Russian Respiratory Society Research Articles

Tactics of primary care physician in the management of patients with asthma in accordance with the latest changes in international and national guidelines

The article addresses to changes in the management of patients with bronchial asthma in accordance with international and national recommendations of 2019. The new management strategy for patients with mild asthma, the rejection of short-acting 2-agonist (SABA) reliever medication monotherapy in favor of an anti-inflammatory bronchodilator drug will improve disease control, patient compliance, reduce the risk of severe exacerbations and death. The use of the algorithm for diagnosing and management asthma by primary care physicians, developed by experts of the Russian Respiratory Society and the Russian Association of Allergologists and Clinical Immunologists, will reduce the time for diagnosing asthma, timely and correctly prescribe anti-inflammatory therapy and control the course of the disease.

Комплексная терапия пациентов с респираторными инфекциями и заболеваниями дыхательных путей

The article provides an overview of the symposium on the complex therapy of patients with respiratory infections and diseases of the respiratory tract, held on October 29, 2020 with the support of Materia Medica Holding as part of the XXX National Congress on Respiratory Diseases, which was held from October 27 to 30 online with the support of the Russian Respiratory Society and the Ministry of Health of the Russian Federation. The aim of the symposium was to familiarize physicians, general practitioners, pulmonologists and infectious disease specialists with possible ways of managing patients with respiratory diseases caused by respiratory infections, as well as with the results of randomized clinical trials (RCTs) on the management of patients with chronic obstructive pulmonary disease (COPD). The co-chairs of the symposium and keynote speakers were three leading experts in this field – professors A. A. Zaitsev (Moscow), R. F. Khamitov (Kazan) and A. A. Wiesel (Kazan). At the symposium, the results of RCTs were presented, proving the effectiveness of antiviral and immune stimulating drug in influenza and other acute respiratory viral infections, regardless of the timing of the therapy started, its favorable safety profile, as well as the ability to reduce the need for antipyretic drugs and help prevent bacterial complications. Data from another RCT demonstrate the ability of antitussive drug to reduce cough and reduce its severity in COPD, reducing the impact of COPD on patients' lives.

A role of inhaled corticosteroids in management of patients with chronic obstructive pulmonary disease: current recommendations. Expert panel conclusion

According to current evidence, therapy with inhales corticosteroids (ICS) is unsuccessful in majority of patients with chronic obstructive pulmonary disease (COPD). Moreover, long-term therapy with ICS significantly increases the risk of adverse events. According to recent international and Russian guidelines, there is a limited role of ICS in the management of COPD patients. The optimal risk/benefit ratio could be achieved in specific populations of COPD patients only. Therefore, an therapeutic algorithm for COPD patients in Russia needs to be updated. A strategy of ICS with-drawal in patients who would not benefit from ICS should be included in the algorithm. Based on actual findings, experts of Russian Respiratory Society updated the Russian algorithm for management of COPD patients including possibility of ICS withdrawal.

A strategy for improvement in diagnosis and treatment of bronchial asthma in primary care

Recently, bronchial asthma is considered as a heterogeneous disease characterized by chronic airway inflammation and respiratory symptoms, which vary in time and intensity and manifest together with variable obstruction of the airways. Asthma is one of the most common chronic respiratory diseases in primary care. Patients with certain respiratory symptoms seek for medical aid initially in primary care physicians, such as therapeutists, general practitioners, and family physicians, who can suspect and diagnose chronic respiratory diseases such as bronchial asthma, chronic obstructive pulmonary disease (COPD), allergic rhinitis, etc. Currently, untimely diagnosis of asthma and late initiation of anti-inflammatory treatment are widespread, mainly due to insufficient knowledge of primary care physicians on diagnostic criteria and therapeutic standards for asthma. Feasible and convenient algorithms for asthma diagnosis and treatment in primary care were developed by experts of Russian Respiratory Society and Russian Association of Allergologists and Clinical Immunologists. A therapeutic algorithm for asthma treatment in primary care institutions uses an approach considering symptom severity both in patients with newly diagnosed and previously treated for asthma. Diagnostic tools, such as a questionnaire for asthma diagnosis and an algorithm for differential diagnosis between asthma and COPD are mainly intended to facilitate diagnosis of chronic respiratory disease, particularly bronchial asthma, by a primary care physician and to improve the healthcare quality for these patients.

