Bronchiectasis in the elderly
Introduction
Introduction to bronchial expansion in the elderly Bronchiectasis refers to the persistent expansion and deformation of the bronchial lumen in the lung. Due to the chronic inflammation of the bronchus and its surrounding tissues and bronchial obstruction, the bronchial wall tissue structure is severely pathologically damaged. Fibrous reconstruction of the wall, abnormal bronchial expansion, clinical manifestations of chronic cough, a large number of purulent or repeated hemoptysis and other symptoms, advanced pulmonary fibrosis, emphysema, pulmonary heart disease, respiratory failure and so on. basic knowledge The proportion of illness: 0.0053% Susceptible people: the elderly Mode of infection: non-infectious Complications: chronic respiratory failure, chronic pulmonary heart disease, lung abscess, hemorrhagic shock
Cause
The cause of bronchiectasis in the elderly
Bacterial infection (30%):
Bronchiectasis is secondary to chronic bronchitis, bronchial pneumonia after measles and whooping cough, tuberculosis and foreign body inhalation, tumors, etc. In the past, pertussis and measles were the most common causes. Currently, Gram-negative bacilli are mostly infected, and there are pneumococcal bacteria. , Staphylococcus aureus and anaerobic bacteria, due to repeated infection of the respiratory tract caused by chronic suppurative inflammation of the bronchial wall, damage to the various layers of the bronchial wall, including smooth muscle, collagen fibers, elastic fibers and cartilage and other important support structures of the bronchial wall At the same time, the chronic inflammation and fibrosis of the lung tissue around the bronchi, the wall of the tube, as well as the increase of intraluminal pressure during coughing and inhalation and the attraction of the negative pressure of the chest, lead to abnormal long-term expansion of the bronchus, which can be a tumor. The consequences of foreign body inhalation or extravascular extranodal lymph node compression, they can lead to distal bronchopulmonary tissue infection or obstructive atelectasis, the right middle lobe bronchial slender, surrounded by clusters of lymph nodes, often swollen by lymphadenitis Bronchial, causing atelectasis in the right lung, repeated infection, called mid-leaf syndrome, Bronchiectasis predilection sites, fibrous tissue contraction puller tuberculosis or tuberculosis endobronchial obstruction causing stenosis, may result in bronchodilation.
Congenital developmental defects and heredity (20%):
Such as giant tracheal-bronchodilator, may be due to bronchial smooth muscle cartilage and elastic fiber dysplasia, weak wall structure and poor elasticity, cartilage hypoplasia or insufficient elastic fiber, resulting in weak or poor elasticity of the local wall, accompanied by Paranasal sinusitis or visceral transposition (right heart), known as Kartagener syndrome, cystic fibrosis is due to poor development of peripheral lung tissue, small bronchioles are columnar, cystic dilatation, bronchial mucous glands secrete a large amount of mucus Causes obstruction of atelectasis and secondary infection, leading to bronchiectasis. This disease is often a pulmonary complication of autosomal recessive pancreatic cystic fibrosis. In addition, some patients with hereditary X-antitrypsin deficiency May be associated with bronchiectasis.
Immune dysfunction (20%):
Immunodeficiency, such as hypogammaglobulinemia induced recurrent respiratory infections, can cause bronchiectasis, in addition to inhalation of corrosive gases such as ammonia or NO2, damage to the trachea, secondary infection after bronchial mucosa can also cause bronchiectasis.
Pathogenesis
Pathology: general inflammatory bronchiectasis occurs in one lung segment, and can also occur in multiple lung segments on both sides. Most of the affected bronchus is related to poor drainage, so the lower leaves are more than the upper leaves, and the left lower leaves are slender and elongated. The main trachea has a large angle and is compressed by the blood vessels of the heart, and the drainage is not smooth. Therefore, the left lower lobe bronchial dilatation is more common. The left lower lobe bronchial opening is adjacent to the lingual bronchial opening. The former inflammatory secretion often involves the latter, and the two leaves expand simultaneously. It is not uncommon to see that the right middle lobe is slender and has three groups of lymph nodes distributed inside and outside. When the infection occurs, the lymph nodes enlarge the middle lobe and the atelectasis occurs, often leading to bronchiectasis. The site of tuberculosis-induced bronchiectasis and tuberculosis The predilection site is consistent and more common in the posterior segment of the upper lobe.
