How long do people live with emphysema? Pulmonary emphysema - what it is, symptoms, treatment regimen, prognosis.

Emphysema– a chronic lung disease characterized by the expansion of small bronchioles (the terminal branches of the bronchi) and the destruction of the partitions between the alveoli. The name of the disease comes from the Greek emphysao - to swell. Air-filled voids form in the lung tissue, and the organ itself swells and increases significantly in volume.

Manifestations of emphysema– shortness of breath, difficulty breathing, cough with a small amount of mucous sputum, signs of respiratory failure. Over time, the chest expands and takes on a characteristic barrel shape.

Reasons for the development of emphysema divided into two groups:

• Factors that impair the elasticity and strength of lung tissue are inhalation of polluted air, smoking, congenital deficiency of alpha-1-antitrypsin (a substance that stops the destruction of the walls of the alveoli).
• Factors that increase air pressure in the bronchi and alveoli are chronic obstructive bronchitis, blockage of the bronchus by a foreign body.

Risk of developing the disease some categories are higher than other people:

• Congenital forms of pulmonary emphysema associated with whey protein deficiency are more often detected in residents of Northern Europe.
• Men get sick more often. Emphysema is detected at autopsy in 60% of men and 30% of women.
• People who smoke have a 15 times higher risk of developing emphysema. Passive smoking also dangerous.

Anatomy of the lungs

Each lung is surrounded by a two-layer membrane, the pleura. One of its layers fuses with the lung, and the other with the chest. Between the sheets of pleura there remains a space - the pleural cavity, in which there is a certain amount of pleural fluid. This structure helps the lungs stretch during inhalation.

Due to anatomical features, the right lung is 10% larger than the left. Right lung consists of three lobes, and the left one of two. The lobes are divided into segments, which in turn are divided into secondary lobules. The latter consist of 10-15 acini.
The hilum of the lung is located on the inner surface. This is the place where the bronchi, arteries, and veins enter the lung. Together they form the root of the lung.

Lung functions:

• ensure blood saturation with oxygen and excretion carbon dioxide
• participate in heat exchange due to liquid evaporation
• secrete immunoglobulin A and other substances to protect against infections
• participate in the transformation of the hormone angiotensin, which causes vasoconstriction

1. bronchi, through which air enters the lungs;
2. alveoli, where gas exchange occurs;
3. blood vessels that carry blood from the heart to the lungs and back to the heart;

1. Trachea and bronchi- called the respiratory tract.

   The trachea at the level of 4-5 vertebrae is divided into 2 bronchi - right and left. Each of the bronchi enters the lung and forms a bronchial tree there. The right and left are the bronchi of the 1st order; at the place of their branching, the bronchi of the 2nd order are formed. The smallest are bronchi of the 15th order.

   Small bronchi branch, forming 16-18 thin respiratory bronchioles. Alveolar ducts depart from each of them, ending in thin-walled vesicles - alveoli.

   Bronchial function– ensure the passage of air from the trachea to the alveoli and back.

   Structure of the bronchi.

   1. Cartilaginous base of the bronchi
      • large bronchi outside the lung consist of cartilage rings
      • large bronchi inside the lung - cartilaginous connections appear between the cartilaginous half-rings. Thus, the lattice structure of the bronchi is ensured.
      • small bronchi - cartilage looks like plates, the smaller the bronchus, the thinner the plates
      • the terminal small bronchi do not have cartilage. Their walls contain only elastic fibers and smooth muscles
   2. Muscular layer of the bronchi– smooth muscles are arranged circularly. They provide narrowing and expansion of the lumen of the bronchi. At the site of the branching of the bronchi there are special bundles of muscles that can completely block the entrance to the bronchus and cause its obstruction.
   3. ciliated epithelium, lining the lumen of the bronchi, performs a protective function - protects against infections transmitted by airborne droplets. Small villi remove bacteria and small dust particles from distant bronchi into larger bronchi. From there they are removed when coughing.
   4. Lung glands
      • single-celled glands that secrete mucus
      • small lymph nodes connected to larger lymph nodes in the mediastinum and trachea.
2. Alveolus – a bubble in the lungs, entwined with a network of blood capillaries. The lungs contain more than 700 million alveoli. This structure allows you to increase the surface area in which gas exchange occurs. It enters the vesicle through the bronchi atmospheric air. Oxygen is absorbed into the blood through the thinnest wall, and carbon dioxide is released into the alveoli during exhalation.

   The area around the bronchiole is called the acinus. It resembles a bunch of grapes and consists of branches of the bronchioles, alveolar ducts and the alveoli themselves

3. Blood vessels. Blood enters the lungs from the right ventricle. It contains little oxygen and a lot of carbon dioxide. In the capillaries of the alveoli, the blood is enriched with oxygen and releases carbon dioxide. After this, it collects in the veins and enters the left atrium.

Causes of emphysema

1. Impaired elasticity and strength of lung tissue:
   • Congenital α-1 antitrypsin deficiency. In people with this abnormality, proteolytic enzymes (whose function is to destroy bacteria) destroy the walls of the alveoli. While normally α-1 antitrypsin neutralizes these enzymes within a few tenths of a second after their release.
   • Congenital defects in the structure of lung tissue. Due to their structural features, the bronchioles collapse and the pressure in the alveoli increases.
   • Inhalation of polluted air: smog, tobacco smoke, coal dust, toxic substances. The most dangerous in this regard are cadmium, nitrogen and sulfur oxides emitted by thermal power plants and transport. Their smallest particles penetrate the bronchioles and are deposited on their walls. They damage the ciliated epithelium and vessels feeding the alveoli and also activate special cells, alveolar macrophages.

     They help increase the level of neutrophil elastase, a proteolytic enzyme that destroys the walls of the alveoli.

   • Violation hormonal balance . An imbalance between androgens and estrogens impairs the ability of bronchiole smooth muscles to contract. This leads to stretching of the bronchioles and the formation of cavities without destruction of the alveoli.
   • Respiratory tract infections: Chronical bronchitis, pneumonia . Immune cells, macrophages and lymphocytes, exhibit proteolytic activity: they produce enzymes that dissolve bacteria and the protein that makes up the walls of the alveoli.

     In addition, clots of sputum in the bronchi allow air into the alveoli, but do not release it in the opposite direction.

     This leads to overfilling and overstretching of the alveolar sacs.

   • Age-related changes associated with poor circulation. In addition, older people are more sensitive to toxic substances in the air. With bronchitis and pneumonia, lung tissue recovers worse.
2. Increased pressure in the lungs.
   • Chronic obstructive bronchitis. The patency of the small bronchi is impaired. When you exhale, air remains in them. With a new breath, a new portion of air enters, which leads to overstretching of the bronchioles and alveoli. Over time, disturbances occur in their walls, leading to the formation of cavities.
   • Occupational hazards. Glassblowers, wind players. A feature of these professions is an increase in air pressure in the lungs. The smooth muscles in the bronchi gradually weaken, and blood circulation in their walls is disrupted. When you exhale, all the air is not expelled; a new portion is added to it. A vicious circle develops, leading to the appearance of cavities.
   • Blockage of the lumen of the bronchus a foreign body leads to the fact that the air remaining in the segment of the lung cannot escape out. An acute form of emphysema develops.
   Scientists have not been able to establish the exact cause of the development of emphysema. They believe that the appearance of the disease is associated with a combination of several factors that simultaneously affect the body.

1. Stretching of bronchioles and alveoli - their size doubles.
2. Smooth muscles are stretched, and the walls of blood vessels become thinner. The capillaries become empty and the nutrition in the acinus is disrupted.
3. Elastic fibers degenerate. In this case, the walls between the alveoli are destroyed and cavities are formed.
4. The area in which gas exchange occurs between air and blood decreases. The body experiences oxygen deficiency.
5. The enlarged areas compress healthy lung tissue, further impairing the ventilation function of the lungs. Shortness of breath and other symptoms of emphysema appear.
6. To compensate and improve respiratory function lungs, the respiratory muscles are actively activated.
7. The load on the pulmonary circulation increases - the vessels of the lungs become overfilled with blood. This causes disturbances in the functioning of the right side of the heart.

Types of emphysema

According to the nature of the flow:

• Acute. It develops during an attack of bronchial asthma, a foreign object entering the bronchi, or sudden physical exertion. Accompanied by overstretching of the alveoli and swelling of the lung. This is a reversible condition but requires urgent medical care.
• Chronic. Develops gradually. At an early stage, the changes are reversible. But without treatment, the disease progresses and can lead to disability.

• Primary emphysema. An independent disease that develops in connection with the congenital characteristics of the body. It can even be diagnosed in infants. It progresses quickly and is more difficult to treat.
• Secondary emphysema. The disease occurs against the background of chronic obstructive pulmonary diseases. The onset often goes unnoticed; symptoms intensify gradually, leading to decreased ability to work. Without treatment, large cavities appear that can occupy an entire lobe of the lung.

• Diffuse form. The lung tissue is uniformly affected. Alveoli are destroyed throughout the lung tissue. At severe forms A lung transplant may be required.
• Focal form. Changes occur around tuberculosis foci, scars, in places where a blocked bronchus approaches. Manifestations of the disease are less pronounced.