Federal Clinical Guidelines on Preventive Vaccination Against Pneumococcal infections in Adults

The Federal Guidelines on preventive vaccination against pneumococcal infections in adults were developed by experts of Russian Respiratory Society and National Non-profit Association of Specialists for Control Healthcare-Associated Infections. Studies published during the previous 5 years were selected from EMBASE, MEDLINE , and PubMed databases and the Cochrane library and were reviewed by independent experts with consideration of practical physicians’ opinions. The results of this analysis underlay the guidelines. Quality of evidence and strength of recommendations were assessed according to widespread criteria. The guidelines include epidemiology, social burden, pathogenesis, and clinical course of pneumococcal infections, characteristic of vaccines used to prevent pneumococcal infections and special considerations of preventive vaccination in patients with comorbidity and in risk groups. The experts discussed efficacy of preventive vaccination and postvaccinal reactions. The guidelines meet the requirements of Healthcare Ministry of Russian Federation.

Clinical recommendations in pulmonology. The role of functional diagnostics methods in their implementation

The article presents excerpts related to the use of functional diagnostic methods from clinical recommendations for the treatment of bronchial asthma, chronic obstructive pulmonary disease, sarcoidosis, and idiopathic pulmonary fibrosis, which have been approved by the Russian Respiratory Society and the Russian Ministry of Health today.

Possibilities to prevent acute exacerbation of chronic obstructive pulmonary disease using inhalational therapy. A Report of Expert Panel of Russian Respiratory Society

An impact of acute exacerbation of COPD (AECOPD) on the course and the prognosis of chronic obstructive pulmonary disease depends on severity of the exacerbation. Moderate and severe exacerbations are considered as clinically significant events. Clinical studies investigating a role of inhalational therapy for the risk of AECOPD differed significantly in important parameters and the patients involved were not fully described in the real clinical practice. Tiotropium alone did not demonstrate any benefit over other inhalational therapies, such as inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) combinations and long-acting muscarinic antagonist (LAMA)/LABA combinations, for risk reduction of moderate to severe exacerbations. A benefit of tiotropium/olodaterol combination over tiotropium for the reduction of risk of clinically significant exacerbations was first shown in DYNAGITO study; patients’ groups in this study did not differ in a rate and a spectrum of adverse events including cardiovascular events. An efficient bronchodilating therapy should be administered to all patients with COPD as it could improve dyspnea and prevent exacerbations. Further escalation of treatment in patients with frequent exacerbations of COPD should be personalized according to clinical course and causes of AECOPD.

Russian guidelines for the management of COPD: algorithm of pharmacologic treatment.

The high prevalence of COPD together with its high level of misdiagnosis and late diagnosis dictate the necessity for the development and implementation of clinical practice guidelines (CPGs) in order to improve the management of this disease. High-quality, evidence-based international CPGs need to be adapted to the particular situation of each country or region. A new version of the Russian Respiratory Society guidelines released at the end of 2016 was based on the proposal by Global Initiative for Obstructive Lung Disease but adapted to the characteristics of the Russian health system and included an algorithm of pharmacologic treatment of COPD. The proposed algorithm had to comply with the requirements of the Russian Ministry of Health to be included into the unified electronic rubricator, which required a balance between the level of information and the simplicity of the graphic design. This was achieved by: exclusion of the initial diagnostic process, grouping together the common pharmacologic and nonpharmacologic measures for all patients, and the decision not to use the letters A–D for simplicity and clarity. At all stages of the treatment algorithm, efficacy and safety have to be carefully assessed. Escalation and de-escalation is possible in the case of lack of or insufficient efficacy or safety issues. Bronchodilators should not be discontinued except in the case of significant side effects. At the same time, inhaled corticosteroid (ICS) withdrawal is not represented in the algorithm, because it was agreed that there is insufficient evidence to establish clear criteria for ICSs discontinuation. Finally, based on the Global Initiative for Obstructive Lung Disease statement, the proposed algorithm reflects and summarizes different approaches to the pharmacological treatment of COPD taking into account the reality of health care in the Russian Federation.

