SaqarTvelos respiraciuli asociacia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministro qronikuli xvelis gaidlaini avtorebi: q barabaZe, i. CxaiZe, k vaWaraZe, p gvetaZe, eqspertebi: T. lobJaniZe, n cxakaia
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- Tbilisi 2006 definicia.
saqarTvelos respiraciuli asociacia 
saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministro 
qronikuli xvelis gaidlaini avtorebi: q.barabaZe, i.CxaiZe, k.vaWaraZe, p.gvetaZe, eqspertebi: T.lobJaniZe, n.cxakaia, d.maRalaSvili Tbilisi 2006 definicia. qronikulad miCneulia xvela, romelic grZeldeba rva kvira da meti periodi. bavSvebSi qronikulad miiCneva xvela, romelic aRiniSneba yoveldRiurad 4 kviraze meti periodis ganmavlobaSi. gaidlainis aucilebloba. pacientTa umravlesobisaTvis qronikuli xSir SemTxvevaSi organizmis damasustebeli simptomia. klinicistebis mier qronikuli xvela ganixileba, rogorc daumorCilebeli da Znelad samarTavi problema. warmatebuli mkurnalobis gasaRebs qronikuli xvelis gamomwvevi daavadebis zusti diagnostireba da Sesabamisad, xvelis mizezis mkurnaloba warmoadgens. WeSmariti idiopaTiuri xvela iSviaTia da ZiriTadad SecdomiT diagnoscirdeba, gansakuTrebiT, im mizezis gamo, rom daavadebis araswori diagnozis mizezi xSirad xvelis provocirebaa sahaero gzebis gare gamRizianebliT. am gaidlainis mizans warmoadgens daavadebis diagnoscirebis da mkurnalobis ZiraTadi mimarTulebebis gamoyofa da samuSao CarCos Seqmna. pacientTa 90%-ze met SemTxvevaSi qronikuli xvelis mizezs warmoadgens sami ZiriTadi nozologia, romelic aRmocendeba anatomiurad diferencirebul sxvadasxva regionSi. asTma, gastroezofaguri refluqsi da riniti is sami ZiriTadi nozologiaa, romelic qronikuli xvelis ZiriTad mizezs warmoadgens. qronikuli xveliT pacientebSi xSirad ar xdeba daavadebis gamomwvevi mizezis sruli Sefaseba. problemis sirTules ganapirobebs aseve qronikuli xvelis atipuroba. ase, mag: pacientebSi qronikuli xveliT - predominanaturi asTmiT SeiZleba ar gamovlindes bronqokonstriqcia da pacientebSi refluqs-asocirebuli xveliT SeiZleba ar gamovlindes gastroezofaguri refluqsis damaxasiaTebeli iseTi simptomic ki, rogoricaa gulZmarva. epidemiologia qronikuli xvela mozrdilebSi mwvave xvela eqimTan konsultaciis erT-erT ZiriTad mizezs warmoadgens. qronikulad iTvleba xvela rva kviraze meti xangrZlivobiT. eWvgareSea, rom populaciis 3–40%-Si qronikuli xvela avadobis ZiriTadi mizezia. evropis respiraciuli sazogadoebis mxardaWeriT da meTvalyureobiT 20-48 wlis asakis 18,277 subieqtis kvleviT, msoflios 16 qveynidan 30%-Si dadginda Ramis xvela, maT Soris produqtiuli xvela 10%, araproduqtiuli xvela 10%-Si. sigaretis mowevas produqtiuli xvelis prevalirebaze doza-damokidebuli gavlena axasiaTebs. miuxedavad amisa, mwevelebi Zalzed iSviaTad eZeben an iTxoven xvelisaTvis samedicino personalis specifiur rCevas. ZiriTadad, xvelis mizeziT eqims qalebi mimarTaven. gaRizianebaze xveliTi pasuxiT qalebi maRal Sinagan mgrZnobelobas avlenen. qalebSi aseve maRali sixSiriT aRiniSneba antiotenzin-makonvertirebuli enzimis (ace) inhibitoriT gamowveuli xvela. sqesis aseTi kavSiri xvelasTan ucnobia. qronikuli xvela bavSvebSi morecidive xvela bavSvTa asakis erT-erTi mniSvnelovani simptomia. xvela umetesad virusul infeqciasTan aris dakavSirebuli. sadiferenciacio Ddaavadebebis ricxvi sakmaod didia. ra sixSiriT axvelebs janmrTeli bavSvi? skolamdeli da adreuli skolis asakis bavSvTa £10%-s aReniSneba persistirebadi xvela, romelic araa dakavSirebuli arc gaciebasTan, arc sunTqvis gaZnelebasTan. xvela sunTqvis gaZnelebis gareSe xSirad asocirdeba garemo faqtorebTan, kerZod, sinestesTan da garemos dabinZurebasTan, aseve socialur-ekonomiur mdgomareobasTan. mSoblis mier sigaretis moweva mwvave xvelis qronikulSi transformirebis erT-erTi kardinaluri mizezia. qr. xvela aReniSneba <11 wlamde asakis im bavSvTa 50%-s, romelTa mSoblebic (orive) ewevian sigarets. janmrTel bavSvs (saSualo Aasaki 10 weli) 24 sT-is manZilze SeiZleba aReniSnos xvelis »10 epizodi, ZiriTadad dRis ganmavlobaSi. es ricxvi SesaZloa gaizardos respiraciuli infeqciis fonze, romelic janmrTel bavSvebSi SeiZleba aRiniSnos weliwadSi 5-8-jer 7-9 dRis xangrZlivobiT. es SeiZleba iyos xvelis damatebiTi mizezi kidev 50 dRis manZilze wlis ganmavlobaSi. adreuli asakis bavSvebs SesaZloa aReniSnoT ufro xSiri infeqciebi da Sesabamisad ufro xSiri xvelac. wina skolamdeli asakis bavSvebSi qronikuli xvela, gaciebis gareSe, aReniSneba 22%-s. bavSvebi xveliT ar warmoadgenen asTmisa da atopiis ganviTarebis mxriv ufro maRal risks, vidre isini, visac ara aqvT xvela daEgaaCniaT filtvis analogiuri funqcia da sasunTqi gzebis mgrZnobeloba. es niSnavs, rom bavSvebs, romelTac axvelebT, aReniSnebaT sasunTqi gzebis iseTive mgrZnobeloba, rogorc sakontrolo jgufis bavSvebs, Tumca xvelis epizodebis periodSi maT SesaZloa sasunTqi gzebis droebiTi hiperreaqtuloba hqondeT gamoxatuli. N bavSvebSi xvela klasificirdeba: s p e c i f i k u r i a r a s p e c i f i k u r i  