• Panacinar emphysema(vesicular, hypertrophic). All acini in the lung lobe or the whole lung are damaged and swollen. There is no healthy tissue between them. The connective tissue in the lung does not grow. In most cases there are no signs of inflammation, but there are manifestations of respiratory failure. Formed in patients with severe emphysema.
• Centrilobular emphysema. Damage to individual alveoli in the central part of the acinus. The lumen of the bronchioles and alveoli expands, this is accompanied by inflammation and mucus secretion. Fibrous tissue develops on the walls of damaged acini. Between the changed areas, the parenchyma (tissue) of the lungs remains intact and performs its function.
• Periacinar(distal, perilobular, paraseptal) - damage to the extreme parts of the acinus near the pleura. This form develops with tuberculosis and can lead to pneumothorax - rupture of the affected area of ​​the lung.
• Okolorubtsovaya– develops around scars and areas of fibrosis in the lungs. Symptoms of the disease are usually mild.
• Bullous(bubble) shape. In place of the destroyed alveoli, bubbles form, ranging in size from 0.5 to 20 cm or more. They can be located near the pleura or throughout the lung tissue, mainly in the upper lobes. Bullae can become infected, compress surrounding tissue, or rupture.
• Interstitial(subcutaneous) - characterized by the appearance of air bubbles under the skin. The alveoli rupture, and air bubbles rise through the lymphatic and tissue gaps under the skin of the neck and head. Bubbles may remain in the lungs, and when they rupture, spontaneous pneumothorax occurs.

• Compensatory– develops after removal of one lobe of the lung. When healthy areas swell, trying to take up the vacant space. Enlarged alveoli are surrounded by healthy capillaries, and there is no inflammation in the bronchi. The respiratory function of the lungs does not improve.
• Senile– called age-related changes in the vessels of the lungs and the destruction of elastic fibers in the wall of the alveoli.
• Lobarnaya– occurs in newborns, more often boys. Its appearance is associated with obstruction of one of the bronchi.

Symptoms of emphysema

Diagnosis of emphysema

Examination by a doctor

Instrumental methods for diagnosing pulmonary emphysema

1. Radiography– examination of the lung condition using x-rays, as a result of which an image of internal organs is obtained on film (paper). A general X-ray of the chest is taken in a direct projection. This means that the patient faces the device during the shooting. An overview image allows you to identify pathological changes in the respiratory organs and the extent of their spread. If the image shows signs of illness, then a additional research: MRI, CT, spirometry, peak flowmetry.

   Indications:

   • Once a year as part of a preventive examination
   • prolonged cough
   • dyspnea
   • wheezing, pleural friction noise
   • decreased breathing
   • pneumothorax
   • suspected emphysema, chronic bronchitis, pneumonia, pulmonary tuberculosis
   Contraindications:
   • breastfeeding period
   Symptoms of pulmonary emphysema:
   • the lungs are enlarged, they compress the mediastinum and overlap each other
   • affected areas of the lung appear excessively transparent
   • expansion of intercostal spaces during active muscle work
   • the lower edge of the lungs is drooping
   • low aperture
   • reduction in the number of blood vessels
   • bullae and areas of tissue airing
2. Magnetic resonance imaging (MRI) of the lungs- a study of the lungs based on the resonant absorption of radio waves by hydrogen atoms in cells, and sensitive equipment records these changes. MRI of the lungs provides information about the condition of large bronchi, vessels, lymphoid tissue, the presence of fluid and focal formations in the lungs. Allows you to obtain sections 10 mm thick and view them from different positions. To study the upper parts of the lungs and areas around the spine, a contrast agent called gadolinium is injected intravenously.

   Disadvantage: air prevents accurate visualization of small bronchi and alveoli, especially at the periphery of the lungs. Therefore, the cellular structure of the alveoli and the degree of destruction of the walls are not clearly visible.

   The procedure lasts 30-40 minutes. During this time, the patient must lie motionless in the magnetic tomograph tunnel. MRI does not involve radiation, so the study is permitted for pregnant and breastfeeding women.

   Indications:

   • there are symptoms of the disease, but x-ray changes cannot be detected
   • tumors, cysts
   • suspicion of tuberculosis, sarcoidosis, in which small focal changes are formed
   • increase in intrathoracic lymph nodes
   • abnormal development of the bronchi, lungs and their vessels
   Contraindications:
   • presence of a pacemaker
   • metal implants, staples, fragments
   • mental illnesses that do not allow lying for a long time without moving
   • patient weight over 150 kg
   Symptoms of emphysema:
   • damage to the alveolar capillaries at the site of destruction of lung tissue
   • circulatory disorders in small pulmonary vessels
   • signs of compression of healthy tissue by expanded areas of the lung
   • increase in pleural fluid volume
   • increase in the size of the affected lungs
   • cavities-bullae different sizes
   • low aperture
3. Computed tomography (CT) of the lungs allow you to obtain a layer-by-layer image of the structure of the lungs. CT is based on the absorption and reflection of X-rays by tissues. Based on the data obtained, the computer creates a layer-by-layer image with a thickness of 1mm-1cm. The study is informative on early stages diseases. With the introduction of a contrast agent, CT gives more full information about the condition of the blood vessels of the lungs.

   During a CT scan of the lungs, the X-ray emitter rotates around the patient lying motionless. The scan lasts about 30 seconds. The doctor will ask you to hold your breath several times. The whole procedure takes no more than 20 minutes. Using computer processing, X-ray images taken from different points are summarized into a layer-by-layer image.

   Flaw– significant radiation exposure.

   Indications:

   • if symptoms are present, no changes are detected on the x-ray or they need to be clarified
   • diseases with the formation of foci or diffuse damage to the lung parenchyma
   • chronic bronchitis, emphysema
   • before bronchoscopy and lung biopsy
   • decision on the operation
   Contraindications:
   • allergy to contrast agent
   • extremely serious condition patient
   • severe diabetes mellitus
   • renal failure
   • pregnancy
   • patient weight exceeding the capabilities of the device
   Symptoms of emphysema:
   • an increase in the optical density of the lung to -860-940 HU – these are airy areas of the lung
   • expansion of the roots of the lungs - large vessels entering the lung
   • dilated cells are noticeable - areas of alveolar fusion
   • reveals the size and location of bullae
4. Lung scintigraphy – injection of labeled radioactive isotopes into the lungs, followed by a series of images taken with a rotating gamma camera. Preparations of technetium - 99 M are administered intravenously or in the form of an aerosol.

   The patient is placed on a table around which the sensor rotates.

   Indications:

   • early diagnosis of vascular changes in emphysema
   • monitoring the effectiveness of treatment
   • assessment of lung condition before surgery
   • suspected lung cancer
   Contraindications:
   • pregnancy
   Symptoms of emphysema:
   • compression of lung tissue
   • disturbance of blood flow in small capillaries


5. Spirometry – functional examination of the lungs, volume study external respiration. The procedure is carried out using a spirometer device, which records the amount of air inhaled and exhaled.

   The patient puts the mouthpiece connected to the breathing tube with sensor. A clamp is placed on the nose to block nasal breathing. The specialist tells you what breathing tests need to be performed. And an electronic device converts the sensor readings into digital data.

   Indications:

   • breathing disorder
   • chronic cough
   • occupational hazards (coal dust, paint, asbestos)
   • smoking experience over 25 years
   • lung diseases (bronchial asthma, pneumosclerosis, chronic obstructive pulmonary disease)
   Contraindications:
   • tuberculosis
   • pneumothorax
   • hemoptysis
   • recent heart attack, stroke, abdominal or chest surgery
   Symptoms of emphysema:
   • increase in total lung capacity
   • increase in residual volume
   • decreased vital capacity of the lungs
   • reduction in maximum ventilation
   • increased resistance in the airways during exhalation
   • reduction in speed indicators
   • decreased compliance of lung tissue
   With pulmonary emphysema, these indicators are reduced by 20-30%
6. Peak flowmetry - measurement of maximum expiratory flow to determine bronchial obstruction.

   Determined using a device - a peak flow meter. The patient needs to tightly clasp the mouthpiece with his lips and exhale as quickly and forcefully as possible through his mouth. The procedure is repeated 3 times with an interval of 1-2 minutes.

   It is advisable to carry out peak flowmetry in the morning and evening at the same time before taking medications.

   Disadvantage: the study cannot confirm the diagnosis of pulmonary emphysema. The exhalation rate decreases not only with emphysema, but also with bronchial asthma, pre-asthma, and chronic obstructive pulmonary disease.

   Indications:

   • any diseases accompanied by bronchial obstruction
   • evaluation of treatment results
   Contraindications does not exist.

   Symptoms of emphysema:

   • reduction in expiratory flow by 20%
7. Determination of blood gas composition – a study of arterial blood during which the pressure in the blood of oxygen and carbon dioxide and their percentage, the acid-base balance of the blood are determined. The results show how effectively the blood in the lungs is cleared of carbon dioxide and enriched with oxygen. For research, a puncture of the ulnar artery is usually done. A blood sample is taken from a heparin syringe, placed on ice, and sent to the laboratory.

