Подходы к терапии обострения хронической обструктивной болезни легких при коморбидной артериальной гипертензии

Aim. Аnalysis of the efficacy and safety of complex therapy including fixed-dose combinations of long-acting bronchodilators (FCLB) in comorbid patients with an exacerbation of chronic obstructive pulmonary disease (COPD) of the spirometry grades III – IV and hypertension.Methods. A total of 232 patients with an exacerbation of COPD of the spirometry grades III – IV were examined. 174 (75%) patients were diagnosed with the third grade (GOLD III), 58 (25%) – with the fourth spirometry grade (GOLD IV). In the GOLD III group, a moderate exacerbation was diagnosed in 22 (12.6%), severe — in 152 (87.4%). In the GOLD IV group, a moderate exacerbation was diagnosed in 5 (8.5%), severe — in 53 (91.5%), respectively. The patients were divided into 4 groups. Group 1 included 50 patients with an exacerbation of COPD of the spirometry grades III – IV without hypertension; Group 2 – 56 patients with an exacerbation of COPD and concomitant hypertension; Group 3 – 64 patients with an exacerbation of COPD without hypertension, who received FCLB in addition to standard therapy from the 3rd day of hospitalization; Group 4 – 62 patients with an exacerbation of COPD of the spirometry grades III – IV and concomitant hypertension who received FCLB in addition to standard therapy from the 3rd day of hospitalization. The examination included clinical and instrumental methods: the changes in the clinical signs and symptoms, the dyspnea index (according to the mМRS scale), the saturation of hemoglobin with oxygen (SaO2), spirometry, heart rate variability, the frequency and nature of arrhythmias, and systolic and diastolic blood pressure (BP).Results. A sympathicotonic disorder of the autonomic balance was revealed in patients with exacerbation of COPD of the spirometry grades III – IV. This tendency intensified in the patients with concomitant hypertension, which indicated an additional negative effect of comorbid hypertension on the studied parameters. Aggravation of sympathicotonia could be a trigger for an increase in ectopic rhythm disturbances, including high-grade ventricular extrasystoles. In the groups with concomitant hypertension, rhythm disturbances were more frequent (p < 0.05). The inclusion of FCLB in the complex therapy of exacerbation of COPD of the spirometry grades III – IV made it possible to improve the condition of patients significantly: to reduce the dyspnea index on the mМRS scale, increase SaО2 and FEV1 (p < 0.05), achieve clinical improvement in COPD faster and shorten the hospitalization period. As a result of the rapid and effective relief of exacerbation of COPD, the influence of pathogenic factors on the cardiovascular system in the examined patients decreased. The addition of FCLB to the treatment COPD with and without comorbid hypertension did not have a negative effect on heart rate variability, did not aggravate rhythm disturbances, and did not destabilize the BP.Conclusion. The positive clinical effects of the inclusion of FCLB in the complex therapy of exacerbation of COPD of the spirometry grades III – IV in patients with comorbid hypertension led to a decrease in shortness of breath, an improvement in respiratory functions, a decrease in tissue hypoxia and eliminated possible adverse events of this group of drugs.Целью работы явился анализ эффективности и безопасности комплексной терапии с включением фиксированных комбинаций пролонгированных бронхолитических препаратов (ФКПБ) у пациентов с коморбидными обострением хронической обструктивной болезни легких (ХОБЛ) ІІІ–ІV спирометрического класса (СК) и артериальной гипертензии (АГ).Материалы и методы. Обследованы пациенты (n = 232) с обострением ХОБЛ ІІІ–ІV СК. В соответствии с положениями Глобальной стратегии диагностики, лечения и профилактики ХОБЛ (Global Initiative for Chronic Obstructive Lung Disease – GOLD) ХОБЛ III CК (GOLD ІІІ) диагностирована у 174 (75 %), IV (GOLD ІV) – у 58 (25 %) больных. У 22 (12,6 %) пациентов группы GOLD ІІІ отмечены признаки среднетяжелого обострения, у 152 (87,4 %) – тяжелого обострения, в группе GOLD ІV – у 5 (8,5 %) и 53 (91,5 %) соответственно. С учетом наличия АГ и характера терапии пациенты были разделены на 4 группы: в 1-ю (n = 50) вошли лица с обострением ХОБЛ ІІІ–ІV СК без АГ; во 2-ю (n = 56) – с коморбидностью ХОБЛ и АГ; в 3-ю (n = 64) – с обострением ХОБЛ без АГ, дополнительно к стандартной терапии с 3-го дня госпитализации получавшие ФКПБ; в 4-ю (n = 62) – с коморбидностью обострения ХОБЛ ІІІ–ІV СК и АГ, получавшие ФКПБ дополнительно к стандартной терапии, начиная с 3-го дня госпитализации. При обследовании клиническими и инструментальными методами оценивались динамика клинической картины, индекс одышки по модифицированной шкале одышки (Modified Medical Research Council – mMRC), насыщение гемоглобина кислородом (SaО2), проводилась спирометрия, изучались вариабельность сердечного ритма (ВСР), частота и характер аритмии, уровни систолического и диастолического артериального давления (АД).Результаты. У пациентов с обострением ХОБЛ ІІІ–ІV СК выявлено симпатикотоническое нарушение вегетативного баланса. При коморбидности ХОБЛ и АГ отмечено нарастание изменений ВСР, что свидетельствовало о дополнительном негативном влиянии коморбидной АГ на изучаемые показатели. Усугубление симпатикотонии могло являться триггером учащения эктопических нарушений ритма, в т. ч. желудочковых экстрасистол высоких градаций. В группах с сопутствующей АГ нарушения ритма отмечались чаще (р < 0,05). При включении ФКПБ в комплексную терапию обострения ХОБЛ ІІІ–ІV СК существенно улучшилось состояние пациентов – уменьшился индекс одышки по шкале mМRS, увеличились показатели SaО2 и объема форсированного выдоха за 1-ю секунду (р < 0,05), быстрее достигнуто клиническое улучшение ХОБЛ, сократились сроки госпитализации. В результате быстрого и эффективного купирования обострения ХОБЛ у обследованных уменьшалось влияние патогенных факторов на сердечно-сосудистую систему. При добавлении ФКПБ как при изолированной ХОБЛ, так и при коморбидной АГ не отмечено отрицательного влияния на ВСР, усугубления нарушений ритма и дестабилизации АД.Заключение. Продемонстрировано, что при коморбидной АГ при включении ФКПБ в комплексную терапию обострения ХОБЛ ІІІ–ІV СК, положительные клинические эффекты, проявляющиеся уменьшением одышки, улучшением функций внешнего дыхания, уменьшением тканевой гипоксии, возможные нежелательные явления, полностью нивелировались

