Emphysema

Definition

Emphysema is a chronic respiratory disease where there is over-inflation of the air sacs (alveoli) in the lungs, causing a decrease in lung function, and often, breathlessness.

Description

Emphysema is the most common cause of death from respiratory disease in the United States, and is the fourth most common cause of death overall. There are 1.8 million Americans with the disease, which ranks fifteenth among chronic conditions that cause limitations of activity. The disease is usually caused by smoking, but a small number of cases are caused by an inherited defect.

Normally functioning lungs are elastic, efficiently expanding and recoiling as air passes freely through the bronchus to the alveoli, where oxygen is moved into the blood and carbon dioxide is filtered out. When a person inhales cigarette smoke or certain other irritants, his or her immune system responds by releasing substances that are meant to defend the lungs against the smoke. These substances can also attack the cells of the lungs, but the body normally inhibits such action with the release of other substances. In smokers and those with the inherited defect, however, no such prevention occurs and the lung tissue is damaged in such a way that it loses its elasticity. The small passageways (bronchioles) leading to the alveoli collapse, trapping air within the alveoli. The alveoli, unable to recoil efficiently and move the air out, over expand and rupture. As the disease progresses, coughing and shortness of breath occur. In the later stages, the lungs cannot supply enough oxygen to the blood. Emphysema often occurs with other respiratory diseases, particularly chronic bronchitis. These two diseases are often referred to as one disorder called chronic obstructive pulmonary disease (COPD).

Emphysema is most common among people aged 50 and older. Those with inherited emphysema may experience the onset as early as their thirties or forties. Men are more likely than women to develop emphysema, but female cases are increasing as the number of female smokers rises.

Causes and symptoms

Heavy cigarette smoking causes about 80-90% of all emphysema cases. However a few cases are the result of an inherited deficiency of a substance called alpha-1-antitrypsin (AAT). The number of Americans with this deficiency is relatively small, probably no greater than 70,000. Pipe, cigar, and marijuana smoking can also damage the lungs. While a person may be less likely to inhale cigar and pipe smoke, these types of smoke can also impair lung function. Marijuana smoke may be even more damaging because it is inhaled deeply and held in by the smoker.

The symptoms of emphysema develop gradually over many years. It is a common occurrence for many emphysema patients to have lost over half of their functioning lung tissue before they become aware that something is wrong. Shortness of breath, a chronic mild cough (which may be productive of large amounts of dark, thick sputum, and often dismissed as "smoker's cough"), and sometimes weight loss are associated with emphysema. Initially, a patient may only notice shortness of breath when he or she is exercising. However, as the disease progresses, it will occur with less exertion or no exertion at all. Emphysema patients may also develop an enlarged, or "barrel,", chest. Other symptoms may be skipped breaths, difficulty sleeping, morning headaches, increased difficulty breathing while lying down, chronic fatigue, and swelling of the feet, ankles, or legs. Those with emphysema are at risk for a variety of other complications resulting from weakened lung function, including pneumonia.

Diagnosis

A variety of pulmonary function tests may be ordered. In the early stages of emphysema, the only result may be dysfunction of the small airways. Patients with emphysema may show an increase in the total amount of air that is in the lungs (total lung capacity), but a decrease in the amount of air that can be breathed out after taking a deep breath (vital capacity). With severe emphysema, vital capacity is substantially below normal. Spirometry, a procedure that measures air flow and lung volume, helps in the diagnosis of emphysema.

A chest x ray is often ordered to aid in the diagnosis of emphysema, though patients in the early stages of the disease may have normal findings. Abnormal findings on the chest x ray include over-inflation of the lungs and an abnormally increased chest diameter. The diaphragm may appear depressed or flattened. In addition, patients with advanced emphysema may show a smaller or vertical heart. The physician may observe blisters in the lungs and bulging of the accessory muscles of the respiratory system. Late in the disease, an EKG will show signs of right ventricular failure in the heart and increased hemoglobin due to lower levels of oxygen in the patient's blood.

Treatment

Treatment methods for emphysema do not cure or reverse the damage to the lungs. However, they may slow the progression of the disease, relieve symptoms, and help control possibly fatal complications. The first step in treatment for smokers is to quit, so as to prevent any further deterioration of breathing ability. Smoking cessation programs may be effective. Consistent encouragement along with the help of health care professionals as well as family and friends can help increase the success rate of someone attempting to quit.

If the patient and the health care team develop and maintain a complete program of respiratory care, disability can be decreased, acute episodes of illness may be prevented, and the number of hospitalizations reduced. However, only quitting smoking has been shown to slow down the progression of the disease, and among all other treatments, only oxygen therapy has shown an increase in the survival rate.

Home oxygen therapy may improve the survival times in those patients with advanced emphysema who also have low blood oxygen levels. It may improve the patient's tolerance of exercise, as well as improve their performance in certain aspects of brain function and muscle coordination. The functioning of the heart may also improve with an increased concentration of oxygen in the blood. Oxygen may also decrease insomnia and headaches. Some patients may only receive oxygen at night, but studies have illustrated that it is most effective when administered at least 18, but preferably 24 hours per day. Portable oxygen tanks prescribed to patients carry a limited supply and must be refilled on a regular basis by a home health provider. Medicare and most insurance companies cover a large proportion of the cost of home oxygen therapy. Patients should be instructed regarding special safety issues involving the transport and presence of oxygen in the home.

A variety of medications may be used in the treatment of emphysema. Usually the patient responds best to a combination of medicines, rather than one single drug.