   Indications:

   • cyanosis and other signs oxygen starvation
   • breathing disorders due to asthma, chronic obstructive pulmonary disease, emphysema
   Symptoms:
   • oxygen tension in arterial blood is below 60-80 mmHg. st
   • blood oxygen percentage less than 15%
   • increase in carbon dioxide tension in arterial blood over 50 mmHg. st
8. General blood analysis - a study that includes counting blood cells and studying their characteristics. For analysis, blood is taken from a finger or from a vein.

   Indications- any diseases.

   Contraindications does not exist.

   Deviations for emphysema:

   • increased number of red blood cells over 5 10 12 / l
   • increased hemoglobin level over 175 g/l
   • increase in hematocrit over 47%
   • decreased erythrocyte sedimentation rate 0 mm/hour
   • increased blood viscosity: in men over 5 cP, in women over 5.5 cP

Treatment of emphysema

• improving the quality of life of patients - eliminating shortness of breath and weakness
• prevention of the development of heart and respiratory failure
• slowing the progression of the disease

• complete cessation of smoking
• exercise to improve ventilation
• taking medications to improve the condition of the respiratory tract
• treatment of the pathology that caused the development of emphysema

Treatment of emphysema with medications

Therapeutic measures for emphysema

1. Transcutaneous electrical stimulation diaphragm and intercostal muscles. Electrical stimulation with pulsed currents with a frequency of 5 to 150 Hz is aimed at facilitating exhalation. At the same time, the energy supply to the muscles, blood and lymph circulation improves. In this way, fatigue of the respiratory muscles, followed by respiratory failure, is avoided. During the procedure, painless muscle contractions occur. The current strength is dosed individually. The number of procedures is 10-15 per course.
2. Oxygen inhalation. Inhalation is carried out for a long time, 18 hours a day. In this case, oxygen is supplied to the mask at a rate of 2–5 liters per minute. In case of severe respiratory failure, helium-oxygen mixtures are used for inhalation.
3. Breathing exercises - training of the respiratory muscles, aimed at strengthening and coordinating muscles during breathing. All exercises are repeated 4 times a day for 15 minutes.
   • Exhale with resistance. Exhale slowly through a cocktail straw into a glass filled with water. Repeat 15-20 times.
   • Diaphragmatic breathing. On the count of 1-2-3, take a strong, deep breath, drawing in your stomach. On the count of 4, exhale - inflating your stomach. Then tense your abdominal muscles and cough loudly. This exercise helps to expel mucus.
   • Lying push-up. Lying on your back, bend your legs and clasp your knees with your hands. As you inhale, draw in lungs full of air. As you exhale, stick your stomach out (diaphragmatic exhalation). Straighten your legs. Tighten your abs and cough.

When is surgery needed for emphysema?

Indications for surgery for emphysema:

• shortness of breath leading to disability
• bullae occupying more than 1/3 of the chest
• complications of emphysema - hemoptysis, cancer, infection, pneumothorax
• multiple bullae
• permanent hospitalizations
• diagnosis of emphysema mild severe degrees"

• inflammatory process – bronchitis, pneumonia
• asthma
• exhaustion
• severe deformation of the chest
• age over 70 years

Types of operations for emphysema

1. Lung transplant and its variants: lung transplantation together with a heart; transplantation of a lung lobe. Transplantation is performed in case of large diffuse lesions or multiple large bullae. The goal is to replace the diseased lung with a healthy donor organ. However, the waiting list for transplantation is usually too long and problems with organ rejection may arise. Therefore, such operations are resorted to only as a last resort.


2. Reduced lung volume. The surgeon removes the most damaged areas, approximately 20-25% of the lung. At the same time, the function of the remaining part of the lung and respiratory muscles improves. The lung is not compressed, its ventilation is restored. The operation is performed in one of three ways.

Opening the chest. The doctor removes the affected lobe and places stitches to seal the lung. Then a suture is placed on the chest.

3. Minimally invasive technique (thoracoscopy) under the control of video equipment. 3 small incisions are made between the ribs. A mini-video camera is inserted into one, and a surgical instruments. The affected area is removed through these incisions.
4. Bronchoscopic surgery. A bronchoscope with surgical equipment is inserted through the mouth. The damaged area is removed through the lumen of the bronchus. Such an operation is possible only if the affected area is located near large bronchi.

Is hospitalization necessary to treat emphysema?

Indications for hospitalization:

• a sharp increase in symptoms (shortness of breath at rest, severe weakness)
• the appearance of new signs of illness (cyanosis, hemoptysis)
• ineffectiveness of the prescribed treatment (symptoms do not decrease, peak flow measurements worsen)
• severe concomitant diseases
• newly developed arrhythmias
• difficulties in establishing a diagnosis;

Nutrition for emphysema (diet).

Basic principles of diet for emphysema

1. Increasing calorie content to 3500 kcal. Meals 4-6 times a day in small portions.
2. Proteins up to 120 g per day. More than half of them must be of animal origin: animal and poultry meat, liver, sausages, fish of any kind and seafood, eggs, dairy products. Meat in any culinary preparation, excluding excessive frying.
All complications of pulmonary emphysema are life-threatening. Therefore, if any new symptoms appear, you should immediately seek medical help.

• Pneumothorax. Rupture of the pleura surrounding the lung. In this case, air escapes into the pleural cavity. The lung collapses and becomes unable to expand. Around him in pleural cavity Liquid accumulates and needs to be removed. There is severe pain in the chest, which gets worse when you inhale, panic fear, rapid heartbeat, the patient takes a forced position. Treatment must be started immediately. If the lung does not expand within 4-5 days, surgery will be required.
• Infectious complications. Decreased local immunity increases the sensitivity of the lungs to bacterial infections. Severe bronchitis and pneumonia often develop, which become chronic. Symptoms: cough with purulent sputum, fever, weakness.
• Right ventricular heart failure. The disappearance of small capillaries leads to an increase in blood pressure in the vessels of the lungs - pulmonary hypertension. The load on the right parts of the heart increases, which become overstretched and wear out. Heart failure is the leading cause of death in patients with emphysema. Therefore, at the first signs of its development (swelling of the neck veins, pain in the heart and liver, swelling), it is necessary to call an ambulance.

• complete cessation of smoking
• prevention frequent infections
• clean air, no smog
• good nutrition
• good sensitivity to drug treatment with bronchodilators.

is a chronic nonspecific lung disease, which is based on persistent, irreversible expansion of the air spaces and increased swelling of the lung tissue distal to the terminal bronchioles. Emphysema is manifested by expiratory shortness of breath, cough with a small amount of mucous sputum, signs of respiratory failure, and recurrent spontaneous pneumothorax. Diagnosis of pathology is carried out taking into account data from auscultation, radiography and CT of the lungs, spirography, and blood gas analysis. Conservative treatment of pulmonary emphysema includes taking bronchodilators, glucocorticoids, oxygen therapy; in some cases, resection surgery is indicated.

Emphysema is accompanied by a significant increase in lung size, which macroscopically becomes similar to a large-porous sponge. When examining emphysematous lung tissue under a microscope, destruction of the alveolar septa is observed.

Classification

Pulmonary emphysema is divided into primary or congenital, developing as an independent pathology, and secondary, occurring against the background of other lung diseases (usually bronchitis with obstructive syndrome). Based on the degree of prevalence in the lung tissue, localized and diffuse forms of pulmonary emphysema are distinguished.

According to the degree of involvement in pathological process acini (structural and functional unit of the lungs, providing gas exchange, and consisting of the branching of the terminal bronchiole with alveolar ducts, alveolar sacs and alveoli) are distinguished the following types emphysema:

• panlobular(panacinar) - with damage to the entire acinus;
• centrilobular(centriacinar) – with damage to the respiratory alveoli in the central part of the acinus;
• perilobular(periacinar) – with damage to the distal part of the acinus;
• peri-scar(irregular or uneven);
• bullous(bullous lung disease in the presence of air cysts - bulls).

Particularly distinguished are congenital lobar (lobar) pulmonary emphysema and McLeod syndrome - emphysema of unknown etiology that affects one lung.

Symptoms of emphysema

The leading symptom of pulmonary emphysema is expiratory shortness of breath with difficulty exhaling air. Dyspnea is progressive, occurring first during exertion and then during calm state, and depends on the degree of respiratory failure. Patients with pulmonary emphysema exhale through closed lips while puffing out their cheeks (as if “puffing”). Shortness of breath is accompanied by a cough with the production of scanty mucous sputum. A pronounced degree of respiratory failure is indicated by cyanosis, puffiness of the face, and swelling of the veins of the neck.

Patients with pulmonary emphysema lose significant weight and have a cachectic appearance. Loss of body weight in pulmonary emphysema is explained by high energy costs spent on intensive work of the respiratory muscles. In the bullous form of pulmonary emphysema, repeated episodes of spontaneous pneumothorax occur.

Complications

The progressive course of pulmonary emphysema leads to the development of irreversible pathophysiological changes in the cardiopulmonary system. The collapse of small bronchioles during exhalation leads to obstructive pulmonary ventilation disorders. Destruction of the alveoli causes a decrease in the functional pulmonary surface and the phenomenon of severe respiratory failure.

