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Presentation on the topic of bronchial asthma in children. Treatment of asthma in the acute period

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Bronchial asthma IN CHILDREN

Concept of bronchial asthma BA is a disease characterized by chronic inflammation of the airways, leading to hyperactivity in response to various stimuli and repeated attacks of bronchial obstruction.

Clinic The main signs of bronchial asthma are attacks of suffocation. Attacks of suffocation are divided into the following periods: Precursors Attack Post-attack Inter-attack

The period of precursors occurs a few minutes or a day before the attack. The period is characterized by: Anxiety Sneezing Itchy eyes Watery eyes Headache Sleep disturbance Dry cough

The attack period is characterized by: Shortness of breath Wheezing Wheezing Pale skin Slight cyanosis Tachycardia, etc. During an attack, a person takes a sitting position and rests his hands on the edge of the bed or chair. The duration of the attack is 10-20 minutes, with a long course of up to several hours.

Risk factors

Internal factors risk genetic predisposition; atopy (overproduction of IgE in response to an allergen); airway hyperresponsiveness; gender (more often in women); race.

Factors that provoke exacerbation of asthma: home and external allergens; indoor and outdoor pollutants; respiratory infections; physical activity and hyperventilation; changes in weather conditions; sulfur dioxide; food, nutritional supplements, medications; excessive emotional stress; smoking (passive and active); irritants (household aerosol, paint smell).

Cells involved in the formation of the inflammatory process in asthma: Primary effector cells: mast cells (histamine); macrophages (cytokines); epithelial cells. Secondary effector cells: eosinophils; T lymphocytes; neutrophils; platelets.

Forms of bronchial obstruction: acute bronchospasm, bronchial wall edema (subacute), chronic mucus obstruction, bronchial wall remodeling. Normal FEV1 (forced expiratory volume in the first second) is at least 75% of vital capacity

Degrees of pulmonary obstruction: - more than 70% - mild; 69-50% - moderate; less than 50% - severe.

CLASSIFICATION of BA (according to ICD X): BA: atopic (exogenous); non-allergic (endogenous, aspirin); mixed (allergic + non-allergic); unspecified. Status asthmaticus (acute severe asthma). Aspirin: In asthma there is a deficiency of PGs, and aspirin (like other NSAIDs) further reduces their levels. Salicylic acid is found in a variety of foods, so it is important not to confuse this form of asthma with a food allergy.

CLASSIFICATION OF BA SEVERITY Stage 1: intermittent asthma symptoms less than once a week; short exacerbations; night symptoms no more than 2 times a month; FEV1 or PEF indicators are 80% or more of the expected values; the variability of PEF or FEV1 is less than 20%.

Stage 3: persistent asthma of moderate severity daily symptoms; exacerbations may affect physical activity and sleep; night symptoms more than once a week; daily intake of inhaled β2-agonists; FEV1 or PEF indicators are 60-80% of the expected values; the variability of PEF or FEV1 is more than 30%.

Stage 2: mild persistent asthma symptoms more than once a week, but less than once a day; exacerbations may affect physical activity and sleep; night symptoms more often than 2 times a month; FEV1 or PEF indicators are 80% or more of the expected values; the variability of PEF or FEV1 is 20-30%.

Stage 4: severe persistent asthma daily symptoms; frequent exacerbations; frequent night symptoms; restriction of physical activity; FEV1 or PEF indicators are less than 60% of the expected values.

TREATMENT OF BA Complex therapy of patients with BA 1. Education of patients. 2. Assessment and monitoring of asthma severity. 3. Elimination of triggers or control of their influence on the course of the disease. 4. Development of a drug therapy plan for ongoing treatment. 5. Development of a treatment plan during an exacerbation. 6. Ensure regular monitoring.

Drug therapy I. Drugs to control the course of asthma, inhaled corticosteroids (beclomethasone dipropionate, budesonide, flunizomide, fluticasone, triamcinolone acetonide); systemic corticosteroids (prednisolone, methylprednisolone); (!) p/e: oral candidiasis, hoarseness, cough from irritation of the mucous membrane; sodium cromoglycate (intal); nedocromil sodium (Tyled); sustained release theophylline (teopec, theodur); long-acting inhaled β2-agonists (formoterol, salmeterol); antileukotriene drugs: a) cysteinyl-leukotriene 1 receptor antagonists (montelukast, zafirlukast), b) 5-lipoxygenase inhibitor (zileuton).

