Emphysema in the elderly
Introduction
Introduction to emphysema in the elderly Emphysema is an excessive expansion of the distal part of the terminal bronchioles (including respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli) accompanied by destruction of the air wall. In 1987, the American Thoracic Society (ATS) The definition of emphysema was revised: "The distal part of the terminal bronchiole has irreversible expansion accompanied by destruction of the alveolar wall, but no obvious fibrosis." The basic characteristic of emphysema is that the lung tissue in the ventilation part is over-inflated and the airflow is blocked, so it is called "obstructive pulmonary emphysema" (obstructive pulmonary emphysema). basic knowledge The proportion of sickness: 0.16% Susceptible people: the elderly Mode of infection: non-infectious Complications: spontaneous pneumothorax Chronic pulmonary heart disease Heart failure Respiratory failure Diffuse intravascular coagulation Gastric ulcer Pulmonary embolism Sleep apnea syndrome
Cause
Causes of emphysema in the elderly
Smoking (20%):
Smoking is the most important cause of emphysema. 80% to 90% of COPD patients are smokers, and about 20% of smokers will develop COPD. Tobacco smoke contains many harmful components. Such as tar, nicotine, carbon monoxide, nitrogen oxides, furfural, etc., these harmful substances can directly or indirectly damage the bronchial mucosal epithelium, and even cause squamous metaplasia; inhibit or damage the movement of bronchial mucociliary; stimulate mucinous gland hyperplasia, excessive mucus Secretion; inhibits the phagocytic function of pulmonary macrophages; secretions are prone to secondary microbial infection; reduce the activity of 1 antitrypsin, leading to imbalance of elastase-elastase inhibitors... This is smoking-emphysema - Chronic bronchitis or smoking - chronic bronchitis - emphysema pattern, Kannel tracking the risk of smoking in 34 years, the results showed that smoking was significantly negatively correlated with chronic cough and FEV1.0, FVC reduction, Heggins on 5201 cases Surveys of older people over the age of 65 also showed a negative correlation between decreased lung function and total smoking.
Environmental pollution (20%):
Long-term exposure to organic or inorganic dust, exposure to harmful gases, prone to emphysema.
Infection (20%):
Repeated airway infection can cause bronchial mucosal congestion, edema, glandular hyperplasia, hypersecretion, increased protease activity, etc., which will lead to emphysema.
Genetic factors (10%):
Due to genetic defects, the severe deficiency of 1 antitrypsin can cause emphysema. This type of emphysema is often adolescent, with a short course of disease and a serious condition. It is more common in white races and rare in China.
Pathogenesis
The pathogenesis of obstructive emphysema is not fully understood. It is generally thought to be related to airway obstruction and protease-antiprotease imbalance. Smoking, infection, air pollution, etc. cause bronchiolitis, inflammatory congestion, edema, exudation, hyperplasia and gas. Hyperreactivity caused by airway stenosis or obstruction, negative pressure in the chest cavity during inhalation, bronchiole dilatation, air into the alveoli; positive pressure in the chest during exhalation, narrowing of the bronchioles, air retention, and elevated alveolar pressure , leading to excessive expansion or rupture of the alveoli, the protease-proteinase inhibitor imbalance disorder theory is the basis of modern understanding of emphysema, anti-trypsin (it is the main protease inhibitor in plasma, has a strong inhibitory effect on leukocyte elastase) Patients with sexual deficiencies are prone to emphysema, etc. These are strong evidences of this theory, proteases related to emphysema formation, such as serine proteases (mainly leukocyte elastase, cathepsin G, protease 3), metalloproteinases, thiol Proteases, etc., which are mainly derived from inflammatory cells such as neutrophils, monocytes and macrophages, They can destroy elastic fibers and can also cause experimental emphysema. Normally they are combined with protease inhibitors such as alpha 1 antitrypsin from plasma, local anti-leukocyte protease (ALP), secretory leukocyte protease inhibitor ( SLPI), metalloproteinase inhibitor (TIMP), etc., maintains a good balance, smoking leads to increased elastase activity and inhibition of protease activity; inflammation causes imbalance of protease-proteinase inhibitors in tiny spaces around inflammatory cells; 1 resistance The hereditary deficiency of trypsin causes the elastic fibers of the alveolar and bronchiole walls to be destroyed and emphysema to occur.
Prevention
Elderly emphysema prevention
Stop smoking and actively prevent respiratory infections are the main measures to prevent emphysema.
Complication
Elderly emphysema complications Complications spontaneous pneumothorax chronic pulmonary heart disease heart failure respiratory failure diffuse intravascular coagulation gastric ulcer pulmonary embolism sleep apnea syndrome
Lower respiratory tract infection
Patients with emphysema due to frail age, malnutrition, decreased immunity, airway stenosis and secretion retention are prone to lower respiratory tract infections, and patients often turn from stable to aggravating period. It is worth noting that elderly patients There is often no fever in the combined infection, the total number of white blood cells is not high, coughing, increased shortness of breath, increased sputum volume, and purulent sputum is the earliest and most important sign of lower respiratory tract infection.
