Chronic obstructive bronchitis: symptoms

The clinical picture of COPD consists of a different combination of several interrelated pathological syndromes.

For COPD, a slow progressive progression of the disease is characteristic, and the majority of patients turn to the doctor late, at the age of 40-50 years, when there are already sufficiently pronounced clinical signs of chronic inflammation of bronchial tubes and bronchial obstructive syndrome in the form of cough, shortness of breath and reduced tolerance for everyday physical activity.

Resolve

When questioning, as a rule, it is possible to find out that the appearance of these symptoms is preceded by smoking cigarettes for at least 15-20 years and / or more or less prolonged exposure to the relevant production hazards. Often the patient notes frequent bronchopulmonary infections ("cold" diseases, viral infections, "acute bronchitis", etc.), as well as chronic diseases of ENT organs or aggravating heredity.

In most cases it is important to conduct a semi-quantitative assessment of one of the most important risk factors for COPD - smoking. For this purpose, the so-called index of a smoker is counted. To do this, the average number of cigarettes smoked per day is multiplied by the number of months in a year, i.e. At 12. If the index exceeds 160, then smoking in this patient is considered a serious risk factor for COPD. If the index exceeds 200, such a patient should be classified as a "malicious" smoker.

Other methods of quantitative evaluation of smoking are suggested. For example, to determine the total number of so-called "packs / years" of smoking, the average number of cigarettes smoked per day is multiplied by the number of years during which the patient continues to smoke and dividing the result by 20 (the number of cigarettes in a standard pack). If the number of "packs / years" reaches 10, the patient is considered an "unconditional" smoker. If this figure exceeds 25 "packs / years", the patient belongs to the category of "malicious" smokers.

It is very important to find out in detail the possible impact on the patient of various adverse environmental factors and production hazards, in particular, long-term residence in ecologically unfavorable areas, work in harmful production, contact with volatile pollutants, etc.

Finally, no less important is the information about frequent "cold" diseases, primarily respiratory viral infections, which have a powerful damaging effect on the respiratory mucosa and lung parenchyma.

Complaints

The earliest symptom that appears in COPD patients at a young age, long before seeking medical help, is a cough with a small separation of mucous or mucopurulent sputum, which appears for a long time only in the morning ("morning smoker's cough"). Just as in patients with chronic non-obstructive bronchitis, cough is an important mechanism of bronchial cleansing from excess bronchial secretion, which is formed due to insufficiency of mucociliary transport, which manifests itself at first only at night. The immediate cause of coughing is irritation of cough reflexogenic zones located at the places of division of large bronchi and in the region of bifurcation of the trachea.

Over time, cough becomes "habitual" and worries the patient during the day and especially at night, when patients occupy a horizontal position in bed. Cough usually intensifies during the cold and damp season, when the most frequent exacerbations of COPD occur. As a rule, such exacerbations differ relatively poor in symptoms and occur with normal or slightly elevated subfebrile body temperature. Nevertheless, even during this period, patients noted difficulty in breathing, dyspnea, as well as malaise, general weakness, rapid muscle fatigue, decreased efficiency. Cough intensifies, becomes more permanent. The sputum becomes purulent, the amount of it increases. The duration of such exacerbations is increasing and reaches 3-4 weeks, especially if they developed against the background of respiratory viral infections.

Especially severe exacerbations of chronic purulent bronchitis, which is characterized by febrile body temperature, marked intoxication and laboratories of inflammation (leukocytosis, a shift of the blood formula to the left, an increase in ESR, an increase in the content of acute inflammation proteins in the blood, etc.).

The immediate causes of exacerbation of chronic bronchitis are "supercooling", viral infections, massive effects of volatile irritants (for example, excessive smoking or exposure to industrial or household pollutants), as well as severe intercurrent illnesses, physical fatigue, etc.

The second mandatory symptom, characteristic for almost all COPD patients, is shortness of breath, which indicates the formation of bronchial obstructive syndrome and lesion of the respiratory parts of the lungs.

