Bronchial asthma in the elderly
Introduction
Introduction to bronchial asthma in the elderly Bronchial asthma (referred to as asthma) is a chronic inflammation of the airway with eosinophils and mast cell responses. Such inflammation in susceptible individuals can cause varying degrees of extensive reversible airway obstruction. The clinical manifestations are recurrent wheezing, difficulty breathing, chest tightness or cough, which can be treated or self-recovery, and the airway has high reactivity to irritants. The above definition of asthma is based on the conclusions of recent studies on the pathophysiology of asthma in young people. As for the mechanism of asthma in the elderly, especially whether airway inflammation is the same as that of young people, there is still no evidence. basic knowledge The proportion of sickness: 0.00523% Susceptible people: the elderly Mode of infection: non-infectious Complications: pneumothorax mediastinal emphysema atelectasis chronic bronchitis bronchiectasis
Cause
The cause of bronchial asthma in the elderly
(1) Causes of the disease
At present, the cause of asthma is still not very clear, and most of them are considered to be related to polygenic inheritance, and are combined by genetic factors and environmental factors.
Many survey data show that the prevalence of relatives of asthma patients is higher than the prevalence of the population, and the closer the relationship is, the higher the prevalence rate; the more serious the patient's condition, the higher the prevalence of relatives, the majority of parents of asthma patients exist. Different degrees of airway hyperresponsiveness, the current asthma related genes have not been fully defined, and studies have shown that there are related genes related to airway hyperresponsiveness, IgE regulation and atopic response, these genes play a role in the pathogenesis of asthma. Important role.
Viral respiratory infections (such as rhinovirus, influenza virus) are common causes of asthma attacks in the elderly, while the systemic and local immune functions of the elderly are reduced, and respiratory infections are recurrent. Repeated respiratory infections can damage the airway epithelium, resulting in high airway. Reactivity (BHR), it has been reported that 84.4% of late-onset asthma is induced by acute upper respiratory tract infection, and many elderly people suffer from cardiovascular disease. Beta blockers such as propranolol, guanolol, and thiophene are used. Increased chances of , metoprolol, acetamide butyrate, long-term use of beta blockers, receptor dysfunction, block bronchial smooth muscle 2 receptors to induce or aggravate asthma, elderly patients with aspirin There are many opportunities for bloody heart disease and cerebrovascular thrombosis. There are many opportunities for non-corticosteroid anti-inflammatory drugs such as ibuprofen and indomethacin. These drugs can inhibit the metabolism of arachidonic acid to make leukotrienes. Increased synthesis leads to asthma, so asthma inducing and aggravating in some elderly patients may be the result of the use of aspirin or non-corticosteroids antipyretic analgesics, and some elderly asthma or Associated with sinusitis and polyposis, the spontaneous remission rate of asthma in the elderly is low. Bronnimann et al. followed a group of elderly asthma for several years, with a regression rate of only 19%, and the regression rate of asthma in children reached 50%, 57% of the elderly. People are prone to gastric-esophageal reflux, and micro-aspiration can cause bronchoconstriction and spasm caused by vagus nerve reflex.
(two) pathogenesis
The basic pathological changes of the airway are mast cells, pulmonary macrophages, eosinophils, lymphocytes and neutrophil infiltration, airway submucosal tissue edema, increased microvascular permeability, bronchial endocrine retention, bronchial smooth muscle spasm Pathological changes such as exfoliation of cilia epithelium, exposure of basement membrane, proliferation of goblet cells and increase of bronchial secretions, referred to as chronic exfoliative eosinophilic bronchitis, the above changes may vary with the degree of airway inflammation, if Long-term recurrent asthma can enter the irreversible stenosis of the airway, mainly manifested as thickening of the bronchial smooth muscle, airway reconstruction under airway epithelial cells, and support of the surrounding lung tissue to the airway. Disappeared, in the early stage of the disease, due to the reversibility of pathology, organic changes are rarely found anatomically. With the development of the disease, the pathological changes are gradually obvious. The lungs are enlarged and emphysema is prominent, and the lungs are soft and loose. , bronchial and bronchioles contain viscous sputum and mucus plug, thickened bronchial wall, mucosal congestion and swelling Pleat, mucous plugs can be found in local atelectasis.
