1. Clinical manifestations
Patients with silicosis are generally asymptomatic or have subtle symptoms in the early stages. As the disease develops, symptoms increase. The main manifestations are as follows:
According to the dust concentration, silica dust content and years of dust exposure, it is divided into three clinical types: chronic silicosis, acute silicosis and accelerated silicosis in between (Table 1).
Patients with silicosis are often asymptomatic or have subtle symptoms in the early stages of the disease. Even if there are obvious signs on chest Only then was it discovered that the lungs had typical silicous nodule changes, and had even reached stage II silicosis. As the disease progresses or there are comorbidities, symptoms of varying degrees may appear, and the severity of the symptoms is often not completely parallel to the extent of the lesions in the lungs.
(1) Dyspnea: Dyspnea that gradually develops slowly and worsens after activity. First, the patient feels shortness of breath or chest pressure, which occurs when exerting force, and then appears when exerting slight force. Similar symptoms are rarely seen at rest. This is mostly due to pulmonary fibrosis, especially combined with emphysema, or due to combined Caused by infection. The presence and severity of shortness of breath do not necessarily parallel the degree of lung function impairment and X-ray findings. Patients in the advanced stage may have extremely severe dyspnea. They may feel short of breath during slight activities or even at rest, and cannot lie down.
(2) Cough and sputum: People with a history of smoking may be accompanied by bronchitis symptoms such as cough and sputum. The cough mainly occurs in the morning and sometimes occurs day and night. In the later stage, there is often persistent coughing. , may be caused by stimulation of nerve receptors in the trachea and bronchi by silica nodules. There is no sputum, or only a small amount of sticky sputum. Purulent sputum may appear during secondary infection, making the cough worse. Hemoptysis in simple silicosis is rare. Generally, there is no wheezing unless combined with chronic bronchitis or allergic asthma. However, some patients may experience wheezing due to narrowing, twisting and fixation of the trachea due to fibrosis, especially in advanced patients or when breathing hard.
(3) Hemoptysis: Hemoptysis occurs occasionally, usually with blood streaks in the sputum. When combined with tuberculosis and bronchiectasis, there may be repeated hemoptysis or even massive hemoptysis.
(4) Chest tightness and chest pain: mostly acupuncture-like pain in the middle and upper part of the chest, or persistent dull pain, which often occurs on rainy days or during climate changes and has nothing to do with breathing, movement, or posture.
(5) Systemic damage: Not obvious, unless combined with tuberculosis or congestive heart failure. Those who have shortness of breath at rest should be suspected of having severe emphysema or extrapulmonary diseases. In addition to respiratory symptoms, patients with advanced silicosis often have symptoms such as loss of appetite, physical weakness, weight loss, and night sweats.
2. Signs: In the early stage of silicosis, there are usually no signs. In the late stage, patients may have signs of chronic obstructive pulmonary disease: such as barrel chest, excessive voicelessness on percussion, prolonged expiratory sounds on auscultation, weakened breath sounds, etc., combined During infection, dry and wet sounds can be heard in both lungs, and a series of corresponding signs can be seen in the late stage when combined with pulmonary heart disease and heart failure.
2. Diagnosis
Diagnosis should be based on: ① Dust exposure history, including free silica content in raw materials and finished products, dust concentration in the production environment, dust particle size, and production operation methods and protective measures (including personal protection); ② the patient’s detailed occupational history and past health conditions; ③ clinical symptoms, physical signs and X-ray examination; ④ past and current illnesses of workers in the same type of work.
(1) X-ray examination The current diagnosis of silicosis, in addition to the above-mentioned basis, is mainly based on the X-ray chest X-ray performance. In December 1986, my country promulgated the "Diagnostic Standards and Treatment Principles of Pneumoconiosis", among which the X-ray diagnostic standards for pneumoconiosis are applicable to various types of pneumoconiosis mandated by the state. The specific standards are as follows:
1. No pneumoconiosis ( Code 0)
(1)0 No X-ray manifestations of pneumoconiosis.
(2)X-ray findings are not enough to diagnose as "I".
2. Stage I pneumoconiosis (code I) (see Figure 12-3).
(1) I have round-like small shadows with density level 1, distributed in at least one place in each of the two lung areas, and the diameter of each place is not less than 2cm; or there are shadows with density level 1 Irregular-shaped small shadows, whose distribution range is no less than two lung areas.
(2) There are significantly more I+ small shadows, but one of the density and distribution range is not enough to be classified as "II".
3. Stage II pneumoconiosis (code Ⅱ), (see Figure 124)
(1) Ⅱ has quasi-circular or irregular small shadows with density level 2, distributed The range exceeds four lung areas; or there are small shadows with density level 3, and the distribution range reaches four lung areas.