The shape of bronchiectasis is divided into cystic and columnar, and often mixed. The bronchiectasis produced in the bronchial development stage is mostly cystic. The expansion of inflammation secondary to adulthood is mostly columnar. The typical pathological change is the destruction of bronchial wall tissue. The resulting lumen is deformed, enlarged, and can be sunken. The cavity contains a large amount of secretions. The epithelium of the wall is often acute, chronic inflammation and ulceration, inflammatory cell infiltration, squamous metaplasia of bronchial mucociliary columnar epithelial cells, cup-shaped Cell and mucous gland hyperplasia, various layers of bronchial wall tissue destruction, or only incomplete muscle and cartilage fragments, often accompanied by telangiectasia or bronchial artery and pulmonary artery terminal branch dilatation and anastomosis, the formation of hemangioma, repeated massive hemoptysis When an infection occurs in bronchiectasis, inflammation can spread to adjacent lung tissue, causing bronchial pneumonia and changes with chronic bronchitis.
Pathophysiology: The pathophysiological changes of bronchiectasis depend on the number of bronchial lesions and the concurrent pulmonary parenchymal lesions. The respiratory function of the elderly gradually declines with age, and the vital capacity (VC) and forced vital capacity (FVC) are significantly reduced due to The elasticity of the thorax and lungs of the elderly is weakened, and the factors such as decreased respiratory muscles cause early trapping of the peripheral airway. The 70-year-old VC is reduced by 40%, and the 90-year-old (MMVV) volume is reduced by 50%, while the functional residual gas (FRc) The ratio of residual gas (RL) and /TLe is increasing, the lung elasticity is reduced, the airway resistance is increased, the gas distribution is uneven, and the proportion of ventilated blood flow (VA/Q) is easily imbalanced. Therefore, even in the early stage, even the lesion is light and limited. Respiratory function can be changed, manifested as mild mixed ventilatory dysfunction. As the extent of the lesion expands, obstructive ventilatory dysfunction increases. When the lesion is severe and extensive, it is characterized by obstructive mixed ventilatory dysfunction due to secretion. The substance stays in the bronchial lumen, which further aggravates the inflammation, and may be accompanied by bronchospasm. The distribution of inhaled gas is uneven. The alveolar ventilation of the lung tissue in the bronchiectasis area is reduced, and the blood flow is very high. Less restricted, ventilation, blood flow ratio decreased, lung movement, venous shunt, and alveolar diffuse dysfunction lead to hypoxemia, when the lesion develops further, pulmonary fibrosis gradually worsens, alveolar capillaries are extensively destroyed, pulmonary circulation resistance increases Hypoxemia caused pulmonary arteriolar spasm, pulmonary hypertension, blood flow to the right heart of the bronchial vein increased, right heart load increased, right heart failure, right ventricular hypertrophy and other pulmonary heart disease.
Prevention
Elderly bronchodilation prevention
The state has adopted a series of public health measures to prevent diseases and promote health. The following preventive measures should be taken for this disease.
First, carry out health education, improve the population's immune level, prevent diseases, organize vaccination, eliminate predisposing factors; improve health, improve disease resistance, pay attention to reasonable nutrition and diet; often carry out physical exercise, cultivate good behavior and life Ways; maintain a good mentality and social adaptability, environmental protection, take protective measures against the atmosphere, water, soil, food, formulate environmental protection laws and health standards, create and maintain a natural and social environment conducive to physical and mental health, reduce Disease factors, after 1992, China formulated the "China Agenda 21", which ensured the implementation of sustainable development strategies in China, and made people gradually realize the importance of the relationship between human survival and environmental protection.
Secondly, preclinical prevention should be done, that is, preventive work for early detection and early diagnosis of early detection in the early stage of the disease to control the development and deterioration of the disease, prevent the recurrence of the disease or turn chronic, and conduct regular health check and early detection. And diagnosis, such as measles, whooping cough, BCG vaccine, etc., should be early isolation and early treatment for tuberculosis patients, and rational use of antibiotics through doctors, treatment of chronic paranasal sinusitis and tonsillitis, pay attention to prevent foreign body inhalation of the trachea, once It was found to be removed immediately by fiberoptic bronchoscopy.