2. Spontaneous pneumothorax
More often due to rupture of the bullae, may have a strong cough or force and other incentives, there may be no incentives, typical manifestations of chest pain and sudden dyspnea, the patient's percussion was unvoiced, elderly patients often have no chest pain and only The performance of progressive dyspnea is aggravated. X-ray examination shows pleural gas accumulation. Because the basic lung function of elderly patients is poor, even if the lung compression is not much, it will be severe and must be rescued in time.
3. Chronic pulmonary heart disease and heart failure
Patients with emphysema may cause pulmonary hypertension due to long-term hypoxemia, hypercapnia and reduction of pulmonary capillary bed, which may further form pulmonary heart disease. Heart failure may occur during aggravation, and heart failure may occur. In the case of decompensation, right heart failure occurs. It is worth noting that left heart failure may also occur, which may be due to myocardial degeneration and arrhythmia caused by chronic hypoxemia and recurrent infection with toxemia. .
4. Respiratory failure
Severe senile emphysema patients with increased exercise due to respiratory movement, diaphragmatic lowering, increased radius of curvature and malnutrition, prone to respiratory muscle fatigue, on this basis often because of lower respiratory tract infection, accompanied by other diseases, surgery, fatigue and other factors Induced respiratory failure, incorrect use of oxygen therapy, sedatives, antitussives and other iatrogenic factors may also cause respiratory failure.
5. Multiple organ failure
Critical elderly emphysema patients often have heart and lung function failure, and even with diffuse intravascular coagulation, liver and kidney failure, etc., leading to very heavy multiple organ failure and life-threatening.
6. Stomach ulcer
Autopsy confirmed that 18% to 30% of emphysema patients with gastric ulcer, the pathogenesis is not fully understood.
7. Pulmonary embolism
Older emphysema, especially in patients with pulmonary heart disease, may be complicated by pulmonary embolism due to hypercoagulability, hyperviscosity, prolonged bed rest, arrhythmia and toxemia. Patients with senile emphysema suddenly have difficulty breathing, palpitation, and increased tingling Be alert to the possibility of pulmonary embolism.
8. Sleep and breathing disorders
Sleep-disordered breathing, including sleep apnea syndrome (SAS) and sleep hypopnea syndrome (HPVS), has received increasing attention in recent years. Foreign reports have shown that the incidence of sleep apnea hypopnea syndrome (SAHS) is 1 in adults. %4%, the incidence rate of the elderly over 65 years old is as high as 20%40%, and the incidence of SAHS in the elderly with emphysema is higher. COPD and SAHS are also called overlap syndrome. Significant hypoxemia and carbon dioxide retention can occur during rapid eye movement (REM) sleep at night, due to decreased sensitivity of the respiratory center during sleep, increased upper airway resistance, and decreased intercostal muscle tone aggravating low alveolar Ventilation; functional residual capacity increases further during sleep aggravation of ventilatory/perfusion ratio imbalance, combined with sleep-disordered breathing will affect sleep quality and exacerbate the condition; hypoxemia during sleep is prone to increase hematocrit and pulmonary hypertension, Then develop into pulmonary heart disease; induce nighttime arrhythmia; may even lead to severe senile emphysema patients who die during sleep, combined with sleep-disordered breathing Patients with emphysema undergoing nighttime oxygen therapy are prone to carbon dioxide retention, whereas patients with simple emphysema who are given hypoxemia at night with continuous low-flow oxygen supply are not at risk of carbon dioxide retention. Emphysema combined with sleep-disordered breathing is often People ignore it, but it is very harmful. If there are conditions, the elderly emphysema, especially the patients with blue swollen type should be examined by polysomnography to confirm the diagnosis and correct treatment.
Symptom
Old people with emphysema symptoms Common symptoms Chest tightness
The onset of emphysema is slow, the course of disease is long, and the stable phase is aggravated.
Symptom
(1) cough and expectoration: patients with emphysema often have a history of cough and cough for many years, stable cough, cough can be light, white sticky; cough with respiratory infection, cough increased, purulent.
(2) Chest tightness and shortness of breath: early in the event, such as going to the building or walking quickly, feeling anxious; gradually develop to the flat road when walking, but also feel anxious; later in the living activities, such as washing your face, brushing your teeth, shoes, dressing, talking Even when you are still at rest, you may feel anxious. Patients often like to take a sitting position (which can help the respiratory muscles participate in activities), and reduce their lips or exhale.
(3) fatigue, anorexia, weight loss, etc.: very common in elderly patients with emphysema.
(4) fever: often have fever when combined with infection.
Drowsiness or irritability, mental disorders, headache, sweating, hand flapping tremors, etc., suggest more likely to have respiratory failure.
Less urine, lower extremity edema, labiasis, palpitation, etc., suggest more likely to have right heart failure with pulmonary heart disease.