Algorithm of biophenotyping and choice of medication for targeted therapy of severe uncontrolled asthma with eosinophilic type of airways inflammation

The article is based on the resolution of the Expert Council, including experts from Russian Association of Allergists and Clinical Immunologists (RAACI) and Russian Respiratory Society (RRS) dated November 20, 2016, and the review of clinical studies results and publications on the biomarker-based diagnosis and biological treatment of severe uncontrolled asthma. The aim of this work is to develop a phenotype-oriented algorithm of diagnostics and treatment of severe asthma, supported by the biomarker testing for subsequent selection of appropriate immunobiological treatment. The article constitutes the summary of results of clinical studies and expert opinions on the treatment of asthma in patients who do not achieve disease control with standard treatment regimens including high doses of inhaled corticosteroids in the combination with long-acting beta-agonists, tiotropium, and medications from other pharmacological groups according to Russian Respiratory Society (2016) and GINA (2016-2017) guidelines. The article summarizes the results of international randomized clinical studies performed to assess safety and efficacy of new class of biological treatments, monoclonal antibodies acting against major cytokines that are responsible for inflammation, in patients with severe asthma, including a new anti-IL-5 antibody, reslizumab (Cinqaero).

Pilot Project «All-Russian Registry of Patients with Severe Bronchial Asthma.» The First Results in a Children’s Group of Patients (Moscow’s Observation Program)

The article presents the first results of the pilot observation program «The All-Russian Severe Asthma Patient Registry» which was started in Moscow. Objectives. The objective of this initiative is the accumulation of clinical data on patients with severe bronchial asthma in the Russian Federation. Methods. The chosen method was a registry, the rights holders of which were 3 professional associations — Interregional Public Organization «Russian Respiratory Society», Public Organization «Union of Pediatricians of Russia», All-Russian Public Organization «Association of Allergologists and Clinical Immunologists». Results. The results of the pilot project are presented by the data analysis of electronic case report forms of 36 children (totally, the project included 100 patients, 64 adults and 36 children) enrolled in the program from June to December 2016. Using the registry, a detailed analysis of the clinical characteristics of a group of children with severe atopic bronchial asthma was carried out, the results of a pharmacoepidemiological evaluation of therapy were given. Obtained by the researchers, a high frequency of the assignment of a genetically engineered biologic drug of omalizumab meets the international recommendations but does not reflect the all-Russian reality and can be explained by inclusion in the registry of pediatric patients observed only in the Federal State Autonomous Institution «National Scientific and Practical Center of Children’s Health» of the Ministry of Health of the Russian Federation. Conclusion. To determine true indicators that characterize bronchial asthma in children in the Russian Federation it is necessary, undoubtedly, to expand the geography of project participants.

History of pulmonology in Russia

History of Russian pulmonology is described in the article. The rise of this science inRussiawas closely related to Sergey P. Botkin who taught physicians not only to recognize diverse variants of respiratory diseases but also to evaluate the patient's status as a whole. Dmitriy D. Pletnev, who investigated severe and complicated pneumonias; Ippolit V. Davydovskiy, who supposed that several pathological processes could exist in the human's lung contemporarily; Nikolay S. Molchanov and Vladimir P. Sil'vestrov, who investigated slowly-resolved pneumonia, and other investigators contributed significantly to the Russian pulmonology. Establishment of the Federal Pulmonology Research Institute, which became as a cooperating center, and "Russian Respiratory Society" Interregional Public Organization, and other important initiatives were main stages of development of the Russian pulmonology. Scientific and practical activity of the Federal Pulmonology Research Institute during last 25 years has been analyzed in the article. Important achievements in the control of such severe and common diseases, as pneumonia, asthma, chronic obstructive pulmonary disease, cystic fibrosis, tuberculosis, etc., have been discussed in the article. Further investigations that would allow bring the pulmonologist's work in line with the current requirements have been outlined in the article.

New opportunities for prevention of exacerbations of chronic obstructive pulmonary disease. Russian Respiratory Society Expert Opinion