avadobaze damokidebuli xvela (mag., virusis Semdgomi xvela, ganpirobebuli xvelis receptorebis momatebuli mgrZnobiarobiT). etiologiuri agenti cnobilia 
“normaluri” an “mosalodneli” xvela araspecifiuri xvela
specifiuri xvela
xvelis uxSiresi mizezebi asakis mixedviT 0-dan 18 Tvemde: Tandayolili paTologia, xvelis asTmis varianti (asTmuri xvela), arteriis Tandayolili anomalia. 18 Tvis asakidan 6 wlamde: xvelis asTmis varianti da sinusiti. 6-dan 18-wlamde: xvelis asTmis varianti da fsiqogenuri xvela. specifikuri xvelis “mimaniSneblebi”
klinikuri anamnezi dawvrilebiT klinikuri anamnezi mniSvnelovani sadiagnostiko “gasaRebis” gamovlenis saSualebas iZleva, romlis safuZvelze SesaZlebeli xdeba Terapiuli Careva Semdgomi labaratoriuli kvlevis gareSe. xvelis sixSire korelaciaSia sigaretis mowevasTan. sigaretis mowevis anamnezi da misi raodenoba saWiroebs naxvelis detalur analizs. Qqronikuli xvela, SeiZleba iTqvas, aris e.w. “doza-damokidebuli” sigaretis wevaze. aRniSnulidan gamomdinare, qronikuli bronqitis fonze ganviTarebuli naxveli SesaZloa iyos lorwovani an lorwovan-Cirqovani. sigaretis mowevis fonze ganviTarebuli xvela, aseve SesaZloa iyos mSrali, iritaciuli efeqtis Sedegad. dRis manZilze didi raodenobis naxvelis produqcia (erT Wiqaze meti) eWvs badebs bronqoeqtaziis arsebobaze. bronqoeqtaziis dros naxveli ZiriTadad Cirqovania da misi gamoyofa dakavSirebulia pozis cvlilebasTan. qr. xvelis gamomwvevi etiologiuri faqtoris gamovlena swori mkurnalobis SemuSavebis sawindaria. ace-inhibitorTan dakavSirebuli mSrali xvela gvafiqrebinebs, rom pacientTa 15%-Si ace-inhibitoris mkurnalobis dawyebisTanave swrafad viTardeba xvela, romelic sustdeba da wydeba mkurnalobis SewyvetisTanave. zeda sasunTqi gzebis infeqcias Tan axlavs xvela, romelic, Cveulebriv, swrafad ukuviTardeba infeqciis CaTavebis Semdeg. miuxedavd amisa, janmrTel individebSi respiraciuli infeqciis CaTavebis Semdeg SesaZloa persistirebdes mSrali xvela. rigi kvlevebSi naCvenebia, rom aramwevelebSi, romlebic ar Rebuloben ace-inhibitorebs, (gulmkerdis normaluri radiografiiT) qronikuli xvela Cveulebriv asTmis, rinosinusitis an gastro-ezofaguri refluqsis Sedegia. SesaZloa adgili hqondes or an ramdenime paTologias. ZiriTadi daavadebis damaxasiaTebeli simptomebi SesaZloa ar arsebobdes da anamnezic gaurkveveli iyos diagnozis miniSnebis TvalTaxedviT. qronikuli mSrali xveliT pacientebSi paTologiuri fizikaluri monacemebi iSviaTia. gaZnelebuli sunTqva, gulmkerdis SeboWiloba da dispnoe, xvelis paroqsizmi asTmis arsebobaze miuTiTebs, Tumca SesaZloa asTmis xveliT mimdinare varianti (CVA) sruli saxiT ar iyos warmodgenili. Ramis gamwvavebebi asTmis savaraudo niSania. xvela aseve SesaZloa iyos ganpirobebuli civi haeriT an fizikuri datvirTviT. daavadeba SesaZloa mimdinareobdes xvelis araasTmuri variantiT. xmauriani sunTqva pacientebSi SesaZloa moisminebodes varjiSis dros. Tu xvela kavSirSia cxviris obstruqciasTan, rinoreasTan, Cirqovan gamonadenTan, saxis tkivilTan an ganmeorebiT “yelis CawmendasTan”, maSin xvelis savaraudo mizezia rinosinusiti. dadasturebulia kavSiri postnazalur wveTsa da xvelas Soris. xaxis gamokvleviT vlindeba eriTema. ukana faringealuri lorwo, lorwovani an Cirqovani Camonadeni damaxasiaTebelia rogorc postnazaluri wveTisTvis, ise refluqsisTvis. refluqsi, Cveulebriv, qveda ezofagaluri sfinqteris gardamavali relaqsaciis Sedegia. xvela SesaZloa ganviTardes kvebis periodSi an kvebis Semdeg, an gulaRma mwoliare welSi moxril mdgomareobaSi. xvela Cveulebriv mcirdeba Zilis periodSi, rodesac qveda ezofagaluri sfinqteri ixureba da rodesac pacienti brundeba vertikalur mdgomareobaSi. sicilma da saubarma aseve SesaZloa gamoiwvios refluqs-asocirebuli xvela. asTmis an rinosinusitis mqone pacientTa mxolod naxevari mimarTavs specialists. Mmiuxedavad imisa, rom xvela SesaZloa iyos am paTologiaTa erTaderTi klinikuri niSani, aman xeli ar unda SeuSalos eqims dawvrilebiT Sekrebos anamnezi. diagnostika mocemuli rekomendaciebi warmoadgens American College of Chest Physicians–is mier mowodebuli konsesusis farTo variants. diagnozi SesaZloa efuZnebodes im laboratoriul kvlevebs da testebs, romlebic SesaZloa ganxorcieldes rogorc hospitalur, ise ambulatoriul pirobebSi zogadi praqtikis eqimis mier. gulmkerdis Ro-grafia