Bronchodilators are sometimes used to help alleviate the patient's symptoms by relaxing and opening the airways. They can be inhaled, taken by mouth, or injected. Another category of medication often used is corticosteroids or steroids. These help to decrease the inflammation of the airway walls. They are occasionally used if bronchodilators are ineffective in preventing airway obstruction. Some patients' lung function improves with corticosteroids, and inhaled steroids may be beneficial to patients with few side effects. A variety of antibiotics are frequently given at the first sign of a respiratory infection, such as increased amounts of sputum, or if there has been a change in the color of the sputum. Expectorants can help to loosen respiratory secretions, enabling the patient to more easily expel them from the airways.

Many of the medications prescribed involve the use of a metered dose inhaler (MDI) that may require special instruction to be used correctly. MDIs are a convenient and safe method of delivering medication to the lungs. However, if they are used incorrectly the medication will not get to the right place. Proper technique is essential for the medication to be effective.

For some patients, surgical treatment may be the best option. Lung volume reduction surgery is a surgical procedure in which the most diseased parts of the lung are removed to enable the remaining lung and breathing muscles to work more efficiently. Preliminary studies suggest improved survival rates and better functioning with the surgery. Another surgical procedure used for emphysema patients is lung transplantation. Transplantation may involve one or both lungs. However, it is a risky and expensive procedure, and donor organs may not be available.

For those patients with advanced emphysema, keeping the air passages reasonably clear of secretions can prove difficult. Some common methods for mobilizing and removing secretions include:

• Postural drainage. This helps to remove secretions from the airways. The patient lies in a position that allows gravity to aid in draining different parts of the lung. This is often done after the patient inhales an aerosol medication. The basic position involves the patient lying on the bed with his chest and head over the side and the forearms resting on the floor.
• Chest percussion. This technique involves lightly clapping the back and chest, and may help to loosen thick secretions.
• Coughing and deep breathing. These techniques may aid the patient in bringing up secretions.
• Aerosol treatments. These treatments may involve solutions of saline, often mixed with a bronchodilator, which are then inhaled as an aerosol. The aerosols thin and loosen secretions. A treatment normally takes 10 to 15 minutes, and is given three or four times a day.

Patients with COPD can learn to perform a variety of self-help measures that may help improve their symptoms and their ability to participate in everyday activities. These measures include:

• Avoiding any exposure to dusts and fumes.
• Avoiding air pollution, including the cigarette smoke of others.
• Avoiding other people who have infections like the cold or flu. Get a pneumonia vaccination and a yearly flu shot.
• Drinking plenty of fluids. This helps to loosen respiratory secretions so they can be brought up more easily through coughing.
• Avoiding extreme temperatures of heat or cold. Also avoiding high altitudes. (Special precautions can be taken that may enable the emphysema patient to fly on a plane.)
• Maintaining adequate nutritional intake. Normally a high protein diet taken in many small feedings is recommended.

Alternative treatment

Many patients are interested in whether any alternative treatments for emphysema are available. Some practitioners recommend supplements of antioxidant nutrients. There have also been some studies indicating a correlation between a low Vitamin A levels and COPD, with suggestions that supplements of vitamin A might be beneficial. Aromatherapists have used essential oils like eucalyptus, lavender, pine, and rosemary to help relieve nasal congestion and make breathing easier. The herb elecampane may act as an expectorant to help patients clear mucus from the lungs. The patient should discuss these remedies with their health care practitioner prior to trying them, as some may interact with the more traditional treatments that are already being used.

Prognosis

Emphysema is a serious and chronic disease that cannot be reversed. If detected early, the effects and progression can be slowed, particularly if the patient stops smoking immediately. Complications of emphysema include higher risks for pneumonia and acute bronchitis. Overall, the prognosis for patients with emphysema is poor, with a survival rate for all those with COPD of four years, and even less for emphysema. However, individual cases vary and many patients can live much longer with supplemental oxygen and other treatment measures.

Prevention

The best way to prevent emphysema is to avoid smoking. Even patients with inherited emphysema should avoid smoking, as it especially worsens the onset and severity. If patients quit smoking as soon as evidence of small airway obstruction begins, they can significantly improve their prognosis.

KEY TERMS

Alveoli— Small cells or cavities. In the lungs, these are air sacs where oxygen enters the blood and carbon dioxide is filtered out.

Pulmonary— Related to or associated with the lungs.

Resources

BOOKS

Beers, Mark H., and Robert Berkow, editors. The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck and Company, Inc., 2004.

PERIODICALS

"Data Mounting on Merits of Lung Volume ReductionSurgery." Family Practice News February 15, 2001: 5.

Lewis, Laurie. "Optimal Treatment for COPD." PatientCare May 30, 2000: 60.

ORGANIZATIONS

American Lung Association. 1740 Broadway New York, NY 10019. (212) 315-8700. 〈http://www.lungusa.org〉.

National Emphysema Foundation. 15 Stevens St. Norwalk, CT 06856. 〈http://www.emphysemafoundation.org〉.

National Heart, Lung and Blood Institute. 〈http://www.nhlbi.nih.gov〉.

Emphysema

Definition

Emphysema is a progressive, incurable chronic lung condition. The air sacs (alveoli) are destroyed and oxygen uptake is restricted due to the loss of elasticity of lung tissue.

Description

As of 1998 there were an estimated two million people suffering from emphysema in America. Between three and five percent were attributed to genetic factors, the remainder being a result of environmental pollution, with smoking ranking far and away as the main cause.

Normally functioning lungs are elastic, and efficiently expand and recoil as air passes freely through their passageways (bronchus) to the alveoli, where oxygen is moved into the blood and carbon dioxide is filtered out. When a person inhales cigarette smoke or airborne pollutants, his or her immune system responds by releasing substances that are meant to defend the lungs against the smoke. These substances can also attack the cells of the lungs, but the body normally inhibits such action with the release of other substances.