Combination therapy with long-acting β2-agonists (LABA) and long-acting muscarinic antagonists (LAMA) can reduce symptoms of chronic obstructive pulmonary disease (COPD) and the risk of future exacerbations. To date, the only fixed combination of long-acting bronchodilators, indacaterol/glycopyrronium, has demonstrated a significant reduction in dyspnea and in the risk of moderate and severe exacerbations of COPD in clinical trials when compared with the combination of salmeterol/fluticasone. Addition of inhaled steroids (ICS) to long-acting bronchodilators is recommended for patients with recurrent COPD exacerbations, especially in those with asthma-COPD overlap syndrome or history of elevated blood or sputum eosinophil levels. It is recommended to consider phenotype-specific therapy including roflumilast, N-acetylcysteine, and macrolides, in patients who continue to exacerbate despite being treated with LABA/LAMA or LABA/LAMA/ICS combinations. Withdrawal of inhaled corticosteroids is possible in patients with the low risk of exacerbation and in those with severe adverse events during ICS treatment. ICS should be withdrawn in a single step in patients with no repeated exacerbations during 12 months and with moderate bronchial obstruction (FEV1 ≥ 50% predicted). Stepwise withdrawal of ICS during 3 month with continuous dual bronchodilator therapy is recommended in COPD patients with severe bronchial obstruction (FEV1 ˂ 50% predicted) without frequent exacerbations in the previous year.

National clinical guidelines on diagnosis and treatment of chronic obstructive pulmonary disease: a clinical decision-making algorithm

Treatment of patients with chronic obstructive pulmonary disease (COPD) is one of the most important tasks of clinical medicine due to high prevalence of and high mortality from COPD. Treatment of COPD as a heterogeneous disease requires different approaches depending on the severity and the clinical course of COPD. Clinical guidelines have become the principal document that regulates different aspects of management of COPD patients. Algorithms of management and clinical decision making are the crucial part of guidelines because they help achieving a balance between making the decision in different clinical situations and simple graphics. The simplified approach is important for implementation the algorithm into clinical practice. Different evidence-based therapeutic schemes proposed by experts of Russian Respiratory Society and other countries have been enclosed into this article with discussion about their strengths and limitations and possibility of practical use. The Russian algorithm reflects a current view on differentiated management of COPD patients and fits the requirements of Healthcare Ministry of Russian Federation and needs of achieving the optimal balance between high informative significance and a simple graphics of the scheme.

Prevalence of external respiratory dysfunction in young people

To investigate the prevalence of impaired external respiration function (ERF) in young Novosibirsk dwellers. A cross-sectional population-based survey in one of the typical districts of Novosibirsk was conducted at the Research Institute of Internal and Preventive Medicine in 2013-2015. ERF was examined by spirometry in accordance with the guidelines. The best indicators of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio were selected and three reproducible attempts were made to evaluate ERF. Spirometry was carried out in 787 respondents (358 males and 429 females) for the entire period. The results were interpreted according to the guidelines of the European Respiratory Society, the American Thoracic Society, and the Russian Respiratory Society. The prevalence of a FEV1/FVC of <70% in the total sample was 10.3% (13.4% for men and 7.7% for women; p=0.009); a FEV1 of <80% was 13.9% (14.5% for men and 13.3% for women; p=0.617); a FVC of <80% was 7% (6.1% for men and 7.7% for women; p=0.397). The obstructive type of ventilation disorders (FEV1/FVC <70%, FVC ≥80%) was recorded in 9.4% of the people, the restrictive type (FVC <80%, FEV1/FVC ≥70%) in 6.1%, and the mixed one (FEV1/FVC <70%, FVC <80%) in 0.9%; normal values (FEV1/FVC ≥70% and FVC ≥80%) were seen in 83.6%. Spirometric screening of a young Novosibirsk population demonstrated the incidence of impaired ERF, which is comparable with Russian and foreign data.

A role of long-acting bronchodilator tiotropium / olodaterol fixed combination as the first-line therapy of chronic obstructive pulmonary disease. A Consensus of Expert Board of Russian Respiratory Society

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Consensus report: indications for use of long-acting antimuscarinic tiotropium in the treatment of bronchial asthma

Relevant indications for tiotropium Respimat in adult patients with bronchial asthma (BA) were reviewed. This consensus represents a collaborative effort of members of the Executive Group of Russian Respiratory Society. The Group consisted of clinicians, pharmacologists and researchers with recognized expertise in therapeutic field. The draft of the recommendations was prepared by initiative group. Each point of the recommendation was discussed during Executive group meeting and was accepted by vote of majority members. Final version of the consensus statement was approved by each member of Executive group. As concluded, tiotropium Respimat could be recommended for adult patients with bronchial asthma as: 1) add-on therapy in patients with severe and moderate severe non-controlled BA on GINA step 3–5 (ICS and LABA, including oral steroids or other controllers, or high doses ICS monotherapy); 2) add-on therapy in patients with asthma-COPD overlap syndrome (ACOS); 3) add-on therapy to ICS in case of side effects, contraindications for use or individual intolerance of LABA; 4) additional indications to consider use of tiotropium Respimat may include: smoking, positive SABA reversibility test, predominant nocturnal asthma symptoms.