diagnostirebis adreul safexurze savaldebuloa, vinaidan am kvleviT dafiqsirebulma mniSvnelovanma paTologiam SesaZloa Secvalos diagnostikuri algoriTmi da Tavidan agvacilos arasaWiro gamokvleva. spirometriam, bronqodilatatoriT inhalaciamde da inhalaciis Semdeg, SesaZloa gamoavlinos sahaero gzebis reaqtiulobis mniSvnelovani Seqcevadoba, rac daadasturebs asTmis diagnozs. Tu spirometriis Catareba SeuZlebelia an misi Sedegi aris normis farglebSi da asTmis diagnozis albaToba gamomdinareobs mxolod anamnezidan, maSin mowodebulia saxlis pirobebSi eqspiratoruli nakadis seriuli gazomva (pik-flou metria). aRniSnulis fonze SesaZloa gamovlindes mniSvnelovani yoveldRiuri cvlilebebi. CVA-s dros aRniSnuli kvlevis Sedegebi SesaZloa iyos normaSi. maSin ganxiluli unda iyos bronqoprovokaciuli testis Catareba. misi negatiuroba saimedod gamoricxavs asTmas, Tumca ar gamoricxavs stereod-mgrZnobiare xvelas. sinusebis radiografia damoukideblad dabal-specifiuria, magram specifiuroba matulobs da sarwmuno xdeba anamnezuri da yel-yur-cxviris inspeqciis monacemebTan kombinaciaSi. kompiuterul tomografias sinusis kvlevisas aqvs ufro maRali specifiuroba, vidre radiografias, romelic qronikuli xvelis rutinuli Sefasebis mcire danamats warmoadgens. Tu GOR simptomebi naTlad Cans anamnezSi, maSin empiriuli anti-refluqsuri reJimis Seqmna win unda uZRodes zeda gastrointestinuri traqtis kvlevas. qronikuli xvelis rutinul SefasebaSi fibro-bronqoskopiis diagnostikuri ”nayofiereba-Sedegi” dabalia: » 5%. miuxedavad amisa, im pacientebSi, romlebSic qronikuli xvelis gamomwvevi ZiriTadi nozologiebi gamoricxulia, igi mniSvnelovan sadiagnostiko potencials warmoadgens. ucxo sxeulis aspiracia ZiriTadad bavSvTa asakSi gvxvdeba, magram SesaZloa aRiniSnos mozrdilebSic. zogierT SemTxvevaSi sasunTqi gzebis mdgomareobis Sefasebam da ucxo sxeulis eqstraqciam SesaZloa bronqoskopiuri kvleva moiTxovos. bronqoskopia aseve uzrunvelyofs nimuSis aRebis SesaZleblobas (lorwovanis an bronquli lavaJis biofsia). damatebiTi kompiuteruli tomografia gulmkerdis safuZvliani gamokvlevis mizniT ar miiCneva aucilebel kvlevad maRali Rirebulebis gamo. kompiuteruli tomografiiT SeiZleba daisvas filtvis parenqimuli daavadebis an bronqoeqtaziis diagnozi, romelTa arsebobac ver iqna identificirebuli gulmkerdis rentgenografiiT.
aramweveli mozardebis 24-19%-Si mravali prospeqtuli kvleva adasturebs asTmis ZiriTad mizezobriv rols qronikuli xvelis paTogenezSi. Cveulebriv, xvela asocirebulia dispnoes da sunTqvis gaZnelebis tipur simptomTan. miuxedavad amisa, asTmiT avadmyofebis qvejgufSi xvela predominanturi an erTaderTi Civilia. es mdgomareoba aRiniSneba, rogorc CVA: asTmis xvelis varianti. pacientebi CVA-Ti daavadebis adreul periodSi, xSirad avlenen diagnozis damadasturebel simptoms, rodesac fizikaluri kvlevisa da filtvis funqciis Seswavlis maCveneblebi mTlianad normis farglebSia. zog SemTxvevaSi ganixileba bronquli provocirebis testis Catarebis aucilebloba. metaqolinis inhalaciiT (MIC) demonstrirebuli bronquli hiperreaqtiuloba (BHR) asTmis xvelis variantis diagnoscirebis oqros standartad miiCneva. klinicistebs mudam unda axsovdeT, rom MIC moicavs, eTavseba arsebul diagnozs, magram sabolood ar gansazRvravs mas. diagnozis saboloo Camoyalibeba ar iqneba marTebuli, sanam antiasTmuri Terapiis fonze ar moxdeba xvelis sruli alageba. ZiriTadad, CVA-s mkurnaloba “klasikuri” asTmis mkurnalobis analogiuria. xvela, rogorc CVA-s Sedegi, Cveulebriv ukuganviTarebas ganicdis bronqodilatatoriT inhalaciis dawyebidan erTi kviris ganmavlobaSi. Mmiuxedavad aRniSnulisa, xvelis sruli alageba zog SemTxvevaSi SesaZloa moxdes £8 kviraSi bronqodilatatorisa da kortikosteroidebis kombinirebuli Terapiis fonze. mSrali fxvniliT inhalireba an dozirebuli speiseriT inhalacia rekomendebulia steroidis inhalaciuri gziT miRebisas. aucileblad unda aRiniSnos, rom zogierT pacientSi steroidiT inhalaciisas xvelis gamwvaveba aRiniSneba, rac aerozolis moqmedebis Sedegi. mag., xSir SemTxvevaSi, beklometazon diproprionatiT inhalaciis Sedegad ganviTarebuli xvela dakavSirebulia triamcinolon acetonidTan, romelic dispertantTan Tanmxleb komponents warmoadgens. aseT SemTxvevaSi sadiagnostiko Terapiul mcdelobad SesaZloa gamoyenebuli iyos mxolod steroidiT inhalacia (40mg prednizoloni). mimdinare kvlevebi mxars uWeren mosazrebas, rom leikotrienebis receptorebis antagonistebi, rogorc asTmis mkurnalobis uaxlesi Terapiuli saSualebebi, SesaZloa gansakuTrebiT efeqturi iyos CVA-s mkurnalobisTvis. zafirlukastiT 14 dRiani mkurnaloba mniSvnelovnad amcirebs xvelas, aseve amcirebs xvelis refleqsis mgrZnobelobas CVA-s mqone