Bronchial asthma (BA) is one of the most common allergic diseases among children. The question of delayed diagnosis of BA in children, on average by 4–5 years, at the primary level of outpatient care remains open. So far, district pediatricians rarely diagnose BA, diagnosis is usually made by an allergist or pulmonologist, often when the disease is already a medium and severe course, which significantly affects the prognosis and outcome of BA.
Bronchial asthma (BA) — the most common of chronic respiratory system diseases in childhood, which, unfortunately, is not always diagnosed or diagnosed late.
In GINA (Global Initiative for asthma) 2006, the section on BA in childhood is rightly placed under the heading «Cases especially difficult to diagnose. There remain poorly developed criteria for early diagnosis of BA, when it makes its debut in the form of repeated obstructive bronchitis and there is a need to differentiate it from a number of respiratory diseases, also occurring with symptoms of bronchial obstruction. Therefore, it is the early diagnosis of BA in children often causes difficulties and errors in practitioners. The frequency of misdiagnoses of BA in children ranged from 5 to 20 %.
Literature analysis indicates that only a small percentage of cases are first diagnosed with BA by pediatricians in polyclinics. Thus, according to a multicenter Russian retrospective study, only 16 % of cases are first diagnosed with BA by district pediatricians. At the same time, the importance of identifying the disease at its early stages is emphasized. It is known that more than half of cases of persistent asthma begin before the age of three and 80 % before the age of six. It has been proved that if asthma manifests in children under the age of three, it is more severe, more pronounced hyperreactive in the bronchial tree (BDT).
Diagnosing asthma at an early age is difficult because episodes of whistling wheezing and coughing are the most common symptoms of various respiratory diseases in children in the early years of life. Repeated bronchoobstructive syndrome (ROS) at an early age develops in numerous congenital and acquired diseases. The existence of such a wide range of diseases in itself makes it difficult to make the initial diagnosis of asthma. Diagnosis is also complicated by the fact that most of these diseases, like CBS, first appear against the background of acute respiratory viral infection (AVI).
BA is an independent nosological form, characterized by complex pathogenesis. BA symptoms are combined with changes in respiratory flow, ie, difficulty in passing the air associated with bronchoconstriction, thickening of the bronchial wall, increasing sputum production. Inflammatory process in the pathogenesis of BA determines the risk of exacerbations, cumulative pathological changes in respiratory function, with a heavier flow — structural changes. Modern genetic studies have proven the role of hereditary predisposition to the development of BA, but the implementation of the endotype is associated with the influence of environmental factors. The IgE-dependent type of allergic reaction plays the key role in the development of BA in children. Sensitization to allergens and their repeated exposure leads to clinical manifestations of BA as a result of inflammation of the respiratory tract, reversible obstruction and increased bronchial reactivity. Exposure to allergens in a sensitized organism, combined with a variety of non-specific factors provokes the development of exacerbations of BA in the form of short or prolonged episodes of obstruction. The state of ecology is important in the formation of BA in children, but the presence of atopy is crucial.
All this leads to great practical and theoretical interest in the problem of early diagnosis of BA in children. Particularly relevant in this aspect is the problem of timely diagnosis of BA at the stage of outpatient pediatric care. It is clear that the leading role in the diagnosis of the debut of the disease belongs to the district pediatrician. At the same time, practice shows that BA is diagnosed more often the most trained on modern medical and diagnostic technologies in BA specialists (allergists, pulmonologists), or doctors in hospitals, which, for objective reasons, the most available information, rather than primary care pediatricians. This leads to late primary diagnosis of the disease, and thus — untimely started basic therapy, progression of the disease and disability of patients. Therefore, it is in the primary health care unit that the main reserve is laid down to address the problem of timely diagnosis of BA in children.
An analysis of works on early diagnosis of BA in children shows that each of the studies conducted addresses a particular aspect of this problem. However, it should be noted that no comprehensive studies covering all aspects of the problem of improving early diagnosis of BA in children have been conducted so far. However, a number of fundamental issues remain unresolved, the most important of which are the following:
– The effectiveness of diagnosis of BA in the conditions of primary health care at the current stage has not been studied: the level of theoretical knowledge of primary care physicians on modern therapeutic and diagnostic approaches, approaches to diagnosis and treatment of this disease;
– The dependence of clinical and laboratory-functional features of BA on the period of diagnosis, including — the consequences of late diagnosis of the disease has not been studied;
– Not sufficiently developed issues of timely diagnosis of BA in the pediatric area. Insufficiently studied the clinical features, as well as the simplest and most accessible to the primary health care predictors of BA in its debut.
Therefore, the problem of early diagnosis of BA in children remains very urgent today and requires scientific and practical reflection and further elaboration of questions on this topic. There is a need for more detailed research on this problem from the standpoint of improving primary health care.
Medical care quality issues are currently addressed in the methodological recommendations of the Association of Medical Societies for Quality (ASMOC). At the same time, one of the criteria for evaluation of the quality of medical care is recognized the criterion of timeliness of medical care. The main reserve for timely diagnosis of BA in children is in the primary health care.
Observed at present, late diagnosis of BA, indicates a lack of quality medical care for this disease. Improvement of primary health care is one of the main directions of the Priority National Health Project. An extremely important expected result of the Project is an increase in early diagnosis of diseases by 1.5 times.
Thus, state policy is focused on improving the quality of medical care and efforts of scientific societies are directed. Much attention in this regard is paid to the BA. However, the situation at present remains far from ideal, primarily due to late diagnosis of BA in the primary health care sector.
Epidemiological studies show that the prevalence of BA is several times higher than official statistics. The reasons for the hypodiagnosis are the lack of knowledge of practical doctors of the diagnosis criteria, reluctance to register the disease for fear of worsening the reporting indicators, as well as often the negative attitude of the child's parents to the diagnosis of chronic disease, the need for inpatient examination to establish the diagnosis, etc. Diagnostic problems lead to the absence or late start of preventive and therapeutic measures, which is why data from epidemiological studies being conducted in the region become important.
- E. M. Yurievna Efficiency of diagnostics of bronchial asthma in children at the primary health care stage.