Prevention
Elderly bronchial asthma prevention
Prevention of asthma is divided into three levels:
Primary prevention aims to prevent asthma by eliminating risk factors.
Secondary prevention is the early diagnosis and treatment of asymptomatic disease to prevent the development of asthma.
Tertiary prevention is to actively control asthma symptoms, prevent the disease from worsening, and reduce complications.
Risk factors and interventions:
1. Asthma is a polygenic genetic disease with a heritability of 70% to 80%. Therefore, heredity is an important risk factor. Genetic counseling should be used when choosing a spouse. If both parents are susceptible, their children are also susceptible. The possibility of sex is far greater than that of only one parent. Therefore, the choice of susceptible person as a spouse should be avoided. There is also a correlation between blood type and asthma. People with type A blood are prone to asthma and allergic rhinitis, while type O blood. People are much less likely to develop this type of disease than those with type A blood.
2. Control environmental triggering factors
Mainly to determine, control and avoid exposure to various allergens, occupational sensitizers and other non-specific irritants, the most common foods causing allergies are fish, shrimps, crabs, eggs, milk, etc., occupational sensitizers such as toluene Diisocyanate, zinc phthalate, ethylenediamine, penicillin, protease, amylase, silk, animal dander or excrement, etc. In addition, non-specific formaldehyde, formic acid, etc., in addition, some specificity And non-specific inhalants can also induce asthma, the former such as dust mites, pollen, fungi, animal dander, etc.; non-specific inhalants such as sulfuric acid, sulfur dioxide, chlorine, ammonia, etc., when temperature, humidity, pressure and / or air When ions are changed, asthma can be induced, so it is more common in the cold season or when the autumn and winter seasons change.
3. Mental factors
Patients with emotional excitement, nervousness, anger, etc., will promote asthma attacks. It is generally thought to be caused by cerebral cortex and vagus nerve reflex or hyperventilation. Therefore, psychological treatment should be carried out for the elderly, self-management, self-relaxation and self-adjustment. .
4. Avoid respiratory infections
The formation and onset of asthma are associated with repeated respiratory infections. In asthma patients, there may be specific IgE of bacteria, viruses, mycoplasma, etc. If the corresponding antigen is inhaled, asthma may be induced, and the respiratory epithelium may be directly damaged after infection. Respiratory responsiveness is increased. Some scholars believe that interferon produced by viral infection and IL-1 increase the amount of histamine released by basophils. Therefore, in daily life, attention should be paid to keeping indoor air fresh and circulating. Avoid entering and leaving public places, increase your resistance, add clothing in time, and wear masks during the cold season.
5. Asthma and drugs
Some drugs can cause asthma attacks, such as propranolol, which causes asthma by blocking -adrenergic receptors, and 2.3% to 20% of asthma patients induce asthma by taking aspirin, which is called aspirin asthma. With nasal polyps and low tolerance to aspirin, it is called aspirin triad, patients may have cross-reaction with other antipyretic analgesics and non-steroidal anti-inflammatory drugs, the elderly need to take cardiovascular and cerebrovascular diseases Aspirin, a beta 2 blocker, should be weighed against the pros and cons of avoiding asthma attacks.
6. Smoking
Older asthma patients account for about 60% of smoking history. Most patients form asthma on the basis of years of smoking. It is because of the high airway responsiveness caused by perennial smoking. The elderly should avoid smoking and quit smoking as soon as possible.
7. Community intervention
Encourage patients to establish partnerships with medical staff, objectively evaluate the degree of asthma attacks through regular pulmonary function tests, avoid and control asthma-inducing factors, reduce recurrence, formulate long-term management medication plans for asthma, formulate treatment plans for episodes, and follow-up care for long-term regular follow-up.
Complication
Broiler complications in the elderly Complications, pneumothorax, mediastinal emphysema, atelectasis, chronic bronchitis
At the time of onset, pneumothorax, mediastinal emphysema, and atelectasis may occur. The author may be associated with respiratory tract infection or chronic bronchitis with bronchiectasis.
