What Factors Affect Emphysema Prognosis?

Emphysema is an over-inflation of the distal part of the terminal bronchioles (including respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli), with the destruction of the air cavity wall. In 1987, the American Thoracic Society (ATS) revised the definition of emphysema: "the irreversible expansion of the distal part of the bronchioles with damage to the alveolar wall, but no obvious fibrosis". The basic feature of emphysema is excessive inflation of the lung tissue and obstruction of airflow in the ventilated part, so it is called "obstructive pulmonary emphysema".

Chinese name: Emphysema in the elderly

Foreign name: emphysema
Department: Respiratory, Geriatrics

Emphysema symptoms and signs in the elderly

Emphysema is slowly onset, the course is long, and the stable-exacerbated phase alternates.

Symptoms

(1) Cough and sputum: Emphysema patients often have many years of cough and sputum history. The cough and sputum in the stable period can be lighter, and it is white sticky sputum; when the respiratory tract infection is combined, the cough and sputum are aggravated and they are purulent sputum.

(2) Chest tightness and shortness of breath: In the early days, I often feel shortness of breath when walking upstairs or walking quickly after an activity; gradually develop into shortness of breath when walking on a flat road; in the later period, I live in activities such as washing my face, brushing my teeth, wearing shoes, dressing, talking , Even short of breath. Patients often prefer to sit in a prone position (allowing the assisted breathing muscles to participate in activities), deflate the lips, or exhale into moaning.

(3) Fatigue, anorexia, weight loss, etc .: Very common in elderly emphysema patients.

(4) Fever: Fever is often associated with infection.

Drowsiness or irritability, psychiatric disorders, headache, sweating, flapping tremors, etc., suggest that there may be respiratory failure.

Lack of urine, edema of the lower limbs, cyanosis of the fingers and fingers, palpitation, etc. are more suggestive of pulmonary heart disease and right heart failure.

2. There are no abnormalities in early signs. In severe cases, "barrel chest" can be seen. In elderly patients with emphysema, the cost of cartilage has been calcified at this time, so typical barrel chests in elderly patients with emphysema are rare, but the costal space is common. Pulmonary percussion showed unvoiced sound, liver dullness decreased, and heart dullness decreased or disappeared. Breath sounds and speech are weakened, exhalation is prolonged, and sometimes dry and wet rales are heard at the bottom of the lungs, and heart sounds are low.

Patients with respiratory failure can also see elevated blood pressure, cyanosis, bulbar conjunctival edema, nystagmus, different pupil sizes on both sides, and flapping tremor.

Patients with right heart failure can also see cyanosis, jugular venous distension, second hypertensive or split pulmonary valve, hepatomegaly, positive hepatic-jugular vein reflux sign, and lower limb depression edema.

3. Typing and staging

(1) Classification: As mentioned above, there are two patterns of emphysema: etiology-emphysema-chronic bronchitis, etiology-chronic bronchitis-emphysema. Obstructive emphysema or COPD can be divided into two types in clinical manifestations, namely, the emphysema type is also known as red asthma type (PP type) and the bronchitis type is also known as purple type (BB type); some patients do not Meet the typical performance of the above two types, also known as "hybrid type" (X-type).

Type BB: Patients with severe bronchial inflammation, mild emphysema, prominent cough and sputum history, fat body, often cyanosis, jugular vein irritation, and lower extremity edema. The lungs often smell dry and wet. Snoring sounds, obvious impairment of pulmonary ventilation function, normal diffusion function, hypoxemia and hypercapnia are often present, and hematocrit increases. This type of patients mostly suffer from chronic pulmonary heart disease, easily develop into respiratory failure or heart failure, the prognosis is poor, this type is rare in elderly patients.

PP type: Patients with severe emphysema lesions and milder bronchitis lesions are more common in the elderly. They are thin and have shortness of breath, and generally have no cyanosis. They usually take special postureshigh shoulders, two-armed beds (chairs) ), Whistle-like exhalation, the chest X-ray film showed significantly increased lung transparency, reduced lung texture, significantly increased residual gas rate, less damage to ventilation function, normal hematocrit, and normal or mild damage to blood gas examination.

