14. Senile bronchiectasis

　　2. Senile bronchiectasis is a persistent expansion of the bronchi caused by the destruction of the elastic layer and muscular layer of the bronchial wall. Its important pathogenic factors are infection of the bronchopulmonary tissue and bronchial obstruction.

　　1. Bronchiectasis often develops secondary to chronic bronchitis, bronchopneumonia following measles and pertussis, tuberculosis, foreign body aspiration, tumors, and others. In the past, whooping cough and measles were the most common causes, while currently, Gram-negative bacilli infection is predominant, followed by Streptococcus pneumoniae, Staphylococcus aureus, and anaerobic bacteria. Repeated infections of the respiratory tract cause chronic suppurative inflammation of the bronchial wall, damaging the various layers of the bronchial wall tissue, including smooth muscle, collagen fibers, elastic fibers, and cartilage, which are important supporting structures of the bronchial wall. At the same time, chronic inflammation and fibrosis of the lung tissue around the bronchus pull on the bronchial wall, and factors such as increased intraluminal pressure during coughing and inhalation, as well as the negative pressure of the pleural cavity, lead to abnormal and persistent expansion of the bronchi. Respiratory tract obstruction can be the consequence of tumors, foreign body aspiration, or compression by enlarged lymph nodes outside the bronchus, all of which can lead to infection or obstructive atelectasis of the distal bronchopulmonary tissue. The middle lobe bronchus of the right lung is slender and surrounded by multiple clusters of lymph nodes, which often swell and compress the bronchus due to lymphadenitis, causing atelectasis of the middle lobe of the right lung, recurrent infection, known as middle lobe syndrome. It is a common site for bronchiectasis. The contraction and traction of fibrous tissue in the fibrotic tissue of tuberculosis or bronchial mucosal tuberculosis can cause stenosis and obstruction of the lumen, leading to bronchiectasis.

　　2. Congenital developmental defects and genetic factors can also cause bronchiectasis, such as massive tracheobronchial ectasia, which may be due to incomplete development of bronchial smooth muscle cartilage and elastic fibers, resulting in weak and poor elasticity of the wall structure. Incomplete cartilage development or insufficient elastic fibers can lead to local wall weakness or poor elasticity, accompanied by sinusitis or visceral transposition (dextrocardia), known as Kartagener syndrome. Cystic fibrosis is caused by poor development of peripheral lung tissue, cylindrical and cystic expansion of small bronchi, excessive secretion of mucus by bronchial mucous glands, leading to obstructive atelectasis and secondary infection, resulting in bronchiectasis. This disease is often a pulmonary complication of the autosomal recessive cystic fibrosis disease. In addition, some patients with hereditary X-antitrypsin deficiency may also have bronchiectasis.

　　3. Disordered immune function and immune deficiency, such as recurrent respiratory infections caused by hypogammaglobulinemia, can also cause bronchiectasis. In addition, inhalation of corrosive gases such as ammonia or NO₂Secondary recurrent infection can also cause bronchiectasis after damage to the tracheal and bronchial mucosa.

　　Elderly individuals with weak constitution may develop other diseases if bronchiectasis is not treated in a timely manner.

　　1. Chronic respiratory failure and chronic pulmonary heart disease
　　In elderly patients with bronchiectasis, recurrent purulent infection of the airways often leads to extensive destruction of their own and distal structures, resulting in a decrease in effective alveolar ventilation function, and the development of hypoxemia and/or hypercapnia, leading to respiratory failure. Subsequently, pulmonary hypertension and hypertrophy and expansion of the right ventricle develop, leading to chronic pulmonary heart disease. This is the main cause of death in bronchiectasis and should be actively prevented.

　　2. Lung abscess
　　Bronchiectasis can lead to lung tissue necrosis and abscess formation on one hand due to structural damage and persistent infection, and on the other hand due to permanent pathological changes in the lower respiratory tract, which can cause respiratory symptoms and the aspiration of upper respiratory tract pathogens (especially anaerobic bacteria), leading to lung abscess. With the application of effective antibiotics, the incidence of lung abscess has decreased.

