Bullae

Introduction to lung bullae Pulmonary bullous is an emphysema alveolus that occurs more than 1 cm in diameter in the lung parenchyma. It usually occurs on emphysema, usually secondary to inflammatory lesions of the bronchi, such as pneumonia, emphysema and tuberculosis. Often coexist with emphysema. The mechanism of occurrence is similar to that of emphysema but to a greater extent. basic knowledge The proportion of illness: the incidence rate is about 0.003%-0.007% Susceptible people: more common in smoking population Mode of infection: non-infectious Complications: spontaneous pneumothorax Tension pneumothorax

Cause of pulmonary bullae

(1) Causes of the disease

Pulmonary bullae is caused by the high alveolar swell, the alveolar wall ruptures and fuses with each other, usually caused by the occlusion of the small bronchi, the same as the formation of emphysema, but to a greater extent, the alveolar diameter of emphysema More than 1cm, occurring in the lung parenchyma, often accompanied by different lung diseases, such as chronic bronchitis and bronchial asthma, advanced silicosis or sarcoidosis, and some lung bullae found in patients with lung and bronchi disease-free, bullae Secondary to pneumonia or lung abscess is more common in infants and young children, there are multiple single and multiple, due to inflammatory lesions, small bronchial mucosa edema, resulting in partial obstruction of the lumen, resulting in a valve, air can enter the alveoli is not easy Excretion, the pressure in the alveoli is increased, and the alveolar space is gradually broken due to the increase of the intravesicular pressure, which forms a huge balloon-containing cavity, which is clinically called a bullous bullae.

Secondary to tuberculosis, most of them are single, and there is no obvious emphysema.

Secondary to emphysema, often multiple, in addition to bullae, often accompanied by most vesicles.

(two) pathogenesis

The wall of the bullous bullae is very thin, consisting of squamous epithelial cells of the alveoli or only fibrous membranes, and can coexist with a variety of emphysema, usually in the paraventricular or paraneoplastic emphysema, with or without charcoal At the end, they were found in the pneumoconiosis and scar tissue emphysema of coal miners. The bullae were divided into three pathological forms.

Type I: occurs mostly in the middle or lingual leaves, and is also common in the upper lobe of the lung. It may be due to the negative pressure in the chest, which protrudes from the surface of the lungs, and has a narrow band connected to the lungs. The valvular obstruction formed by scar tissue, the enlarged volume of pulmonary bullae is due to alveolar collateral ventilation and gas retention. The type I lung bullae is thin, often formed by the pleura and connective tissue. The lung can be found on conventional X-ray films. The presence of bullae.

Type II: between the visceral pleural and emphysema lung tissue, the superficial base of the superficial pulmonary bullae is located in the surface of the lung, connective tissue space can be seen in the bullous cavity, but it does not constitute the wall of the bullae. Can be seen in any part of the lungs.

Type III: is a deep basal deep bullae, the structure is similar to type II, but the site is deep, surrounded by emphysema lung tissue, lung bullae can be extended to the hilar, visible in any lung lobe.

When the volume of the lung bullae increases, the surrounding lung tissue is compressed and causes the lungs to shift. The compressed lung tissue is on the chest X-ray, which shows the density increase around the bullae, and the above 3 types are found in chronic bronchitis. Associated with chronic diffuse obstructive pulmonary disease, lobular central emphysema does not involve pulmonary bullae, and lower lobe bullae are common in coal mine workers with pneumoconiosis and concomitant silicosis with complications.

Pulmonary bullet prevention

Respiratory care is especially important: after the operation, low-flow continuous oxygen should be given, deep breathing should be encouraged, and the back should be taken once every 2 hours; psychological care should be done to avoid coughing and coughing due to pain or fear of tube loss; patients should learn to correct The method of sputum drainage, such as: holding a breath after deep inhalation, coughing several times, will cough to the pharynx, press the chest at the same time, and finally cough up the cough; if the sputum is thick, you should drink more water, Dilute the sputum to facilitate sputum discharge.

Pulmonary bullous complications Complications spontaneous pneumothorax tension pneumothorax

Spontaneous pneumothorax is the most common complication of bullous bullae, followed by infection and spontaneous blood pneumothorax.

