The clinical picture and over. The greatest clinical significance of chronic diffuse obstructive pulmonary emphysema. It usually mean when we are talking about emphysema in the narrow sense of the word as progressive disease, leading to respiratory and cardiovascular failure. It is often secondary complication abdulrosa forms of chronic bronchitis. Rare is the so-called Hesse emphysema, where clinically and anatomically inflammatory changes in the bronchus is not detected. However, this form is a narrowing of the bronchi on the exhale as a result of atrophy of the walls with a violation of their elastic properties.
The main complaints of patients with emphysema, complicating chronic bronchitis,is short of breath, and often a cough. In the early stages of emphysema there is a slight primitively, pristupoobrazny cough. Unlike conventional chronic bronchitis, emphysema lungs cough lasts for a longer time before separated sputum. The latter can be purulent or only slightly cloudy, glassy, "pearl" (to Be), but, as a rule, is sparse. As the progression of emphysema pristupoobrazny, "difficulty" cough increased. Cough hoarse and contributes little to phlegm. Sick when coughing, straining, his face and neck were red, neck veins dramatically blown up, hardly separated 1-2 spitting phlegm. The cough increases during periods of exacerbation, in damp and cold season, the first time calming down in the summer. Isolated lesion of small bronchi cough may not be due to a lack of receptors for kashlevogo reflex.
Shortness of breath at first observed only during physical stress. Its intensity depends on eating, weather changes drastically seeking after coughing, - patients cannot "breath". Shortness of breath, especially in the beginning, variable - "day to day is not necessary", which distinguishes it from more permanent heart shortness of breath. Sooner appears characteristic of apnea patient with emphysema prolonged expiratory: after a short "enough" breath drawn in a long exhalation. The ratio of the duration of inspiration and expiration can reach 1 : 2, 1 : 3 and 1 : 4. By this time usually appears the jugular veins during exhalation first in lying, half-sitting, and then in vertical position of the patient.
Appearance patients often typical, especially when expressed degrees of emphysema. The patient is represented by a picnic, with a short neck, widely deployed costal angle. So, obviously, and it is believed that individuals piccicacco type are particularly predisposed to emphysema. However, experience (Yu. N. Sokolov, M. N. Voropaeva, B. E. Votchal) showed rather more predisposition to emphysema people asthenic type.
Gradually as a result of lifting of a thorax and a humeral belt neck as if shortened, eyes in the later stages few protruding"the frog face"). Barrel-shaped or bell-shaped chest is a late symptom.
Characteristic and some kyphosis with increasing anteroposterior size of the chest. Marked more horizontal than normal, the location of ribs and a symptom of a retraction of intercostal space, rather indrawing and bulging depending on breathing, and as a reflection of increased fluctuations in intrathoracic pressure.
In apparent cases of emphysema there is cyanosis. At first it acrocyanosis, not associated with lowering of the blood oxygen saturation, and with a slowing of blood flow in the small veins (3. I. Modestova).
In the future, upon the occurrence of significant respiratory failure appears diffuse cyanosis of the skin, mucous membranes, tongue, first grey shade, and then "cast-iron" (accession sclerosis pulmonary artery). At survey draws attention to itself participation in the act of inhaling the sternoclavicular-sokovyh and stair muscles, with expiration - voltage abdominals and front teeth, muscles; often bulging supraclavicular spaces.
Marked change of tone pulmonary percussion sound: you receive a box shade, sometimes irregularity of percussion sound, "mosaic". Parts of the lungs, located at a distance of 5-6 cm, give different percussion. This phenomenon is most frequent in cases of "multifocal" emphysema, practically established from many areas of emphysema in circumference rough focal pneumosclerosis, often with bronchiectasis.
Due to the low standing of the diaphragm of the lower boundary of the lungs almost, and sometimes completely coincides with the costal margin. Her mobility is limited. Chest excursion reduced. The size of the absolute dullness of heart reduced, sometimes it is not defined.
Relative dullness of heart difficult to determine.
Classic auscultatory a sign of emphysema is the weakening of breath ("cotton" breath) is a symptom seen in advanced cases and prognostically unfavorable. First, though, exhale usually extended, strengthened, hard, with a sibilant rale (especially in the supine position of the patient and forced breathing). During exacerbations of chronic bronchitis this symptom is particularly distinct. After using bronchodilators is sometimes possible to identify areas of moist rales, often voiced, indicating related bronchiectasis. Voice trembling more relaxed somewhat. Heart sounds are muffled, in later stages, sometimes marked strengthening of the second tone of the pulmonary artery as a symptom of pulmonary hypertension, there is often tachycardia, arrhythmia, particularly AF, are very rare.
The bottom edge of a liver may come out from under the edges, since the liver is one's pressing away low standing aperture, which complicates the diagnosis starting right ventricular failure. For the last indicative of the sensitivity of liver, especially its left lobe, combined with the constant swelling of the neck veins, not vanishing on the breath. Picture of primary (Hesse) emphysema is different from the one described, only the absence of a history and clinical symptoms of bronchitis, but most often attached bronchitis, and the distinction between these two forms is erased.
For emphysema of the lungs characterized by periods of sharp breathlessness (described Laennec), which sometimes makes it difficult differential diagnosis of emphysema with bronchial asthma. For emphysema is different. Usually it is slowly but steadily progressing. Periodically marked the outbreak of the infection, bronchitis and pneumonia. Clinically this outbreak is manifested by increased breathlessness and cough. Often grows cyanosis. Temperature reaction can be expressed little (in patients with emphysema out outbreaks often observed hypothermia). The manifestation of infection are often the and sweating upper body and head, especially at night, "symptom of wet cushion and easy chilling and sense of feeling ill. The infection can cause a drastic violation of the respiratory function and even lead to a terrible picture of the so-called hypercapnic coma. The accumulation of carbon dioxide in the blood observed in severe cases of emphysema, can reach degrees, which for respiratory center is not exciting, and drugs. At first glance the status of the patient as if improved: decrease shortness of breath, cough. However, breathing becomes shallow, grow cyanosis, tachycardia, arterial pressure falls. Note low oxygen saturation, significantly" increase the partial pressure of carbon dioxide, increase of alkaline reserve, sometimes lowering the pH. With the further development come blackout, mental disorders, convulsions. The infection can cause and rapidly increasing lung-heart failure. Spontaneous pneumothorax is a relatively rare complication in generalized emphysema, more frequent when bullous limited and acute pulmonary emphysema (for example, pertussis). Chronic diffuse emphysema lung pneumothorax due to pleural growths often limited and not always diagnosed. It can include sudden localized pain and chest with some local weakening of breath when listening. Draws the attention of the comparative frequency of ulcer disease in patients with emphysema.