　　16. 3. Abscesses in adjacent or distant organs
　　15. Local extension of purulent bronchitis or lung abscess, such as pleurisy, empyema, pericarditis, or via the blood circulation to unseparated organs, causing intracranial metastatic abscess. Due to the wide application of antibiotics, such complications are now very rare.

　　14. 4. Shock or asphyxia
　　13. Patients with massive hemoptysis in a short period of time may develop hemorrhagic shock or asphyxia. In addition to the active use of hemostatic drugs in internal medicine and maintaining an unobstructed respiratory tract, emergency intervention such as bronchial artery embolization is often required.

　　10. The clinical symptoms of elderly bronchial dilation mainly include the following points:

　　9. 1. The course of the disease is often chronic, with long-term coughing, sputum, and recurrent hemoptysis lasting for tens of years. The onset age is mostly in children or young adults, and most patients have a history of measles, pertussis, or bronchopneumonia in childhood, and there are often recurrent lower respiratory tract infections. Some early symptoms of the disease may not be obvious, and the disease may be suspected occasionally due to hemoptysis.

　　8. The severity of clinical symptoms is related to the severity of bronchial lesions and the degree of infection. The condition worsens year by year due to repeated infections, with an increasing amount of sputum, sometimes up to 100-500ml per day; if there is an anaerobic bacterial infection, the sputum and exhaled air have an odor; secondary infection may cause systemic symptoms such as fever, fatigue, and loss of appetite. The typical sputum collected in a glass bottle may show stratified characteristics, with the upper layer being foam, the lower layer hanging with purulent mucus, and the bottom layer being a sediment of necrotic tissue.

　　7. Some patients present mainly with recurrent hemoptysis, accounting for 50% to 70%, with a large difference in the amount of hemoptysis, varying in severity, from blood in sputum to massive hemoptysis. The amount of hemoptysis is not necessarily consistent with the severity of the disease and the extent of the lesion. Some patients have recurrent hemoptysis as the only symptom. There are no coughing, sputum, or other respiratory symptoms in daily life, and it is clinically called 'dry bronchial dilation', which is common in tuberculous bronchial dilation, and the lesions are mostly located in the upper lobe bronchus, with good bronchial drainage.

　　6. Repeated infections can cause systemic toxic symptoms, such as intermittent fever, fatigue, loss of appetite, and anemia. In severe cases, shortness of breath and cyanosis may occur.

　　5. Early and mild bronchial dilation may not show obvious signs. When the lesion is severe or secondary infection occurs, the lesion site may show dullness on percussion and fixed moist rales, sometimes wheezing sounds may be heard, and patients with a large amount of sputum may have clubbing (toes).

　　China has taken a series of public health measures to prevent diseases such as elderly bronchial dilation and promote people's health.

　　1. Firstly, carry out health education to improve the immune level of the population, prevent diseases, and organize preventive vaccinations. Eliminate triggering factors; enhance health and disease resistance, pay attention to reasonable nutrition and diet; regularly engage in physical exercise, cultivate good behavior and lifestyle; maintain a good mental state and social adaptability. Environmental protection, adopt protective measures for air, water sources, soil, and food, formulate environmental protection regulations and health standards, create and maintain a natural and social environment conducive to physical and mental health, and reduce pathogenic factors.

　　2. Secondly, it is necessary to do a good job in the preclinical stage of prevention, that is, to do early detection, early diagnosis, and early treatment of prevention work before the disease, in order to control the development and deterioration of the disease, prevent the recurrence or transformation of the disease into chronic, and regular health checks should be carried out for early detection and diagnosis. For example, the preventive vaccination of vaccines such as measles, pertussis, and BCG. For tuberculosis patients, isolation and early treatment should be carried out as soon as possible, and the reasonable use of antibiotics should be guided by doctors. The treatment of chronic para-nasal sinusitis and tonsillitis, attention should be paid to prevent foreign bodies from being inhaled into the trachea, and once found, they should be removed immediately through fiberoptic bronchoscopy.