(2) Staging and indexing:

The American Thoracic Society divided emphysema into 5 stages in 1972:

Phase I (asymptomatic phase): The patient has no obvious symptoms, no abnormalities in X-ray and pulmonary function tests, and only mild emphysema changes in pathological sections.

Phase II (Pulmonary Hypoventilation Phase): Patients may have cough, sputum, shortness of breath, shortness of breath, physical examination and X-ray examination with emphysema signs, pulmonary function tests with ventilation dysfunction and increased residual volume.

Phase III (hypoxemia): In addition to the above manifestations, there are also reductions in cyanosis and PaO2.

Stage 4 (Carbon Dioxide Retention Period): Patients may experience mental and conscious disturbances with elevated PaCO2.

Five stages (chronic pulmonary heart disease): It is divided into compensatory period and decompensated period.

This staging method is rarely used clinically in recent years because its three, four, and five phases often occur out of order or coexist.

The American Thoracic Society later divided it into 3 stages based on lung function impairment:

Phase I: Second amount (FEV1.0) 50% of expected value.

Phase II: FEV1.0 is 35% 49% of the expected value.

Phase III: FEV1.0 <35% of expected value.

There are also indexing based on residual gas rate (RV / TLC):

Mild emphysema: RV / TLC = 40% 50%.

Moderate emphysema: RV / TLC = 50% 60%.

Severe emphysema: RV / TLC 60%.

The more commonly used clinical stages are divided into stable and exacerbated stages based on their clinical manifestations.

Aggravated emphysema: The patient's condition worsens sharply due to climate and other incentives, cough, sputum, shortness of breath, increased sputum volume, sputum becomes purulent, and may be accompanied by fever, dense dry and wet rales in the lung, The total number of white blood cells or the proportion of neutrophils, cyanosis, etc. Even cardiac and / or respiratory failure manifestations such as palpitation, jugular vein distension, hepatomegaly, hematoma, lower limb edema and / or conscious-conscious disturbance, bulbar conjunctival edema, hand flapping tremor-like tremor.

Emphysema in stable phase: The patient's condition is stable, the sputum is white sticky sputum, the lungs have little or no wet sounds, no fever, an increase in the total number of white blood cells, or an increase in the proportion of neutrophils, and no signs of cardiopulmonary failure.

Treatment of emphysema in the elderly

The treatment of elderly emphysema should include the management of stable phase and the treatment of exacerbation phase.

1. Management of stable period The focus of stable period management is rehabilitation treatment, the purpose of which is to improve the quality of life of patients, reduce the number of acute attacks and prolong survival.

(1) Improve the general condition of patients:

Mobilize patients to quit smoking: Smoking is the number one risk factor for emphysema. Quitting smoking can reduce symptoms and slow the progress of lung function damage. A large amount of data proves that stopping smoking and long-term oxygen inhalation can significantly delay the natural process of emphysema.

Strengthen nutrition and enhance the body's immunity: Malnutrition not only damages lung function and respiratory muscle function, but also weakens the body's immune mechanism. Therefore, emphysema patients should strengthen nutrition. Cold hard exercise, moderate exercise (such as walking, aerobics, tai chi, etc.), righteous Chinese medicine, casein (nucleus casein) or freeze-dried BCG vaccine can enhance physical fitness, prevent colds and lower respiratory tract infections.

Education and guidance of scientific knowledge: Elderly emphysema patients are often in anxiety, depression, or fear due to their long course, recurrent episodes, and limited social activities. This is not conducive to rehabilitation and quality of life. Publicize health knowledge, guide patients to carry out correct rehabilitation exercises, and enhance mental health.

(2) Respiratory training: Instruct patients to perform abdominal breathing and neck-pumping exhalation-first make a neck-pumping exhalation. Abdominal muscle contraction causes abdominal pressure to rise and diaphragmatic muscles rise; then inhale through the nose and relax the abdominal muscles. Diaphragm contraction moves down. This deep and gentle abdominal breathing can coordinate chest and abdomen breathing, increase tidal volume, reduce ineffective cavity ventilation, slow breathing frequency, increase oxygenation, and reduce oxygen consumption; retinal exhalation can make the outer part of the airway When the pressure increases, the isobaric point moves to the central airway, preventing the small airway from closing prematurely during exhalation, reducing the residual gas in the lungs, and alleviating the imbalance of the ventilation / blood flow ratio.