pacientebSi, aseve pacientTa im qvejgufSic, sadac xvela ar iqna moxsnili steroidebiT inhalaciis Semdeg. eozinofiluri bronqiti (EB) amJamad mTlianadaa Secnobili. is vlindeba qronikuli xveliT da naxvelSi eozinofiliiT (>3%). am tipis xvela Cveulebriv kortikosteroidebiT inhalaciaze dadebiT pasuxs iZleva. miuxedavad amisa, pacientTa umravlesobaSi am xvelis gamomwvevi mizezi arasworad Seicnoba da SecdomiT ismeba CVA-s diagnozi. pacientebi eozinofiluri bronqitiT klasikuri asTmatikebisagan gansxvavebiT ar avlenen haeris nakadis Seqcevad obstruqcias an bronqebis hipermgrZnobelobas metaqolinze. prospeqtuli kvleviT dadginda, rom qronikuli xveliT pacientTa 13%-s, romlebmac mimarTes specialistebs, daudasturdaT EB-s diagnozi. asTmuri xvelisTvis rekomendebuli Terapia gulisxmobs bronqodilatatoris da kortikosteroidebis inhalacias, leikotrienebis receptorebis antagonistebis da oraluri kortikosteroidebis gamoyenebas. xvela da gastro-ezofaguri refluqsi mravali kvleva ganixilavs GOR-s, rogorc qr. xvelis erT-erTYyvelaze umniSvnelovanes mizezs. vagusiT inervirebuli ezofaguri receptorebis stimulacia, peristaltikis darRveva da/an refluqsirebadi kuWis SigTavsis aspiracia miCneulia GOR-Tan dakavSirebuli xvelis pirdapir mizezad. xvela SesaZloa iyos GOR-is erTaderTi simptomi manam, sanam anamnezis safuZvelze moxdeba GOR-is iseTi klasikuri simptomis gamovlena, rogoricaa gulZmarva. GOR yovelTvis asocirebulia qveda ezofagaluri sfinqteris gardamaval relaqsaciasTan. qveda ezofagaluri sfinqteris fiziologiis zusti gageba da Seswavla uzrunvelyofs swor diagnostikur xedvas. zogierTi mZime daavadebebis gamoklebiT, qveda ezofagaluri sfinqteri ixureba Zilis peridSi, ris gamoc xvela iSviaTad aris Semawuxebeli RamiT, magram kvlav Rebulobs Semawuxebel xasiaTs, rodesac pacienti dgeba fexze. diafragmis relaqsacia pacientis saubris periodSi amcirebs qveda ezofagaluri sfinqteris tonuss. kveba qveda ezofagaluri sfinqteris relaqsaciis mizezia faringealur-ezofagaluri refluqsis saSualebiT. refluqsi aRwevs zeda sasunTq gzebs da iwvevs simptomTa farTo diapazons: dispnoes, yelis tkivils, “yelSi burTis SegrZnebis” CaTvliT. GOR-iT gamowveuli xvelis diagnostirebisaTvis saukeTeso tests warmoadgens 24 sT-iani ezofagaluri pH monitoringi (OpHM), Tumca misi ganxorcileba Cvens pirobrbSi TiTqmis SeuZlebelia. OpH-iT gansazRvruli refluqsis paTologiuri indeqsi SeiZleba gamoyenebuli iyos GOR dakavSirebuli xvelis diagnostirebisTvis. prospeqtuli kvlevebi aCveneben, rom OpHM-iT miiReba refluqsis indeqsis dadebiTi da uaryofiTi moculoba, Sesabamisad 89 da 100%. sawinaaRmdego azrs gamoTqvams Quers et al. maTi monacemebiT qr. xvelis da paTologiuri pH profilis mqone pacientTa mxolod 35% pasuxobs protonuli tumbos inhibitoriT Terapias, ase rom OpHM ar aris sarwmuno maCvenebeli mJava-damokidebuli xvelis SemTxvevaSi. rodesac OpHM-is Catareba SeuZlebelia an miRebuli Sedegebi aris urTierTgamomricxavi, Catarebuli anti-refluqsuri empiriuli mkurnaloba SesaZloa sasargeblo iyos mqone im pacientebSi, sadac qronikuli xvelis wyarod eWvoben gastro-ezofagur refluqss. rig SemTxvevebSi efeqturia arafarmakologiuri Carevac, rogoricaa Zili Tavis SemaRlebul poziciaSi, Tambaqoze uaris Tqma, wonis Semcireba, dieta cilis maRali da cximis dabali SemcvelobiT, da im sakvebis da sasmelis miReba, romelic xels uwyobs qveda ezofagaluri sfinqteris relaqsacias: alkoholi, Sokoladi, pitna, xaxvi, Cai, yava, kola, citrusebi. am arafarmakologiuri meTodebis asociacia H2 antagonistebTan da/an prokinetikuri agentebTan »3 Tvis manZilze pacientTa 70-100%-Si xsnis GOR inducirebuli xvelas. protonuli tumbos inhibitorebis miReba 8 kviris manZilze iwvevs xangrZlivad persistirebadi GOR inducirebuli xvelis mniSvnelovan Semcirebas da zrdis xvelis zRurbls ezofaguri refluqsis mqone pacientebSi. protonuli tumbos inhibitorebis uefeqtoba SeiZleba dadasturdes mxolod adeqvaturi doziT xangrZlivi, ³12 kviriani mkurnalobis Semdeg. Aprokinetikuri agentebis efeqti vlindeba qveda ezofagaluri sfinqteris tonusis gazrdiT da kuWis dacarielebis gaadvilebiT. isini Cveulebriv gamoiyeneba H2 antagonistebTan da tumbos inhibitorebTan asociaciaSi an monoTerapiis saxiT (bavSvebSi). riniti da sinusiti qr.xvelis mniSvnelovani mizezi post-nazaluri wveTi, GOR da yuris problemebia. diagnoscireba gansakuTrebulad rTulia, vinaidan qronikuli xvela multifaqtoruli daavadebaaa da Tanmxlebi calkeuli komponentis diferencireba sirTules warmoadgens. mag. asTmiT daavadebul pacientTa did nawils aReniSnebaT riniti, xSiria post-nazaluri wveTic. post-nazaluri wveTis kavSiri qronikul xvelasTan sadiagnostikod rTulia. zogierTi mkvlevari mxars uWers