When individuals are exposed to pollution over a long period of time the lung tissue is damaged in such a way that it loses its elasticity. When damage has occurred to the alveoli, sufferers have difficulty making a complete exhalation, which causes residual volume—air trapped inside the lungs. With the passage of time, this causes the chest to permanently expand and become barrel shaped. As the disease progresses, increasingly more effort is needed to breathe. Emphysema frequently occurs with one or more other respiratory diseases, such as bronchitis and asthma . It is one of the diseases that are collectively referred to as chronic obstructive pulmonary disease (COPD). As a cause of death, it ranks fourth after heart disease, cancer and stroke .

Causes & symptoms

People who smoke or live in polluted atmospheres are possible candidates for emphysema. People with a genetic defect (alpha 1-antitrypsin deficiency) are also at risk. The early stages of emphysema may go undiagnosed, but the main symptoms are breathlessness, blueness of the lips and fingernails, and exhaustion. Sufferers of chronic bronchitis and asthma are also at risk. People who develop emphysema as a result of their work often develop asthma prior to symptoms of their condition.

Emphysema is traditionally a disease suffered by miners, particularly coal miners, as the fine dust that results from mining attacks the alveoli over a period of time. Most miners suffer from emphysema to some degree after a lifetime "down in the pit." In fact, emphysema is sometimes referred to as miner's lung or black lung.

The situation has somewhat improved in recent years due to awareness of the causes of emphysema and improved work conditions for many workers. Others who may be at risk for emphysema include sand blasters, metal grinders, anyone whose job exposes him or her to silica (silicosis), asbestos (asbestososis), or iron filings (siderosis). In addition, dust from wood, cotton, talc, cereal grains coffee, pesticides, drug or enzyme powders, or fiberglass may cause emphysema. People who use their lungs in their work are also susceptible (such as trumpet players and glass blowers). Any worker who is exposed to abnormal levels of dust, fumes, smoke, gases, vapors, or mists over a long period of time may be at risk for emphysema.

Sufferers typically complain that they "can't get enough air" as stale air builds up inside the lungs and the patient becomes starved of oxygen. Coughing, wheezing, and chronic mucous production are other common symptoms.

Diagnosis

A diagnosis of emphysema will not be made on the basis of the above symptoms alone. A detailed medical history will be taken along with x rays and pathology examinations. Peak flow tests will also be conducted.

Treatment

Damage to the lungs as a result of emphysema cannot be reversed, so preventative measures to limit its progression

are essential. The following measures and treatments are regarded as beneficial for emphysema sufferers.

Herbalism

Herbs can be beneficial in relieving the symptoms of emphysema, helping the body to ward off infection, and easing the asthmatic symptoms that often accompany emphysema.

Some of them are:

• Lobelia: This is a mild sedative, also having strong expectorant properties. It is widely used for chest complaints, including emphysema and bronchitis, and can help to cut an asthma attack short.
• Thyme : A tea made with thyme is recommended for overcoming shortness of breath. It is also a powerful antiseptic.
• Mullein: This is another traditional remedy for chest complaints. Boil two tablespoons of the dried leaves with a glass of milk and drink.
• Echinacea : Echinacea is a powerful immune system stimulant and will strengthen the body in general, warding off colds and infections .
• Lungwort: A member of the borage family, this herb is very healing for the lungs. It should be taken as an infusion.
• Black cohosh: This herb is an expectorant and astringent. It relieves coughing.
• Sage: This is one of the most useful of all herbs and is said to be good for whatever it is taken for. It is antiviral and bactericidal.
• Garlic : A very powerful anti-viral, garlic can be of real help to those trying to avoid infections and lung congestion.

Chinese herbal medicine

Qing Qi Hua Tan Wan (Pinellia expectorant pills) are the Chinese herbalists' treatment for chronic lung complaints, particularly bronchitis and asthma.

Juices for emphysema

Herbalist Kitty Campion recommends the following juices for the treatment of emphysema: equal parts of carrot juice, parsnip juice, watercress juice and potato juice, or equal parts of orange juice and lemon juice, diluted half and half with a strong decoction of rosehip tea.

Aromatherapy

Aromatherapy involves massaging the patient with potent plant essential oils , which have been proven to enter the circulation through the skin. The constituents of the oils can have a powerful effect on a variety of illnesses, but since their beneficial qualities are also transported through the air, they are considered to be doubly beneficial to those who suffer from respiratory ailments.

Aromatherapy oils for respiratory disease:

• Canada balsam may alleviate respiratory symptoms and is an expectorant. It is also a bactericide and recommended for those suffering from chronic chest ailments.
• Tolu balsam is an excellent treatment for chest infections.
• Frankincense is good for infection and catarrhal discharge.
• Niaouli is a very strong antiseptic and beneficial for pulmonary trouble.
• Rose damascena is recommended for bronchial complaints, and also uplifts the spirits.
• Tea tree oil was recently discovered to be one of the most potent anti-viral, anti-bacterial and anti-fungal agents known to medicine. Therefore highly beneficial as a preventative measure against chest infection.

Acupuncture

This ancient Chinese system of holistic treatment works on the principal that illness is the result of blockage in the flow of life force. The practitioner aims to stimulate relevant meridians in the body, and so release trapped life force, returning bodily functions to normal. The treatment is virtually painless.

Treatment can be expected to improve blood circulation and the capacity of the body to restore itself. Research has indicated that acupuncture can produce changes in the electrical fields of body cells, promoting a return to the body's normal state. Consequently, few negative side effects are associated with acupuncture treatment.