(3) Respiratory muscle exercise: Respiratory muscle malnutrition and fatigue in elderly patients with emphysema are important foundations and causes of hypoventilation and respiratory failure. Respiratory muscle exercise is very important for the rehabilitation of elderly emphysema patients. Respiratory muscle exercise commonly used methods are resistance breathing and exercise training. If you use a breathing resistance device to breathe, it increases the inhalation resistance and achieves the purpose of exercising the breathing muscles. After training, the strength and endurance of the breathing muscles can be significantly improved. It should be noted that during resistance breathing exercise, too small resistance will not achieve the purpose of exercise, and too large will easily induce respiratory muscle fatigue.

(4) Home oxygen therapy: Oxygen therapy can improve patient symptoms, improve work efficiency, increase activity intensity, expand activity range, and extend survival. Persistence of low-flow continuous oxygen for 15h every day is better than intermittent oxygen inhalation. With the improvement of oxygen supply equipment, home oxygen therapy has become possible. The oxygen concentrator, liquid oxygen reservoir, etc. are small in size and convenient to use, and are suitable for home oxygen therapy.

The following stable patients should undergo home oxygen therapy-PaO28.0kPa (60mmHg), but SaO2 <88% during night sleep.

(5) Others: Non-traumatic mechanical ventilation is also suitable for family management of patients with severe emphysema. Mask and intermittent assisted mechanical ventilation under the guidance of a doctor can make the respiratory muscles rest, relieve respiratory muscle fatigue, and improve respiratory muscle function.

There have been many reports recently that almitrine bismesylate can not only excite breathing, but also improve ventilation / blood flow ratio, increase blood oxygen partial pressure, and is suitable for stable treatment of severe emphysema.

2. Aggravated Treatment

(1) Control of respiratory tract infections: The pathogens of emphysema combined with mild to moderate respiratory tract infections are mostly pneumococcus, haemophilus influenzae, catarrhalis, and staphylococcus aureus; in severe cases, G-bacteria are the most common. Once an infection occurs, sensitive antibiotics should be used early and in sufficient quantities, and the course of treatment should be appropriately extended.

Mild and moderate respiratory infections are mostly oral antibiotics. As experimental treatment, carbenicillin (carbenicillin), a new generation of macrolide antibiotics, fluoroquinolone antibiotics, and first and second generation cephalosporin antibiotics can be selected. The course of treatment is usually 5 to 10 days.

Severe respiratory infections are dominated by intravenous antibiotics. Can choose the second or third generation of cephalosporin antibiotics, fluoroquinolone antibiotics, experimental treatment for 3 to 5 days, and then adjust the antibiotics in time based on phlegmology and drug sensitivity results. In elderly patients with emphysema complicated by severe respiratory infections, the proportion of anaerobic and fungal infections is relatively high and should be highly vigilant. For anaerobic infection, tinidazole, clindamycin (clindamycin) or third-generation cephalosporin antibiotics can be selected first. Fungal infections (mostly Candida albicans) can be treated with fluconazole, 100 mg orally twice a day, for at least 2 weeks.

Renal function in the elderly decreases significantly with aging, so antibiotics such as aminoglycosides, which are mainly excreted by the kidney or have obvious renal toxicity, should be used with caution, and should be appropriately reduced when necessary.

(2) Expectorant: The commonly used drugs in clinical practice are expectorant and mucolytic. The former mostly increases the secretion of the respiratory tract by stimulating gastric mucosa reflex, making the sputum thinner and easier to cough; the latter is to directly cleavage the viscous components to reduce the viscosity of the sputum and easy to cough. Ambroxol (mucosolvan) can regulate and balance the secretory function of mucus and serous glands, increase the secretion of serous fluid and make the sputum thinner; stimulate and improve ciliary movement, promote sputum excretion; stimulate the formation of pulmonary surfactant, and reduce mucus Adhesion to the terminal airway, prevent the mucus from forming clumps and flow easily, prevent the terminal airway from collapsing, and keep the small airway unobstructed; not only can it play a good expectorant role, but it can also increase the concentration of antibiotics in the lesion , Is an ideal expectorant, daily dose of 60mg.