mosazrebas, rom nazaluri an sinusidan sekretirebuli wveTi xaxasa da xorxSi xvelis adgilobrivi receptorebis stimulacias iwvevs. lorwos gadasvla cxviridan da sinusebidan xaxaSi fiziologiuri procesia, romelic garkveuli individualobiT xasiaTdeba. pacientebs rinosinusitiT an romelTac Catarebuli aqvT sinusis qirurgiuli mkurnaloba xaxis areSi, aReniSnebaT rogorc fiziologiuri, ise anTebiTi lorwos didi raodenoba. qronikuli sinusitis an polipi dros post-nazaluri wveTi vlindeba 60%-Si, xolo qronikuli xvela 74 %-Si. araasTmatur pacientebSi aRniSnuli maCvenebeli Sesabamisad aris 51% da 65%. ase rom, qronikuli rinosinusiti post-nazaluri wveTiT an mis gareSe SeiZleba iyos qronikuli xvelis mizezi da qveda sasunTqi gzebis daavadebebis maCvenebeli. vinaidan post-nazaluri wveTi ara daavadeba, aramed simptomia, igi saWiroebs diferencialur diagnostikas alergiuli rinitis, vazomotoruli rinitis, virusuli da baqteriuli infeqciis da nazaluri polipis CaTvliT. Tu saeWvoa yel-yur cxviris paTologia, saWiroa Catardes gamokvleva nazaluri endoskopiis CaTvliT. Tu es sindromis predominantuli aspeqtia, nazaluri lavaJi marilwylis xsnariT SesaZloa damxmare saSualebas warmoadgendes. Mmarilxsnari SesaZloa iyos Seyvanili grZeli (20ml) SpriciT an nazaluri SxapiT. nazaluri anTebas SesaZloa vumkurnaloT topiuri kortikosteroidebiT. amasTan, qr. xvelis dros ganixileba pirveli generaciis antihistaminebis gamoyeneba, xSirad simpatomimetikur “dekongestantebTan” erTad. antihistaminebi gavlenas ar axdens nazalur Segubebaze (cxviris gaWedvaze). alergiuli rinitiT avadmyof bavSvebSi qronikuli xvela SesaZloa predominanturi simptomi iyos, rac moiTxovs zeda sasunTqi gzebis daavadebebis mkurnalobas. aseT bavSvebSi inhalaciuri steroidebi ar iZlevian dadebiT efeqts. yuridan wamoWrili problemebi vagaluri nervis (arnoldis nervi) aurikularuli totis gaRizianeba xvelis stimulacias iwvevs. Ees refleqsi pacientTa 2,3%-Si vlindeba. gogirdma, ucxo sxeulma, yuris ineqcirebam SesaZloa refleqsis stimulireba gamoiwvios. SedarebiT iSviaTad xvelis mizezi SesaZloa iyos Sua yuris paTologia. sasmeni milis gaRizianeba SeiZleba advilad dadgindes otoskopiuri kvleviT. sasmeni milidan aRgznebis gamomwvevi faqtoris mocileba simptomTa Semcirebas iwvevs ramdenime dReSi. qronikuli xvela bavSvebSi pediatriuli asakisaTvis damaxasiaTebeli paTologiis gamomwvevi ZiriTadi mizezis amocnoba Zalze mniSvnelovania. qronikuli produqtiuli xvela Cirqovani naxveliT ar ukavSirdeba asTmas. pediatriuli asakisaTvis metad Tu naklebad specifiur diagnozebs warmoadgens kistofibrozi, ucxo sxeulis aspiracia, Tandayolili anatomiuri anomalia, pirveladi ciliaruli diskinezia. aRniSnulze xSirad SesaZloa eWvi iqnes mitanili anamnezis dawvrilebiTi Sekrebis da klinikuri gasinjvis safuZvelze. asTma
sicocxlis pirvel wlebSi asTmis arsebobaze eWvis mitana SesaZlebelia, rodesac qronikuli xvela asocirdeba atopur egzemasTan da asTmasa da alergiaze ojaxis anamnezTan. amasTan, adreuli asakis bavSvebSi anTebis “asTmuri” tipi damaxasiaTebeli eozinofiluri infiltraciiT da qronikuli xveliT iSviaTad vlindeba. skolis asakis bavSvTa xvelis sixSiris Sedarebam or jgufs _ asTmatikebsa da janmrTel bavSvebs Soris Setevebs Soris gansxvaveba ar aCvena, Tumca bronqokonstriqciis dros asTmatikebSi gacilebiT mZime xvela aRiniSneba. skolis asakis bavSvebSi Ramis xvela mstvinavi sunTqvis (wheezing) dros ar ukavSirdeba filtvis funqciis gauaresebas da hipermgrZnobelobas. skolamdeli asakis bavSvebSi qronikuli xvela, mstvinavi sunTqviT mimdinare xvelasTan SedarebiT, keTilsaimedo prognoziT xasiaTdeba da umravles SemTxvevebSi qreba 6 wlamde asakSi. refluqsi da aspiracia kuWis SigTavsis aspiraciiT an mis gareSe mimdinare refluqsi pediatriuli asakis mniSvnelovan paTologiaTa, kerZod, xveliTa da mstvinavi sunTqviT mimdinare qronikuli respiraciuli sindromis umTavresi mizezia. GOR-is zogierTi stadia axalSobilobis periodisaTvisaa damaxasiaTebeli da asakis matebasTan erTad spontanurad umjobesdeba. aSkaraa, rom es “normaluri” refluqsi xSirad ar aris asocirebuli xvelasTan. infeqcia