1. Spontaneous pneumothorax:

Pulmonary bullae can be free of any symptoms. Sudden exertion, such as severe coughing, sudden increase in pressure during lifting or physical exercise, rupture of bullae, gas entering the pleural cavity from the lungs, and spontaneous pneumothorax may cause difficulty breathing. , shortness of breath, palpitation, rapid pulse, etc., pneumothorax makes the pleural cavity negative pressure disappear, the gas compresses the lung tissue to collapse to the hilar, the degree of collapse depends on the amount of gas entering the chest, and the original lesion of the lung and pleura The pathological condition, the amount of gas entering the chest cavity is large, the original lesion of the lung tissue is light, the compliance is still good, the lung collapses more, sometimes it can reach 90% of the side of the chest cavity, the gas quickly enters the chest cavity, and the lung tissue rapidly shrinks, then Symptoms are serious, and even have cyanosis. If the patient has pulmonary bullae, pulmonary emphysema, long-term chronic infection of lung tissue, etc., although some of the gas enters the chest cavity, the lung tissue is wilted. The degree of depression can be lighter, but because the patient's original lung function has subsided, the symptoms are also heavier. X-ray examination shows the pneumothorax line formed by the compressed lung, if there is adhesion Exist, the pneumothorax line is irregular. After the bullous rupture, a small part of the rupture is small. After the lung tissue is atrophied, the rupture itself closes, the air leak stops, the pleural effusion gradually absorbs, the chest negative pressure recovers, and the lung re-expands.

2. Tension pneumothorax:

If the bullous blister ruptures and forms a flap, the negative pressure in the chest increases when inhaling, the gas enters the chest cavity, the flap is closed when exhaling, the gas can not be discharged, especially when coughing, the glottic pressure closes the airway pressure, and the gas enters the chest cavity. After the glottis is opened, the airway pressure is reduced and the gap is closed. Each breath and cough increases the amount of gas in the thoracic cavity, forming a tension pneumothorax. When the tension pneumothorax is completely atrophied, the mediastinum is pushed to the healthy side. When the healthy lung tissue is also compressed, the large blood vessels of the heart are displaced, and the large veins are distorted and deformed, which affects the blood return, causing serious disturbances in the respiratory cycle. The patient may have difficulty breathing, fast pulse, blood pressure drop, or even suffocation, shock, and suffering. The lateral thoracic bulge is accompanied by subcutaneous emphysema on the affected side. The trachea is obviously displaced to the healthy side. The condition is critical and often requires emergency treatment.

3. Spontaneous hemothorax:

Spontaneous hemothorax caused by bullous bullae, mostly from the bullae of the lung tip or the lung tissue around the bullae and the adhesion of the thoracic and adhesion tears, the diameter of the small artery in the adhesion zone can reach 0.2cm, the origin of blood vessels In the systemic circulation, the pressure is high, and the negative pressure in the thoracic cavity increases the tendency of bleeding. In addition, due to the defibration of the lungs, heart, and diaphragm muscles, the blood in the chest cavity does not coagulate, so the bleeding is difficult to stop automatically. Clinical symptoms may vary depending on the speed of bleeding. When the bleeding is slow, the patient may show a progressive increase in chest tightness, difficulty in breathing, X-rays showing dull angles, or parabolic images of pleural effusion. When bleeding is rapid, there may be a short period of time. Shock performance.

4. Spontaneous blood pneumothorax:

When the bullae and the surrounding lung tissue and the chest wall are torn apart, if there is a blood vessel rupture in the adhesion zone and the lung tissue is also damaged, a spontaneous blood pneumothorax is formed.

In recent years, some scholars have pointed out that the amplitude of diaphragmatic activity may play a decisive role in the occurrence of spontaneous blood pneumothorax. When the breath is vigorously exercised, the amplitude of diaphragmatic activity increases, and the adhesion of the thoracic crest is directly or indirectly. The pulling force, because the lung tissue is looser than the pleura, it is easy to tear in the lung side to cause bloody pneumothorax which is both bleeding and leaking. If it is avulsed in the wall side or the central part of the cord, only the hemothorax, the elongated long diaphragm muscle The range of activity is large, and because the body is thin and undeveloped, it is more dependent on abdominal breathing, but the accumulation of fat in the abdominal cavity gradually increases after middle age, which limits the diaphragm muscle activity to varying degrees, so even if the above pathological changes exist, it is rare. Onset, women with chest-type respiration, the incidence rate is low, the right lung is 3 leaves, the leaf space has a certain buffering effect on the sudden downward pulling, and there is still liver in the right armpit, which may be the right side There are fewer reasons. Therefore, patients with spontaneous blood pneumothorax are younger, more male than female, with more left side than right side, mostly elongated and long body type. Both spontaneous spontaneous pneumothorax also occur from time to time. The first side of the left side, the right side of the hair, in some cases, both sides occur at the same time, the condition is critical, and even life-threatening.

5. Secondary infection of lung bullae:

In most cases, bullous bullae occur in the distal extremities of grade 8 or above, and most of them are not infected. However, if the drainage bronchi is blocked, the bullae of the bullae are filled with inflammatory secretions, and the patient may have fever, cough, and cough. Symptoms such as sputum, sometimes after anti-infective treatment, clinical symptoms improved, and the signs of infection on the chest radiograph can still last for a long time.