In most cases in COPD patients, shortness of breath appears after several years from the onset of the disease, i.e. Significantly after the appearance of cough with phlegm. Often, the initial manifestations of obstructive syndrome and respiratory insufficiency are perceived by patients only as a small difficulty in breathing, respiratory comfort arising during physical exertion. Moreover, patients during this period alone can not complain about shortness of breath or shortness of breath, and only an attentive analysis of all subjective feelings of the patient allows the doctor to initial manifestations of respiratory failure.

In these cases, patients with COPD can observe an increasing decrease in exercise tolerance, which is manifested by an intuitive decrease in the pace of walking, the need to stop for rest, for example, when climbing stairs, etc. Often, there is a feeling of pronounced muscular fatigue during the performance of the usual exercise for a given patient

Over time, the difficulty of breathing becomes more and more specific and the patients themselves pay attention to this important symptom of the disease. Moreover, dyspnea becomes the main complaint of a COPD patient. In the expanded stage, dyspnea becomes expiratory, intensifying with physical exertion and exacerbations of chronic bronchitis. Inhalation of cold air, lowering of atmospheric pressure (high mountains, airplane flights) also cause an increase in dyspnea.

Finally, in severe cases, bronchoobstructive syndrome is manifested by attacks of a superficial, ineffective cough, the diagnostic and prognostic significance of which is fundamentally different from the cough caused by mucociliary transport deficiency and hypersecretion of mucus. Seizures are often accompanied by a brief increase in signs of obstructive respiratory failure - dyspnea, cyanosis, tachycardia, and swelling of the cervical veins, which may be due to the manifestation of an early expiratory collapse of small bronchi. As you know, this mechanism of bronchial obstruction is based on two main reasons:

1. If the movement of air through small bronchi is difficult due to the presence of sputum, edema of the mucous membrane or bronchospasm during expiration, the pulmonary pressure increases dramatically, which leads to an additional compression of the small bronchi and an even greater increase in their resistance to air flow. The role of this mechanism increases with attacks of painful, unproductive cough and emphysema, accompanied by a marked decrease in the elasticity of the lung tissue.
2. The phenomenon of Bernoulli is the second most important mechanism of early expiratory collapse of the bronchi in narrowing them. The sum of the air pressure along the longitudinal axis and the lateral pressure on the bronchial wall is constant. With normal bronchial lumen and a relatively small linear air flow rate during exhalation, the lateral air pressure on the bronchial wall is large enough to prevent their early collapse.

With constriction of the bronchi and during coughing, the linear velocity of the airflow increases, and the lateral pressure decreases sharply, which contributes to the early collapse of small airways at the very beginning of exhalation.

Thus, the most characteristic sign of COPD is the early appearance of cough with phlegm, and only after a few years - the attachment of expiratory dyspnea. Only in rare cases, dyspnea may be a manifesting symptom of the disease that occurs simultaneously with a productive cough. This feature of the development of clinical manifestations of COPD is typical for patients exposed to simultaneous intense exposure to several risk factors, for example, malicious smoking combined with work in hazardous production in the atmosphere of volatile pollutants.

Physical examination

When general examination of COPD patients in the initial stages of the disease, significant differences from the norm, as a rule, do not show. With further progression of the disease, the formation of bronchial obstructive syndrome and severe respiratory failure in COPD patients, cyanosis appears. As a result of arterial hypoxemia, reduction of oxyhemoglobin and an increase in the concentration of reduced hemoglobin in the blood flowing from the lungs, cyanosis usually acquires a diffuse character and has a peculiar grayish shade (diffuse gray cyanosis). Mostly it is noticeable on the face, the upper half of the trunk. The skin is warm to this touch if there are no signs of cardiac decompensation in patients with a chronic pulmonary heart. It should be remembered that there is no direct correlation between the degree of respiratory failure and the severity of cyanosis.

In the presence of concomitant bronchiectasis or chronic purulent bronchitis, in some cases, during examination, it is possible to reveal a peculiar thickening of the end phalanges of the fingers in the form of tympanic sticks and the change in the nails in the form of watch glasses (a symptom of "drumsticks" and "watch glass").