Reduction of the capillary network in the lungs entails the development of pulmonary hypertension and an increase in the load on the right side of the heart. With increasing right ventricular failure, edema occurs lower limbs, ascites, hepatomegaly. An emergency condition for pulmonary emphysema is the development of spontaneous pneumothorax, requiring drainage of the pleural cavity and aspiration of air.

Diagnostics

The history of patients with pulmonary emphysema includes a long history of smoking, occupational hazards, and chronic or hereditary lung diseases. When examining patients with pulmonary emphysema, attention is drawn to an enlarged, barrel-shaped (cylindrical) chest, widened intercostal spaces and epigastric angle (obtuse), protrusion of the supraclavicular fossa, shallow breathing with the participation of auxiliary respiratory muscles.

Percussion is determined by the displacement of the lower borders of the lungs by 1-2 ribs downwards, a box sound over the entire surface of the chest. On auscultation, with pulmonary emphysema, weakened vesicular (“cotton”) breathing and muffled heart sounds are heard. In the blood with severe respiratory failure, erythrocytosis and increased hemoglobin are detected.

Pulmonary emphysema (translated as “bloating” from the Greek “emphysema”) is a pathology belonging to chronic obstructive pulmonary disease (COPD), provoking the expansion of the alveoli - the air sacs located in the bronchioles, the destruction of their walls and irreversible changes in the lung tissue. The lungs increase in volume, and the chest takes on the shape of a barrel. This is a deadly disease where every hour is important to take urgent measures to provide medical care.

Emphysema affects men twice as often, especially those who have reached old age.

The disease has high risk loss of ability to work, disability, development of complications in the heart and lungs for males at a younger age.

The pathology is characterized by progressive and chronic courses.

The mechanism of the disease is:

• the predominance of the volume of incoming air over the volume of outgoing air, while the alveoli double in size when stretched;
• accumulation of excess air - carbon dioxide and other impurities - disrupting the blood supply to the lungs and destroying tissue;
• an increase in intrapulmonary pressure, at which the arteries and lung tissue are compressed, shortness of breath and other signs of illness appear;
• thinning of vascular walls, stretched smooth muscles, impaired nutrition in the acinus (structural unit of the lungs);
• the occurrence of oxygen deficiency.

In this mechanism of lung damage, the heart muscle ( Right side) experiences serious stress, resulting in a pathology called chronic cor pulmonale.

It is important to know! Emphysema is a dangerous disease damaging systems breathing and heart, causing a lack of oxygen in the lung tissue. Symptoms of shortness of breath as a result of untimely medical care rapidly intensify, leading to negative consequences and even death.

Emphysema classification system

Character of the current:

• Acute form (caused by increased muscle load, asthmatic attacks, the presence of a foreign body in the bronchi. The lung swells, the alveoli stretch. It is necessary to start treatment urgently).
• Chronic form (transformation in the lung occurs gradually, without medical intervention disability is possible, otherwise, you can be completely cured at the initial stage of the disease).

Origin:

• Primary emphysema. It is considered as an independent disease diagnosed in infants and sometimes in newborns. A rapidly progressing pathology that develops against the background of congenital characteristics of the body is practically not subject to treatment.
• Emphysema secondary. The disease is associated with obstructive pulmonary pathologies in a chronic course. The problem that has arisen may not be noticed; due to increased symptoms, the ability to work is lost.

Prevalence:

• Diffuse. With this form, the entire lung tissue is affected, the alveoli are destroyed. It is possible to transplant a donor lung after suffering a serious illness.
• Focal. Parenchymal transformations are studied at sites of bronchial blockage, scars and in the area of ​​tuberculosis foci. The symptoms of emphysema are not clearly expressed.

Anatomical features that distinguish the following forms of emphysema:

• Hypertrophic (or panacinar/vesicular). It is registered as a severe form. With respiratory dysfunction, inflammation is not observed, as is the absence of healthy tissue among the damaged and swollen acini.
• Centrilobular. The center of the acinus is affected by destructive processes. Enlarged lumens of the alveoli and bronchi provoke the occurrence of an inflammatory process. Mucus is separated into large quantities, the walls of the acini undergo fibrous degeneration. The pulmonary parenchyma, located among the areas that have undergone destructive changes, is not damaged.
• Periacinar (distal/perilobular). Its development is promoted by tuberculosis. The disease often ends in pneumothorax, a rupture of the affected part of the lung.
• Okolorubtsovaya. The manifestation of pathology occurs near fibrous foci and scars in the lung. The symptomatic picture has no obvious signs.
• Bullous or vesicular. The entire parenchyma is affected by bullae of varying sizes (from a few millimeters to 21 centimeters) that arise in places of damaged alveoli. Tissues under the influence of bubbles are compressed, destroyed, and infected.
• Interstitial. Bursted alveoli form air bubbles under the skin. They migrate through the lymph and tissue lumens into the subcutaneous space of the neck and head. Bubbles localized in the lungs contribute to the occurrence of pneumothorex.

Cause:

• Senile type. Appears due to the presence of an altered vascular system, destruction of the elasticity of the alveolar walls due to old age.
• Lobar type. It is registered in newborn children; the disease is promoted by obstruction of any bronchial tube.

It is important to know! Chronic emphysema is typical for adults; children hardly suffer from this disease. Children's age characterized by a disease of the so-called obstructive type, affecting either one or two lungs. One-sided pathology in a child is most often due to a foreign body entering the bronchi.

Factors influencing the development of emphysema

The occurrence of pathology can be facilitated by causes of external and internal origin associated with:

• chronic obstructive bronchitis;
• bronchial diseases;
• bronchiolitis of a chronic course of an autoimmune nature;
• interstitial pneumonia;
• tuberculosis;
• congenital features of the respiratory system;
• poor environmental conditions, polluted air with harmful impurities;
• active and passive smoking;
• harmful conditions of professional activity;
• unfavorable heredity;
• imbalance of hormones in the body;
• age-related changes;
• respiratory tract infections;
• blocking the lumen of the bronchi with a foreign body.

A specific cause contributing to the onset and progression of emphysema has not been established to date. In scientific circles, it is believed that pathology manifests itself from the combined influence of several factors.

Symptomatic picture of pulmonary emphysema

The picture of the developing disease is dynamic and fast.

The main signs of emphysema are the following:

• severe and sharp pain that occurs in the chest area or in one of the halves of the chest;
• rapid decline blood pressure, shortness of breath and difficulty breathing appear;
• wheezing in the lungs;
• the appearance of tachycardia, expansion of the heart to the right side;
• breathing is carried out with the inclusion of the abdominal press and other muscles;
• enlarged neck veins;
• cough with hemoptysis;
• expansion of the sternum, protrusion of the supraclavicular fossa and intercostal segments;
• severe headaches, decreased breathing, sometimes loss of consciousness;
• disturbances in speech, coordination of movement, shortness of breath with any physical effort;
• rapid weight loss;
• prolapse of an enlarged liver;
• manifestation of paresis, paralysis;
• deformation of the nail plates due to insufficient breathing;
• abdominal pain, bloating, liquid stool mixed with blood;
• the skin of the extremities is pale, there is pain in them;
• signs of cyanosis (blueness) on the face;
• numbness of the affected area, which feels colder to the touch than other areas;
• the appearance of gangrene on the extremities, manifested by black spots, blisters filled with dark-colored liquid.

These and other signs appear in different cases depending on the type of pathology. The severity of their course is influenced by the duration of the developing disease.

It is important to know! With emphysema, the air subpleural cavities may rupture, resulting in the penetration of air into the pleural cavity. The risk of such a complication is very high.

Diagnostic measures

At the first symptoms of emphysema or suspected pathology, the patient is referred to a pulmonologist or therapist who takes an anamnesis. Using leading questions, the doctor elicits information from the patient that is important for making a diagnosis. Through auscultation - listening to the chest with a phonendoscope, percussion - tapping with fingers - the specialist determines and evaluates possible signs illness.

The doctor prescribes a number of instrumental methods for diagnosing pathology, consisting of:

1. X-rays.
2. MRI of the lungs.
3. Computed tomography of the lungs.
4. Scintigraphy (a gamma camera takes photographs of the lungs after radioactive isotopes are injected into them).
5. Spirometry (using a spirometer that records the volume of air during exhalation and inhalation).
6. Peak flowmetry (measuring the maximum velocity of outgoing air in order to determine bronchial obstruction).
7. Taking blood from a vein to assess the ratio of gas components - oxygen and carbon dioxide.
8. Clinical blood test.

Treatment of emphysema

Treatment of emphysema should have an integrated approach and be aimed, first of all, at combating the main causes of the development of the disease. Forms of the disease that do not have a complicated course can be treated at home, regularly consulting with a doctor. Advanced and severe stages require hospital treatment to avoid complicated processes.

Treatment of emphysema is carried out with medication (in order to reduce the progressive processes of cardiac and respiratory failure), in special cases– by surgical intervention, as well as by means alternative medicine, improving respiratory function. The duration of therapy courses is directly dependent on existing complications.