II. Symptomatic drugs (for emergency care) inhaled fast-acting β2-agonists (salbutamol, fenoterol, terbutaline, reperone); systemic GCS; anticholinergic drugs (ipratropium bromide (Atrovent), oxytropium bromide); methylxanthines (iv theophylline, aminophylline).

III. Non-traditional methods of treatment: acupuncture; homeopathy; yoga; ionizers; speleotherapy; Buteyko method; etc.

Examination methods X-ray examination Sputum examination Blood examination

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Slide 2

Bronchial asthma -

Chronic inflammatory disease of the airways involving mast cells, eosinophils, T-lymphocytes, mediators of allergy and inflammation, accompanied in predisposed individuals by hyperreactivity and variable (reversible) obstruction of the bronchi, which is manifested by an attack of suffocation, wheezing, coughing and/or difficulty breathing.

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The prevalence of asthma in Europe has doubled since the beginning of the 80s. In Ukraine, the prevalence of asthma among children over the last decade has increased 1.6 times. According to the European Association of Allergists, the prevalence of asthma among children in various countries Europe ranges from 5 to 22% Children in urbanized regions suffer from asthma much more often

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TYPES OF BRONCHIAL OBSTRUCTION:

Acute - due to spasm of the smooth muscles of the bronchi Subacute - due to swelling of the bronchial mucosa Chronic - blockage of small and medium bronchi with viscous secretions Irreversible - due to the development of sclerotic changes in the wall of the bronchi during long-term and severe course of the disease

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Predisposing factors:

Atopy - hereditary predisposition to allergic reactions Bronchial hyperreactivity - increased response of the bronchial tree to specific and nonspecific stimuli Hyperproduction of immunoglobulin E

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Sensitization factors:

Household: house and library dust, waste products of house dust mites, cockroaches, dry fish food, feather pillows Non-pathogenic fungi (molds, yeasts) Epidermal allergens (cats, dogs) Plant allergens (pollen from trees, weeds, flowers) Plays an important role prematurity due to immaturity of the lung tissue and immune system

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Permissive factors (triggers):

Pollutants - compounds of sulfur, nitrogen, nickel, CO - the result of factories, car exhaust gases Smoking - active and passive ARVI Food Household, plant and other allergens Physical activity Stress Meteorological factors

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Ways to activate the immune response:

Allergen Mast cell Inflammatory mediators Allergen T-helper 2nd order Eosinophils, basophils, mast cells, etc. Mediators of inflammation Allergen T-helper 2nd order B-lymphocyte IgE Mast cell Types I, III and IV of allergic reactions take part in the development of asthma

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Classification of asthma in children by severity

Mild – attacks no more than once a month, mild, relieved spontaneously or with a one-time use of bronchodilators, during the period of remission there are no symptoms. PEF and FEV1 are more than 80% of normal, daily fluctuations are no more than 20%. Moderate severity - attacks 3 - 4 times a month, with impairment of external respiration function, controlled with bronchodilators or parenteral corticosteroids, remission is incomplete. PSV and FEV1 60 - 80% of normal, daily fluctuations 20 - 30%. Severe - attacks several times a week or daily, severe, can be treated with bronchodilators and parenteral corticosteroids in a hospital setting, remission is incomplete (respiratory failure of varying degrees. PEF and FEV1 are less than 60% of normal, daily fluctuations are more than 30%.

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Treatment of asthma in the acute period:

Termination of contact with the allergen Oxygen therapy Inhaled B2-adrenomimetics (salbutamol (Ventolin), terbutaline (Berotec)) or combined B2-adrenergic agonists + M-anticholinergics (Berodual, Combivent) If 3 inhalations of B2-adrenergic agonists within an hour are ineffective - intravenous theophylline and systemic glucocorticosteroids

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Basic therapy for asthma:

Hypoallergenic diet, regimen measures Allergen-specific immunotherapy Cromones: sodium cromoglycate (Intal), sodium nedocromil (Tyled) Inhaled glucocorticosteroids: flunisolide (Ingacort), belometasone dipropionate (Becotide, Beclazone, Beclocort, Aldecine), budesonide (Pulmicort), fluticasone (Flixotide ) Long-acting B2-adrenergic agonists: salmeterol (Serevent), formoterol (Foradil) Anti-leukotriene drugs: montelukast, zafirlukast

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BRONCHIAL ASTHMA is a disease that develops on the basis of chronic allergic inflammation of the bronchi, their hyperreactivity and is characterized by periodic attacks of difficulty breathing or suffocation as a result of widespread bronchial obstruction caused by bronchoconstriction, hypersecretion of mucus, swelling of the bronchial wall.

