 Tveze; ¾ simptomebi meordeba (>3 epizodze weliwadSi).
adamianuri da materialur-teqnikuri resursi adamianuri resursi: ojaxis eqimi, ubnis Terapevti an pediatri. materialur-teqnikuri resursi: gamanaTebeli mowyobiloba xaxis dasaTvaliereblad, enis supresori (Spadeli), fonedoskopi.
protokoli
eyrdnoba
saqarTvelos
respiraciuli
asociaciis
“mwvave bronqitis marTvis” gaidlains.
16
mwvave bronqitis marTvis protokoli (stacionari) daavadebis definicia. mwvave bronqiti bronquli xis lorwovani garsis mwvave anTebaa, romelic grZeldeba 2-3 kviramde da romlis aucilebel simptoms warmoadgens xvela naxvelis gamoyofiT an mis gareSe.
simptomebi da niSnebi mwvave bronqiti uxSiresad gamowveulia respiraciuli virusebiT, amitom
igi
iwyeba
Semcivneba,
saerTo
respiraciuli sisuste,
infeqciis
msubuqi
niSnebiT,
cxeleba
rogoricaa
(araumetes
3
dRe),
cxviridan gamonadeni, yelis tkivili, kunTebis tkivili, xmis CaxleCa. ZiriTadi klinikuri niSani xvelaa, romelic daavadebis dawyebidan 2-4
dRis
Semdeg
iCens
Tavs.
Tavidan
is
mSrali,
Semawuxebeli
xasiaTisaa, Semdeg produqtiuli xdeba. naxveli Tavidan lorwovania, mogvianebiT
Cirqovani
SeiZleba
gamowveulia
leikocitebis
gaxdes.
migraciiT
Tumca
da
Cirqovani
yovelTvis
ar
naxveli
miuTiTebs
baqteriuli infeqciis arsebobaze. adreuli asakis bavSvebi naxvels ylapaven, rasac SeiZleba mohyves Rebineba. dinamikaSi naxveli TandaTan Txierdeba
da
5-10
dReSi
xvela
gaivlis.
bronqitis
simptomebi
Cveulebriv 2 kviramde grZeldeba, Tumca iSviaTad SeiZleba xvela gaxangrZlivdes 4-6 kviramde. temperatura
normaluria
an
subfebriluri.
adreul
etapze
SesaZloa gamoxatuli iyos nazofaringiti, koniunqtiviti da riniti. daavadebis progresirebis da xvelis intensivobis matebasTan erTad moismineba mSrali da sxadasxva yalibis sveli xixini. zog pacientSi SeiZleba moisminebodes mstvinavi sunTqva. bronqitisaTvis ar aris damaxasiaTebeli
lokaluri
simptomatika:
lokaluri
krepitacia,
bronquli sunTqva, perkutoruli xmianobia moyrueba. aseT SemTxvevaSi gamosaricxia pnevmoniis arseboba. mikoplazmuri
etiologiis
pnevmoniis
SemTxvevaSi
SesaZlebelia
kanze gamonayaris gaCena.
17
bronqitze eWvi unda iqnes mitanili im pacientebSi, romelTanac mwvave
respiraciuli
sruli
anamnezuri
infeqciis
gamokvleva
niSnebi unda
asocirebulia
moicavdes
xvelasTan.
garemo
aris
da
sigaretis zegavlenis dadgenas, epidemiologiur monacemebs. sruli obieqturi gamokvleva aucilebelia, raTa gamoiricxos xvelis sxva mizezebi,
rogoricaa
kardiovaskularuli
daavadebebi
da
filtvis
parenqimis dazianeba.
diagnostikur-laboratoriuli
testebi
da
specialistTa
konsultaciebi a) pirvel 4 saaTSi •
sisxlis saerTo analizi;
•
gulmkerdis organoebis rentgenologiuri kvleva;
•
Jangbadis saturaciis gansazRvra (Cvenebis mixedviT).
b) pirvel 24 saaTSi •
sisxlis saerTo analizi;
•
gulmkerdis rentgenologiuri kvleva;
•
Jangbadis saturaciis gansazRvra (Cvenebis mixedviT);
•
ekg (Cvenebis mixedviT)
g) pirvel 3 dReSi •
sisxlis saerTo analizi;
•
Sardis saerTo analizi;
•
gulmkerdis rentgenologiuri kvleva;
•
Jangbadis saturaciis gansazRvra (Cvenebis mixedviT).;
•
mikrobiologiuri kvleva (Cvenebis mixedviT);
•
serologiuri kvleva (Cvenebis mixedviT);
•
ekg (Cvenebis mixedviT).
sisxlis diagnostikis
saerTo da
misi
analizi
mkurnalobis
-
ar
gansazRvris
iZleva
daavadebis
saSualebas. mwvave
bronqitis dros SeiZleba gamovlindes leikopenia an leikocitozi, limfocitozi, Tumca es ar aris specifiuri am daavadebisaTvis.