For a significant and rapid expansion of the lumen of the alveoli and bronchi, preference in treatment is given to:

• bronchodilators “Neophylline”, “Berodual”, “Salbutamol”, “Theophylline”;
• antitussive drugs with expectorant action “Ambroxol”, “Bromhexine”, “Libexin”, “Flavamed”, “Gerbion”;
• antibiotics “Ofloxacin”, “Sumamed”, “Amoxiclav”, “Amoxil”, etc., prescribed in the event of the development of complicated disease conditions;
• glucocorticosteroids “Prednisolone”, “Dexamethasone”, which help reduce the inflammatory process in the lungs;
• analgesics "Pentalgin", "Analgin", "Ketalong", "Sedalgin" - in cases of severe pain in the sternum area;
• vitamins “Undevita”, “Dekamevit”, multivitamin complexes to strengthen the immune system.

It is important to know! All medications are taken only as prescribed by a doctor and under his supervision to avoid complicating processes.

Smoking and drinking alcohol with emphysema is strictly prohibited, as this aggravates the development of the disease.

Application of the surgical method

Surgery is resorted to in cases of unsuccessful drug treatment, a large area of ​​​​pulmonary damage, and also taking into account the absence of contraindications to intracavitary surgery.

A patient cannot undergo surgery if he:

• severely exhausted;
• has a chest deformity;
• suffers from severe bronchitis, asthma, pneumonia;
• V old age.

Surgical assistance is indicated in situations:

• formation of multiple bullae in an area occupying a third of the chest;
• presence of severe shortness of breath;
• pneumothorax, infectious/oncological processes, sputum mixed with blood;
• regular hospitalizations;
• transformation of pathology into severe forms.

Surgical intervention is divided into several types, including:

• transplantation of a donor lung (in case of formation of multiple bullae, a large area of ​​affected lungs);
• elimination of affected areas with a reduction in lung volume to 1/4 by opening the sternum;
• thoracoscopy (resection of affected areas of the lungs using a minimally invasive method);
• bronchoscopy (carried out through the mouth if the damaged area is located near large bronchi).

Surgical treatment restores lung ventilation, no longer compressed by the affected parts of the organ. Improvement in condition is recorded after three months from the date of surgery. But shortness of breath may return seven years after surgery.

How to eat with emphysema

For this pathology, diets No. 11 and No. 15 are used, which can have a strengthening effect on the body’s protective functions, replenish energy reserves and remove toxins.

Dietary nutrition consists of the following principles:

• daily calorie content should be at least 3600 Kk with six meals a day in small portions;
• daily fat content (as a result of consuming vegetable, butter, fatty dairy products) – up to 100 g;
• daily protein intake is 110-115 g (they contain eggs, meat of all types, fish, seafood, liver, etc.);
• carbohydrates should supplement the daily diet in the amount of up to 0.4 kg (cereals, bread, honey, pasta, etc.);
• consumption of fruits, vegetables, bran to provide the body with vitamins and fiber;
• drinking juices, kumis, rosehip compote;
• limiting salt to 5 g to prevent swelling and cardiac dysfunction.

It is important to know! Patients with emphysema exclude from the diet alcoholic beverages, cooking fats, sweets, baked goods, cakes, pastries and other products containing a high percentage of fat.

The use of traditional medicine methods in the treatment of emphysema

As mentioned above, in uncomplicated forms of pathology it is possible to be treated at home, using folk remedies in addition to medications. They have proven themselves in practice and are easy to use.

• freshly squeezed potato juice(drink up to three times a day), which effectively affects the organs of the respiratory tract;
• natural honey (a large spoon three times a day), which has an anti-inflammatory effect;
• lemon balm (for 30 g, 0.5 liters of boiling water, infuse throughout the day, consume 30 ml twice a day);
• walnuts (eat up to 2 g every day);
• plantain (for 20 g of dry leaves, 500 ml of boiling water, leave for three days, strain, drink 15 ml twice a day for a month);
• steam inhalation over potatoes (for an anti-inflammatory effect).

In fact ethnoscience offers a huge selection of recipes for herbal decoctions and infusions for emphysema, but each patient, after consultation with a doctor, settles on what is acceptable to him in order to avoid various complications, for example, allergic ones.

The patient is also recommended to perform breathing exercises to improve oxygen exchange and restore impaired functions of the bronchi and alveoli. During the day, you should do the following exercise four times for 15 minutes: take a deep breath, hold your breath with periodic “fractional” exhalation.

Application of coursework (up to 20 days) therapeutic warming massage The chest helps improve breathing by expanding the bronchi, coughing, and expectoration of sputum. After the course you need to take a break for 14 days.

Prevention of emphysema

Among the most important preventive measures are simple rules concerning:

• quitting smoking, drinking alcohol, and using drugs;
• immediate treatment of diseases of the bronchi and other organs involved in the breathing process;
• physical education for therapeutic purposes, as well as sports on an ongoing basis;
• compliance with personal hygiene standards;
• use of personal respiratory protection, avoiding inhalation of dust, exhaust gases, chemical, toxic, carcinogenic substances etc.;
• daily walks in the fresh air in the forest, park areas;
• strengthening the immune system with both pharmaceutical and folk remedies.

Forecast

It should be remembered that this disease is dangerous and is related to bronchopulmonary pathologies. Consequently, the altered lung tissue is not restored. Treatment consists of slowing down the progressive process and reducing signs of respiratory dysfunction by ensuring bronchial patency.

The prognosis of the disease is based on the timeliness and adequacy of treatment for the underlying pathology, the duration of the disease, and adherence to the rules of “behavior” by the patient. It is impossible to completely get rid of emphysema, but medicine can influence the developing process. If you follow the recommendations of specialists, a person can lead his usual lifestyle. This prognosis against the background of a stable course with maintenance of a minimal level of emphysema can be considered favorable.

With severe pathology, the prognosis may not be favorable. Patients should use expensive medications, maintaining the necessary respiratory parameters. Such people cannot hope for an improvement in their condition.

Life extension is directly dependent on the patient’s age, the body’s ability to recover and compensate to the required extent for the pathological process.

Pulmonary emphysema is a common disease that predominantly affects middle-aged and elderly men, occurring with significant impairment of pulmonary ventilation and circulation, in contrast to the conditions listed in the differential diagnosis, which have only an external resemblance to true emphysema.

Frequency. The prevalence in the population is more than 4%.

Emphysema is an increase in the volume of the airways located distal to the bronchioles. Centrilobular emphysema is characterized by dilation of predominantly alveolar ducts and respiratory bronchioles. In contrast, with panlobular emphysema, the terminal alveoli expand. They speak of a “flabby” lung if only elastic traction decreases. Pathological changes can affect only a limited area (local emphysema) or the entire lung (diffuse emphysema). Emphysema is one of the most common reasons death of a person.

Causes of emphysema

Emphysema, as shown by observations of cases of rapid development of the disease in young people following a chest injury, can be a consequence of severe damage to the bronchi and interstitial tissue of the lungs. Apparently, a violation of bronchial patency, especially the terminal branches of the bronchi, due to mucus blockage and spasm, along with a decrease in the nutrition of the alveoli when their blood circulation is impaired (or vascular damage), can lead to stretching of the alveoli with persistent changes in the structure of the walls and their atrophy.

When the bronchi are not completely closed, the mechanism described in the section devoted to the description of bronchial obstruction disorders comes into play, when air enters the alveoli during inhalation, but does not find an outlet during exhalation, and intra-alveolar pressure increases sharply.

Experimentally, emphysema was obtained by stenosis of the trachea after just a few weeks. A similar mechanism is believed to underlie true emphysema, which develops in old age without obvious preliminary inflammatory diseases or blockage of the bronchi. Apparently, this also concerns chronic, sluggish bronchitis and interstitial inflammatory processes, possibly with vascular lesions, accompanied by functional spasm, which is why the name obstructive emphysema is currently considered rational for true emphysema.

Pulmonary emphysema often accompanies both bronchial asthma, peribronchitis, and various types of pneumosclerosis, with which it thus has a close pathogenetic and clinical affinity. Peri-bronchitis and inflammatory-degenerative lesions of the pulmonary parenchyma, according to a number of authors, are a necessary condition for the development of pulmonary emphysema with loss of elastic properties (Rubel).

Previously, in the origin of pulmonary emphysema, priority was given to individual constitutional weakness, premature wear and tear of the elastic tissue of the lungs and even changes in the skeleton, ossification of the cartilage of the chest, which seems to stretch the lungs in the inhalation position; emphysema was related to atherosclerosis and metabolic disorders. They also attached great importance to purely mechanical inflation of the lungs (glassblowers, musicians on wind instruments, etc.). However, as clinical experience shows, without obstruction of the bronchial tubes and bronchioles and damage to the lungs, these moments are not enough for the development of emphysema.

There is no doubt that in the origin of pulmonary emphysema, as well as bronchial asthma and bronchiectasis, a violation of nervous regulation all activity of the broncho- pulmonary system, arising both as a reflex from adjacent organs and from the receptor fields of the respiratory tract, and as a result of disruption of the central nervous system, as evidenced, for example, by the development of acute emphysema and cerebral contusion.