Breathing techniques

Very few people actually breathe correctly, and if lung function is not up to par, the difference between breathing fully and taking shallow ineffective, breaths can make a remarkable difference in the way a person feels and the way his or her body functions. Oxygen shortage in the body promotes disease, and ensuring that oxygen levels are kept up can avert disaster, even with the existence of lung-impairment. Improved breathing techniques can rid the body of free radicals, neutralize environmental toxins, and destroy many harmful microbes that cannot exist in an oxygen-rich environment. Without sufficient oxygen, the body cannot fully utilize nutrients from food, and bodily functions generally become less efficient. Every effort must be made to promote proper breathing, in order to offset the effects of reduced lung function.

In cases of emphysema, it is particularly important to ensure that the out-breath expels all of the previous inbreath. When exhalation is incomplete, wastes produced by breathing are not expelled from the body in the normal way, and residual volume, which is a common occurrence with progressive emphysema, may cause chest enlargement.

Homeopathy

Homeopathy is the treatment of illness according to a system of "like cures like" that stimulates the body to heal itself. While it could definitely contribute to the successful treatment of emphysema, Homeopathy requires a qualified practitioner, as the patient's condition must be accurately assessed in order that the correct remedy be prescribed. Even for the same disorder, no two patients will receive the same treatment.

Lifestyle

For lung dysfunction of any kind, it is vital to take steps to ensure that a person's lifestyle is not contributing to the problem. Pollution must be avoided at all costs, and steps should be taken to ensure that the living environment is free of chemical irritants. This may involve avoiding fragrances, as they can overburden damaged lungs. Some unscented products use a masking fragrance which only increases toxicity. Common household products, such as fabric softeners, bleach, scented detergents, and furniture polish, can harm the body and the environment.

It must be noted that pesticides, fungicides, herbicides, and fertilizers are all neurotoxins, (poisonous to the nervous system). Natural alternatives are obtainable for most household cleaning products. Personal care products can also cause damage, so only natural sources should be used. Chlorinated pools should be avoided.

Every effort should be made to obtain food that is organically grown, in order to avoid pesticides and chemicals. Processed foods should be avoided because they often contain chemicals, dyes, and preservatives, and because the food is stripped of most of its nutritional value. Notably, artificial sweeteners, particularly aspartame, break down into deadly poisons in the body.

Clothing should be all natural fibers, as permanent press and wrinkle-resistant clothes have often been treated with formaldehyde which does not wash out. For the same reasons, synthetic fiber bed coverings should also be avoided. All plastic products should be avoided as far as possible as they all have toxic elements. Windows should be open as often as possible to increase oxygen in the atmosphere. Some houseplants should be acquired, as they give off oxygen.

It is also very important to undertake some form of gentle, regular exercise as this can do much to improve symptoms. Suitable forms of exercise may be swimming, walking and gentle rebounding. If an emphysema patient is very weak, he or she could sit on a mini-trampoline while a helper does the strenuous bit; very real benefits will still be obtained in this way. Strenuous activities are not suitable for anyone with lung impairment.

Naturopathy

According to the principles of naturopathy, the body has the power to heal itself. Treatment should focus on providing the system with optimum nutrition so it can carry out all repairs necessary. This involves ensuring that all food that is eaten is of the highest quality.

Naturopaths advocate dietary supplements to assist with this process, and certain dietary supplements can be very valuable in arresting the progress of Emphysema. Trials have been conducted involving treating emphysema patients with vitamin A , which is known to play an important role in healthy body tissue. Vitamin E can also be helpful, and vitamin C should always be taken, as it is a catalyst for other nutrients. For best results, it is advised to consult a practitioner.

Allopathic treatment

Prior to any other treatment, it is essential that emphysema sufferers who smoke take steps to give up the habit. Otherwise, damage to the lungs will continue to go unchecked and other measures will be very limited in their success. Apart from lifestyle changes, physicians generally recommend avoidance of infection, and antibiotics may be prescribed as a preventative measure.

A physician may also prescribe bronchodilator medicines, which are usually prescribed for asthma patients, if there is any obstruction of the airways. For the same reason, anti-inflammatories may also be prescribed.

Chest physiotherapy, breathing exercises, and a program of physical exercise (collectively referred to as pulmonary rehabilitation) are considered beneficial to all emphysema patients, regardless of the degree of impairment. Supplementary oxygen may be required at some stage.

In extreme cases, lung volume reduction surgery may be recommended. If successful, this can eliminate the need for supplemental oxygen and improves breathing function. In this procedure, the damaged parts of the lung are removed in order to allow healthy lung tissue to expand. Careful evaluation of patients is carried out prior to this procedure. A final resort is lung transplant surgery. Because of the relatively large risk involved, this is carried out in only a small minority of patients.

Expected results

It is generally accepted that emphysema is incurable. Physicians and alternative medicine practitioners assert that they can relieve sufferers greatly from symptoms and halt the progress of the disease with appropriate management and preventative measures.

Prevention

Any person who feels that his/her work conditions are likely to be a possible cause of emphysema should take steps to protect him/herself. A respirator should be worn, at least until work conditions can be improved. Several steps may be taken to improve conditions, primary of which should be to improve ventilation.

Early diagnosis is vital to the successful management of emphysema. If preventative and therapeutic measures are taken at the early onset of symptoms, damage can be restricted and the outlook can be positive. At all times, care should be taken to eliminate sources of pollution or chemical irritants from the environment, both in the home and elsewhere. The first step in overcoming emphysema for any patient should be to remove the cause, whether working conditions, polluted atmosphere or smoking.

Resources

BOOKS

Ryman, Daniele. Aromatherapy London: Piatkus Books, 1999.

