The dissertation work was performed at the Department of Occupational Diseases, Clinical Immunology and Clinical Pharmacology of Dnipro State Medical University on the basis of the Municipal Non-Profit Enterprise "City Clinical Hospital №4 of the Dnipro City Council".
The dissertation solves an important task of modern pulmonology - developed treatment and diagnostic tactics of patients with bronchiectasis in Ukraine by determining independent predictors of risk of frequent exacerbations, as well as optimizing therapy taking into account clinical and functional characteristics and microbiological spectrum of sputum, anamnestic, anthropometric, laboratory, functional and statistical research methods.
The work describes for the first time the main clinical and anamnestic, anthropometric, laboratory and functional characteristics of patients with bronchiectasis in Ukraine.
For the first time, the structure of the main etiological factors of the disease in a representative cohort of patients in Ukraine was determined.
For the first time, a range of pathogens colonizing the airways of patients with stable phase bronchiectasis in Ukraine was established and their antibiotic resistance profile was determined: the dominant pathogens are P. aeruginosa, which was characterized by polyresistance, and H. influenzae, which was characterized only by certain resistance ampicillin in five percent of cases. The necessity of visual assessment of sputum on the Murray scale and routine microbiological examination of sputum in the stable phase with determination of sensitivity to antibiotics for the rational appointment of antibacterial therapy is substantiated.
Independent clinical-anamnestic (age over 53 years, duration of characteristic symptoms more than 6 years, presence of concomitant bronchial asthma and purulent sputum according to Murray) and laboratory-functional (Ig A level more than 3.84 g / l and postbronchodilator volume of forced exhalation in the first second less than 79% of the appropriate) predictors of frequent exacerbations of bronchiectasis, in the presence of one of which patients need proactive monitoring and treatment.
Extended understanding of predictors of frequent exacerbations of bronchiectasis that can be potentially modified (excess body weight, sputum colonization by pathogens, bronchial obstruction).
Pathogenetically substantiated and proven expediency of measuring the fraction of nitric oxide in exhaled air and the fraction of nasal nitric oxide in patients with bronchiectasis in order to personify treatment tactics.
Three special clinical phenotypes of patients with bronchiectasis have been identified. An algorithm for the appointment of personalized basic therapy in accordance with the defined clinical phenotype has been developed. Additional indications for the appointment of short-term differentiated inhalation therapy with mucolytic, bronchodilator and antiseptic drugs for bronchiectasis are substantiated.
The feasibility of routine FeNO measurement to determine eosinophilic airway inflammation and timely administration (or dose adjustment) of inhaled glucocorticosteroids has been substantiated. The expediency of using a certain algorithm for detecting primary ciliary dyskinesia (PICADAR score ≥ 5 and nasal nitric oxide level ≤ 182 ppb) has been proven to further correct the management of such patients.
An algorithm for prescribing short-term differentiated inhalation therapy with mucolytic, bronchodilator and antiseptic drugs for bronchiectasis, depending on the presence of bronchial obstruction and sputum colonization by pathogens, has been developed and implemented in health care facilities. An algorithm for the appointment of personalized long-term therapy in accordance with the defined clinical phenotype: patients belonging to the first phenotype of bronchodilator therapy with long-acting cholinolytics and mucolytic therapy, according to the indications of antibacterial therapy for eradication type of inflammation; patients belonging to the second phenotype daily breathing exercises, mucolytic therapy; patients belonging to the third phenotype mucolytic therapy, daily nasal lavage and active physiotherapy aimed at clearing the airways of sputum, the appointment of bronchodilator therapy with long-acting cholinolytics, according to the indications antibacterial therapy to eradicate P. aeruginosa.