The prevalence of asthma in Russia is from 10 to 25% In Perm, at the end of 2010, more than 3,700 children were registered (an increase in 2010 of ≈ 4.1%) In Perm, 400-500 children are diagnosed with bronchial asthma for the first time each year. In 67%, bronchial asthma manifests itself in the first 5 years of life (Balabolkin I.I., 2003)

A new version National program: “Bronchial asthma in children. Treatment strategy and prevention” 1992 recommendations of the international pediatric group on asthma 1997, on the initiative of the All-Russian Scientific Society of Pulmonologists of Russia, the first National program “Bronchial asthma in children” was developed 2005 (second edition) of the National program “Bronchial asthma in children. Treatment strategy and prevention". 2008. a new version(third edition), revised and expanded The goal of the program is to form a unified position in the fight against the most widespread lung disease in children. RUSSIAN RESPIRATORY SOCIETY UNION OF PEDIATRICS OF RUSSIA NATIONAL PROGRAM “BRONCHIAL ASTHMA IN CHILDREN. TREATMENT STRATEGY AND PREVENTION" ((THIRD EDITION)

Heredity The risk of asthma in a child from parents with signs of atopy is 2-3 times higher than in a child from parents who do not have it. Genetic factors determine predisposition to allergic diseases. Allergic diseases are more often observed in the pedigree on the mother's side. The polygenic type of inheritance is considered predominant.

Atopy This is the body's ability to produce increased amounts of Ig. E in response to exposure to allergens environment. It is detected in 80-90% of sick children.

Bronchial hyperreactivity This is a condition expressed in an increased reaction of the bronchi to an irritant, in which bronchial obstruction develops in response to an impact that does not cause such a reaction in most healthy individuals. This is a universal characteristic of bronchial asthma; its degree correlates with the severity of the disease. There is evidence of genetic determination of bronchial hyperreactivity

Etiological factors In children 1 year of age - food and drug allergies. Children 1 - 3 years old have household, epidermal, fungal allergies. Over 3-4 years - pollen sensitization. When living in polluted industrial areas - sensitization to industrial substances. Recently, with bronchial asthma in children, the frequency of polyvalent sensitization has increased.

Causes of respiratory allergoses household allergens :: mites of the domestic dust of the Pyroglyphidae family :: DD Ermatophagoides pteronissinus, Farinae and Microcras, Euroglyphus animal allergen allergens, rodents, horses fungal allerge Aspergillus, Candida pollen allergens of food allergens trigger AD factors are: atmospheric pollutants (exhaust gases, ozone, nitrogen oxide, sulfur dioxide); indoors - tobacco smoke

Factors contributing to the occurrence of bronchial asthma are frequent respiratory infections, pathological pregnancy in the mother of the child, prematurity, the presence of atopic dermatitis, air pollution and residential air pollution, tobacco smoking, including passive smoking.

Factors causing exacerbation of bronchial asthma (triggers): contact with allergens, respiratory viral infection, physical activity, psycho-emotional stress, changes in the weather situation.

Mechanisms of development of bronchial asthma Under the influence of allergens, hyperproduction of Ig occurs in patients with asthma. E B-lymphocytes There is an interaction between causally significant allergens and specific Igs fixed on mast cells and basophils.

This leads to the activation of target cells and the secretion of mediators and cytokines from them, which, in turn, contribute to the involvement of other fixed cells in the lungs and blood cells in the allergic process. Mediators such as histamine, prostaglandins, serotonin, etc. are released from mast cell granules .

An acute allergic reaction develops, proceeding according to the immediate type and manifested by bronchial obstruction syndrome. An attack of asthma develops 10-20 minutes after contact with a causally significant allergen. The attack is caused by the occurrence of bronchospasm, swelling of the bronchial mucosa, and increased secretion of mucus.