Pulmonary ventilation, gas exchange and the lungs are impaired in emphysema due to poorer ventilation of the alveoli. In fact, although the minute volume of air, due to the frequency and tension of respiratory movements, can even be increased, the air is exchanged mainly in the large airways, deep into the bronchioles Fresh air penetrates less, mixes worse and changes in the alveoli, unventilated “dead” space increases. The volume of residual air in emphysema can increase to 3/4 of the total lung capacity (instead of 1/4 normally). The increase in residual air, as well as the decrease in additional air, is explained by stretching of the lungs due to the loss of elasticity of the lung tissue. Due to these mechanisms, oxygen uptake during high ventilation may be abnormally low (uneconomical use). The force of the stream of incoming and especially outgoing air, due to small expiratory movements of the chest, is insignificant: a patient with emphysema is not able to blow out candles. The respiratory muscles of the chest, like the diaphragm, are the most important respiratory muscle, due to DC voltage as a result of stimulation of the respiratory center by the altered composition of the blood, they hypertrophy and subsequently degenerate, which contributes to respiratory decompensation.

At the same time, blood circulation in the pulmonary circulation suffers, which further reduces external respiration. Increased intra-alveolar pressure bleeds the pulmonary capillaries embedded in the thin-walled interalveolar septa; the capillaries disappear with the progressive atrophy of these septa. "Besides inflammatory process Often the vessels of the bronchial and pulmonary systems embedded in the interstitial tissue of the lungs, which carry blood for the nutrition and respiratory function of the lungs, are affected.

This decrease in the blood capillary bed of the pulmonary circle causes a corresponding increase in the work of the right ventricle, compensating for blood circulation at a higher hemodynamic level; the pressure in the pulmonary artery system and its branches increases several times, what is called pulmonary hypertension occurs, which ensures the pressure in the pulmonary artery system necessary to transfer the entire amount of blood entering the right ventricle into the left ventricle; the velocity of blood flow in the pulmonary circle does not change during powerful contractions of the sharply hypertrophied right ventricle.

The experiment shows that when one main branch of the pulmonary artery in an animal is ligated, the pressure in the artery trunk almost doubles.

Due to the greater pressure in the lesser circle, the arteriovenous anastomoses of the lungs open to a greater extent, transferring non-arterialized blood into the bronchial veins of the systemic circle. The resulting congestion of the bronchi contributes to the chronic course of bronchitis. Of course, all altered conditions of gas exchange and blood circulation in the lungs lead to hypoxemia and hypercapnia characteristic of emphysema. Already in the aorta or in the radial artery, which is more accessible to research, the blood in emphysema is undersaturated with oxygen (central or arterial pulmonary cyanosis). Retention of carbon dioxide in the blood occurs with great difficulty due to its easier release in the lungs (greater diffusion capacity).

In this period of emphysema, despite the impairment of the pulmonary function of gas exchange or external respiration, we can speak of cardiac-compensated pulmonary emphysema (similar to the idea of ​​compensated heart defects and cardiac compensation of hypertension).

However, the very long-term overstrain of the myocardium, along with the reduced oxygen content in the arterial blood supplying the heart muscle (and other organs), creates the prerequisites for cardiac decompensation, which is facilitated by incident infections, bronchitis, pneumonia, often simultaneously existing atherosclerosis of the coronary arteries of the heart, etc. .; this decompensation of the heart in pulmonary emphysema is discussed in the section on cor pulmonale.

It should be added that the very increase in intrathoracic and intrapleural pressure in patients with emphysema, lower suction force and functional shutdown of the diaphragm cause an adaptive increase in venous pressure in the vena cava, ensuring an approximately normal drop in pressure as blood passes into the chest; therefore, only a moderate increase in venous pressure does not definitely indicate myocardial weakness. Due to a decrease in the capillary bed of the pulmonary circle, even with left heart failure, the lungs do not give a pronounced picture of stagnation, in particular, a sharp veiling of the pulmonary fields.

Centrilobular emphysema develops mainly against the background of obstructive pulmonary disease: in the case of a “flabby” lung, the mass of connective tissue is reduced, and with diffuse emphysema, there is also a rupture of the interalveolar septa. With age, the ratio between the volume and area of ​​the alveoli usually increases. In some cases (approximately 2% of patients), there is deficiency of an α 1 -proteinase inhibitor (α 1 -antitrypsin), which normally inhibits the activity of proteinases (eg, leukocyte elastase, serine proteinase-3, cathepsin and matrix metalloproteinase). Insufficient inhibition of proteinases leads to increased protein breakdown and, as a result, loss of elasticity of lung tissue. Impaired secretion and accumulation of defective proteins can cause liver damage. Finally, as a result of a lack of proteinase inhibitors, pathology of other tissues, such as glomeruli of the kidneys and pancreatic cells, may develop. Smoking causes oxidation and therefore inhibition of agantitrypsin, which accelerates the development of emphysema even in the absence of a genetic predisposition.

In addition to the lack of inhibitors, the development of emphysema can be caused by increased production of elastase (for example, the formation of serine elastase by granulocytes, metalloproteinases by alveolar macrophages and various proteinases by pathogenic microorganisms). Excessive elastase content during chronic inflammation leads, in particular, to the destruction of the elastic fibers of the lungs.

Considering the changes that occur with pulmonary emphysema, it becomes obvious how significant the decrease in elastic traction of the lung tissue is. To exhale, elastic traction of the lungs creates positive pressure in the alveoli relative to the external environment. External compression (as a result of contraction of the respiratory muscles) causes positive pressure not only in the alveoli, but also in the bronchioles, which creates additional resistance to air flow. Therefore, the maximum expiratory flow velocity (V max) depends on the relationship between elastic traction (T) and resistance (R L). Thus, as a result of a decrease in elastic traction, changes occur similar to those in obstructive pulmonary disease. Elastic traction increases by increasing the volume of inhaled air, which ultimately leads to a shift of the resting point towards inhalation (barrel chest). If the volume of inspired air remains constant, the FRC and residual volume (and sometimes dead space) increase. However, due to a decrease in expiratory volume, vital capacity decreases. Shifting the resting point leads to flattening of the diaphragm and, according to Laplace’s law, requires increased muscle tension. When the interalveolar septa are destroyed, the diffusion area decreases; a reduction in the number of pulmonary capillaries leads to an increase in functional dead space and an increase in pulmonary arterial pressure and vascular resistance, with the eventual development of cor pulmonale. Different resistance to air flow in individual bronchioles in centrilobular (non-extended) emphysema causes disturbances in its distribution. The result of the abnormal distribution is hypoxemia. In patients with centrilobular emphysema against the background of obstructive pulmonary disease, diffuse cyanosis develops. In contrast, with widespread emphysema, the skin takes on a pink tint, which is explained by the need for deeper breathing due to increased functional dead space. However, impaired diffusion leads to hypoxemia only if there is a significant decrease in diffusion capacity or an increase in O 2 demand.

Pathoanatomically the lungs are pale, swollen, inelastic, and retain impressions from the ribs. The wall of the right ventricle of the heart, as well as the trabecular muscles, are sharply thickened, even without a pronounced increase in the cavity. The wall of the left ventricle is often thickened due to concomitant hypertension.

Classification. According to pathogenesis, primary (congenital, hereditary) and secondary pulmonary emphysema are distinguished, which occurs against the background chronic diseases lungs (usually chronic obstructive pulmonary disease); by prevalence - diffuse and localized pulmonary emphysema; according to morphological characteristics - proximal acinar, panacinar, distal, irregular (irregular, uneven) and bullous.

Symptoms and signs of emphysema

The clinical picture is characterized by shortness of breath, cyanosis, cough, and changes in the chest.

Shortness of breath, the most constant complaint of those suffering from emphysema, appears at first only during physical work, which becomes possible in smaller and smaller amounts, as well as with exacerbations of bronchitis and incident pneumonia, with asthmatic spasms of the bronchi. Later, shortness of breath does not leave the patient even in a position of complete rest, intensifying even after eating, with excitement, and conversation. Since hypoxemia is already present in a resting state, it is clear that physical work further worsens the composition of the blood and, by pumping blood from the skeletal muscles into the vena cava, right heart, further increases the pressure in the pulmonary circulation, which also reflexively increases shortness of breath.

Cyanosis is a constant sign of emphysema. In accordance with persistent hypoxemia with normal blood flow velocity and unchanged peripheral circulation, with emphysema, unlike the state of cardiac decompensation, cyanosis is not accompanied by coldness of distant parts of the body (the hands remain warm).

The cough is of a peculiar nature due to the weakness of the chest excursions, the weakness of the expiratory air stream and therefore is often especially painful and persistent. The causes of cough are varied: inflammatory bronchitis, asthmatic bronchospasms, high pressure in the vessels of the pulmonary circulation, which also causes cough by neuroreflex.

Often patients have a characteristic appearance: a purplish-cyanotic face with a pattern of dilated skin veins, a shortened neck due to expansion of the chest, as if inhaling, swollen neck veins, especially during coughing fits, when the cyanosis of the face increases sharply. Characterized by interrupted speech due to lack of air, muscle tension during exhalation, and often a barrel-shaped chest with an increased anteroposterior size.