qr. xvelis mqone adreuli asakis bavSvTa jgufSi BAL monacemebi infeqciuri genezis maRal procents avlens. qronikuli xvelis mizezs mravali infeqcia warmoadgens, maT Soris yivanaxvela, tuberkulozi, morecidive virusuli infeqcia da yel-yur-cxviris qronikuli infeqcia. axalSobilebSi qronikuli xvelis mizezs SesaZloa aseve warmoadgendes qlamidia, citomegalovirusi, Ureaplazma urealitica. yivanaxvelas SemTxvevaSi xvela ramodenime Tvis manZilze grZeldeba da ar emorCileba mkurnalobas. epidemiis procesSi daavadeba SesaZloa aRiniSnos yivanaxvela-vaqcinirebul bavSvebSic. qronikuli xvelis mizezs SesaZloa warmoadgendes tuberkulozi limfuri jirkvlebis gadidebis an perforaciis gamo sasunTqi gzebis obstruqciis an filtvis segmentis meoradi dainficirebis Sedegad. imunodeficiti Tu sasunTqi gzebis infeqcia uCveulod, arabunebrivad xSiri da mZimea, maSin ganxiluli unda iqnes sxva daavadebebis arseboba pirveladi imunodeficitis msubuqi variantis CaTvliT. Tu sasunTqi gzebis qronikuli infeqcia asocirebulia zrdaSi CamorCenasa da malabsorbciasTan, oflis testis saSualebiT unda moxdes kistofibrozis gamoricxva. pirveladi ciliaruli diskinezia (PCD) PCD ganapirobebs yel-yur-cxviris da qveda sasunTqi gzebis mZime infeqciis kombinacias. Situs inversus aRiniSneba » 50%-Si da SesaZloa dadgindes prenatalur periodSi rutinuli eqografiiT. Tandayolili anomalia traqeobronqomalacia SesaZloa arsebobdes rogorc izolirebuli anomalia an rogorc sindromis nawili. igi damaxasiaTebeli ”uxeSi” xvelis mizezia. traqeo-ezofaguri fistulis an laringealuri napralis arseboba iwvevs xvelas kvebis dros ganviTarebuli aspiraciis Sedegad. arsebobs sasunTqi gzebis kompresiis an stenozis gamomwvevi mravali mizezi. mag. sisxlZarRvovanma rgolma da sxva vaskularulma malformaciam SesaZloa qronikuli respiraciuli simptomi gamoiwvios. sasunTq gzebSis infeqciiT xSiri avadoba SesaZloa rogorc filtvis mzardi perfuziis, ise atrialuri an parkuWTa Zgidis defeqtis an Ria botalis sadinaris Sedegi iyos. ucxo sxeulis aspiracia aspirirebuli ucxo sxeulis amocnoba SesaZloa xangrZlivi drois manZilze ver moxdes. ucxo sxeulis aspiracia ufro xSiria adreuli asakis vaJebSi, vidre gogonebSi da gansakuTrebiT maRali sixSiriT gvxvdeba <4 wlamde bavSvTa asakSi. literaturaSi arsebuli monacemebiT, qronikuli xvelis dros ucxo sxeulze eWvis ararsebobis SemTxvevaSi ucxo sxeulis bronqoskopiiT diagnoscirebis sixSire mcirea. Tumca Godfrey et all axsenebs warmatebuli bronqoskopiebis Sesaxeb, rodesac ucxo sxeulis arseboba naTlad ar iyo gaazrebuli. fsiqogenuri xvela fsiqogenuri xvela bavSvTa asakSi xSiri araa. man SeiZleba ganapirobos “yiyinis” an “signalis” xmianobis msgavsi xvela, romelic SeiZleba moTxovnis mixedviT ganxorcieldes. diagnozi unda daisvas sxva daavadebebis, gansakuTrebiT turetis sindromis gamoricxvis gziT, romelic bavSvTa asakSi SeiZleba mxolod xvelis saxiT gamovlindes.
xvelis gamowveva xvelis gamowveva tusigenuri agentiT xvelis refleqsis sensoruli (“xvelis zRurbli”) da motoruli komponentebis matebas iwvevs. xvelis gamowvevam SesaZloa uzrunvelyos mZime xvela da Sefasdes mZlavr refleqsad nevrologiuri darRvevis mqone pacientebSi, Tumca momatebuli xvelis refleqsis arseboba ar aris daavadebis specifiuri niSani. naxvelis analizi im pacientebis naxvelis analizSi, romelTac aReniSnebaT asTma, CVA da EB aRmoCenilia eozinofilebisa da metaqromatuli ujredebis momatebuli raodenoba. sasunTqi gzebis eozinofiluri anTebis dadgena SeiZleba sasargeblo aRmoCndes qronikuli xvelis mizezis dadgenis da mkurnalobis TvalsazrisiT.
xvelis marTvis Tanamedrove strategia ganicdis e.w. fasi-efeqturobis analizs. sakiTxisadmi midgoma: “gamoikvlie yvelaferi, Semdeg umkurnale” Zalian Zviri iyo, Tumca xasiaTdeboda mkurnalobis umciresi periodiT. sapirispiro midgoma - mkurnaloba etapobrivad, dawyebuli rinitiT, xasiaTdeba ufro iafia, magram mkurnalobis periodi xangrZlivia. aRniSnulidan gamomdinare, optimaluria kvlevis fasisa da mkurnalobis xangrZlivobis optimaluri balansireba. ase magaliTad, pacientebSi asTmisa da postnazaluri wveTis gareSe, empiriuli orkviriani mkurnaloba protonuli tumbos inhibitorebis maRali doziT ufro mizanSewonilia, vidre kvleva manometria dahpH-testireba. laboratoriuli kvlevis da empiriuli mkurnalobis kombinireba xels uwyobs qronikuli xvelis marTvis saukeTeso strategiis SemuSavebas. gaidlainSi ganxilulia ori mimarTuleba: I. mkurnalobis empiriuli meTodis gamoyeneba; II. rekomendebuli gamokvlevebis Catareba. Tumca es strategiebi paralelurad unda iqnes ganxiluli. qronikuli xvelis mkurnalobis efeqturi saSualeba jer-jerobiT ar arsebobs. xvelis ramodenime axali meqanizmis identificirebam SesaZloa uzrunvelyos iseTi medikamentebis gansazRvra, romlebic Seamcirebs gaxangrZlivebuli xvelis gamomwvevi sensoruli boWkoebis momatebul mgrZnobelobas. bevri potenciuri medikamenti efeqturia cxovelebSi gamowveuli xvelis inhibirebaSi da ukve testirebulia adamianebSi. Aaxali medikamentebi gansxvavdebian qronikuli xvelis gamomwvevi ZiriTadi mizezebis inhibirebis mixedviT. esenia asTmis an CVA-s dros arsebuli xvelis samkurnalo antianTebadi medikamentebi, GOR-is samkurnalo protonuli tumbos axali inhibitorebi, naerTebi, romelic ainhibireben sensoruli nervis aqtivobas.