To prevent and treat bronchitis, patients with existing diseases should prevent or reduce the occurrence of respiratory tract infections, maintain airway patency and sputum drainage, rational use of antibiotics, limited lesion location, and repeated hemoptysis treatment should be treated with surgical resection.
Risk factors and interventions: In terms of physiological function, the elderly with age, organ function gradually declines, the body's regulatory mechanism is reduced, respiratory physiology is manifested in weakened defense reflexes, such as cough reflex, cell-mediated immunity decline, bronchi The ciliary movement is weakened, thereby increasing the chance of respiratory infection, the elasticity of the lungs and thorax is weakened, the thoracic and pulmonary elastic retraction is weakened, the alveolar collapse around the lungs, the anatomical shunt is increased, the ventilated blood flow is out of proportion, the airway resistance is increased, and the gas distribution is uneven. Older lung tissue fibrosis, capillary bed reduction, decreased diffusion, all cause respiratory function decline, body hypoxia, defense function decline, psychologically, in the later years due to family and social environment changes and other factors, will show different properties Behavioral disorders such as loneliness and suspiciousness, inferiority, depression, and emotional instability.
Establish a care and support organization for the whole society and implement all-round care, not only for diseases, but also for the influence of factors such as material, spiritual, social and natural environment, including the entire happy life of the elderly, including through the organization of senior citizens. Stylistic activities for mutual health and well-being, mutual assistance and mutual aid activities.
Community intervention: First, establish and improve the health records and system management of the elderly, investigate the health status and quality of life of the elderly in the community and the content of the services required, and conduct a scientific analysis of the data obtained from the survey. And evaluation, on the basis of this, establish a health record for the elderly, and at the same time, through the registration and construction of the elderly in the community, health check, their self-care ability, age and illness, respectively, give different health care monitoring, the implementation Hierarchical system management and provide a series of continuous health care measures from health education, psychological counseling to inpatient outpatient treatment, daily life care, etc. At the same time, establish a sound old-age social health network, community old-age system management needs all sectors of society Support and cooperation, community doctors should bear the main responsibility, and need to work with the health and non-health departments in the community to establish and improve the elderly community health network. In addition to the health department, all levels of government from the central to local governments have established old-age work offices. To coordinate and support geriatric care.
Complication
Bronchiectasis complications in the elderly Complications Chronic respiratory failure Chronic pulmonary heart disease Lung abscess Hemorrhagic shock
1. Chronic respiratory failure and chronic pulmonary heart disease bronchiectasis due to repeated airway suppurative infection, the late stage is often extensively destroyed by its own and distal structures, resulting in decreased effective alveolar ventilatory function, hypoxia and/or Hypercapnia, developed into respiratory failure; followed by pulmonary hypertension, right ventricular hypertrophy, and development of chronic pulmonary heart disease, which is the main cause of death of bronchiectasis, should be actively prevented.
2. Lung abscess bronchodilation on the one hand due to the original structure damage, there is a persistent infection, on the basis of this local infection is difficult to control, it is easy to lead to lung tissue necrosis, the formation of abscess; on the other hand due to long-term lower respiratory tract permanent The pathological changes, respiratory symptoms continue to occur, prone to inhalation of upper respiratory tract colonies (especially anaerobic bacteria), leading to lung abscess, due to the application of effective antibiotics, the occurrence of lung abscess has decreased.
3. Adjacent or distant organ abscess septic bronchitis or lung abscess and other local spread, can cause pleurisy, empyema, pericarditis, or menstrual blood circulation to reach the non-separated organ, metastatic abscess in the brain, due to the widespread use of antibiotics, Such complications are now rare.
4. Shock or asphyxia in the short-term large hemoptysis patients, may be combined with hemorrhagic shock or asphyxia, in addition to the active application of hemostatic drugs in the internal medicine, to maintain airway patency, often need emergency bronchial artery embolization and other interventional treatment.