18
rentgenologiuri
gamokvleva
– mwvave bronqitis dros
gulmkerdis rentgenograma normaluria an aRiniSneba bronqogenuri gaZliereba. gulmkerdis rentgenogramis Cvenebebia: ¾ pacients aqvs cxeleba, magram ar aqvs zemo sasunTqi gzebis dazianebis simptomebi; ¾ pacients aqvs Tanmxlebi davadeba, romelic xels uwyobs pnevmoniis ganviTarebas – bronqoeqtazia, diabeti, gulis, RviZlis an Tirkmlis paTologia; ¾ anamnezSi pnevmonia (< 1 weli); ¾ anamnezSi tuberkulozis arseboba; ¾ daavadebis gaxangrZliveba an uCveulo mimdinareoba; ¾ eWvi pnevmoniaze. etiologiuri virusis
gamoyofa,
kvleva Tumca
- nazofaringuli sekretidan SeiZleba
es
ar
aris
aucilebeli
diagnozis
dasasmelad an mkurnalobisTvis. vinaidan mwvave bronqiti ZiriTadad virusuli genezisaa, ar aris rekomendebuli naxvelis mikrobiologiuri Tu mikroskopuli kvlevis Catareba. filtvis
funqciis
S e s w a v l a . filtvis funqciis Seswavla
tardeba bronqul asTmaze eWvis dros.
mkurnaloba mwvave
bronqitis
antibiotikoTerapia
ar
ZiriTadi aris
gamomwvevia
naCvenebi.
virusi,
amitom
antibiotikoTerapiaze
unda
vifiqroT, Tu: ¾ zogadi mdgomareoba uaresdeba; ¾ cxeleba grZeldeba erT kviraze met xans; ¾ cxeleba Tavidan iwyeba; ¾ aRiniSneba profuzuli da Cirqovani naxveli; ¾ epidemiologiuri
situaciidan
gamomdinare
eWvia
mikoplazmur,
qlamidiur infeqciaze an yivanaxvelaze; ¾ Tu mwvave bronqitis simptomebTan erTad aRiniSneba sinusiti an otiti; ¾ Tu
daavadeba
SeuZliaT
mimdinareobs gazardon
im
faqtorebis
pnevmoniis
fonze,
ganviTarebis
romelTac riski
19
(imunodeficiti,
alkoholizmi,
gulis
qronikuli
ukmarisoba,
filtvis qronikuli paTologia). mikoplazmur da qlamidiur infeqciaze eWvis dros rekomendebulia makrolidis gamoyeneba. mkurnalobis principebi bavSvebSi 1. mSvidi, komfortuli garemo; 2. siTxeebis damatebiTi miwodeba; 3. antipiretuli saSualebebi; 4. bavSvebSi
xvelis
damTrgunvelebis
gamoyeneba
amasTan
ar
naxvelis
amcirebs
daavadebis
xangrZlivobas,
evakuaciis
daTrgunvam
SeiZleba xeli Seuwyos baqteriul garTulebas;
5. bavSvebSi ar arsebobs mwvave bronqitis dros β2-agonistebis efeqturobis damadasturebeli monacemebi; 6. antihistaminuri preparatebi ar aris rekomendebuli, radgan isini iwveven naxvelis gamoSrobas da SeiZleba gaaZlieron xvela. mSobels unda miewodos informacia, rom dauyovnebliv mimarTos eqims,
Tu
bavSvs
gaZnelebuli;
gamoexata
daewyo
Semdegi
FRebineba
niSnebi:
yoveli
sunTqva
kvebis
Semdeg;
gaxda
ufro
ver
iRebs
siTxeebs; gamoixata zogadi mZime mdgomareoba – daTrgunva, Zilianoba. mkurnalobis principebi mozrdilebSi 1. siTxeebis damatebiT miwodeba bronquli sekretis gamoSrobis Tavidan acilebis mizniT; 2. sigaretis mowevisagan Tavis Sekaveba; 3. antipiretuli saSualebebi; 4. xvelis damTrgunveli saSualebebi xSirad iniSneba bronqitis dros. maT SeiZleba Seamciron xvela, magram maTi miReba ar amcirebs daavadebis xangrZlivobas. 5. amosaxvelebeli saSualebebis rutinuli gamoyeneba ar aris rekomendebuli.