Treacher, Sylvia. Practical Homeopathy UK: Parragon Books, 2000.

ORGANIZATIONS

The National Emphysema Foundation <http://emphysemafoundation.org/>

OTHER

"Progress in Emphysema Research. <"http://www.lrri.org/gobmasso.html> (January 17, 2001).

Patricia Skinner

Emphysema

Definition

Emphysema is a chronic respiratory disease in which overinflation of the alveoli or air sacs causes a decrease in respiratory function and often dyspnea.

Description

Emphysema is the most common cause of death from respiratory disease in the United States, and is the fourth most common cause of death overall. There are1.8 million Americans with the disease, which ranks fifteenth among chronic conditions that cause limitations of activity. Around 44% of those with emphysema state that their activities of daily living have been affected by the disease.

Normally functioning lungs are elastic, efficiently expanding and recoiling as air passes freely through the bronchus to the alveoli, where oxygen is moved into the blood and carbon dioxide is filtered out. When a person inhales cigarette smoke, his or her immune system responds by releasing substances that are meant to defend the lungs against the smoke. These substances can also attack the cells of the lungs. Normally, the body inhibits such action by releasing other substances. In smokers and those with the inherited emphysema defect, however, no such prevention occurs, and the lung tissue is damaged in such a way that it loses its elasticity. The small passageways leading to the alveoli collapse, trapping air within the alveoli. The alveoli, unable to recoil efficiently and move the air out, overexpand and rupture. The smaller areas of alveoli destruction are known as blebs and the larger ones are called bullae. As the disease progresses coughing and dyspnea occur. In the later stages the lungs cannot supply sufficient oxygen to the blood. Emphysema often occurs with other respiratory diseases, particularly chronic bronchitis. These two diseases are often referred to as one—chronic obstructive pulmonary disease (COPD).

Emphysema is most common among people aged 50 years and older. Those with inherited emphysema may experience the onset as early as their 30s or 40s. Men are more likely than women to develop emphysema, but female cases are increasing as the number of female smokers rises.

Causes and symptoms

Heavy cigarette smoking causes about 80–90% of all emphysema cases. However, a few cases are the result of an inherited deficiency of alpha-1-antitrypsin (AAT). The number of Americans with this deficiency is relatively small, probably no greater than 70,000. Pipe, cigar, and marijuana smoking can also damage the lungs. While a person may be less likely to inhale cigar and pipe smoke, these types of smoke can also impair lung function. Marijuana smoke is even more damaging because it is inhaled deeply and held in the lungs longer by the smoker.

The symptoms of emphysema develop gradually over many years. It is a common occurrence for many emphysema patients to have lost 50–70% of their functional lung tissue before they become aware that something is wrong. Dyspnea, a chronic mild cough (which may be productive of large amounts of dark, thick sputum, and often dismissed as "smoker's cough"), and sometimes weight loss are associated with emphysema. Initially, a patient may notice shortness of breath only when he or she is exercising. However, as the disease progresses, it will occur during less exertion, and ultimately with no exertion at all. Emphysema patients may also develop an enlarged, or "barrel," chest. Other symptoms may include skipped breaths, insomnia, morning headaches, nasal flaring, increased difficulties breathing while lying down, chronic fatigue, and swelling of the feet, ankles, or legs. Those with chronic emphysema are at risk for other complications resulting from weakened lung function. These include pneumonia , pulmonary hypertension , cor pulmonale, and chronic respiratory failure .

Diagnosis

A history of heavy smoking alone is not enough for a physician to differentiate emphysema from other respiratory diseases. A physician will combine information on symptoms, medical history, physical examination , lung function tests, and chest x ray results to make a diagnosis of emphysema. One of the first clues may be a hollow sound heard through a stethoscope as the patient's chest is being tapped. The hollow sound is the result of the enlargement or rupture of the lungs' alveoli.

A variety of pulmonary function tests may be ordered. In the early stages of emphysema, the only result may be dysfunction of the small airways. Patients with emphysema may show an increase in the total amount of air that is in the lungs (total lung capacity), but a decrease in vital capacity. With severe emphysema, vital capacity is substantially below normal. Spirometry, a procedure that measures respiratory gases and resulting pulmonary function, aids in the diagnosis of emphysema.

A chest x ray is often ordered to aid in the diagnosis of emphysema, though patients in the early stages of the disease may have normal findings. Abnormal findings on the chest x ray include excessive inflation of the lungs and an abnormally increased chest diameter. The diaphragm may appear depressed or flattened. In addition, patients with advanced emphysema may show an enlargement of the heart . The physician may observe blisters in the lungs and bulging of the accessory muscles of the respiratory system . Late in the disease an EKG will show signs of right ventricular failure in the heart and increased hemoglobin due to lower oxygen in the patient's blood.

Other tests that may be performed include peak flow measurements, arterial blood gases , and pulse oximetry.

Treatment

Treatment methods for emphysema do not cure or reverse the damage to the lungs. However, they can slow the progression of the disease, relieve symptoms, and help control possibly fatal complications. The first step in treatment for smokers is to quit smoking to prevent any further deterioration of breathing ability. Smoking cessation programs may be effective. Consistent encouragement, along with the help of health care professionals as well as family and friends, can help increase the quit rate.

If the patient and the health team develop and maintain a complete program of respiratory care, disability can be decreased, acute episodes of illness may be prevented, and the number of hospitalizations reduced. However, only smoking cessation has been shown to slow down the progression of the disease; and among all other treatments, only oxygen therapy has exhibited an increase in survival rate.