Symptom
Bronchial symptoms in the elderly Common symptoms Chest tightness, dry cough, sputum, breathing, tracheal obstruction, odd pulse rate, sneezing, passive position, three concave signs
Symptom
Typical bronchial asthma, there are aura symptoms such as sneezing, runny nose, cough, chest tightness, etc. before the attack, if not treated in time, asthma may occur due to aggravation of bronchial obstruction, severe cases may be forced to take a seat or sit in the breath, dry cough Or a large amount of white foam sputum, or even cyanosis, etc., but generally can be relieved after treatment with self-medication or anti-asthmatic drugs, some patients can re-emerge after a few hours of relief, and even lead to persistent asthma, in addition, clinically There are atypical manifestations of asthma, such as cough variant asthma, patients have no obvious incentives for cough for more than 2 months, night and early morning attacks, exercise, cold air and other induced aggravation, airway reactivity determination is highly reactive, antibiotics or Antitussive and expectorant drugs are not effective, and bronchial spasmolytic agents or corticosteroids are effective, but other diseases that cause coughing need to be excluded.
2. Signs
Passive position, sitting position, can be accompanied by sweating, increased respiratory rate, can be >30 times / min, use auxiliary breathing muscles, three concave signs, lung auscultation can be heard and wheezing sound, common in the end of expiration, there are strange veins Increased heart rate, abnormal chest and abdomen activity and cyanosis are found in patients with severe asthma. No matter what kind of asthma, mild symptoms can be relieved by themselves. There are no symptoms and abnormal signs during the remission period.
Examine
Elderly bronchial asthma examination
Blood routine examination
There may be eosinophilia at the time of onset, such as increased total white blood cells and increased proportion of classified neutrophils in concurrent infections.
2. Sputum examination
The smear showed more eosinophils under the microscope, sharp-edged crystals (Charcort-Leyden crystals), mucus plugs (Curschmann spirochetes) and transparent asthma beads (Laennec beads), such as bacterial infections in the respiratory tract, sputum smear Gram Dyeing, bacterial culture and drug sensitivity tests are helpful for the diagnosis and guidance of pathogens.
3. Blood gas analysis
If there is hypoxia during asthma attack, PaO2 may decrease. PaCO2 may decrease due to excessive ventilation, and the pH value will rise. It may cause respiratory alkalosis, such as severe asthma, severe airway obstruction, CO2 retention, and PaCO2 rise. It is characterized by respiratory acidosis, such as hypoxia, which can be combined with metabolic acidosis.
4. Respiratory function check
Among the many indicators of lung function tests, peak expiratory flow rate (PEFR) and forced expiratory volume in the first second (FEV1) are the two most commonly used ventilation function indicators in asthma patients.
The National Heart, Lung, and Blood Center's National Asthma Education Program recommends peak expiratory flow rate (PEFR) as an objective measure of resistance to airflow obstruction and treatment. It is measured in PEFR and commonly used pulmonary function tests in all tests that patients can perform. The FEV1 has a good correlation and the table below shows the expected average of PEFR for normal adult males and females (Table 1).
Even a highly experienced doctor estimates that PEFR is unreliable based on clinical conditions. It is also unreliable for patients to estimate PEFR based on their perception of airflow obstruction. Therefore, PEFR values must be measured repeatedly to evaluate treatment effects and recovery. In terms of the situation, PEFR is also very important for outpatients. Each patient should establish the best PEFR of the individual when the asthma is well controlled. The deviation from the above PEFR value is obvious, indicating that the condition is worse. At this time, the patient should consult the doctor immediately. In order to make appropriate adjustments to the medication, the percentage of PEFR measured value to the expected value can be used as an indicator to determine the severity of asthma, mild asthma: 80% of the estimated PEFR value; moderate asthma: measured PEFR accounted for the expected PEFR value 60%80%; moderate asthma: the measured PEFR value is expected to be 60% of the PEFR value. The clinical value of PEFR can be used as an indicator of lung function for measuring airway responsiveness; an indicator for judging the severity of asthma; and evaluating the efficacy of bronchodilator; Finding no clinically symptomatic deterioration of lung function at home or at work, predicting possible "asthma death" patients; finding and confirming Determine the cause of asthma.