DIAGNOSIS, TREATMENT AND PREVENTION OF OSTEOPOROSIS IN GENERAL PRACTICE. CLINICAL GUIDELINES

Clinical Recommendations for diagnosis, treatment and prevention of osteoporosis were approved at the IV All-Russian Congress of general practitioners (family doctors) of the Russian Federation, November 15, 2013 in Kazan. Developed on the basis of the guidelines of the Russian Association on Osteoporosis (2009, 2012) and clinical recommendations for the glucocorticoid osteoporosis of the Russian Association of Osteoporosis, Russian Respiratory Society and the Association of Rheumatologists of Russia (2013). The text specified levels of evidence (A, B, C or D), which are provided at the respective statements in parentheses.

New possibilities for the treatment of glucocorticoid-induced osteoporosis

Glucocorticoid-induced osteoporosis (GIO) is the most common cause of secondary osteoporosis (OP) and a main cause of drug-induced OP. Fractures of the skeleton are registered in 30–50% of patients who have taken oral glucocorticoids (GCs) for a long time, during which the frac- tures develop with the use of any daily GC dose and with higher bone mineral density (BMD) than in postmenopausal OP. In patients who have taken oral GCs long or in high daily doses, decrease of BMD and low bone tissue quality leading to fractures are largely associated with the reduction of bone formation. This gives proof to the administration of antiosteoporotic agents that enhance the formation of bone during its remodeling. Teriparatide, a recombinant human parathyroid hormone, enhances osteoblast function, decreases the apoptosis of osteoblasts and osteocytes, increases the differentiation of osteoblast precursors, and can prevent the negative effect of exogenous GCs on bone. According to clinical trials results, teriparatide treatment increases BMD and reduces the risk of vertebral fractures in patients who have taken oral GCs long. In accordance of the clinical recommendations for the diagnosis, prevention, and treatment of GIO, which have been developed by the Russian Osteoporosis Association jointly with the Association of Rheumatologists of Russia and the Russian Respiratory Society, teriparatide is the drug of first choice for the treatment of GIO in men and women at high risk for fractures (with the history of fragility fractures or having high FRAX 10-year absolute fracture risk). Teriparatide may be prescribed in case of previous antiosteoporotic treatment failure (new fractures occurring during treatment and/or continuing to decrease BMD), as well as when other drugs to treat OP are intolerable or when there are contraindications to their use.

RUSSIAN RESPIRATORY SOCIETY. FEDERAL GUIDELINES ON DIAGNOSIS AND TREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

The guidelines have been developed by the Russian Respiratory Society (RRS) based on analysis of papers published during the last 5 years in MEDLINE and ENBASE databases and the Cochrane library. The results of the analysis were subsequently reviewed by independent experts with consideration of the opinion of physicians and general practitioners. A quality and a strength of the evidence were assessed using worldwide criteria. The guidelines are focused on epidemiology and social burden of chronic obstructive pulmonary disease (COPD), pathogenesis, clinical signs, characterization of phenotypes and severity, current diagnostic and differentiating methods and therapeutic approaches including long-tern oxygen therapy at home, long-term respiratory support at home, surgical treatment, pulmonary rehabilitation, treatment of complications and acute exacerbation of COPD. The guidelines are fully consistent with requirements of the Healthcare Ministry of Russia for federal guidelines on principal nosologies and treatment techniques

Federal guidelines on diagnosis and management of severe influenza on behalf of Russian Respiratory Society

Influenza is an acute respiratory viral infection with high morbidity. The 2009 influenza pandemic known as "swine flu" was caused by А / H1N1 / 09 influenza virus and was characterized by several specific features including frequent injury of the lower respiratory tract with development of progressive pneumonia and acute respiratory distress syndrome (ARDS) in children, young and middleaged adults. Clinical course of pneumonia complicating swine flu and management of such patients have been discussed in these guidelines. Admission to a hospital ward and to ICU, antiviral drugs, therapy of pneumonia and ARDS including supplemental oxygen, respiratory support, noninvasive ventilation and extracorporal membrane oxygenation, and preventive measures were also reviewed