Home oxygen therapy may improve the survival times in those patients with advanced emphysema who also have hypoxemia, or low blood oxygen levels. It may improve the patient's tolerance of exercise , as well as improve their performance in certain aspects of brain function and muscle coordination. The functioning of the heart may also improve with an increased concentration of oxygen in the blood. Oxygen may also decrease insomnia and headaches. Some patients may receive oxygen only at night, but studies have illustrated that it is most effective when administered for at least 18, but preferably, 24 hours per day. Those patients just beginning the therapy may wish to postpone continuous oxygen administration until it becomes absolutely necessary because of inconvenience and decreased mobility. Portable oxygen tanks prescribed to patients carry a limited supply and must be refilled on a regular basis by a home health care provider. Medicare and most insurance companies cover a large proportion of the cost of home oxygen therapy. Patients should be instructed regarding special safety issues involving the transport and presence of oxygen in the home.

A variety of medications may be used in the treatment of emphysema. Usually the patient responds best to a combination of medicines rather than one single drug. Bronchodilators are sometimes used to help alleviate the patient's symptoms by relaxing and opening the airways. There are three primary categories of bronchodilators:

sympathomimetics (isoproterenol, metaproterenol, terbutaline, albuterol), which can be inhaled, taken by mouth, or injected; parasympathomimetics (atropine); and methylxanthines (theophylline), which may be administered intravenously, orally, or rectally.

Another category of medication often used is corticosteroids or steroids (beclomethasone, dexamethasone, triamcinolone, flunisolide). These help to decrease the inflammation of the airway walls. They are occasionally used if bronchodilators are ineffective in preventing airway obstruction. Some patients' lung function improves with corticosteroids, and inhaled steroids may be beneficial to patients with few side effects.

A variety of antibiotics are frequently given at the first sign of a respiratory infection , such as increased amounts of sputum or a change in the color of the sputum. Expectorants can help loosen respiratory secretions, enabling the patient to more easily expel them from the airways.

Many of the medications prescribed involve the use of a metered dose inhaler (MDI) that may require special instruction to be used correctly. MDIs are a convenient and safe method of delivering medication to the lungs. However, if they are used incorrectly the medication will not get to the right place. Proper technique is essential for the medication to be effective.

For some patients, surgical treatment may be the best option. Lung volume reduction surgery is a surgical procedure

KEY TERMS

Alveoli —Small cells or cavities. In the lungs, these are air sacs in which oxygen enters the blood and carbon dioxide is filtered out.

Arterial blood gases —A test to analyze blood for oxygen, carbon dioxide, and bicarbonate content, as well as blood pH. Used to test the effectiveness of respiration.

Cor pulmonale —A disease characterized by an increase in bulk of the right ventricle of the heart that can lead to heart failure.

Hypoxemia —A condition characterized by deficient oxygen supply in the blood.

Peak flow measurement —Measurement of the maximum rate of airflow attained during a forced vital capacity determination.

Pulmonary —Related to or associated with the lungs.

Pulse oximetry —The noninvasive monitoring or determination of oxygen-hemoglobin saturation of the blood.

in which the most diseased parts of the lung are removed to enable the remaining lung and breathing muscles to work more efficiently. Preliminary studies suggest improved survival rates and better functioning with the surgery. Another surgical procedure used for emphysema patients is lung transplantation. Transplantation may involve one or both lungs. However, it is a risky and expensive procedure and donor organs may not be available.

For those patients with advanced emphysema, keeping the air passages reasonably clear of secretions can prove difficult. Some common methods for mobilizing and removing secretions include:

• Postural drainage. This technique helps to remove secretions from the airways. The patient lies in a position that allows gravity to aid in draining different parts of the lung. This is often done after the patient inhales and aerosol medication. The basic position involves the patient lying on the bed with chest and head over the side and forearms resting on the floor.
• Chest percussion. This technique involves a caregiver lightly clapping the back and chest of the patient. It may help to loosen thick secretions.
• Coughing and deep breathing. These techniques may aid the patient in bringing up secretions.
• Aerosol treatments. These treatments may involve solutions of saline, often mixed with a bronchodilator, which are then inhaled as an aerosol. The aerosols thin and loosen secretions. A treatment normally takes 10–15 minutes and is given three or four times a day.

Patients with COPD can be instructed to perform a variety of self-help measures that can help improve their symptoms and ability to participate in activities of daily living. These measures include:

• Avoiding any exposure to dust and fumes.
• Avoiding air pollution, including secondhand cigarette smoke.
• Avoiding other people who have infections like the cold or flu, and getting a pneumonia vaccination and a yearly flu shot.
• Drinking plenty of fluids to help loosen respiratory secretions so they can be coughed up more easily.
• Avoiding extreme heat or cold and high altitudes (special precautions can be taken that may enable the emphysema patient to fly on a plane).
• Maintaining adequate nutritional intake; normally, a high-protein diet taken in many small feedings, is recommended.

Many patients are interested in whether any alternative treatments for emphysema are available. Some practitioners recommend supplements of antioxidant nutrients. There have also been some studies indicating a correlation between a low vitamin A status and COPD, with suggestions that supplements of vitamin A might be beneficial. Aromatherapists have used essential oils like eucalyptus, lavender, pine, and rosemary, to help relieve nasal congestion and make breathing easier. The herb elecampane may act as an expectorant to help patients clear mucus from the lungs. The patient should discuss these remedies with their health care practitioner prior to trying them, as some may interact with the more traditional treatments already being given.

Prognosis

Emphysema is a serious and chronic disease that cannot be reversed. If detected early effects and progression can be slowed, particularly if the patient ceases smoking immediately. Complications of emphysema include higher risks for pneumonia and acute bronchitis. Overall, the prognosis for patients with emphysema is poor, with a medical survival rate for all COPD patients of four years, and even less for emphysema patients. However, individual cases vary, and many patients can live much longer with supplemental oxygen and other treatment measures.

