Silicosis patients generally have no symptoms or early symptoms are not obvious. With the development of the disease, the symptoms are aggravated, mainly as follows:
According to dust concentration, silica dust content and dust exposure years, it can be divided into three clinical types: chronic silicosis, acute silicosis and accelerated silicosis between them (Table 1).
At the initial stage of onset, silicosis patients often have no symptoms or symptoms are not obvious. Even if there are obvious signs on chest X-rays, they can still have no symptoms. Only in regular physical examination or chest radiography for other reasons can we find that there are typical silicon nodules in the lungs, even reaching the changes of secondary silicosis. With the progress of diseases or complications, different degrees of symptoms may appear, and the severity of symptoms is often not completely parallel to the degree of lung lesions.
(1) Dyspnea: Dyspnea develops gradually, especially after exercise. At first, the patient feels poor breathing or chest pressure, which appears when exerting force, and then appears when exerting force slightly. There are few similar symptoms at rest, which are mostly caused by pulmonary fibrosis, especially complicated with emphysema, and can also be caused by complicated infection. The existence and severity of shortness of breath are not necessarily parallel to the degree of lung function damage and X-ray manifestations. Patients with terminal dyspnea will be extremely serious, even when resting, they will feel short of breath and can't lie flat.
(2) Cough and expectoration: Those who have a history of smoking may be accompanied by symptoms of bronchitis such as cough and expectoration. Cough mainly occurs in the morning, sometimes intermittently day and night, and there are often persistent bouts of cough in the later period, which may be caused by silicon nodules stimulating nerve receptors in trachea and bronchus. No phlegm, or only a small amount of sticky phlegm, secondary infection can appear purulent sputum, cough can be aggravated. Simple silicosis hemoptysis is rare. Generally, there is no wheezing, unless there is chronic bronchitis or allergic asthma, but some patients are fixed because of tracheal stenosis, distortion and fibrosis, especially in advanced patients or when breathing is difficult.
(3) Hemoptysis: occasional hemoptysis, usually with bloodshot sputum, complicated with tuberculosis, bronchiectasis, repeated hemoptysis or even massive hemoptysis.
(4) Chest tightness and chest pain: Most of them are pinprick-like pain in the middle and upper part of the chest, or persistent dull pain, which mostly occurs in rainy days or climate change, and has nothing to do with breathing, exercise and body position.
(5) General damage: not obvious, unless complicated with pulmonary tuberculosis or congestive heart failure. Those who are short 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 There are no signs in the early stage of silicosis, and signs of chronic obstructive pulmonary disease may appear in patients in the late stage, such as bucket chest, clear sound of percussion, prolonged auscultation breathing sound, and weakened breathing sound. And both lungs can hear dry and wet sounds when combined with infection? A series of corresponding signs can be seen in patients with pulmonary heart disease and heart failure in the late stage.
Two. diagnose
The diagnosis should be based on: ① dust exposure history, including free silica content in raw materials and finished products, dust concentration in production environment, dust particle size, production operation methods and protective measures (including personal protection); ② The patient's detailed occupational history and past health status; ③ Clinical symptoms, signs and X-ray examination; (4) Past and present incidence of workers of the same type of work.
(a) X-ray diagnosis of silicosis, in addition to the above basis, mainly based on X-ray chest film performance. In China, the diagnostic criteria and treatment principles of pneumoconiosis were published in February, 1986. X-ray diagnostic criteria for pneumoconiosis are applicable to all kinds of pneumoconiosis legally prescribed by the state, and the specific criteria are as follows:
1, no pneumoconiosis (code 0)
X-ray manifestations of (1)0 pneumoconiosis.
(2) The X-ray findings are not enough to diagnose me.
2. Primary pneumoconiosis (code I) (see figure 12-3).
(1)I There are small circular shadows with the density of 1, which are distributed in at least one lung area, each with a diameter of not less than 2cm or irregular small shadows with the density of 1, and the distribution range is not less than two lung areas.
(2) The number of I+small shadows has obviously increased, but the density and distribution range of one of them is not enough to be classified as "II".
3. Secondary pneumoconiosis (code Ⅱ) (see figure 124).
(1) Ⅱ has round or irregular small shadows with density of grade 2, which are distributed in four lung areas; Or there are small shadows with a density of 3, and the distribution range reaches four lung areas.
(2) Ⅱ+has a small shadow, the density is grade 3, and the distribution range exceeds four lung areas; Or there is a big shadow that is not enough for "ⅲ".