The most important clinical sign of emphysema is almost complete absence respiratory mobility of the chest, which often decides the diagnosis of emphysema even in the absence of a barrel-shaped chest itself. A rim of dilated small veins is visible on the chest along the line of attachment of the diaphragm and along the edge of the heart in front. Patients, even with severe cyanosis, usually maintain a low position of the upper body in bed (orthopnea is not observed), possibly due to the absence of any significant enlargement of the heart. The apical impulse is not detected, but under the xiphoid process on the left it is possible to feel an increased impulse of the right ventricle. Percussion of the lung gives, instead of normal, very varying intensity a typical loud box or pincushion sound caused by excess air in the alveoli, especially in the lower part of the lungs along the axillary line. Inflated lungs push the liver down and cover the heart, which makes determining its size by percussion impossible (the lungs also push the apex of the heart away from the chest wall).

Excursion of the lower edge of the lungs along the anterior axillary line and an increase in the circumference of the chest during breathing, which are normally 6-8 cm, fall to 2-1 cm. Weakened, usually harsh breathing with prolonged exhalation, dry rales, whistling and buzzing, are often heard. focal pneumonia with greater sonority of moist rales and increased bronchophony.

Heart sounds are muffled due to displacement hearts and lungs, which weakens the emphasis of the second tone of the pulmonary artery.

An X-ray examination reveals horizontally running ribs with wide intercostal spaces, often ossification of the costal cartilages, and a flattened, poorly mobile diaphragm. The normal pulmonary pattern is poorly expressed due to the poverty of the lungs with blood vessels. Heaviness and enlargement of the bronchial lymph nodes are also often found. It should be emphasized that the lungs are anemic; expansion of the root shadow is possible due to enlargement of the lymph nodes (wheezing in the lungs of inflammatory origin).

The heart itself is often not dilated, perhaps also due to difficulty in the flow of blood into the left and right hearts due to increased intrathoracic pressure, limiting the suction of blood into the heart; rather, the small heart of patients with emphysema is characteristic with bulging of the pulmonary artery arch as a result high blood pressure in the system of this artery.

It is not possible to measure the pressure in the pulmonary artery directly, although an attempt to do so Lately and was done by catheterizing the chambers of the right heart through the jugular or ulnar vein. Blood pressure in the systemic circle is rather reduced, possibly due to the transfer of blood through the anastomoses and a decrease in blood flow to the left heart. The liver is usually prolapsed.

From the blood: erythrocytosis up to 5,000,000-6,000,000 - a consequence of irritation bone marrow hypoxemic blood composition; sometimes eosinophilia (usually in sputum).

Course, forms and complications of emphysema

As a rule, the onset of pulmonary emphysema is gradual, the course is chronic, usually many years. During emphysema, three periods can be schematically distinguished.

The first period is the so-called bronchitis, when prolonged or repeated bronchitis, as well as focal bronchopneumonia, creates conditions for the development of emphysema. There may be signs asthmatic bronchitis. The well-being of patients fluctuates sharply, improving significantly in the summer, in a dry, warm climate.

The second period is severe emphysema with constant pulmonary insufficiency, cyanosis, shortness of breath, even worsening with inflammatory complications; lasts for many years, up to 10 or more, which is rarely observed in other diseases with the same sharp cyanosis.

The third, relatively short period is cardiac, or, more precisely, pulmonary-cardiac failure, when a patient with emphysema develops congestion - in a large circle, painful swelling of the liver, edema, stagnant urine, simultaneously with expansion of the heart, tachycardia, slowing of blood flow, etc. ... (the so-called chronic pulmonary heart).

According to the forms, in addition to classic senile or presenile emphysema, which mainly affects men 45-60 years old, who do not have obvious bronchopulmonary diseases in the anamnesis, emphysema should be distinguished young. In this form of emphysema, often more acute, occurs due to obvious diseases of the bronchi and lungs, such as gas poisoning, gunshot wounds of the chest (with pneumothorax and hemoaspiration), kyphoscoliosis, bronchial asthma etc., when in the course of the disease, in addition to emphysema as such, the underlying lung disease with its immediate consequences plays a major role. Essentially, in the classical form there are similar changes in the lungs in the form of peribronchitis and pneumosclerosis, but a slower, less clinically pronounced course.

Complications of emphysema include the rarely observed pneumothorax and interstitial emphysema.

Diagnosis and differential diagnosis of emphysema

Although a common and well-defined disease, emphysema nevertheless often leads to misdiagnosis. It is not recognized where it undoubtedly exists and is detected only at autopsy; Along with this, sometimes a diagnosis of emphysema is made, which is not justified by the entire clinical and anatomical picture. It is important not only to correctly recognize emphysema in general, but to correctly indicate the period of the disease, possible complications and concomitant (or primary) diseases, as this determines prognosis, disability and treatment methods.

Very often, in addition to pulmonary emphysema, a patient is mistakenly diagnosed with cardiac decompensation or myocardial dystrophy on the basis of existing shortness of breath, cyanosis, muffled heart sounds, emphasis on the pulmonary artery, sharp epigastric pulsation, wheezing in the lungs, protrusion of the liver from under the ribs in the presence of sensitivity in the liver areas. Meanwhile, these false cardiac signs are characteristic of emphysema as such without heart failure. In these cases, the wheezing in the lungs is bronchitis and not congestive, the liver is sunken and not enlarged, the tenderness refers to the abdominal muscles. The absence of orthopnea is also characteristic. A patient with emphysema is essentially a pulmonary patient, and he remains so for many years, while heart failure (pulmonary heart failure) is only the end of the disease, accompanied by completely undoubted cardiac signs.

In the presence of heart enlargement, systolic murmur at the apex, liver enlargement, edema, etc., the diagnosis of decompensated mitral valve disease or decompensated atherosclerotic cardiosclerosis, etc. is often mistakenly made without taking into account the whole picture of the development of the disease, the presence of severe cyanosis, erythrocytosis, low blood pressure pressure, absence of arrhythmias, etc.

With emphysema with cyanosis in an elderly patient, atherosclerotic coronary sclerosis is recognized on the basis of pain in the heart area, although these pains can be pleural, muscular, and in rare cases, true angina pectoris is caused by the hypoxemic composition of the blood (the so-called blue angina pectoris).

Due to a sharp change in percussion sound and weakened, almost absent breathing in the lungs, pneumothorax is mistakenly recognized, although with emphysema the damage is bilateral and uniform.

The box sound in the sloping parts of the lungs does not always indicate pulmonary emphysema as a specific pathological condition.

Such changes can cause:

1. The so-called functional pulmonary emphysema with left ventricular failure of the heart, when, due to overstretching of the small circle vessels by stagnant blood, the chest becomes almost motionless during respiratory movements, and the lungs are definitely dilated. Persistent organic changes—atrophy of the septa in the alveoli—are not detected; a decrease in blood mass during bloodletting, under the influence of Mercusal, with increased contractile force of the myocardium, stops this condition. The presence of a gallop rhythm, angina pectoris, pallor of the face, and relief under the influence of nitroglycerin also speak against emphysema. This explains why in acute nephritis or coronary sclerosis occurring with cardiac asthma, the doctor is often inclined to diagnose pulmonary emphysema (or bronchial asthma).
2. The so-called senile emphysema, depending on age-related atrophy of the elastic tissue of the lungs in the absence of obstruction of the bronchi and increased intra-alveolar pressure, therefore, not accompanied by the most significant disturbances of pulmonary ventilation and pulmonary circulation; in addition, a slight decrease in external respiration may correspond to decreased tissue metabolism—reduced “internal” respiration in old age. Therefore, although the box sound of the sloping parts of the lungs is established by percussion and the x-ray shows a large airiness of the corresponding pulmonary fields, there is no shortness of breath, cyanosis, wheezing, and essentially this condition does not deserve the name of lung disease. In these forms, due to relative atrophy of the lung tissue, overextension of the lungs may occur, since the chest remains of normal volume or is even enlarged due to calcification of the ribs. A similar state of atrophy of the lung tissue, in a certain sense of an adaptive nature, is found regardless of the age of the patients and in other dystrophies - nutritional, wound, cancer, which also occur with a decrease in tissue metabolism.
3. The so-called compensatory emphysema, limited to the part of the lung adjacent to the affected area or one lung when the other is affected.

   Basically, the disease is explained by a change in the normal ratio of intrathoracic elastic forces, as discussed in the section on atelectasis, effusion pleurisy, and therefore only partially deserves the name “compensatory” emphysema.

4. Interstitial, or interstitial, pulmonary emphysema is mentioned by us only for the purpose of completeness and systematic presentation. It occurs after a lung injury as a result of rupture of the alveoli inside the lung with the release of air pumped into the lungs into the intermediate tissue of the lungs, the mediastinum, into subcutaneous tissue neck and chest. Interstitial emphysema is easily recognized by the crunchy swelling of tissue on the neck and other characteristic signs.