Finally, the development of decompensated chronic pulmonary heart and right ventricular failure may be accompanied by the appearance of peripheral edema, and also by the change in the nature of cyanosis - it becomes mixed: against a background of diffuse coloring of the skin, more intense cyanosis of the lips, fingertips, and the like. (acrocyanosis).

Practically all COPD patients have an emphysematous thoracic mark when examined. In typical cases, it is observed:

• an increase in the transverse and especially anteroposterior size of the thorax (in some cases it becomes "barrel-like");
• "Short neck" due to the fact that the chest is frozen at the height of inspiration;
• deployed (more than 90 °) epigastric angle;
• smoothness or swelling of the supraclavicular pits;
• more horizontal direction of the ribs and an increase in intercostal spaces;
• tight fit of the blades to the chest, etc.

Voice tremor due to the development of emphysema is weakened, but equally in the symmetrical areas of the chest.

Percussion over the entire surface of the lungs determine the box percussion sound. The lower borders of the lungs are shifted downward, and the upper ones are upward. The respiratory excursion of the lower edge of the lung, normally 6-8 cm, is reduced.

With auscultation, weakened vesicular breathing is more likely to occur, acquiring a particularly low shade (cotton breath), which is also associated with the presence of m emphysema of the lungs. Attenuation of respiration, as a rule, is expressed equally over symmetrical sites of the lungs. There is also an extension of the exhalation phase due to the presence of bronchial obstructive syndrome (normally the ratio of inspiration and expiration is 1: 1.1 or 1: 1.2). At the initial stages of COPD development, when inflammatory changes in the bronchi predominate, and emphysema of the lungs is not so pronounced, hard lungs can be heard above the pulmonary fields.

The most characteristic auscultative sign of chronic obstructive bronchitis is scattered dry wheezes. Their tonality depends on the caliber of the bronchi in which they form. High (treble) dry wheezes indicate a significant narrowing of the distal (small) bronchi due to the presence there of a large amount of viscous sputum, edema of the mucosa or spasm of small bronchi. Chryps are better heard during the exhalation and change when you cough (the bowl disappears or decreases). Forced exhalation, on the contrary, leads to an increase or appearance of high-toned dry wheezes.

Low (bass) buzzing and "buzzing" dry wheezes indicate a presence of viscous sputum in proximal (large and medium) bronchi.

In some relatively rare cases, patients with COPD can also listen to wet small- and medium-bubbling rales, which indicates the presence of liquid sputum in the bronchi or in the cavity associated with the bronchi. In these cases, most often we are talking about the presence of bronchiectasises.

An important auscultatory phenomenon in patients with chronic obstructive bronchitis and COPD is remotely audible at a distance. They usually have the character of long, prolonged, multi-tone dry wheezes, usually more pronounced in exhalation.

When the syndrome of bronchial obstruction is expressed, remote rales are often audible much better than dry wheezing revealed during chest auscultation.

In patients with COPD, it is always important to correctly assess the physical data obtained in the study of the cardiovascular system, which may indicate the presence of pulmonary arterial hypertension and pulmonary heart. Among these signs include increased and diffuse cardiac shock and epigastric pulsation, indicating the presence of severe hypertrophy and dilatation of the right ventricle. With percussion in these cases, you can find a rightward right-right-right dilatation of the relative stupidity of the heart (dilatation of the right ventricle and right atrium), and with auscultation, a decrease in I tone and mild systolic murmur of tricuspid regurgitation, which usually develops in severe dilatation of the right ventricle in patients with decompressed pulmonary heart. Noise is often amplified during a deep inspiration (symptom Rivero-Corvallo), because during this period of the respiratory cycle increases the flow of blood to the right heart and, accordingly, the volume of blood regurgitating in the right atrium.

In severe disease, accompanied by the formation of pulmonary arterial hypertension and pulmonary heart, a paradoxical pulse can be detected in COPD patients - a decrease in systolic blood pressure during a calm deep inspiration of more than 10 mm Hg. Art. The mechanism of this phenomenon and its diagnostic significance are described in detail in Chapter 13 of the first volume of this manual.