naxvelis
gamaTxierebeli
saSualebebis
daniSvna SesaZlebelia mxolod webovani, Znelad gamosayofi naxvelis SemTxvevaSi; 6. bronqodilatatorebis gamoyeneba umniSvnelo efeqts iZleva gaxangrZlivebuli xvelis dros; 20
7. kortikosteroidebis gamoyeneba ar aris rekomendebuli.
specialistTa konsultacia: a. yel-yur-cxviris specialisti; b. kardiologi, qirurgi, fTiziatri (Cvenebis mixedviT).
reabilitacia da dakvirveba Semdgomi meTvalyureoba Cveulebriv ar aris saWiro, garda im SemTxvevebisa, roca: ¾ mdgomareoba uaresdeba an axali simptomebi Cndeba; ¾ xvela xangrZlivdeba >1 Tveze; ¾ simptomebi meordeba (>3 epizodze weliwadSi).
protokoli
eyrdnoba
saqarTvelos
respiraciuli
asociaciis
“mwvave bronqitis marTvis” gaidlains.
adamianuri da materialur-teqnikuri resursi adamianuri resursi: Terapevti an pediatri. materialur-teqnikuri resursi: gamanaTebeli mowyobiloba xaxis dasaTvaliereblad,
enis
supresori
(Spadeli),
fonedoskopi,
rentgenografiis aparati, ekg, spirografiis aparati.
21
mwvave bronqitis marTvis algoritmi
pnevmoniis niSnebi saxezea? •
respiraciuli distresi;
•
guliscemis sixSire >100/wT –ze;
•
sunTqvis sixSire * >24/wT –ze;
•
temperatura >380C;
•
lokalurad perkutoruli xmis moyrueba,
ifiqreT pnevmoniaze (ix.
diax
pnevmoniis marTvis gaidlaini)
krepitacia, bronquli sunTqva ara gulmkerdis rentgenografia da sxva laboratoriuli kvleva rutinulad ar aris saWiro
xangrZlivoba < 10-14
xvelis xangrZlivoba >
xvelix xangrZlivoba 4-
dReze, mdgomareoba
10-14 dReze
8 kvira
damakmayofilebeli • simptomebis kontroli; • siTxeebis damatebiT miwodeba
ifiqreT yivanaxvelasa an atipur (mikoplazma, qlamidia) infeqciaze
•• • •
**bavSvebSi xvelis damTrgunveli da amosaxvelebeli saSualebebis efeqturoba ar aris dadasturebuli. ***mSobelma dauyovnebliv unda mimarTos eqims, Tu bavSvs gamoexata: Zilianoba; gaZnelebuli sunTqva; Rebineba yoveli kvebis Semdeg; ver iRebs siTxeebs.
• asTma; • ucxo sxeuli;
• xvelis sawinaaRmdego pacientTan/mSobelTan saSualebebi**; isaubreT: antipiretuli saSualebebi; antibiotikis uefeqtobaze; daavadebaze; garemos gamRizianeblebTan antibiotikis gamoyenebas kontaqtis SezRudva. Tan dakavSirebul riskze
ifiqreT sxva mizezze:
Tu dadasturda laboratoriuli kvleviT, gamoiyeneT makrolidi
• tuberkulozi; • mukoviscidozi; • bronqoeqtazia; • fqod da sxva.
ganmeorebiTi konsultacia da gamokvleva saWiroa, Tu: • mdgomareoba uaresdeba*** an Cndeba axali simptomebi; • xvela xangrZlivdeba 1 Tveze met xans; • simptomebi meordeba (>3 epizodze weliwadSi). * bavSvebSi pnevmoniis erT-erT ZiriTad sadiagnostiko niSnad miCneulia sunTqvis sixSire: • 2 Tvemde > 60-ze wuTSi, • 2-dan 12 Tvemde > 50-ze wuTSi, • 12 Tvidan 5 wlamde > 40-ze wuTSi, • 5 welze meti asaki > 30 -ze wuTSi. sunTqvis sixSiris daTvla unda moxdes erTi wuTis ganmavlobaSi, rodesac bavSvi mSvid mdgomareobaSia da ar tiris. bavSvebSi gulmkerdis retraqcia (gulmkerdis qveda mesamedis Cazneqva sunTqvis procesSi) miCneulia mZime pnevmoniis erT-erT ZiriTad sadiagnostiko niSnad, Tumca gaTvaliswinebuli unda iyos, rom msubuqi retraqcia damaxasiaTebelia axalSobilebsa da 22 Cvil bavSvTa asakisTvis da iTvleba normad.