Health care team roles

Many members of the health care team may treat the patient with emphysema. The patient usually seeks help from a physician first, who will make the diagnosis. In the course of the diagnostic workup, x-ray technicians and respiratory therapists may treat the patient. The nurse plays an important role in assessing the patient, administering medications, in teaching the patient how best to cope with and understand the disease, and—in some cases—provides home care . The physical therapist may assist the patient to find ways of increasing their strength and activity tolerance.

Prevention

The best way to prevent emphysema is to avoid smoking. Even patients with inherited emphysema should avoid smoking, as it hastens onset and worsens severity of the disease. If patients quit smoking as soon as evidence of small airway obstruction begins, they can significantly improve their prognosis.

Resources

BOOKS

Beers, Mark H., and Robert Berkow. The Merck Manual of Diagnosis and Therapy, 17^th ed. Whitehouse Station, NJ: Merck and Company, Inc., 1999.

PERIODICALS

"Data Mounting on Merits of Lung Volume Reduction Surgery." Family Practice News (February 15, 2001): 5.

Lewis, Laurie. "Optimal Treatment for COPD." Patient Care (May 30, 2000): 60.

ORGANIZATIONS

American Lung Association. 1740 Broadway, New York, NY 10019. (212) 315-8700. <http://www.lungusa.org>.

The National Emphysema Foundation. 15 Stevens St., Norwalk, CT 06856. <http://www.emphysemafoundation.org>.

National Heart, Lung and Blood Institute. <http://www.nhlbi.nih.gov>.

Deanna M. Swartout-Corbeil, R.N.

Emphysema

Definition

Emphysema is a chronic respiratory disease in which overinflation of the alveoli, or air sacs, causes a decrease in respiratory function and often dyspnea.

Description

Emphysema is the most common cause of death from respiratory disease in the United States, and is the fourth most common cause of death overall. There are 1.8 million Americans with the disease, which ranks fifteenth among chronic conditions that cause limitations of activity. Around 44% of those with emphysema state that their activities of daily living have been affected by of the disease.

Normally functioning lungs are elastic, efficiently expanding and recoiling as air passes freely through the bronchus to the alveoli, where oxygen is moved into the blood and carbon dioxide is filtered out. When a person inhales cigarette smoke, his or her immune system responds by releasing substances that are meant to defend the lungs against the smoke. These substances can also attack the cells of the lungs. Normally, the body inhibits such action by releasing other substances. In smokers and those with the inherited emphysema defect, however, no such prevention occurs, and the lung tissue is damaged in such a way that it loses its elasticity. The small passageways leading to the alveoli collapse, trapping air within the alveoli. The alveoli, unable to recoil efficiently and move the air out, overexpand and rupture. The smaller areas of alveoli destruction are known as blebs and the larger ones are called bullae. As the disease progresses coughing and dyspnea occur. In the later stages the lungs cannot supply sufficient oxygen to the blood. Emphysema often occurs with other respiratory diseases, particularly chronic bronchitis. These two diseases are often referred to as one—chronic obstructive pulmonary disease (COPD).

Emphysema is most common among people aged 50 years and older. Those with inherited emphysema may experience the onset as early as their 30s or 40s. Men are more likely than women to develop emphysema, but female cases are increasing as the number of female smokers rises.

Causes and symptoms

Heavy cigarette smoking causes about 80-90% of all emphysema cases. However, a few cases are the result of an inherited deficiency of alpha-1-antitrypsin (AAT). The number of Americans with this deficiency is relatively small, probably no greater than 70,000. Pipe, cigar, and marijuana smoking can also damage the lungs. While a person may be less likely to inhale cigar and pipe smoke, these types of smoke can also impair lung function. Marijuana smoke is even more damaging because it is inhaled deeply and held in the lungs longer by the smoker.

The symptoms of emphysema develop gradually over many years. It is a common occurrence for many emphysema patients to have lost 50-70% of their functional lung tissue before they become aware that something is wrong. Dyspnea, a chronic mild cough (which may be productive of large amounts of dark, thick sputum, and often dismissed as "smoker's cough"), and sometimes weight loss are associated with emphysema. Initially, a patient may only notice shortness of breath when he or she is exercising. However, as the disease progresses, it will occur during less exertion, and ultimately with no exertion at all. Emphysema patients may also develop an enlarged, or "barrel," chest. Other symptoms may include skipped breaths, insomnia, morning headaches, nasal flaring, increased difficulties breathing while lying down, chronic fatigue, and swelling of the feet, ankles, or legs. Those with chronic emphysema are at risk for other complications resulting from weakened lung function. These include pneumonia, pulmonary hypertension, cor pulmonale, and chronic respiratory failure.

Diagnosis

A history of heavy smoking alone is not enough for a physician to differentiate emphysema from other respiratory diseases. A physician will combine information on symptoms, medical history, physical examination, lung function tests, and chest x ray results to make a diagnosis of emphysema. One of the first clues may be a hollow sound heard through a stethoscope as the patient's chest is being tapped. The hollow sound is the result of the enlargement or rupture of the lungs' alveoli.

A variety of pulmonary function tests may be ordered. In the early stages of emphysema, the only result may be dysfunction of the small airways. Patients with emphysema may show an increase in the total amount of air that is in the lungs (total lung capacity), but a decrease in vital capacity. With severe emphysema, vital capacity is substantially below normal. Spirometry, a procedure that measures respiratory gases and resulting pulmonary function, aids in the diagnosis of emphysema.