　　3. Prevention and treatment of bronchitis. For patients already suffering from the disease, prevent or reduce the occurrence of respiratory tract infections, maintain the patency of the respiratory tract and the drainage of sputum, and use antibiotics reasonably. For those with localized lesions and poor therapeutic effects from repeated hemoptysis, surgical resection should be performed.

　　4. Risk factors and intervention measures: Physiologically, with the increase of age, the organ function of the elderly gradually decreases, and the regulatory mechanism of the body decreases. In terms of respiratory physiology, it is manifested in the weakening of defense reflexes, such as cough reflex, the decline of cell-mediated immunity, the weakening of bronchial cilia movement, thereby increasing the opportunity of respiratory tract infections. The elasticity of the chest and lungs decreases, leading to the weakening of elastic recoil of the chest and lungs, the atrophy of peripheral lung alveoli, the increase of anatomical shunt, the imbalance of ventilation and perfusion ratio, the increase of airway resistance, and the uneven distribution of gas. The fibrosis of the elderly lung tissue, the reduction of capillary bed, and the decrease of diffusion volume all lead to the decline of respiratory function, body hypoxia, and the decline of defense function. Psychologically, in the later years, due to the influence of factors such as changes in family and social environment, various behavioral disorders may occur, such as loneliness, suspicion, inferiority, depression, and emotional instability.

　　5. Establish a caring and safeguarding organization for the whole society, and implement comprehensive care, not limited to diseases, but also considering the influence of factors such as material, spiritual, and social natural environment, including the whole of the elderly's happy life. This includes organizing various physical and mental health-related cultural and sports activities, mutual assistance activities, etc.

　　6. Community Intervention: Firstly, establish and improve the elderly health records and systematic management. According to the differences in the health status and quality of life of the elderly in the community, and the different service needs, conduct investigations, and scientifically analyze and evaluate the information obtained from the investigations. On this basis, establish elderly health records. At the same time, through the registration and record-keeping of the elderly in the community, health checks, and according to their different self-care abilities and age-related illness conditions, provide different medical and health care supervision. Implement a graded systematic management and provide a series of continuous health care measures from health education, psychological counseling, to inpatient and outpatient treatment, and daily life care. At the same time, establish and improve the elderly social health care network. The systematic management of elderly in the community requires the support and cooperation of all departments of the society. The community doctor should take the main responsibility and needs to work closely with health and non-health departments in the community to establish and improve the elderly community health care network. In addition to the health department, at all levels from the central to the local governments, establish elderly work offices to coordinate and support elderly health care work.

　　Older patients with bronchiectasis can be diagnosed through the following examinations.

　　1. Chest X-ray
　　It is not a specific examination method for bronchiectasis. Bronchiectasis is caused by chronic inflammation of the bronchial wall, leading to thickening of the wall and proliferation of surrounding connective tissue, which is manifested as increased, thickened, and disordered texture in the lesion area. If there is secretory retention in the dilated bronchi, it will appear as a columnar thickening. Severe cystic bronchiectasis can be seen as a spiral shadow along the bronchus on the plain film, and short liquid levels can be seen in the spiral shadow in case of secondary infection. Due to the bronchiectasis often accompanied by interstitial inflammation, there are also reticular changes at the same time as the increase in pulmonary texture. Generally, there are no obvious abnormalities or specificity in the chest radiographs of patients with bronchiectasis.

　　2. Bronchial iodine oil造影
　　It can determine the severity, location, extent, and type of bronchiectasis, which is the most important basis for diagnosing bronchiectasis, and has a definite significance for whether surgery can be performed and the extent of resection. To ensure satisfactory bronchography and prevent complications, good anesthesia is required during bronchography to ensure that the patient can cooperate well. Children under 10 years old are not easy to cooperate, so this examination is not suitable for them.