Aerosolized inhalation can also dilute respiratory secretions and make sputum easier to cough.

(3) Antispasmodic and asthma: Elderly patients with emphysema often have chronic bronchitis. The airflow obstruction caused by them is progressive, which may be accompanied by airway hyperresponsiveness, and some of them are reversible. Antispasmodic and asthma medications can improve airflow obstruction. Antispasmodic and asthma drugs commonly used in clinical practice are 2-adrenergic receptor agonists, anticholinergics, theophylline and corticosteroids. 2-adrenergic receptor agonists and anticholinergics should be based on inhalation. Elderly patients use 2- because of reduced beta receptor sensitivity

Emphysema diet health care for the elderly

Avoid irritating food.

Avoid spicy spicy food such as pepper, onion, garlic, wine, etc., because it stimulates the tracheal mucosa, it will aggravate cough, asthma, palpitations and other symptoms and induce asthma, so it should be avoided.

Do not eat greasy products.

Fish made by non-steaming methods can easily get angry because of the large amount of oil used.

Avoid eating gas-producing food.

Such as sweet potatoes, leeks, etc., because it is not good for reducing lung qi, you should eat more alkaline foods.

No smoking.

Because smoking is one of the bane of the development of bronchitis, it is extremely detrimental to asthma bronchitis and should be absolutely prohibited.

Elderly people who know emphysema cannot eat. In addition, people with allergies and people with high blood uric acid (such as gout patients) should also eat less yellow croaker, band fish, shrimp, crab, and fatty meat. Helps fire sputum.

Emphysema prevention and care in the elderly

Stopping smoking and actively preventing respiratory infections are the main measures to prevent emphysema.

Pathogenesis of emphysema in the elderly

The etiology of obstructive emphysema is very complicated, and it is the result of several factors.

1. Smoking Smoking is the most important factor leading to the onset of emphysema. 80% to 90% of COPD patients are smokers, and about 20% of smokers will develop COPD. Tobacco smoke contains a variety of harmful ingredients, such as tar, nicotine, carbon monoxide, nitrogen oxides, furfural and so on. These harmful substances can directly or indirectly damage the bronchial mucosal epithelium and even cause squamous metaplasia; inhibit or damage the movement of bronchial mucosal cilia; stimulate the proliferation of mucous glands, excessive secretion of mucus; inhibit the phagocytosis of lung macrophages; secretion Prone to secondary microbial infections; reduce 1 antitrypsin activity, leading to imbalance of elastase-elastase inhibitors ... This is smoking-emphysema-chronic bronchitis or smoking-chronic bronchitis-emphysema Disease pattern. Kannel tracked the risk of smoking for 34 years, and the results showed that there was a significant negative correlation between smoking volume and chronic cough and reduction of FEV1.0 and FVC. Heggins's survey of 5201 elderly people over 65 years of age also showed a negative correlation between reduced lung function and total smoking.

2. Environmental pollution Long-term exposure to organic or inorganic dust, harmful gases, prone to emphysema.

3. Infection Repeated airway infection can cause bronchial mucosal hyperemia, edema, glandular hyperplasia, hypersecretion, and increased protease activity, etc., which will cause emphysema.

4. Genetic factors A severe deficiency of 1 antitrypsin due to genetic defects can cause emphysema. This type of emphysema often occurs in adolescence, has a shorter course and is more severe, and is more common in white races. My country is rare.

Diagnosis of emphysema in the elderly

Elderly emphysema should be distinguished from tuberculosis, lung tumors, and occupational lung disease. The clinical manifestations combined with chest X-ray, CT, MRI, sputum examination, and fiberbronchoscopy are not difficult to identify. The important thing is that they often exist at the same time. Don't relax your vigilance of 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 causal to each other. The main points of the three are listed in Table 1.

Emphysema examination method for the elderly

Laboratory inspection:

Arterial blood gas examination: Arterial blood oxygen partial pressure (PaO2) can be in the normal range in the early stage, that is, the expected value-1.3kPa (10mmHg) (expected value: sitting position 104.2mmHg-0.27 × age; lying position: 103.5mmHg-0.42 × age; Or 13.3kPa0.04 × age); there may be different degrees of decline in the later period [6.0kPa (45mmHg)]; arterial blood oxygen saturation (SaO2) can be normal in the early stage, and there may be different degrees of decline in the later stage (<95%); The alveolar gas-arterial oxygen pressure difference (A-aDO2) increased [2.7kPa (20mmHg)].