The late phase of the allergic reaction in the bronchi in response to exposure to allergens develops after 6-8 hours and is characterized by an influx of pro-inflammatory cells into the lungs with the subsequent development of allergic inflammation of the airways, hyperreactivity and bronchial obstruction

Bronchial remodeling Mass death epithelial cells Large number of mucus plugs Thickening of the basement membrane Hypertrophy and hyperplasia of goblet cells and serous glands Smooth muscle hypertrophy (200%) Active angioneogenesis

Classification of bronchial asthma Form (atopic, mixed) Stage of the disease (exacerbation indicating the severity of the attack, remission) Severity of the disease (mild episodic and persistent, moderate, severe) Complications

frequency of attacks: mild intermittent - less than once a month mild persistent - 1-3 times a month moderate - 1-2 times a week severe - 3 or more times a week

severity of attacks: mild asthma - only mild attacks moderate asthma - at least one attack of moderate severity severe asthma - at least one severe attack or history

Duration of the post-attack period for mild - 1-2 days, moderate - 1 - 2 weeks for severe - 2 - 4 weeks

duration of one-stage remission: mild BA – more than 3 months; moderate BA – 1-3 months; severe BA – 1 month

effectiveness of basic therapy: mild BA - symptoms are controlled, II - - IIII stage of basic therapy moderate BA - - IIIIII stage of basic therapy severe BA - - IVIV - - V V stage of basic therapy

CRITERIA FOR ASTHMATIC STATUS 1. 1. the duration of an intractable attack of bronchial asthma is at least 6 hours; 2. 2. violation of the drainage function of the bronchi; 3. 3. hypoxemia (partial pressure of oxygen less than 60 mm Hg) and hypercapnia (partial pressure carbon dioxide more than 60 mm Hg. Art.); 4. 4. resistance to sympathomimetic drugs.

Stages of status asthmaticus Stage I - the stage of relative compensation - clinically represents a prolonged attack of asthma. It is characterized by severe disturbances of bronchial obstruction and resistance to sympathomimetics.

Rapid, difficult noisy breathing, increasing emphysema, harsh breathing and a significant amount of dry and sometimes wet wheezing. Delayed sputum discharge. Severe tachycardia, increased blood pressure. Signs of respiratory failure in the form of restlessness in the child, pale skin, acrocyanosis.

Stage of increasing respiratory failure Develops as a result of total obstruction of the bronchial lumen with a thick viscous secretion with the simultaneous presence of pronounced swelling of the mucous membrane of the bronchial tree and spasm of the smooth muscles of the bronchi.

Characteristic is the weakening and subsequent disappearance of respiratory sounds, first in individual segments of the lungs, then in its lobes, and in the whole lung. The so-called “silent syndrome in the lungs” is formed. Simultaneously with the weakening of breathing, diffuse cyanosis increases and tachycardia persists. Blood pressure decreases.

Hypoxic coma Deep respiratory failure with the presence of “silence” syndrome throughout the entire field of the lungs, adynamia followed by loss of consciousness and convulsions. On examination, there was diffuse cyanosis of the skin and mucous membranes, absence of respiratory sounds in the lungs, muscle and arterial hypotension, and a drop in cardiac activity.

Clinical diagnosis of bronchial asthma in children is based on identifying symptoms such as: episodic expiratory shortness of breath wheezing, feeling of constriction in the chest paroxysmal cough

Clinical manifestations of bronchial asthma in children early age An attack of difficulty breathing and/or coughing is manifested by pronounced anxiety of the child (“tossing around”, “can’t find a place for himself”) Bloating of the chest, fixation of the shoulder girdle in the inhalation phase Tachypnea with a slight predominance of the expiratory component Impaired breathing in the basal parts of the lungs Severe perioral cyanosis

During a physical examination in the lungs, against the background of uneven breathing, diffuse dry, wheezing rales, as well as moist rales of various sizes, are heard. The presence of moist rales is especially characteristic of asthmatic attacks in young children (the so-called wet asthma). Symptoms of the disease usually appear or intensify at night and in the morning hours

Anamnestic data Hereditary burden of allergic diseases The presence of concomitant diseases of allergic origin in the sick child Indications of the dependence of the onset of disease symptoms on exposure to certain allergens Improvement in condition after the use of bronchodilators

Laboratory and instrumental methods for diagnosing bronchial asthma 1. 1. Examination of blood smears (increase in the number of eosinophils by more than 400 - 450 in 1 μl of blood) 2. 2. Determination of local eosinophilia (eosinophilia index is normally no more than 15 units) 3. 3. Definition causative allergen using skin testing

