What Are the Effects of Emphysema?

Pulmonary bullae are usually secondary to inflammatory lesions of small bronchi, such as pneumonia, emphysema, and tuberculosis, which are most often co-existed with emphysema in clinical practice.

Bullous emphysema

Pulmonary bullae are usually secondary to inflammatory lesions of small bronchi, such as pneumonia, emphysema, and tuberculosis, which are most often co-existed with emphysema in clinical practice.

Bullous emphysema disease

Disease Name: Bullae

Other names: bullae

Disease Code: ICD-9: 492-12ICD-10: J43.953

Location: Chest,

Departments: Respiratory Medicine, Thoracic Surgery, Pediatrics

Pulmonary bullae secondary to pneumonia or lung abscess are more common in infants and young children, both single and multiple. Due to inflammatory lesions, there is edema in the small bronchial mucosa, causing partial obstruction of the lumen, producing a valve effect, air can enter the alveoli and is not easy to discharge, the pressure in the alveoli increases, and the alveolar interval gradually ruptures due to the increase in the pressure in the alveoli, forming a huge The balloon-containing cavity is clinically referred to as bullae; clinically, those secondary to pulmonary tuberculosis are single, and no obvious emphysema exists simultaneously; those secondary to emphysema are often multiple, except for bullae. In addition, it is often accompanied by most vesicles. ^[1]

Classification of bullous emphysema disease

Respiratory diseases

Clinical manifestations of bullous emphysema

1 Symptoms and signs: The walls of the alveoli are very thin, consisting of flat epithelial cells of the alveoli, or they may be fibrous membranes only. It can coexist with a variety of emphysema, which is common in the lateral or interstitial emphysema, and can be accompanied by carbon deposition, such as coal workers' pneumoconiosis, or without carbon deposition, such as scar tissue emphysema. The pulmonary bullae are divided into three types according to the pathological morphology.

1.1 Type I: narrow neck lung bullae. It protrudes from the surface of the lung and has a narrow band connected to the lung. Because of the valvular obstruction formed by bronchial scar tissue, the increase in alveolar volume is due to the alveolar side branch ventilation and gas retention. Type pulmonary bullae have thin walls and are often formed by pleura and connective tissue. They usually occur in the middle lobe or tongue and are also common in the upper lobe of the lung. It may be due to the large negative pressure in the chest cavity. presence.

1.2 Type : superficial pulmonary alveoli with a wide base. Located on the surface of the lungs, between the visceral pleura and emphysema lung tissue. The connective tissue space can be seen in the bullae cavity, but it does not form the wall of the bullae and can be seen in any part of the lung.

1.3 Type : deep alveoli at the base of the broad base. The structure is similar to type II, but it is deeper and surrounded by emphysema lung tissue. The bullae can extend to the hilum and can be seen in any lobe.

1.4 When the volume of the pulmonary bullae increases, the surrounding lung tissue is compressed and causes displacement of the lungs. The compressed lung tissue is shown on the X-ray chest radiograph as a shadow of increased density around the bullae. All three types are seen in chronic bronchitis. Lobulo-centric emphysema is not complicated by bullae. Lower lobe bullae are common in pneumoconiosis and fusion silicosis in coal miners with complications.

1.5 Small bullae do not cause symptoms by themselves, and patients with simple bullae often have no symptoms. Some bullae may remain unchanged for many years, and some bullae may gradually increase. The enlargement of the bullae or new bullae in other parts can cause lung dysfunction and gradually develop symptoms. Large pulmonary bullae can make patients feel chest tightness and shortness of breath. Sudden increase in pulmonary bullae rupture can produce spontaneous pneumothorax, cause severe breathing difficulties, and chest pain similar to angina pectoris.

1.6 Patients with bullae often have chronic bronchitis, bronchial asthma, and emphysema. The clinical symptoms are also mainly caused by these diseases, but after the formation of bullae, the clinical symptoms are further aggravated. Secondary infection of the bullae can cause cough, sputum, chills, and fever, and cyanosis in severe cases. If the drainage bronchus is blocked, the alveolar cavity is filled with inflammatory substances and the cavity can disappear. Clinically, the symptoms of infection may disappear after treatment, but the pulmonary alveolar shadow on the chest radiograph persists for weeks or months.