FEV1 is a lung function index for assessing the degree of airway obstruction. The first second forced force occupancy capacity (FEV1/FCV%) is an early, sensitive indicator for determining airway obstruction and can identify restrictive ventilation function. Obstruction or obstructive ventilatory dysfunction, in the acute phase of asthma, FEV1 is no better than PEFR for predicting disease progression.
Carbon monoxide diffusion (DLCO) and plethysmography as part of a pulmonary function test for all asthma patients help to rule out both emphysema and interstitial disease.
Airway hyperresponsiveness is an important pathophysiological basis for symptomatic asthma, but airway hyperresponsiveness is also present in asymptomatic asthma patients and some non-asthmatic patients. Airway hyperresponsiveness is helpful when lung capacity is normal. The diagnosis of asthma, but because it can not accurately reflect the severity of asthma, and the determination is more complicated, it is not suitable for guiding the clinical treatment of asthma, mainly for clinical research work.
All indicators of expiratory flow rate decreased during the onset of asthma, forced expiratory volume in the first second (FEV1), forced expiratory capacity in the first second (FEV1/FVC%), and maximum expiratory flow rate (MMFR) The maximum expiratory flow (MEF25% vs. MEF50%) and the peak expiratory flow rate (PEFR) at 25% and 50% of the lung capacity are reduced, and the remission period can be gradually restored. Effective bronchodilators can improve the above indicators.
5. Skin Sensitive Test In the asthma remission period, suspicious allergens are used for skin scratching or intradermal testing. Conditional inhalation stimulation test can be used to make allergen judgment.
6. X-ray examination of the chest in the imaging room: In the early asthma attack, the brightness of both lungs is increased. If it is over-inflated, there is no obvious abnormality in the remission period. For example, if the respiratory infection is complicated, the lung texture is increased and the inflammatory infiltration is visible. Attention should be paid to the presence of complications such as atelectasis, pneumothorax or mediastinal emphysema. In Fjndie's study, only 1% of 90 cases of acute asthma attack showed new infiltrates, 55% normal, 33% hyperventilation, 7 % showed mild pulmonary interstitial abnormalities. This study confirmed that chest X-ray examination has little value for the treatment of uncomplicated asthma attacks, and X-ray examination has certain value for the diagnosis of new-onset wheezing patients. Exclude potential cardiopulmonary disorders such as congestive heart failure, pneumonia, etc.
7. Complement test for radionuclide-specific allergens: Specific IgE can be measured by radioactive allergen adsorption test (RAST). Serum IgE in patients with allergic asthma can be 2 to 6 times higher than normal, and can be judged during remission. Allergens, but should prevent allergic reactions, or calculate the histamine release rate with basophils histamine release test, > 15% positive, can also determine immune and IgE, IgA, IgM and other immune cells in blood and respiratory secretions protein.
Diagnosis
Diagnosis and diagnosis of bronchial asthma in the elderly
Diagnostic criteria
For typical cases, clinical diagnosis can be made based on medical history, symptoms, signs and response to antiasthmatic drugs. However, the clinical manifestations of elderly asthma are mostly atypical, and mixed with other diseases, should improve the vigilance of diagnosis, for similar Patients with COPD symptoms should be aware of the presence of asthma when the following clinical features exist:
1. Symptoms are highly volatile, with a significant increase or significant remission period.
2. Symptoms are significantly related to seasonal or climate change.
3. There is obvious time rhythm, more than night or morning symptoms.
4. Pulmonary function declines faster.
5. Antiasthmatic drugs can significantly relieve symptoms.
Detailed medical history, dynamic observation (including response to drugs) is helpful for diagnosis and identification, and pulmonary function tests can provide a more powerful basis for diagnosis.
Differential diagnosis
Older asthma is usually characterized by shortness of breath and wheezing. Some patients do not have wheezing, but only cough or shortness of breath, so pay attention to COPD, cardiogenic asthma, panbronchiolitis, upper airway obstructive disease (such as Tracheal tumors can be narrowed, etc., and the identification of diseases such as spontaneous pneumothorax, through detailed medical history, physical examination, chest X-ray, lung function and response to drugs, etc., is usually not difficult to identify.