Cvenma Sexedulebebma qronikuli xvelis diagnoscirebasa da mkurnalobaze ukanaskneli 20 wlis manZilze radikaluri cvlilebebi ganicada. gamocdileba aCvenebs, rom qronikuli xvelis udidesi nawili emorCileba mkurnalobas. gamoyofen im sami ZiriTadi daavadebis Taviseburebebs, romlebic warmoadgenen qronikuli xvelis ZiriTad mizezs. esenia: asTma, gastro-ezofaguri refluqsi da riniti. xvelis sixSiris Semcireba Catarebuli mkurnalobis fonze adasturebs refluqsis plastiurobas. xvelis makontrolebeli faqtorebis gageba fundamenturi sakiTxia da gansazRvravs mkurnalobis efeqturobas. xvela warmoadgens sasunTqi gzebis sasicocxlo mniSvnelobis damcav refleqss. mkurnalobis ZiriTad mizans unda warmoadgendes xvelis normaluri refleqsis aRdgena. xvelis receptorebis molekuluri da fiziologiuri organizaciis Sesaxeb codnis gaRrmaveba saSualebas mogvcems axlo momavalSi mivaRwioT dasaxul mizans. gaidlainis miRebis wyaro. winamdebare gaidlainis ZiriTadi wyaroa evropis respiraciuli asociaciis gaidlaini The diagnosis and management of chronic cough (Eur Respir J 2004). garda amisa, gaTvaliswinebulia sxvadasxva gaidlainebi da samecniero publikaciebi (ix. literatura). literatura 1. McGarvey LP, Heaney LG, Lawson JT, et al. Evaluationand outcome of patients with chronic non-productive cough using a comprehensive diagnostic protocol. Thorax 1998; 53:738–743. 2. Palombini BC, Villanova CA, Araujo E, et al. A pathogenic triad in chronic cough: asthma, postnasal drip syndrome, and gastroesophageal reflux disease. Chest 1999; 116: 279–284. 3. Brightling CE, Ward R, Goh KL, Wardlaw AJ, Pavord ID. Eosinophilic bronchitis is an important cause of chronic cough. Am J Respir Crit Care Med 1999; 160: 406–410. 4. Simpson G. Investigation and management of persistent dry cough. Thorax 1999; 54: 469–470. 5. McGarvey LPA, Heaney LG, MacMahon J. A retrospective survey of diagnosis and management of patients presenting with chronic cough to a general chest clinic. Int J Clin Pract 1998; 52: 158–161. 6. Lin L, Poh KL, Lim TK. Empirical treatment of chronic cough: a cost-effectiveness analysis. Proc AMIA Symp: 2001:383–387. 7. Munyard P, Bush A. How much coughing is normal? Arch Dis Child 1996; 74: 531–534. 33. Shann F. How often do children cough? Lancet 1996; 348: 699–700. 8. Luyt DK, Burton PR, Simpson H. Epidemiological study of wheeze, doctor diagnosed asthma, and cough in preschool children in Leicestershire. Br Med J 1993; 306: 1386–1390. 9. Brooke AM, Lambert PC, Burton PR, Clarke C, Luyt DK, Simpson H. Recurrent cough: natural history and significance in infancy and early childhood. Pediatr Pulmonol 1998; 26: 256–261. 10.Swanson KL, Edell ES. Tracheobronchial foreign bodies. Chest Surg Clin N Am 2001; 11: 861–872. 11. Pratter MR, Bartter T, Akers S, Dubois J. An algorithmic approach to chronic cough. Ann Intern Med 1993; 119: 977–983. 12. Vela M, Camacho-Lobato L, Hatlebakk J, Katz PO, Castell DO. Effect of omeprazole (PPI) on ratio of acid to nonacid gastroesophageal reflux. Studies using simultaneous intraesophageal impedance and pH measurement. Gastroenterology 1999; 116: G0910. 13. Kiljander TO, Salomaa ER, Hietanen EK, Terho EO. Chronic cough and gastro-oesophageal reflux: a doubleblind placebo-controlled study with omeprazole. Eur Respir J 2000; 16: 633–638. 14. A.H. Morice and committee members. The diagnosis and management of chronic cough. Eur Respir J 2004; 24: 481–492 15. Hiew YH, Smith JA, Earis JE, Cheetham BMG, Woodcock AA. DSP algorithm for cough identification and counting. Proceedings of the International Conference of Acoustic, Speech and Signal Processing (ICASSP). Orlando, USA IV, 2002; pp. 3888–3891. 16. Piirila P, Sovijarvi AR. Differences in acoustic and dynamic characteristics of spontaneous cough in pulmonary diseases. Chest 1989; 96: 46–53. 17. Niimi A, Amitani R, Suzuki K, Tanaka E, Murayama T, Kuze F. Eosinophilic inflammation in cough variant asthma. Eur Respir J 1998; 11: 1064–1069. qronikuli xvelis protokoli definicia. qronikulad miCneulia xvela, romelic grZeldeba rva kviras da meti periodi, pacientTa umravlesobisaTvis warmoadgens saerTo da, xSir SemTxvevaSi, organizmis damasustebel simptoms. klinicistebis mier ganixileba, rogorc daumorCilebeli da Znelad samarTavi problema. WeSmariti idiopaTiuri xvela iSviaTia da ZiriTadad SecdomiT diagnoscirdeba. bavSvebSi qronikulad miiCneva xvela, romelic aRiniSneba yoveldRiurad 4 kviraze ufro meti periodis ganmavlobaSi. xvelis uxSiresi mizezebi asakis mixedviT 0-dan 18 Tvemde: Tandayolili paTologia, xvelis asTmis varianti (asTmuri xvela), arteriis Tandayolili anomalia. 18 Tvis asakidan 6 wlamde: xvelis asTmis varianti da sinusiti. 6-dan 18-wlamde: xvelis asTmis varianti da fsiqogenuri xvela. specifikuri xvelis arsebobas “mimaniSneblebi”