Other auxiliary checks:

1. X-ray examination: increased lung transparency, reduced lung texture, low diaphragm, flattened ribs, widened intercostal space, and overhanging heart shadows. It can also show enhanced lung texture, enlarged heart shadow, and widened right lower pulmonary artery.

2. Pulmonary function test: total lung capacity (TLC), residual capacity (RV), functional residual capacity (FRC) increased; vital capacity (VC) normal or decreased; maximum ventilation capacity (MBC), forced vital capacity (FVC), first Forced expiratory volume per second (FEV1.0), maximum expiratory flow (MMEF), maximum expiratory flow volume (MEFV) and other indicators of ventilation function decreased significantly; carbon monoxide lung diffusion (DLco) decreased.

Emphysema complications in the elderly

1. Lower respiratory tract infections Emphysema patients are prone to lower respiratory tract infections due to their frailty, malnutrition, decreased body immunity, airway stenosis, and retention of secretions. As a result, patients often transition from stable to exacerbated. It is worth noting that elderly patients often do not have fever when co-infected, and the total number of white blood cells is not high. Cough, shortness of breath, increased sputum volume, and purulent sputum are the earliest and most important signs of lower respiratory infections.

2. Spontaneous pneumothorax usually occurs due to ruptured bullae. There may be causes such as severe cough or exertion, or there may be no cause. Typical manifestations are chest pain and sudden dyspnea, and the patient's percussion has been unvoiced. Elderly patients often do not have chest pain and only show progressive dyspnea. X-ray examination showed pleural effusion. Due to poor lung function in elderly patients, even if the lungs are not compressed, they are severe and must be rescued in time.

3. Patients with chronic pulmonary heart disease and emphysema due to heart failure may cause pulmonary hypertension due to long-term hypoxemia, hypercapnia, and reduced pulmonary capillary beds, which may further cause pulmonary heart disease. Heart function may be decompensated during the exacerbation and heart failure may occur. In most cases, its decompensation occurs in right heart failure, and it is worth noting that left heart failure may also occur. This may be due to myocardial degeneration and heart rhythm caused by long-term hypoxemia and repeated infection toxemia. Cause of abnormality.

4. Respiratory failure Severe elderly emphysema patients are prone to respiratory muscle fatigue due to increased respiratory exercise work, low flattened muscles, increased radius of curvature, and malnutrition. On this basis, respiratory failure is often induced by lower respiratory infections, concomitant other diseases, surgery, fatigue and other factors. Respiratory failure can also be caused by incorrect use of iatrogenic factors such as oxygen therapy, sedatives, and antitussives.

5. Elderly emphysema patients with severe multiple organ failure often suffer from cardiopulmonary failure at the same time, even with diffuse intravascular coagulation, liver and kidney failure, etc., leading to very severe multiple organ failure and life-threatening.

6. Autopsy of gastric ulcer confirmed that 18% to 30% of patients with emphysema had gastric ulcer, and the pathogenesis was not completely clear.

7. Pulmonary embolism Elderly emphysema, especially patients with pulmonary heart disease, may be complicated by pulmonary embolism due to hypercoagulability, high viscosity, prolonged bed rest, arrhythmia, and toxemia. Elderly emphysema patients should be alert to the possibility of pulmonary embolism when sudden dyspnea, palpitation, and cyanosis worsen.