Regional climate moderately influences species-mixing effect on tree growth-climate relationships and drought resistance for beech and pine across Europe

Increasing species diversity is considered a promising strategy to mitigate the negative impacts of global change on forests. However, the interactions between regional climate conditions and species-mixing effects on climate-growth relationships and drought resistance remain poorly documented. In this study, we investigated the patterns of species-mixing effects over a large gradient of environmental conditions throughout Europe for European beech (Fagus sylvatica L.) and Scots pine (Pinus sylvestris L.), two species with contrasted ecological traits. We hypothesized that across large geographical scales, the difference of climate-growth relationships and drought resistance between pure and mixed stands would be dependent on regional climate. We used tree ring chronologies derived from 1143 beech and 1164 pine trees sampled in 30 study sites, each composed of one mixed stand of beech and pine and of the two corresponding pure stands located in similar site conditions. For each site and stand, we used Bootstrapped Correlation Coefficients (BCCs) on standardized chronologies and growth reduction during drought years on raw chronologies to analyze the difference in climate-tree growth relationships and resistance to drought between pure and mixed stands. We found consistent large-scale spatial patterns of climate-growth relationships. Those patterns were similar for both species. With the exception of the driest climates where pure and mixed beech stands tended to display differences in growth correlation with the main climatic drivers, the mixing effects on the BCCs were highly variable, resulting in the lack of a coherent response to mixing. No consistent species-mixing effect on drought resistance was found within and across climate zones. On average, mixing had no significant effect on drought resistance for neither species, yet it increased pine resistance in sites with higher climatic water balance in autumn. Also, beech and pine most often differed in the timing of their drought response within similar sites, irrespective of the regional climate, which might increase the temporal stability of growth in mixed compared to pure stands. Our results showed that the impact of species mixing on tree response to climate did not strongly differ between groups of sites with distinct climate characteristics and climate-growth relationships, indicating the interacting influences of species identity, stand characteristics, drought events characteristics as well as local site conditions

Regional climate moderately influences species-mixing effect on tree growth-climate relationships and drought resistance for beech and pine across Europe

Increasing species diversity is considered a promising strategy to mitigate the negative impacts of global change on forests. However, the interactions between regional climate conditions and species-mixing effects on climate-growth relationships and drought resistance remain poorly documented. In this study, we investigated the patterns of species-mixing effects over a large gradient of environmental conditions throughout Europe for European beech (Fagus sylvatica L.) and Scots pine (Pinus sylvestris L.), two species with contrasted ecological traits. We hypothesized that across large geographical scales, the difference of climate-growth relationships and drought resistance between pure and mixed stands would be dependent on regional climate. We used tree ring chronologies derived from 1143 beech and 1164 pine trees sampled in 30 study sites, each composed of one mixed stand of beech and pine and of the two corresponding pure stands located in similar site conditions. For each site and stand, we used Bootstrapped Correlation Coefficients (BCCs) on standardized chronologies and growth reduction during drought years on raw chronologies to analyze the difference in climate-tree growth relationships and resistance to drought between pure and mixed stands. We found consistent large-scale spatial patterns of climate-growth relationships. Those patterns were similar for both species. With the exception of the driest climates where pure and mixed beech stands tended to display differences in growth correlation with the main climatic drivers, the mixing effects on the BCCs were highly variable, resulting in the lack of a coherent response to mixing. No consistent species-mixing effect on drought resistance was found within and across climate zones. On average, mixing had no significant effect on drought resistance for neither species, yet it increased pine resistance in sites with higher climatic water balance in autumn. Also, beech and pine most often differed in the timing of their drought response within similar sites, irrespective of the regional climate, which might increase the temporal stability of growth in mixed compared to pure stands. Our results showed that the impact of species mixing on tree response to climate did not strongly differ between groups of sites with distinct climate characteristics and climate-growth relationships, indicating the interacting influences of species identity, stand characteristics, drought events characteristics as well as local site conditions