pacientTa umravlesobaSi qronikuli xvelis mizezs warmoadgens darRvevaTa ramodenime saxe-paTologiur mdgomareobaTa kombinacia da mxolod SemTxvevaTa nawilSi mis gamomwvevad erTi nozologia gvevlineba. kerZod, xvelis mizezi pacientTa 82%-Si aris 1 nozologia, xolo 18%-Si qronikuli xvelis gamomwvevad miiCneva multifaqtoruli paTologia. sworad marTuli mkurnalobis pirobebSi SemTxvevaTa 97%-Si qronikuli xvela srulad ixsneba. pacientTa 14-23%-Si qronikuli xvela eqimTan pirveli vizitis mizezs warmoadgens. qronikuli xvelis ZiriTadi da damatebiTi mizezebi Z gulis daavadebebi; kibo (filtvis, saylapavis); filtvis intersticiuli daavadeba (emfizema, sarkoidozi);
sxva qronikuli infeqcia, kisto-fibrozi;
sxva ekologiuri gaRizianeblebi;
asTma;
hipermgrZnobeloba;
qronikuli xvela (beta-blokatorebi, ACE inhibitorebi). diagnostikis da mkurnalobis algoriTmi I safexuri yvela pacients qronikuli xveliT, romelmac mimarTa eqims pirveli kviris ganmavlobaSi, utardeba postnazaluri rinitis empiriuli mkurnaloba `antihistamin-dekongestantebi~-s kombinaciiT. Tu arsebuli mkurnalobis fonze xvela Semcirda, mkurnaloba grZeldeba mis srul aRmofxvramde. im pacientebSi, romlebic ar emorCileba dawyebul mkurnalobas, damatebiT gamoiyeneba nazaluri steroidebi 2 kviris manZilze. Tu xvela grZeldeba da ar miiRweva dadebiTi Sedegi, pacients unda Cautardes Tavis qalis wiaRebis kvleva (rentgenografia, kompiuteruli tomografia) qronikuli sinusitis diagnostirebis mizniT. qronikuli sinusitis identificirebis SemTxvevaSi pacients utardeba empiriuli mkurnaloba augmentiniT, II an III Taobis oraluri cefalosporinebiT, pacienti saWiroebs yel-yur-cxviris specialistis konsultacias. II safexuri I safexurze miRebuli zomebis miuxedavad, Tu pacients ugrZeldeba xvela, saWiroa asTmis gamoricxva. aramwevel pacientebis 24%-s qronikuli xvelis mizezs warmoadgens asTma, asTmis zusti diagnostirebisaTvis unda Sefasdes eqspiratoruli haeris nakadis pikuri moculoba spirometris saSualebiT. asTmiT avadmyofebSi aRiniSneba eqspiratoruli nakadis pikuri moculobis Semcireba da Semdgomi bronqodilataciuri Terapiis fonze misi moculobis zrda. bronquli asTmis dadgenis SemTxvevaSi pacientebi gafrTxilebulebi unda iqnen xangrZlivi prevenciuli mkurnalobis aucileblobaze. III safexuri Tu pirvel 2 safexurze Catarebuli kvlevebis miuxedavad ver moxerxda diagnostireba, am etapze aucilebelia moxdes Tandayolili anomaliebis gamovlena da Sesabamisi mkurnaloba. IV safexuri Tu am safexurisaTvis ver moxerxda qronikuli xvelis gamomwvevi mizezis identifikacia unda Catardes simptomurad: gastroaciduri daTrgunvis testi antirefluqsur mkurnalobasTan erTad. pacientebi gastro-ezofaguri refluqsiT yovelTvis grZnobdnen wvas da diskomforts gulmkerdis areSi. xSirad, am paTologiiT pacientebSi erTaderT simptoms warmoadgens qronikuli xvela. pacientTa umravlesobaSi antiaciduri mkurnalobis fonze xvelis arSemcirebis SemTxvevaSi iricxeba refluqsis arseboba. protonuli tumbos inhibitorebis (mag.: omeprozolis 80 mg/dReSi) gamoyeneba iwvevs refluqsis srul daTrgunvas. es testi mgrZnobiarea pacientTa 83-90% SemTxvevaSi. arasasurveli Sedegis miRebis SemTxvevaSi protonuli - tumbos inhibitorebiT agresiuli Terapia unda gagrZeldes aranakleb 8 kvira. V safexuri pacientebs, romlebic jer kidev ugrZeldebaT xvela, unda Cautardes bronqoskopuli kvleva. Tu aRniSnulis fonze ver moxdeba qronikuli xvelis mizezis diagnostireba, unda Catardes antihistaminuri Terapiis ganmeorebiTi kursi β agonostebTan da steroidebTan erTad.
saeWvo asTma
pH-is 24 saaTiani H monitoringi saeWvo riniti cxviris danamati Rruebis rentgenografia kompiuteruli tomografia
  
qronikuli xvelis diagnostikuri algoritmi klinikuri anamnezi, o
dasaSveb farglebSi
pik-flou metria (asaki > 6w) Tu paTologiaa: specifiuri testebi Tu normaluria: refluqsis kvleva, oflis testi Tu paTologia ar aris da xvela grZeldeba, keTdeba bronqoskopia specifiuri paTologiis mimaniSnebeli → ciliaruli diskinezia __ ciliaruli funqciis Seswavla → mukoviscidozi → oflis testi → ucxo sxeuli → bronqoskopia → Cirqovani infeqcia → → refluqsi, aspiracia → → maRali riskis jgugi → tuberkulozi, HIV → yivanaxvela qlamidia→kultura, serologia CMV PCR
paTologia → alergia, asTma → → →
alergiis testi, pik-flou metria, asTmis mkurnalobis cda alveoluri fibrozi, auto-imunuri daavadeba naxvelis kultura, mikrobiologia imunologia, oflis testi
Tandayolili anomalia
bronqokopia CT/MRI, angiografia
autoantisxeulebi          
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