　　3. CT scan
　　In recent years, high-resolution CT applied in clinical practice can accurately diagnose bronchiectasis and has a tendency to replace bronchography. Pulmonary CT is suitable for patients who are not suitable for bronchography and have typical clinical symptoms. CT examination can provide information on whether there is a lesion and the extent of the lesion for patients suspected of having bilateral bronchiectasis.

　　Patients should pay attention to taking light and easily digestible foods in their diet, and it is advisable to eat more fresh vegetables and fruits, especially recommended to eat more foods such as white fruit, lily, white radish, and lotus root slices; at the same time, avoid eating spicy and irritating foods; avoid smoking, drinking, and drinking strong tea.

　　The treatment principle of bronchodilation is to remove the cause, promote sputum excretion, control infection, and perform surgery to remove the lesion if necessary.

　　First, maintain the patency of the respiratory tract
　　Postural drainage can exclude sputum accumulation, reduce secondary infection, and alleviate systemic toxic symptoms. For patients with a lot of purulent sputum and poor drainage, its effect is sometimes not inferior to the use of antibiotics. Sputum is diluted with expectorants and bronchodilators and then cleared through postural drainage to reduce secondary infection and alleviate systemic toxic symptoms.

　　1. Expectorants:Ammonium chloride 0.3 to 0.6g, bromhexine 8 to 16mg, 3 times a day, taken orally. Trypsin 5mg or normal saline for ultrasonic nebulization inhalation. It makes sputum thin and facilitates its excretion. Some patients may experience bronchospasm and spasm due to increased bronchial reactivity or inflammation stimulation, which can affect the excretion of sputum. Therefore, theophylline preparations can be taken, and bronchodilators such as β2 receptor agonists can be added if necessary.

　　2. Positional drainage:Different positions should be taken according to the location of the lesion, taking the high position of the affected bronchus, so that the opening of the draining bronchus is downward, which is conducive to the excretion of sputum. 2-3 times a day, about 15 minutes each time. If the position drainage is still difficult to expel, fiberoptic bronchoscopy can be used to aspirate sputum, and normal saline can be used to rinse and dilute the sputum before aspiration. If necessary, 1:1000 epinephrine can be instilled into the bronchial mucosa to reduce edema, reduce obstruction, and facilitate the excretion of sputum. Antibiotics can also be locally instilled.

　　II. Infection Control
　　It is the main treatment measure for the acute infectious stage of bronchiectasis. Antibiotics should be selected according to symptoms, signs, sputum color, and bacterial culture results. The dosage of antibiotics should be determined according to the severity of the disease, and whether combined medication is needed. At the same time, attention should be paid to fungal and anaerobic infections. Mild cases can be treated with oral amoxicillin 0.5g or cefahydroxam 0.5g, 4 times a day; fluoroquinolones such as levofloxacin 0.2g, 3 times a day. Severe patients often require parenteral combined medication, and penicillin and third-generation cephalosporins can have synergistic effects with aminoglycosides. If there is an anaerobic infection, metronidazole or tinidazole can be added. Antibiotics can also be locally applied, such as adding antibiotics to nebulized inhalation solutions or instilling antibiotics locally through a fiberoptic bronchoscope.

　　III. Surgical Treatment
　　For patients with recurrent respiratory tract infections or massive hemoptysis, if the lesion is localized to a lobe or a side of the lung tissue, and the disease cannot be controlled with medication, the patient's overall condition is good, there is no dysfunction of important organs, and lung resection or segmental resection can be performed according to the extent of the lesion.

　　IV. Interventional Treatment
　　It is a new treatment method with the advantages of minimal trauma and rapid recovery, which can find the bleeding focus through selective bronchial artery angiography and give local arterial embolism.

　　V. Optimal Treatment Plan
　　The main treatment for bronchiectasis is conservative medical treatment, with a small amount of repeated and massive hemoptysis, the focus is localized, and surgery or interventional treatment should be performed if medical treatment is ineffective.