4. Stage III pneumoconiosis (code III) (see figure 125).
ⅲ has a big shadow, its long diameter is not less than 2cm and its wide diameter is not less than 1cm.
ⅲ+The sum of single large shadow area or multiple large shadow areas exceeds the right upper lung area.
When using the above standards, we should follow the following concepts:
(1) lung field division method: divide the vertical distance from the apex of lung into three parts, and divide each lung field into upper, middle and lower parts with equal horizontal lines.
(2) Small shadow: refers to the shadow whose diameter or width does not exceed 1cm. It can be divided into two types: ① quasi-circular (R) with circular or nearly circular shape and regular or irregular edges; (2) Irregular shape (IR) refers to a group of dense shadows with different thickness, length and shape. They can be disconnected from each other, or they can be intertwined in disorder, in a network and sometimes in a honeycomb shape. According to the size or thickness, these two kinds of small shadows can be called P (diameter about 1.5mm or less), Q (diameter about 1.5 ~ 3 mm) and R (diameter 3 ~ 10 mm). Irregular shapes are called S (width about 1.5mm or less), T (width about 1.5 ~ 3 mm) and U (width about 3 ~ 10 mm) respectively.
(3) Small shadow density: refers to the number of small shadows in a certain range, which can be divided into three grades:
Density of small quasi-circular shadows:
1 positive, a certain amount of quasi-circular small shadows. The lung texture is clearly visible (if it is P, there are about 10 up and down within 2cm in diameter).
Grade 2 has a large number of quasi-circular shadows, and the lung texture is generally recognizable.
At grade 3, there were a lot of small round shadows, and the lung texture disappeared partially or completely.
Irregular small shadow density:
There are many small irregular shadows at grade 1, and the lung texture is generally recognizable.
2-level multi-quantity irregular small shadows. Lung markings usually partially disappear.
There are a lot of irregular small shadows in the third grade, and the lung texture generally disappears completely.
The density and range determination method should comprehensively determine the density of all small shadows in each lung area: 1. Determine that the small shadow in the lung area accounts for two-thirds of the area; 2. The distribution range is the number of lung areas with small shadows; 3. The density of most lung areas is the main criterion; 4. Take the higher horizontal density with the distribution range not less than two lung areas as the main standard.
(4) Large shadow: refers to the shadow with the maximum diameter of 1cm. The big shadow that is not defined as "ⅲ" refers to: ① Small shadows gather and have not yet formed a uniform and dense block shadow; ② The mass shadow did not reach 2 cm×1cm; (3) There are "patches" or "whitish areas".
(5) Pleural changes (including thickening, adhesion and calcification), pneumoconiosis complications or other diseases (such as rheumatoid pneumoconiosis) were recorded with corresponding codes.
(6) About each period (+) In order to facilitate the dynamic observation of diseases, 0+, I+, II+ and III+ are added in each period, which is not independent staging.
For silicosis, when exposed to dust with high silicon content and concentration, circular and quasi-circular shadows usually appear first in the middle zone of the middle and lower fields of both lungs and gradually expand upward; There are also those that first appeared in the two upper lungs. When the silicon content is low or mixed dust is inhaled, the quasi-circular shadow (so-called mesh shadow) is the main one. The big shadow of silicosis is the increase, density and final fusion of local shadows, which is common in the upper field of both lungs. The outline is clear, and the lungs are symmetrical in a "wing" shape or a figure of eight. The fusion block contracts inward and upward, causing the hilum to be pulled and displaced. The hilar shadow often increases, the density increases, and sometimes there is "eggshell calcification" of lymph nodes, which is caused by calcium deposition under the capsule of lymph nodes. Lung markings increased and thickened.
(2) Laboratory examination of silicosis has no special significance. Serum proteins such as hexose, hexosamine, mucin, immunoglobulin, ceruloplasmin and urinary hydroxyproline tend to increase, but most of them are nonspecific, and their normal range fluctuates greatly, so their clinical value is not great.
(3) Measurement of lung function Because the compensatory function of lung tissue is very strong, the damage of lung function in early patients is not obvious. With the increase of lung fibrous tissue and the decrease of elasticity, vital capacity decreases. With the progress of the disease, the forced expiratory volume and maximal ventilation in one second also decreased, while the residual volume and its proportion in the total lung volume increased. The more serious emphysema is, the more obvious these changes will be, which will cause diffuse sexual dysfunction. At rest, arterial oxygen partial pressure can be reduced to varying degrees. The determination of lung function is of little significance in diagnosis, but it can be used as the basis for the identification of labor ability of silicosis patients.