Prognosis and work ability. Emphysema lasts for many years: infectious factors, working and living conditions are important for progression. In the first period, the patient can engage in usual, even physical work; in the second period, emphysema leads to significant, sometimes complete, and in the third period, always to complete loss of ability to work.

Most often, patients die from severe heart failure or from acute pulmonary diseases - lobar or focal pneumonia, from general acute infectious diseases, in the postoperative period, etc.

Prevention and treatment of emphysema

Prevention of true pulmonary emphysema consists in preventing inflammatory, traumatic injuries bronchial tree and intervascular tissue of the lungs, in the fight against asthma, etc.

Treatment of advanced pulmonary emphysema is not very successful. In the early stages, various foci of irritation that reflexively disrupt the coordinated activity of the bronchopulmonary system should be eliminated, and measures should also be taken to regulate the activity of the central nervous system. Based on these general provisions, it is necessary to persistently treat bronchitis and focal pneumonia; for inflammatory exacerbations, chemotherapeutic agents and antibiotics are indicated; with a spastic component, which almost always occurs, antispastic ones: ephedrine, belladonna. Climatic treatment is indicated, especially in the autumn and early spring months, as with bronchiectasis, at dry, warm climatic stations.

Previously, they tried to enhance exhalation by compressing the chest with devices or to ensure exhalation into a rarefied space, but it is more advisable to strive to improve the patency of the bronchi (with antispasmodic agents, in extreme cases, suction of viscous mucus through a bronchoscope) and treat interstitial pneumonia.

Attempts at surgical treatment were abandoned.

In advanced cases, rest, oxygen treatment; Morphine is prohibited.

WHO statistics indicate that 4% of the population suffers from emphysema. As a rule, the disease affects men of average and older than age. There are chronic, acute forms, local (vicarious) or diffuse. The disease impairs pulmonary ventilation and blood circulation, which leads to disability and decreased comfort of life.

What is emphysema

This disease increases the amount of air in the alveolar tissue of the lungs more than normal. Excess gas that accumulates in the organ can lead to a number of complications, for example, damage to bronchial tissue. The disease emphysema provokes excess gases not due to the addition of oxygen, but due to retention, accumulation of carbon dioxide and other impurities. This leads to disruption of the normal blood supply to the lung tissues and to their destruction. Pressure increases inside the organ, and compression of nearby organs and arteries occurs.

Species

This pathology is divided into several types and forms. Each of them has specific symptoms that can be detected during diagnosis and history. Emphysema can be acute or chronic (the latter is extremely rare in children). Moreover, each of the forms has an unfavorable prognosis without proper therapy. Types of emphysema:

• paraseptal;
• diffuse;
• panlobular;
• bullous

Why is emphysema dangerous?

The disease leads to irreversible changes structure of organ tissues, which manifests itself in the form pulmonary insufficiency. This is one of the reasons why emphysema is dangerous. Pulmonary hypertension leads to a significant increase in the load on the right myocardium. Because of this, some patients develop right ventricular heart failure, edema of the lower extremities, myocardial dystrophy, ascites, and hepatomegaly.

The timeliness of detection of the disease directly affects the further prognosis. Ignoring the problem therapeutic measures leads to progression of the pathology, loss of the patient’s ability to work and further disability. In addition to the disease itself, complications of pulmonary emphysematosis pose a serious threat to human health.

Life forecast

Emphysematous lungs cannot be completely cured. Even with treatment, the pathology continues to progress. Timely appeal to the hospital, compliance with all medical recommendations, therapeutic measures help to slow down the disease, improve the standard of living, delay disability, and reduce mortality. The prognosis for life with pulmonary emphysema due to a congenital defect is usually unfavorable.

Emphysema - symptoms

Manifestations of the disease depend on the type and form of the pathology, but there are also the main signs of emphysema, which are always the same. TO general symptoms include:

• cyanosis;
• tachysystole;
• expiratory shortness of breath (exacerbation of organ inflammation, bronchitis occurs, often occurs with increased physical activity);
• cough (painful dry cough in the secondary type of pathology, scanty sputum production);
• shortened neck size;
• bulging of the supraclavicular areas;
• increasing respiratory failure;
• weight loss;
• pathological changes in the chest, expansion of the intercostal space;
• diaphragm position;
• excessive fatigue;
• due to the expansion of the chest, there is a lack of motor mobility (barrel chest);
• when coughing, the neck veins swell;
• purple complexion, the pattern of capillaries appears.

Bullous emphysema

Most experts agree that bullous disease is a manifestation of hereditary/genetic abnormalities. The pathogenesis and etiology of this form of the disease are not fully understood. The pathology is characterized by the appearance of bullae in the lungs (bubbles of different sizes); they are often localized in the marginal parts of the organ. Bubbles can be multiple or single, local or widespread. The diameter of the bulla ranges from 1 to 10 centimeters. With this form of the disease, respiratory failure develops at the first stage.

Paraseptal

With this pathology, the pulmonary alveoli expand so much that the interalveolar septa are destroyed. Paraseptal emphysema leads to disruption of the functioning of lung tissue, but the risk fatal outcome extremely small. The body receives less oxygen than in healthy condition, but the shortage is not so critical as to lead to death.

Vicar

This form of the disease is characterized by hypertrophy, expansion of the parts of the lungs remaining after surgery, and increased blood supply. Vicarious emphysema is part of true emphysema. The organ does not lose elasticity; adaptive reactions cause functional changes. The air volume of the remaining lung increases, the bronchioles dilate, this prevents the manifestations typical of emphysematous exhale lightly.

Diffuse

Pathology can be secondary or primary. The latter diffuse pulmonary emphysema is accepted as an independent nosological unit, which implies different variants of the pathology. The disease is classified as idiopathic because the causes have not been fully elucidated. There is only a connection between obstructive bronchial diseases, which leads to the further development of emphysema. The secondary type of pathology often becomes a complication after chronic bronchial obstruction, bronchitis, or pneumosclerosis.

Diagnostics

The main symptoms of the pathology include shortness of breath, which occurs after physical activity. The development of the disease is indicated by a decrease in the diffusion capacity of the lungs, which occurs due to a reduction in the respiratory surface of the organ. This develops against the background of a significant increase in ventilation. The following examination methods are used for diagnosis:

1. Emphysema is visible on a radiograph (x-ray). The image helps to identify possible pathologies and see the full picture of the organ. There will be a noticeable narrowing of the heart shadow, it will stretch out, and there will be a noticeable increase in airiness pulmonary tract.
2. CT scan(CT). The study helps to see hyperairiness, bullae, and increased density of the bronchial wall. CT provides the opportunity to detect the disease at an early stage.
3. External manifestations and symptoms. The onset of shortness of breath at a young age may indicate hereditary form diseases. This is a serious reason to contact a specialist and conduct an examination.

Emphysema - treatment

Modern medicine offers several effective areas of therapy that help slow down the progression process. Treatment of pulmonary emphysema is carried out in the following areas:

1. Performance breathing exercises. They are aimed at improving gas exchange in the lungs. Minimum rate treatment is 3 weeks.
2. You should completely stop smoking, this most important factor if desired, effectively treat the pathology. After this, many patients experience shortness of breath and cough over time, their breathing becomes easier, and their general well-being improves.
3. Antibacterial drugs are usually anticholinergics. The dosage of the medication is prescribed by the doctor in individually. This indicator is influenced by additional symptoms accompanying the disease. General therapeutic effect increased by medications with expectorant action.
4. Inhalations. This effective way treat this disease, gives good results together with drug therapy. The minimum duration of treatment is 20 days.
5. Surgical intervention. It is carried out only in the most severe cases, by opening the chest or using endoscopy. Timely surgical intervention helps to avoid complications, for example, pneumothorax.

Folk remedies

Therapy will be effective only with an integrated approach to treatment. The disease cannot be cured only with tinctures at home. Treatment of pulmonary emphysema with folk remedies can be carried out using the following recipes:

1. Medicinal mixture 2. You will need dandelion root, birch leaves, juniper fruits. Mix the ingredients in a ratio of 1:2:1. In a quarter liter of boiling water you need to infuse a tablespoon of this collection. Then filter the liquid through gauze and take 15 ml after meals, 30 minutes later.
2. Ledum is used for inhalation or as a tincture. In the latter option, you need to leave 1 tsp for about an hour. crushed, dried plant in a half-liter jar with boiling water. You need to drink 15 ml of the product twice a day.
3. Collection number 3. For it you will need the roots of licorice, marshmallow, sage, anise, and pine buds. Mix all crushed ingredients in equal proportions. Brew a tablespoon of the mixture in a glass of boiling water. After 1-2 hours, the tincture will be ready, which must be poured into a thermos. During the day you need to drink the product 3 times, 6 ml each before meals.

Breathing exercises

This is one of the types of prevention and stages of treatment of the disease. Breathing exercises for pulmonary emphysema improve gas exchange, especially successfully used in initial stages pathology. The therapy is carried out in a medical facility, the essence of the method is that the patient first inhales air with a low amount of oxygen for 5 minutes, then the same amount with a normal content. A session consists of 6 such cycles, the course is usually 20 days, 1 session per day.

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