2. Signs
There are no abnormalities in the early stage. In severe cases, the "barrel chest" can be seen. The age of the emphysema is relatively late. At this time, the costal cartilage has been calcified. Therefore, the typical barrel chest in elderly emphysema patients is rare, but common. The ribbed space was widened, the lung percussion was unvoiced, the liver dullness was moved down, the heart sounding circle was reduced or disappeared, the breath sound and voice were weakened, the exhalation was prolonged, and sometimes the lung bottom could smell dry and wet, and the heart sound was low.
Patients with respiratory failure can also see elevated blood pressure, cyanosis, conjunctival edema, nystagmus, different pupil sizes on both sides, and flapping tremors.
Patients with right heart failure can also be seen with cyanosis, jugular vein engorgement, pulmonary artery 2nd tone hyperthyroidism or division, liver enlargement, liver-jugular vein reflux sign positive, lower limb depression edema.
3. Classification and staging
(1) Classification: As mentioned above, there are two modes of emphysema: etiology - emphysema - chronic bronchitis, etiology - chronic bronchitis - emphysema, obstructive emphysema or COPD in clinical manifestations Can be divided into two types, namely, emphysema type also known as red asthma type (PP type) and bronchitis type also known as purple type (BB type); some patients do not meet the typical performance of the above two types, also known as It is called "hybrid type" (type X).
1BB type: patients with bronchial inflammatory lesions are more serious, emphysema lesions are lighter, cough, cough history is prominent, body type is more fat, often cyanosis, jugular vein engorgement and lower extremity edema, lung bottom can often smell dry, wet Voice, lung ventilatory function damage, diffuse function is normal, often hypoxemia and hypercapnia, increased hematocrit, this type of patients suffer from chronic pulmonary heart disease, easy to develop into respiratory failure or heart Failure, poor prognosis, this type is rare in elderly patients.
2PP type: patients with emphysema lesions are heavier, chronic bronchitis lesions are lighter, more common in the elderly, physical weight loss, obvious shortness of breath, generally no hair, often take a special position - two shoulders tall, two-armed bed (chair ), whistling exhale, X chest radiographs increased significantly, lung texture decreased, residual gas rate increased significantly, ventilatory function damage was light, hematocrit was normal, blood gas examination was normal or mild damage.
(2) Staging and division:
1 American Thoracic Society divided emphysema into 5 phases in 1972:
Phase I (asymptomatic period): The patient had no obvious symptoms, no obvious abnormalities in X-ray and pulmonary function tests, and only mild emphysema changes in the pathological sections.
Phase II (pulmonary ventilatory dysfunction): Patients may have cough, cough, shortness of breath, shortness of breath, physical examination and X-ray examination for emphysema, pulmonary function tests for ventilatory dysfunction and increased residual capacity.
Phase III (hypoxemia period): In addition to the above performance, there is hair loss and PaO2 reduction.
Phase IV (Carbon Dioxide Retention): Patients may have consciousness and disturbance of consciousness, and PaCO2 is elevated.
Phase 5 (chronic pulmonary heart disease): It is divided into compensation period and decompensation period.
Examine
Examination of emphysema in the elderly
Arterial blood gas examination: arterial partial pressure of oxygen (PaO2) can be in the normal range, that is, the expected value is ~-1.3kPa (10mmHg) (predicted value: sitting position 104.2mmHg-0.27×age; lying position: 103.5mmHg-0.42× age; Or 13.3 kPa - 0.04 × age); there may be different degrees of decline in the later stage [<predicted value -1.3 kPa (10 mmHg)], arterial blood carbon dioxide partial pressure (PaCO2) can be normal in the early stage [4.7 ~ 6.0 kPa (35 ~ 45 mmHg) ], there may be different degrees of increase in the later stage [>6.0kPa (45mmHg)]; arterial oxygen saturation (SaO2) can be normal in the early stage, there may be different degrees of decline in the later period (<95%); alveolar gas-arterial oxygen The partial pressure difference (A-aDO2) is increased [ 2.7 kPa (20 mmHg)].
1. X-ray examination: enhanced lung transmittance, reduced lung texture, flat and flat ribs, ribs flattened, rib gap widened, heart shadow overhang, can also be expressed as lung texture enhancement, heart shadow enlargement, lower right The pulmonary artery is widened.
2. Pulmonary function test total lung volume (TLC), residual gas volume (RV), functional residual capacity (FRC) increased; vital capacity (VC) normal or decreased; maximum ventilation (MBC), forced vital capacity (FVC), first The forced expiratory volume in seconds (FEV1.0), the maximum expiratory mid-flow (MMEF), and the maximum expiratory flow volume (MEFV) reflect a significant decrease in the ventilation function index; the carbon monoxide lung diffusion (DLco) decreases.
Diagnosis
Diagnosis and diagnosis of emphysema in the elderly
Older emphysema should be differentiated from tuberculosis, lung cancer, occupational lung disease, clinical manifestations combined with chest X-ray, CT, MRI, sputum examination, fiberoptic bronchoscopy, etc., identification is not difficult, it is important that they often exist simultaneously Don't relax your vigilance against the latter because of emphysema.
Emphysema, chronic bronchitis, and bronchial asthma all have airflow obstructive damage. There are connections and differences between the three, which can be mutually causal.