Diagnosis and identification of bullous emphysema

1 Medical examination

1.1 Chest X-ray: The best way to diagnose bullae. The apical lung bullae appear as thin, translucent cavities at the edge of the lung field, which can be round, oval, or flattened rectangular, of varying sizes. In large lung bullae, sometimes transverse interval. Multiple bullae can be polyhedral close together. Generally, it is not in direct communication with the larger bronchus, there is no liquid level, and the bronchial contrast agent cannot enter. The bullae at the base of the lung are often not easily seen on the chest radiograph. Some may be located completely below the level of the diaphragm. Others may be located only partially above the diaphragm. The ring-shaped shadow is easily mistaken for apical pleural adhesions. Giant pulmonary bullae generally have tension, and there may be a laminar forced atelectasis around it, making the bubble wall thicker, and it is not clear what is close to the chest wall. The nearby lungs were pushed and caused partial atelectasis. The texture of the lungs gathered and the transparency decreased. Bullae can fuse with each other to form a large space bullae, which looks like a local pneumothorax. Bullae can also rupture and produce localized pneumothorax.

1.2 X-ray and expiratory chest radiographs: help to find the pulmonary bullae, because the gas retention during exhalation makes the volume of the pulmonary bullae appear relatively large, and the edges are clearer. The tomography is also helpful in defining the outline of the bullae and showing the compression and displacement of the surrounding lung tissue. When co-existing lobular emphysema, tomography can also show abnormal pulmonary blood vessel shape.

1.3 CT examination: It can be found that common chest radiographs under the pleura are not easy to display large pulmonary alveoli with a diameter of less than 1 cm.

1.4 Pulmonary angiography: It can accurately show the degree of pulmonary blood vessel damage and the condition of the blood vessels surrounding the bullae.

2 Diagnosis basis

2.1 Have a history of chronic cough, palpitations, shortness of breath, and recurrent spontaneous pneumothorax.

2.2 X-ray or CT examination: there are vesicle-like changes in the lungs, there are many strand-like shadows in different directions in the vesicles, and there is no lung texture in the vesicles. The capsule wall is thin, and some capsules have a liquid-gas surface.

3 Misdiagnoses

3.1 Localized pneumothorax: The distinguishing points of pulmonary alveoli and localized pneumothorax are: pulmonary alveolar swelling around, so compressed lung tissue can be seen in the apical region, intercostal angle, or palpital angle region; and the limitation Pneumothorax mainly pushes lung tissues into the lungs. Usually, the edges of the compressed lungs can be seen shrinking to the hilum. This phenomenon is not found in bullae. Therefore, although strip-shaped intervals are visible in both, a distinction can still be made.

3.2 Pulmonary tuberculosis cavity: Inflammation that occurs in a small bronchi, causing local congestion and swelling. Due to the thick secretions and bronchospasm, the small bronchi are narrowed or valve-shaped, and the air can enter the lungs during inhalation and not all the gas can be expelled during exhalation. More and more air is in the alveoli, and the pressure gradually increases, causing the alveoli to expand excessively and rupture to form alveolar emphysema, which merge into each other into a large alveoli. The large bubble and the bronchi are only indirectly connected, so the gas is not easy to discharge, and it can often remain unchanged for several years. Some may form progressive bullae, which continue to expand to a lung that is replaced by bullae. Bullae are not uncommon, but they are easily confused with tuberculosis cavities. However, tuberculous cavities are formed by the dissolution and discharge of casein-like substances. Generally, the walls of the cavity are thick, and there are tuberculosis lesions and infiltration nearby. Tuberculosis bacteria can be detected in the sputum. The anti-TB treatment is effective and can be identified.

3.3 Spontaneous pneumothorax

3.31 Although both of them are compression of lung tissue by the gas cavity, due to the different locations of the gas, the contours and the shape of the compression of the lung are also different. Giant alveoli are formed by the rupture and expansion of alveoli in the lung tissue. The lung tissue is pushed around and is compressed by "centrifugal" pressure. The compressed lung tissue can be seen on the apex or diaphragm of the lung, and the edges are sometimes seen upward or downward. Arc shadow. Spontaneous pneumothorax is rupture of the visceral pleura, small trachea and alveoli communicate with the thorax, a large amount of gas enters the thorax, and compresses the lung tissue inward, forming "concentric" compression (except those with pleural adhesions). If the idiopathic pneumothorax is lightly compressed, a light-transmitting area is formed in the middle and outer regions of the lung field, and the inner side of the lung tissue can be seen to bend inwardly. If it is a tension pneumothorax, the lung tissue can be pushed near the hilum, forming a round mass shadow.