Laboratory and instrumental methods for diagnosing bronchial asthma (continued) 4. Radioimmune, immunoenzyme, chemiluminescent methods for determining specific Igs. E and Ig. G-antibodies in the blood 5. Inhalation provocation tests with allergens 6. Chest X-ray (diffuse increase in the transparency of the lung tissue)

Laboratory and instrumental methods for diagnosing bronchial asthma (continued) 7. 7. Peak flowmetry (decrease in peak expiratory volume flow rate and forced expiratory volume in the first second) 8. 8. Spirography (bronchial obstruction at the level of small bronchi and a positive test with bronchodilators) 9. 9. Detection of a large number of eosinophils in the bronchial secretion, as well as Courschmann spirals and Charcot-Leyden crystals

Laboratory and instrumental methods for diagnosing bronchial asthma (continued) 10. Immunological examination 11. Study of blood gases 12. Bronchoscopy 13. Determination of eosinophilic cationic protein 14. Determination of nitric oxide in exhaled air

Primary prevention of bronchial asthma in children; elimination of occupational hazards in the mother during pregnancy; stopping smoking during pregnancy; rational nutrition of a pregnant or lactating woman with a limitation of foods with high allergenic activity;

prevention of acute respiratory viral infections in the mother during pregnancy and in the child; limiting drug treatment during pregnancy to strict indications; breast-feeding; hypoallergenic environment for the child; stopping passive smoking; the use of methods of physical recovery, hardening of children; favorable environmental conditions.

Hypoallergenic diet Exclusion of causally significant allergens Exclusion of histamine-releasing products (chocolate, citrus fruits, tomatoes, canned food, smoked meats, marinades, sauerkraut, fermented cheeses, etc.)

Pet allergens Get rid of pets if possible, do not get new ones Animals should never be in the bedroom Wash animals regularly

Elimination of pollen allergens Stay indoors more during flowering plants Close the windows in the apartment, raise the windows and use a protective filter in the car air conditioner while driving outside the city Try to leave your permanent place of residence to another climate zone (for example, take a vacation) during the flowering season

Elimination of house dust allergens Use protective coverings for beds Replace down pillows and mattresses, as well as woolen blankets with synthetic ones, wash them every week at a temperature of 6000 C Get rid of carpets, thick curtains, soft toys (especially in the bedroom), do not wet clean less than once a week, and use washing vacuum cleaners with disposable bags and filters or vacuum cleaners with a water tank, pay special attention to cleaning furniture upholstered with fabrics. It is advisable to do cleaning when the patient is not in the room. Install air purifiers in the apartment

Key Points Asthma can be effectively controlled in most patients, but cannot be completely cured. The most effective treatment for asthma is elimination of the causative allergen. Insufficient diagnosis and inadequate therapy are the main causes of severe disease and mortality from asthma.

The choice of treatment should be made taking into account the severity and period of bronchial asthma. Upon appointment medicines A “stepwise” approach is recommended. In complex therapy, non-drug treatment methods are often used. Successful treatment of asthma is impossible without establishing a partnership and trusting relationship between the doctor, the sick child, his parents and relatives.

Basic therapy agents Glucocorticosteroids Leukotriene receptor antagonists Long-acting β 22 agonists in combination with inhaled glucocorticosteroids Cromones (cromoglycic acid, nedocromil sodium) Long-acting theophyllines Antibodies to Ig.

Cromones Sodium cromoglycate (Intal) - 1-2 doses 4 times a day Nedocromil sodium (Tyled) 1-2 doses 2 times a day

ICS for asthma Beclomethasone Budesonide Fluticasone Beclazone Clenil-jet Tafen-novolizer Pulmicort Flixotide

Average doses of ICS beclomethasone up to 600 mcg per day budesonide up to 400 mcg per day fluticasone up to 500 mcg per day

Anti-leukotriene drugs 1. lipoxygenase 5 inhibitors (leukotriene biosynthesis): zileuton (Zyflo) used mainly in the USA 2. Cys. LT 1 antagonists: : montelukast (Singulair), zafirlukast (Accolate), pranlukast (Ono) Clinical studies are underway (not yet in clinical practice) of so-called FLAP inhibitors, which interfere with 5-LO activation of proteins. .