Symptom
Bronchiectasis in the elderly Common symptoms Two lungs texture increased appetite, bloody wheezing, fatigue, purulent sputum, repeated infection, cyanosis, rupture, secondary infection, secondary infection
The course of the disease is mostly chronic, long-term cough, cough, repeated hemoptysis can be up to 10 years, the age of onset is mostly in children or young people, most patients have measles, history of pertussis or bronchial pneumonia in childhood, and often have recurrent lower respiratory tract Infection, the early symptoms of some diseases may not be obvious, and the disease is suspected due to hemoptysis.
The severity of clinical symptoms is related to the severity of bronchial lesions and the degree of infection. The condition is gradually increased due to repeated infections. The amount of cough and sputum is increasing day by day, sometimes up to 100-500 ml per day. If there is anaerobic infection, sputum and call Gas has an odor. In the case of secondary infection, the patient has fever, lack of appetite and other systemic symptoms. Typical sputum collected in glass bottles can be found to have stratified characteristics. The upper layer is foam, the lower suspicious mucus, and the bottom layer is necrotic tissue. Precipitate.
Some patients with repeated hemoptysis as the main clinical manifestations, accounting for 50% to 70%, hemoptysis varies greatly, varying degrees, from sputum with blood to a large number of hemoptysis, hemoptysis and disease severity range is not necessarily consistent, some patients Repeated hemoptysis as the only symptom, usually no cough, phlegm and other respiratory symptoms, clinically known as "dry bronchodilation", common in tuberculous bronchiectasis, lesions in the upper bronchus, bronchial drainage is better.
Repeated infections can cause symptoms of systemic poisoning, such as intermittent fever, fatigue, loss of appetite and anemia. In severe cases, shortness of breath and cyanosis can occur.
Early and mild bronchiectasis can be seen without obvious signs. When the lesion is severe or secondary infection, the lesions may have percussive voiced sounds and fixed wet voices. Sometimes they may smell wheezing. People with cough and large purulent may have clubbing fingers. (toe).
Examine
Examination of bronchiectasis in the elderly
A large number of neutrophils can be seen in the sputum smear. For example, smear can be seen as Gram staining, and the main pathogens are pneumococcal, Haemophilus influenzae, etc. Pseudomonas aeruginosa is also a common bacterium. Others are still visible Staphylococcus aureus, anaerobic bacteria and non-tuberculous mycobacteria.
1. X-ray chest flat film
It is not a specific examination method for bronchiectasis. Bronchiectasis is caused by thickening of the bronchial wall and thickening of the surrounding connective tissue. It is characterized by increased texture, thickening and disorder of the lesion area. If there is secretion retention in the dilated bronchus , it is columnar thickening, heavier cystic bronchiectasis can be seen on the plain film, the shadow of curly hair distributed along the bronchus, secondary infection can be seen in the shadow of the short hair, due to bronchiectasis often accompanied by interstitial inflammation, so in the lungs The increase in texture is accompanied by a network change. Generally, patients with bronchiectasis have no obvious abnormal changes on the chest radiograph, and there is no specificity. Even if the above-mentioned characteristics of bronchiectasis are changed, the severity of bronchiectasis cannot be determined accordingly. , nature and extent of lesions.
2. Bronchial lipiodol angiography
The severity, location and extent of the diagnosis of bronchiectasis, the type of lesions, is the most important basis for the diagnosis of bronchiectasis. It has a positive significance for the scope of surgery and resection. In order to satisfy the angiography and prevent complications, it is required. Good anaesthetic effect should be obtained during angiography, so that patients can cooperate well. Children under 10 years old are not easy to cooperate, so it is not suitable for this examination. The viscosity of iodine oil contrast agent should be just right. It can perfuse the 7th to 8th grade bronchus. When iodized oil easily enters the alveoli, if it is too thick, the bronchioles are poorly filled, which will affect the correctness of the reading. The appropriate amount of sulfonamide powder should be adjusted to make the viscosity appropriate. Although the bronchial iodized oil angiography can be clearly diagnosed, the symptoms are mild. Patients who are not scheduled for surgical resection, or who are estimated to have severe lesions, especially bilateral cases, heart and cardiopulmonary dysfunction, should not be treated with bronchial iodine oil angiography to avoid unnecessary pain and accidents.