Pulmonary bullae symptoms Common symptoms Chest tightness, suffocation, cold, cold, shortness, chest tightness, fever, cough, slightly...

Due to the size of the bullous bullae, the different clinical manifestations of the original lung lesions and complications are not the same. Patients with small pulmonary bullae have no obvious symptoms. Patients with simple bullae are often without symptoms. Some pulmonary bullae can be used. No change for many years, some bullae can gradually increase, the chest percussion has excessive reverberation, the breath sounds weaken or even disappear, the enlargement of the bullae or the emergence of new bullae in other parts can cause pulmonary function disorder and Symptoms gradually appear. Giant lung bullae can make patients feel chest tightness, shortness of breath, some patients lose their labor, and even their actions are restricted. The bullae suddenly enlarges and ruptures, and spontaneous pneumothorax can occur. There is sudden chest pain and difficulty breathing. In cases of severe tension pneumothorax, dyspnea is correspondingly aggravated, and purpura can occur, and severe dyspnea and chest pain similar to angina pectoris, severe emphysema complicated with pulmonary bullae can promote pulmonary heart disease. Or increase the development of pulmonary heart disease.

Patients with pulmonary bullae often have chronic bronchitis, bronchial asthma, emphysema, and clinical symptoms are mainly caused by these diseases, but after the formation of bullous bullae, the clinical symptoms are further aggravated, and the lung signs are often pulmonary complication. Performance, pulmonary bullae secondary infection, can cause chills, fever, cough and cough, severe cyanosis, if the drainage bronchial obstruction, the bullous cavity is filled with inflammatory substances, can make the cavity disappear, clinically there may be Symptoms of infection disappear after treatment, and the shadow of the bullae on the chest radiograph does not resolve for weeks or months.

Pulmonary bullae examination

1. Chest X-ray examination :

The apical pulmonary bullae appear as a very thin, translucent cavity at the edge of the lung field. It can be round, elliptical or flattened, of varying sizes, larger in the bullae, sometimes visible across the lung. Interval, multiple lung bullae close together can be multi-faceted, generally not directly connected with the larger bronchus, no liquid level, bronchial contrast can not enter, lung bullae at the bottom of the lung, often difficult to see on the chest Some of them can be completely under the dome level, while others are only partially above the dome. If the lung bullae wall does not appear as a continuous annular line shadow, it is easy to be mistaken for the apical pleural adhesion. Giant lung bullae generally have tension, and there may be a laminated compulsive atelectasis around it, which makes the blister wall appear thicker. It is unclear to be close to the chest wall. The nearby lungs are pushed to cause partial atelectasis, and the lungs are gathered. The translucent brightness is reduced, and the bullae can be fused to each other to form a large bullae, which is shaped like a localized pneumothorax. The bullae can also be ruptured to produce a localized pneumothorax. The fluoroscopy and expiratory chest can help to find Pulmonary bullae due to gas during exhalation The volume of the lung bullae appears relatively enlarged, and the edge is clearer. The fault also helps to define the outline of the bullae and the compression and displacement of the surrounding lung tissue. When the lobular emphysema is present, the tomogram can also show the pulmonary vessels. Anomalous shape.

2. CT examination :

Pulmonary bullae with a diameter of less than 1 cm, which is not easily displayed under the subpleural common chest radiograph, can be found, and CT can more clearly show the extent of the bullae.

3. Pulmonary angiography :

It can accurately indicate the extent of pulmonary vascular damage and the compression of blood vessels around the bullae.

4. Radionuclide lung perfusion scan:

Pulmonary perfusion examination with 133 sputum can be used to understand the ventilation and perfusion of the bullous bullae to reflect whether it is connected to the bronchus and to understand lung function.

Diagnosis and diagnosis of bullae

diagnosis

According to clinical manifestations, chest X-ray, CT is the best way to diagnose bullous bullae.

Differential diagnosis

It must be differentiated from the localized pneumothorax. The bullae are inflated around, so the compressed lung tissue can be seen in the apical region, the rib angle or the palpebral horn. The localized pneumothorax is mainly the lung tissue to the lung. Internal pressure, usually visible pressure of the lung edge retracted to the hilar, lung bullae does not have this phenomenon, so although there are strips between the two can be seen, can still be differentiated, in addition, thoracic closed drainage exploration Touching the big blister wall with tension, only a small amount of gas is introduced after the tube is placed, or only the negative pressure water column is fluctuated without gas discharge, and the giant bullae can be diagnosed to exclude the pneumothorax. The disease also needs to be congenital pulmonary cyst, spontaneous Sexual pneumothorax, empty tuberculosis and other diseases.

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