3.32 Once the giant pulmonary bullae are formed, they can exist for many years, and the light transmission area can be checked repeatedly without change. Clinical symptoms and signs can persist. Spontaneous pneumothorax onset is more rapid, and the light-transmitting area can be significantly enlarged or reduced in a short period of time.

3.33 Giant pulmonary bullae are usually free of fluids and no liquid-gas levels without co-infection. If pneumothorax is not treated properly, fluid pneumothorax is formed in a short period of time.

3.34 Large lung bullae are generally contraindicated for chest puncture, manometry, and aspiration, because piercing the visceral layer of the pleura can easily cause pneumothorax and aggravate the condition. If the puncture pressure is mistakenly diagnosed as qi, the fluctuation of pressure during breathing is atmospheric pressure, which fluctuates above and below "0". The light-transmitting area of the radiograph does not shrink after suction, and the symptoms do not improve. The tension pneumothorax is punctured. The pressure is higher than the atmospheric pressure during the pressure measurement, and fluctuates above "0". After the gas is drawn, the measurement can be significantly reduced, the symptoms are improved, the film is reviewed, and the light transmission area can be significantly reduced.

3.4 Congenital pulmonary cyst.

3.5 Diaphragmatic hernia.

3.6 Differentiation of diseases such as lung abscess.

Treatment for bullous emphysema

1 Principles of treatment

1.1 Asymptomatic pulmonary bullae need no treatment, and patients with chronic bronchitis or emphysema are mainly treated for primary lesions. For secondary infections, antibiotics are used.

1.2 Lung bullae are large in volume, occupying 70% to 100% of one side of the thorax, clinically symptomatic, and patients with no other lesions in the lung. Surgical removal of the bullae can cause compressed lung tissue to expand and increase the breathing area. Intrapulmonary shunt disappeared, arterial oxygen pressure increased, airway resistance decreased, ventilation increased, and patients with chest tightness, shortness of breath, and other symptoms of dyspnea could be improved.

1.3 Surgery should preserve as much healthy lung tissue as possible, and strive to be used only for pulmonary bullae resection and suture, or local lung tissue wedge resection to avoid unnecessary loss of lung function.

1.4 Spontaneous pneumothorax caused by ruptured pulmonary bullae can be cured by non-surgical treatment such as thoracentesis and closed chest flow. However, spontaneous pneumothorax that occurs repeatedly should be treated surgically. Lung bullae are ligated or sutured during surgery. At the same time, tetracycline or 2% iodine can be used to smear the chest cavity to fix the pleural adhesion and prevent pneumothorax from recurring.

1.5 Patients with blood pneumothorax sometimes have severe clinical symptoms, often chest pain, dyspnea, and a series of symptoms of internal bleeding. Clinical changes should be closely observed, and non-surgical measures such as blood transfusion, chest When wearing, etc., no obvious improvement in symptoms, decisive chest exploration should be performed. At this time, there is often a large active bleeding, long observation time for non-surgical treatment often delays the disease, and the prognosis is not as good as the surgical hemostasis.

Prevention of bullous emphysema

1.1 Although there are no special requirements in the diet, nutrition should be increased, eat more high-quality protein, eat more foods rich in vitamins, eat less irritating foods, drinks, avoid tobacco and alcohol, and avoid infection.

1.2 Patients and their families often worry about the cost, the effect of the operation, and even the fear of surgery. Therefore, meticulous psychological care during the perioperative period can relieve the patient's tension and reduce stress reactions.

1.3 Preoperative cessation of smoking, deep breathing training, effective cough and sputum preparation and other airway preparations can improve the clearance of secretions, relieve bronchospasm, and reduce respiratory secretions.

1.4 When preventing complications, respiratory care is particularly important: low-flow continuous oxygen should be given after surgery to encourage deep breathing and turn around every 2 hours to pat back; do psychological care to avoid refusing to cough due to pain or fear of tube fall Sputum; patients should learn the correct sputum discharge method, such as: hold your breath after deep inhalation, cough several times, cough the sputum to the pharynx, press the chest at the same time, and finally cough the sputum with a strong cough; if the sputum is thick, Drink plenty of water to dilute sputum to facilitate sputum discharge.