8. Sleep apnea Sleep apnea includes sleep apnea syndrome (SAS) and sleep hypoventilation syndrome (HPVS). It has received increasing attention in recent years. Reported abroad, the incidence of sleep apnea hypopnea syndrome (SAHS) in adults is 1% to 4%, the incidence of elderly people over 65 years of age is as high as 20% to 40%, the elderly with emphysema have a higher incidence of SAHS, COPD Coexisting with SAHS is called "overlap syndrome", and this type of patients can have significant hypoxemia and carbon dioxide retention during rapid eye movement (REM) sleep at night. The reason is that the decreased sensitivity of the respiratory center during sleep, increased resistance to the upper airways and decreased intercostal muscle tension aggravate hypoventilation of the alveoli; further increase in functional residual volume during sleep aggravates the ventilation / blood perfusion ratio imbalance. Combining sleep apnea will affect the quality of sleep and make the disease worse; hypoxemia during sleep can easily lead to increased hematocrit and pulmonary hypertension, and then develop into pulmonary heart disease; induce nocturnal arrhythmia; and may even cause severe elderly lung Qi The swollen patient died during sleep. Elderly emphysema patients with sleep-disordered breathing are prone to carbon dioxide retention at night with simple oxygen therapy, while patients with simple emphysema who have hypoxemia given continuous low-flow oxygen at night have no danger of carbon dioxide retention. Emphysema combined with sleep disordered breathing is often overlooked, but its harmfulness is very large. Conditionally, elderly people with emphysema, especially those with purple swelling, should be examined for "multisomnography" (polysomnography). To clear the diagnosis and deal with it properly.

Prognosis of elderly emphysema

Smoking is the most important risk factor for emphysema. Smoking will also directly damage lung function. Non-smoker healthy people after 30 years of age will lose 25 to 30 ml of FEV1 every year, while smokers will fall by 50 to 100 ml. Although the original lung function damage cannot be recovered after quitting smoking, the decline rate of FEV1 will slow down. It can be seen that stopping smoking is the most important measure to prevent emphysema. Prevent and improve environmental pollution (including organic or inorganic dust, harmful gases and passive smoking, etc.). Active prevention of respiratory infections will also effectively reduce the incidence of emphysema. Experimental studies have shown that elastase inhibitors can reduce the incidence of emphysema. Foreign countries are actively developing non-antigenic and inhalable low-molecular-weight inhibitors of leukocyte elastase, and synthetic anti-leukocyte protease (ALP) / secreting leukocyte protease. Inhibitor (SLPI) formulations are undergoing safety trials.

The main factors affecting the prognosis of emphysema are its pulmonary function and comorbidities. When FEV1> 1.5L, there is often a normal survival time; and when FEV11.0L, the average survival time is 5 years; most of the patients with dyspnea at the beginning of stable phase will develop severe dyspnea within 6-10 years. The annual case fatality rate is about 10%. BB has a poor prognosis and is generally difficult to reach advanced age. Patients with hypoxemia, hypercapnia, decompensated pulmonary heart disease, and pulmonary embolism have a poor prognosis.

The pathogenesis of emphysema in the elderly

The pathogenesis of obstructive emphysema is not fully understood. Generally believed to be related to airway obstruction and protease-antiprotease imbalance. Smoking, infection, air pollution, etc. cause bronchiolitis, and inflammatory congestion, edema, exudation, hyperplasia, and hyperresponsiveness of the airway cause narrowing or obstruction of the airway. Negative pressure in the chest during inhalation, bronchiectasis, air enters the alveoli; positive chest pressure during exhalation, bronchiole lumen contraction, air retention, increasing alveolar pressure, leading to excessive inflation or rupture. The theory of protease-protease inhibitor imbalance is the basis of modern understanding of emphysema. Papaya endotracheal perfusion can replicate animal emphysema models; 1 antitrypsin (it is the main protease inhibitor in plasma and has a strong inhibitory effect on leukocyte elastase). Patients with hereditary deficiency are susceptible to emphysema. Is a strong proof of the doctrine. Proteases related to the formation of emphysema, such as serine proteases (mainly leukocyte elastase, cathepsin G, protease 3), metalloproteinases, thiol proteases, etc. They mainly come from inflammatory cells, such as neutrophils, monocytes Cells and macrophages, which can destroy elastic fibers and cause experimental emphysema. Under normal circumstances, they maintain good relationship with protease inhibitors, such as plasma-derived 1 antitrypsin, local anti-leukocyte protease (ALP), secreted leukocyte protease inhibitor (SLPI), and metalloproteinase inhibitor (TIMP). Of balance. Smoking leads to increased elastase activity and inhibition of anti-protease activity; inflammation causes imbalance of protease-protease inhibitors in the tiny space around inflammatory cells; genetic deficiency of 1 antitrypsin, which destroys the elastic fibers of the alveoli and bronchioles, Emphysema occurred.