It should be noted that most of these symptoms appear with the development of pronounced signs of the pulmonary heart and chronic heart failure. Sensitivity of the most characteristic clinical sign of hypertrophy of the right ventricle - an increased cardiac shock and epigastric pulsation - even in severe cases does not exceed 50-60%.

The most characteristic signs of bronchoobstructive syndrome in COPD patients are:

• Dyspnoea, predominantly of an expiratory nature, appearing or intensifying with physical exertion and coughing.
• Attacks of a superficial, low-productivity cough, in which a small number of sputum requires a large number of coughing thrusts, the strength of each of which decreases markedly.
• Extension of the exhalation phase with calm and especially forced breathing.
• Secondary emphysema of the lungs.
• Scattered high-toned dry wheezing in the lungs, heard with calm or forced breathing, and also remote rales.

Thus, chronic obstructive bronchitis is a slowly progressing disease with a gradual increase in the severity of clinical symptoms and mandatory occurrence at different stages of disease progression:

• syndrome of mucociliary transport disorders (cough, sputum);
• bronchoobstructive syndrome;
• respiratory failure according to the obstructive type, accompanied by arterial hypoxemia, and then hypercapnia;
• pulmonary arterial hypertension;
• compensated and decompensated chronic pulmonary heart.

The possibility of a different combination of clinical manifestations of these syndromes explains the diversity of the individual clinical course of the disease.

Of practical importance are different combinations of signs of chronic bronchitis and emphysema, depending on which the bottom of the main clinical types of XOBL are isolated:

Emphysematous type (type A, "dyspnea", "pink puffer") is characterized by a significant predominance of morphological and functional signs of pulmonary emphysema, whereas the symptoms of chronic bronchitis proper are much less pronounced. Emphysematous type COPD more often develops in individuals with asthenic build and reduced body weight. Increase in the airyness of the lungs is provided by the valve mechanism ("air trap"): during inhalation, the airflow enters the alveoli, and at the beginning or in the middle of the exhalation the small airways are closed due to the expiratory collapse of the small bronchi. On exhalation, thus, the resistance of the respiratory tract to the air flow increases substantially.

The presence of pronounced, usually panacinar pulmonary emphysema and increased extensibility of the lung tissue, which does not exert significant resistance to inhalation, causes a significant increase in alveolar ventilation and a minute volume of respiration. Therefore, respiration at rest, as a rule, is rare and deep (hypoventilation is absent).

Thus, in patients with emphysematous type of COPD, a normal vertical gradient of ventilation and blood flow in the lungs is preserved, therefore, there are no significant violations of ventilation-perfusion relations and, accordingly, gas exchange disturbances and the normal gas composition of blood is preserved.

Nevertheless, the diffusion capacity of the lungs and the reserve volume of ventilation are sharply reduced due to a decrease in the total surface of the alveolar-capillary membrane and the reduction of capillaries and alveoli. In these conditions, the slightest physical load leads to an acceleration of pulmonary blood flow, whereas a corresponding increase in the diffusivity of the lungs and the volume of ventilation does not occur. As a result, PaO2 decreases, arterial hypoxemia develops, and dyspnea appears. Therefore, in patients with emphysematous type of COPD for a long time, shortness of breath appears only with physical exertion.

Progression of the disease and a further decrease in the diffusive capacity of the lungs is accompanied by the appearance of dyspnea at rest. But even in this stage of the disease there is a clear dependence of the manifestation of dyspnea on the amount of physical activity.

In accordance with this dynamics of respiratory disorders in patients with emphysematous type of COPD, a detailed picture of respiratory failure, pulmonary arterial hypertension and chronic pulmonary heart is formed relatively late. Cough with a small sputum in these patients, usually occurs after the onset of dyspnea. According to Mitchell RS, all symptoms of COPD develop 5-10 years later than in the bronchial type of COPD.

The presence of dyspnoea with physical exertion, after which the patients "puff" for a long time, inflating their cheeks, intuitively achieving an increase in intrapulmonary pressure, which somewhat reduces the phenomenon of early expiratory bronchial collapse, as well as the prolonged absence of cyanosis and signs of the pulmonary heart, served as the basis for patients with emphysema type COPD called "pink puffing" ("pink puffer").