(2) II+ has small shadows with a density of level 3, and its distribution range exceeds four lung areas; or there are large shadows that are not enough to be classified as "Ⅲ".
4. Stage III pneumoconiosis (code III), (see Figure 125)
III has a large shadow, its long diameter is not less than 2cm, and its wide diameter is not less than 1cm.
Ⅲ+ The area of ??a single large shadow or the sum of the areas of multiple large shadows exceeds the area of ??the right upper lung area.
When using the above standards, the following concepts should be used:
(1) Lung area division method: Divide the vertical distance from the lung apex to the top of the diaphragm into three equal parts, and use equal The horizontal line of dividing points divides the lung field on each side into upper, middle and lower regions.
(2) Small shadow: refers to a shadow whose diameter or width does not exceed 1cm.
It can be divided into two types: ① Round (R), which is round or nearly round in shape, with neat or irregular edges; ② Irregular (IR), which refers to a group of dense shapes of different thickness, length, and shape. Shadows, they can be disconnected, or they can be haphazardly intertwined, appearing as a mesh or sometimes a honeycomb. The two types of small shadows can be called p (diameter about 1.5mm or less), q (diameter about 1.5~3mm), r (diameter 3~10mm) according to their size or thickness; the irregular ones are called s (width) About 1.5mm or less), t (width about 1.5~3mm), u (width about 3~10mm).
(3) Small shadow density: refers to the number of small shadows within a certain range, which can be divided into 3 levels:
Density of round-like small shadows:
Level 1 is a certain amount of small round shadows. The lung texture is clearly visible (if it is p, there are about 10 up and down within a diameter of 2cm).
Level 2 has a large number of small round shadows, and the lung texture is generally identifiable.
Level 3: A large number of small round shadows, and the lung texture is partially or completely disappeared.
Intensity of small irregular shadows:
A considerable amount of small irregular shadows at level 1, and the lung texture is generally identifiable.
Level 2, a large number of small irregular shadows. The lung markings are often partially lost.
Level 3 has a large number of irregular small shadows, and the lung texture usually disappears.
The density and range determination method requires a comprehensive determination of the density of all small shadows appearing in each lung area: 1. To determine the lung area, small shadows require two-thirds of the area; 2. The distribution range is the number of lung areas with small shadows; 3. The main judgment basis is the density in most lung areas; 4. The main judgment basis is the higher-level density with a distribution range of no less than two lung areas.
(4) Large shadow: refers to a shadow with a longest diameter of more than 1cm. Large shadows that are not enough to be classified as "Ⅲ" refer to: ① Small shadows gather and have not yet formed a uniform and dense block shadow; ② The block shadow does not reach 2cm × 1cm; ③ "Patch strips" or "white areas" appear.
(5) Pleural changes (including thickening, adhesion, calcification), pneumoconiosis complications or other diseases (such as rheumatoid pneumoconiosis) will be recorded with corresponding codes.
(6) Regarding each stage (+), in order to facilitate the dynamic observation of the disease, , Ⅰ+, Ⅱ+, Ⅲ+ are added in each stage, which is not an independent stage.
For silicosis, when exposed to dust with high silica content and high concentration, round and quasi-round shadows often appear, which first appear in the inner and middle zones of the middle and lower fields of both lungs, and gradually Expands upward; some also appear first in the two upper lungs. When the silicon content is low or mixed dust is inhaled, round shadows are the main ones (the so-called mesh shadows). The large shadow of silicosis is a local shadow that increases, becomes dense, and finally merges. It is common in the upper outdoor zone of both lungs. It has a clear outline and the two lungs are symmetrical and have a "wing-like" or figure-eight shape. The fusion mass shrinks inward and upward, pulling and displacing the hilum. The hilar shadows often become enlarged and dense, and sometimes "eggshell-like calcification" of lymph nodes appears, which is caused by calcium deposition under the lymph node capsule. The lung texture increases and thickens.
(2) Laboratory examination Routine examination of silicosis has no special significance. Serum protein hexoses, aminohexoses, mucins, immunoglobulins, ceruloplasmin, and urinary hydroxyproline often tend to increase, but most of them are non-specific, and the normal range fluctuates greatly, so their clinical value is not great.
(3) Pulmonary function measurement Because the lung tissue has a strong compensatory function, the lung function damage in early patients is not obvious. As lung fibrous tissue increases and elasticity decreases, lung capacity decreases. As the disease progresses, forced expiratory volume in one second and maximum ventilation also decrease, while residual volume and its ratio to total lung volume increase. The more severe the emphysema, the more obvious these changes are and cause diffusion dysfunction. The partial pressure of oxygen in arterial blood at rest can be reduced to varying degrees. Pulmonary function measurement is of little diagnostic significance, but it can be used as a basis for identification of the working ability of silicosis patients.