3.CT scan
In recent years, high-resolution CT applied to the clinic can accurately diagnose bronchiectasis, and gradually replaces the trend of bronchography. The CT of the lung is typical for patients who are not suitable for bronchography and clinical symptoms. Patients suspected of bilateral bronchiectasis, CT examination can provide the scope of lesions and lesions. According to some scholars, the sensitivity of CT diagnosis of bronchiectasis is 63.9%-97.0%, the specificity is 93%-100%, and the layer thickness is 0.5mm or 1.0. Layer-scan high-resolution scanning is easier to find bronchiectasis than conventional scanning, thin layer can reduce volume effect, high resolution makes image more clear, lung CT can diagnose lung segment and sub-segment bronchiectasis, small bronchiectasis is difficult to diagnose, high Resolution CT scan can show 2mm diameter bronchus, <1mm bronchus can not be displayed, it is easier to distinguish between cystic and columnar bronchiectasis, the type of bronchiectasis and the presence or absence of infection and the presence or absence of secretions in the bronchi can be different, columnar bronchiectasis When there is a mucus column or infection, it is a columnar or nodular high-density image. When there is no secretion in the lumen, it is ring-shaped. Ellipsoidal or tubular images, the diameter of the bronchial tube is often larger than that of the accompanying pulmonary artery, and the wall is thickened; the cystic bronchiectasis is characterized by a majority of distribution, and the smooth cavity inside and outside the wall changes, and the liquid level is generally visible. Located in the lung field, the bronchiectasis caused by the traction of the lung lesions often leads to bronchial distortion, often accompanied by consolidation of the lungs or segments.
Diagnosis
Diagnostic differential diagnosis of bronchiectasis
Diagnostic criteria
For patients with long-term cough, cough and sputum, and repeated aggravation of intermittent hemoptysis, the possibility of bronchiectasis should be considered. Chest X-ray films show signs of "double-track", ring-shaped high-density or cystic changes. It can basically make a clinical diagnosis of bronchiectasis. For suspicious patients, chest CT (especially HRCT) is one of the important non-invasive diagnostic methods.
For those who are difficult to diagnose or consider surgery, selective bronchography remains the gold standard for diagnosis, and unless a decision is made to determine the treatment plan, bronchography is generally not considered.
Bronchoscopy can not be used for the diagnosis of bronchiectasis, but it is beneficial for clear bleeding, obstruction and obstruction of airway obstruction. It can also be used for bronchoscopy for selective bronchography. In addition, bronchial or nasal mucosal biopsy is performed. Electron microscopy confirmed the presence or absence of cilia abnormalities.
Paranasal sinus imaging can determine whether patients with bronchiectasis have paranasal sinusitis, which is helpful for the diagnosis of ciliary immobility syndrome.
Other cultures such as sputum or bronchial secretions can accurately determine pathogenic microorganisms and have guiding significance for the selection of antibiotics.
Differential diagnosis
Bronchiectasis should be an irreversible lung injury that must be differentiated from some diseases with similar clinical signs, signs, and imaging changes, primarily with the following diseases.
1. Chronic obstructive pulmonary disease (COPD) Unlike bronchiectasis, chronic obstructive pulmonary disease often has a history of smoking or exposure to harmful dust or occupational history. It is clinically characterized by chronic cough, cough, and white mucus. Purulent sputum is rare, rarely hemoptysis, pulmonary function is obstructive ventilatory dysfunction, HRCT often found signs of central lobe emphysema.
2. Lung abscess often has a history of acute onset, the initial manifestations of high fever, cough and cough, a large number of pus sputum, etc., chest imaging examination can be seen in local inflammatory high-density shadows, which have voids and liquid level, lesions often appear single The hair is mostly located in the posterior segment of the right upper lobe, the dorsal segment of the lower lobe or the posterior basal segment of the inferior lobe. The anti-infective treatment or the curative effect is not given in time, and the cavity is thick-walled chronic fibroplasia. The disease lasts for more than 3 months, forming chronic .
3. Tuberculosis is common in the afternoon, low fever, night sweats, weight loss and fatigue and other symptoms of tuberculosis; lung lesions are mostly located in the upper or lower back of the lung, the wet voice of the lesion is more common after cough; chest imaging can be seen proliferating , infiltration and voids and other manifestations; sputum tuberculosis test positive can be diagnosed.