The bronchitis type (type B, "blue bloater" - "cyanotic edematous") generally corresponds to the above described manifestations of chronic obstructive bronchitis in combination with centroacinar pulmonary emphysema. In this variant of COPD, as a result of hypersecretion of mucus, mucous edema and bronchospasm, there is a significant increase in resistance both to exhalation and inspiration, which determines the occurrence of general and alveolar hypoventilation mainly in the lower parts of the lungs, a change in the vertical ventilation gradient and early onset violations of ventilation-perfusion relations leading to the appearance of arterial hypoxemia and dyspnea. At later stages of the disease, as a result of fatigue of the respiratory muscles and increase in functional dead space, RaCO2 increases and hypercapia arises.

In patients with bronchitis of COPD, pulmonary arterial hypertension develops earlier than with emphysematous type, signs of decompensated chronic pulmonary heart appear.

In the lungs, auscultatory signs of bronchial obstructive syndrome (dry wheezing, expiratory exhalation) are revealed, cyanosis, peripheral edema and other signs of respiratory insufficiency and chronic pulmonary heart are often observed in connection with which such patients are sometimes figuratively referred to as "bluish swelling" bloater ").

The described two clinical variants of the disease course in pure form are rare, especially emphysematous type COPD. Practitioners often meet with a mixed version of the course of the disease.

Complications of chronic obstructive bronchitis

The most significant complications of chronic obstructive bronchitis include:

• emphysema of the lungs;
• respiratory failure (chronic, acute, acute on the background of chronic);
• bronchiectasis;
• secondary pulmonary arterial hypertension;
• pulmonary heart (compensated and decompensated).

It should pay attention to the high incidence of acute pneumonia in patients with chronic obstructive bronchitis. This is due to the blockage of the bronchi viscous sputum, a violation of their drainage function and a sharp decrease in the function of the local bronchopulmonary protection system. In turn, acute pneumonia, which can be severe, aggravates violations of bronchial patency.

An extremely serious complication of chronic obstructive bronchitis is acute respiratory failure with the development of acute respiratory acidosis. The development of acute respiratory failure is often due to the effect of acute viral, mycoplasmal or bacterial infection, less often - pulmonary embolism, spontaneous pneumothorax, iatrogenic factors (treatment with beta-adrenoblockers, hypnotics, sedatives, narcotics depressing the respiratory center).

One of the most common and prognostically unfavorable complications of long-term chronic obstructive bronchitis is the chronic pulmonary heart.

Current and forecast

The course of COPD is characterized by a steady progression of bronchial obstruction and respiratory failure. If normal non-smokers are healthy individuals over the age of 35-40 years, FEV1 is reduced annually to 25-30 ml, then the rate of reduction of this integral rate of pulmonary ventilation in patients with COPD and smoking patients is much higher. It is believed that the annual decline in FEV1 in COPD patients is at least 50 ml.

The main factors that determine the unfavorable prognosis in COPD patients are;

• age over 60 years;
• a long history of smoking and a large number of cigarettes smoked at the present time;
• frequent exacerbations of the disease;
• baseline low values and rates of decline in FEV1;
• formation of pulmonary arterial hypertension and chronic pulmonary heart;
• presence of severe concomitant diseases;
• male;
• low social status and general cultural level of COPD patients.

The most common causes of death in COPD patients are acute respiratory failure and chronic heart failure. Less often COPD patients die from severe pneumonia, pneumothorax, heart rhythm disturbances and pulmonary embolism.

It is known that approximately 2/3 of patients with severe COPD die within the first 5 years after the signs of decompensation of the blood circulation against the background of the formed chronic pulmonary heart. According to research data, 7.3% of patients with COPD with compensated and 29% of patients with decompensated pulmonary heart die within 2 years of follow-up.

The appointment of adequate therapy and the implementation of preventive measures can reduce the rate of buildup of bronchial obstruction and improve the prognosis of the disease. So, only stopping smoking in a few months can lead to a significant decrease in the rate of increase in bronchial obstruction, especially if it is largely due to a reversible component of obstruction, this leads to an improvement in the prognosis of the disease.

[1], [2], [3], [4], [5], [6]