Pranlukast. Montelukast. Zafirlukast Recommended dose Chemical name Trade name Acolat Singulair Ono, Ultair 20-40 mg 2 times a day 1 hour before or 2 hours after meals for children over 12 years old Children 6-14 years old: 5 mg Children 2-5 years old: 4 mg 1 once a day, at night, chewable tablet Adults: 225 mg 2 times a day not registered in Russia Leukotriene receptor antagonists used in clinical practice

Long-acting B22-adrenergic receptor agonists Salmeterol: Serevent Serevent rotadisc Salmeter Formoterol: Oxis Foradil Atimos

Antibodies to Ig. E (omalizumab - Xolair) The drug is: humanized monoclonal antibodies obtained from recombinant DNA. Pharmacotherapeutic group: other agents for systemic use in obstructive respiratory diseases. Included in the international and Russian standards treatment of asthma as an additional therapy when control is not achieved with existing medications

Verified diagnosis of moderate to severe atopic asthma (the atopic nature of the disease is confirmed by skin tests or radioallergosorbent test (RAST) Anti-Ig. E therapy is indicated for asthma poorly or partially controlled by the use of basic therapy: - > 2 severe exacerbations per year, requiring the use of systemic GCS; - frequent daytime symptoms (> 2 episodes per week); - nighttime symptoms; - significantly restricted lifestyle Age 12 years and older Ig.E level ranging from 30 to 700 IU/ml

Relief of an attack of bronchial asthma by inhalation of a β 22 agonist (salbutamol, Berotec) or anticholinergic (Atrovent) or their combination (Berodual) at an age-specific dose using a MDI (1 dose before 10 years, 2 doses after 10 years) or through a nebulizer (Berodual 1 drop per kg of body weight) if there is no effect, after 20 minutes repeat the drug at the same dose if there is no effect from the second inhalation: call an ambulance,

Short-acting B22-adrenergic receptor agonists Salbutamol Salamol Eco Easy breathing Ventolin (nebulas) Salben Bricanil (Terbutaline) Fenoterol Berotec Hexoprenaline Ipradol Iprotropium bromide/fenoterol Berodual

1. 1. administer prednisolone IM or IV 2 mg/kg or dexazone 0.3 mg/kg 2. 2. administer aminophylline 2.4% solution, 8 mg/kg IV drip, 3. 3. if there is no effect within 1-2 hours of the above treatment, prednisolone again up to 10 mg/kg or dexazone 1 mg/kg over 6 hours, aminophylline 1 mg/kg/hour IV drip (titration),

6. in case of moderate and severe attack, additionally O 22, 7. in case of status: β 22 – temporarily cancel agonists, glucocorticoids up to 30 mg/kg/day, bronchoscopy and lavage of the tracheobronchial tree, mechanical ventilation, correction of acid base, water and electrolyte balance, titration of aminophylline before stopping the status.

Step 1 Step 2 Step 3 Step 4 Step 5GINA 2006: Steps of Therapy Patient Education Environmental Control ββ 22 - rapid-acting agonist on demand ββ 22 - rapid-acting agonist on demand Disease control drug options Select one Add one or more Add one or both ICS in low doses ++ ββ 22 -long-acting agonists ICS in medium or high doses ++ ββ 22 -long-acting agonists Antileukemia new drug ICS in medium or high doses + Anti-leukotriene drug + po GCS (lowest dose)) Cromon ICS in low doses plus antileukotriene drug + Theophylline MB + Anti-Ig. E-therapy ICS in low doses plus theophylline MB decrease increase ICS: inhaled ICS MB-slow release

adjustment of the dose of the drug (every two months) In the absence of attacks - a constant reduction in the dose In the presence of only mild attacks that are rarer than those characteristic of the given severity of the disease - maintain the dose for the next two months In case of more frequent mild attacks or attacks of moderate or severe severity - the dose of the drug increase

Non-drug methods of treating bronchial asthma in children 1. 1. Diet therapy 2. 2. Respiratory therapy 3. 3. Relaxation and autogenic training 4. 4. Chest massage (vibration, percussion) 5. 5. Physical therapy with breathing exercises

6. 6. Speleotherapy and halotherapy 7. 7. Physiotherapy 8. 8. Laser therapy 9. 9. Acupuncture 10. Herbal medicine 11. Psychotherapeutic correction of the patient’s neuropsychic status

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