Bullous emphysema complications

1 Complications: Spontaneous pneumothorax is the most common complication of bullae, followed by infection and spontaneous pneumothorax.

1.1 Spontaneous pneumothorax: Bullae can be without any symptoms. Sudden exertion, such as a sudden cough, heavy lifting, or sudden increase in pressure during physical exercise, ruptured pulmonary bullae, gas from the lungs into the pleural cavity, and the formation of spontaneous pneumothorax may cause dyspnea, shortness of breath, palpitation, and increased pulse Pneumothorax makes the pleural cavity negative pressure disappear, and the gas compresses the lung tissue and causes it to collapse toward the hilar. The degree of collapse depends on the amount of gas entering the chest cavity, as well as the pathological conditions of the original lesions of the lung and pleura, and the gas entering the chest cavity. Large amount, the original lesion of the lung tissue is light, the compliance is good, the lung collapses more, sometimes it can reach 90% of one side of the chest cavity, the gas quickly enters the chest cavity, the lung tissue rapidly shrinks, the symptoms are severe, and even cyanosis. If the patient is accompanied by emphysema, pulmonary fibrosis, long-term chronic infection of lung tissue and other lesions in addition to the bullae, although some of the gas enters the chest cavity when the bullae ruptures, the degree of lung tissue collapse can be mild, but Because the patient's original lung function has decreased, the symptoms are also severe. X-rays show the pneumothorax formed by the compressed lungs. If adhesions are present, the pneumothorax is irregular. After the pulmonary bullae ruptured, a small part of them were small. After the atrophy of the lung tissue, the fissures closed on their own, the air leakage stopped, the pleural effusion gradually absorbed, the thorax was restored, and the lungs recovered.

1.2 Tensile pneumothorax: If a pulmonary valve is formed after rupture of the bullae, the negative pressure in the thoracic cavity increases during inhalation, the gas enters the thoracic cavity, the valve closes during exhalation, and the gas cannot be expelled, especially when coughing, the pressure of the glottic closure airway increases After the gas enters the chest cavity and the glottis is opened, the airway pressure is reduced and the cleft is closed. Each breath and cough increases the amount of gas in the chest cavity, forming a tension pneumothorax. During tension pneumothorax, the affected lung tissue completely atrophies, the mediastinum is pushed to the healthy side, while the healthy lung tissue is compressed, the large blood vessels of the heart are displaced, the large veins are distorted and deformed, which affects blood flow and causes severe disturbances in the respiratory cycle. Patients Dyspnea, rapid pulses, decreased blood pressure, and even suffocation and shock can occur. The thoracic bulge on the ipsilateral side is often accompanied by subcutaneous emphysema on the ipsilateral side, and the trachea is obviously shifted to the healthy side. The condition is critical and often requires emergency treatment.

1.3 Spontaneous hemothorax: Spontaneous hemothorax caused by bullae, most of which are caused by bullae at the apex of the lung or the surrounding lung tissue and adhesions to the chest and bleeding. The arterioles in the adhesive bands can be up to 0.2 cm in diameter. The blood vessels originate from the systemic circulation and the pressure is high. At the same time, there is negative pressure in the chest cavity, which increases the tendency of bleeding. In addition, due to the defibrotic effect of lung, heart, and diaphragm muscle movements, blood in the chest cavity does not coagulate, so bleeding is difficult to stop automatically. The clinical symptoms may vary depending on the speed of the bleeding. When the bleeding is slow, the patient may present with progressively increasing chest tightness, dyspnea, X-ray blunt corners, or parabolic images of pleural effusion. Shock can occur in the short term when bleeding is rapid.

1.4 Spontaneous blood pneumothorax: When the adhesions of the bullae and surrounding lung tissue to the chest wall are torn, if there are blood vessels in the adhesion band and the lung tissue is also damaged, spontaneous blood pneumothorax is formed.

1.5 Secondary infection of bullae: In most cases, bullae occur in the distal bronchus above grade VIII, and most of them are not infected, but if the drainage bronchus is blocked, the bronchi of the bullae are filled with inflammatory secretions. Patients may develop symptoms such as fever, cough, and sputum. Sometimes, after anti-infective treatment, clinical symptoms improve, and the signs of infection on the chest radiograph can continue for a long time.