A chest x ray is often ordered to aid in the diagnosis of emphysema, though patients in the early stages of the disease may have normal findings. Abnormal findings on the chest x ray include excessive inflation of the lungs and an abnormally increased chest diameter. The diaphragm may appear depressed or flattened. In addition, patients with advanced emphysema may show an enlargement of the heart. The physician may observe blisters in the lungs and bulging of the accessory muscles of the respiratory system. Late in the disease an EKG will show signs of right ventricular failure in the heart and increased hemoglobin due to lower oxygen in the patient's blood.

Other tests that may be performed include peak flow measurements, arterial blood gases, and pulse oximetry.

Treatment

Treatment methods for emphysema do not cure or reverse the damage to the lungs. However, they can slow the progression of the disease, relieve symptoms, and help control possibly fatal complications. The first step in treatment for smokers is to quit smoking to prevent any further deterioration of breathing ability. Smoking cessation programs may be effective. Consistent encouragement, along with the help of health care professionals as well as family and friends, can help increase the quit rate.

If the patient and the health team develop and maintain a complete program of respiratory care, disability can be decreased, acute episodes of illness may be prevented, and the number of hospitalizations reduced. However, only smoking cessation has been shown to slow down the progression of the disease, and among all other treatments, only oxygen therapy has exhibited an increase in survival rate.

Home oxygen therapy may improve the survival times in those patients with advanced emphysema who also have hypoxemia, or low blood oxygen levels. It may improve the patient's tolerance of exercise, as well as improve their performance in certain aspects of brain function and muscle coordination. The functioning of the heart may also improve with an increased concentration of oxygen in the blood. Oxygen may also decrease insomnia and headaches. Some patients may only receive oxygen at night, but studies have illustrated that it is most effective when administered for at least 18, but preferably, 24 hours per day. Those patients just beginning the therapy may wish to postpone continuous oxygen administration until it becomes absolutely necessary because of inconvenience and decreased mobility. Portable oxygen tanks prescribed to patients carry a limited supply and must be refilled on a regular basis by a home health care provider. Medicare and most insurance companies cover a large proportion of the cost of home oxygen therapy. Patients should be instructed regarding special safety issues involving the transport and presence of oxygen in the home.

A variety of medications may be used in the treatment of emphysema. Usually the patient responds best to a combination of medicines rather than one single drug. Bronchodilators are sometimes used to help alleviate the patient's symptoms by relaxing and opening the airways. There are three primary categories of bronchodilators: sympathomimetics (isoproterenol, metaproterenol, terbutaline, albuterol), which can be inhaled, taken by mouth, or injected; parasympathomimetics (atropine); and methylxanthines (theophylline), which may be administered intravenously, orally, or rectally.

Another category of medication often used is corticosteroids or steroids (beclomethasone, dexamethasone, triamcinolone, flunisolide). These help to decrease the inflammation of the airway walls. They are occasionally used if bronchodilators are ineffective in preventing airway obstruction. Some patients' lung function improves with corticosteroids, and inhaled steroids may be beneficial to patients with few side effects.

A variety of antibiotics are frequently given at the first sign of a respiratory infection, such as increased amounts of sputum or a change in the color of the sputum. Expectorants can help loosen respiratory secretions, enabling the patient to more easily expel them from the airways.

Many of the medications prescribed involve the use of a metered dose inhaler (MDI) that may require special instruction to be used correctly. MDIs are a convenient and safe method of delivering medication to the lungs. However, if they are used incorrectly the medication will not get to the right place. Proper technique is essential for the medication to be effective.

For some patients, surgical treatment may be the best option. Lung volume reduction surgery is a surgical procedure in which the most diseased parts of the lung are removed to enable the remaining lung and breathing muscles to work more efficiently. Preliminary studies suggest improved survival rates and better functioning with the surgery. Another surgical procedure used for emphysema patients is lung transplantation. Transplantation may involve one or both lungs. However, it is a risky and expensive procedure and donor organs may not be available.

For those patients with advanced emphysema, keeping the air passages reasonably clear of secretions can prove difficult. Some common methods for mobilizing and removing secretions include:

• Postural drainage. This technique helps to remove secretions from the airways. The patient lies in a position that allows gravity to aid in draining different parts of the lung. This is often done after the patient inhales and aerosol medication. The basic position involves the patient lying on the bed with chest and head over the side and forearms resting on the floor.
• Chest percussion. This technique involves a caregiver lightly clapping the back and chest of the patient. It may help to loosen thick secretions.
• Coughing and deep breathing. These techniques may aid the patient in bringing up secretions.
• Aerosol treatments. These treatments may involve solutions of saline, often mixed with a bronchodilator, which are then inhaled as an aerosol. The aerosols thin and loosen secretions. A treatment normally takes 10-15 minutes and is given three or four times a day.

Patients with COPD can be instructed to perform a variety of self-help measures that can help improve their symptoms and ability to participate in activities of daily living. These measures include:

• Avoiding any exposure to dust and fumes.
• Avoiding air pollution, including secondhand cigarette smoke.
• Avoiding other people who have infections like the cold or flu, and getting a pneumonia vaccination and a yearly flu shot.
• Drinking plenty of fluids to help loosen respiratory secretions so they can be coughed up more easily.
• Avoiding extreme heat or cold and high altitudes (special precautions can be taken that may enable the emphysema patient to fly on a plane).
• Maintaining adequate nutritional intake; normally, a high-protein diet taken in many small feedings, is recommended.

Many patients are interested in whether any alternative treatments for emphysema are available. Some practitioners recommend supplements of antioxidant nutrients. There have also been some studies indicating a correlation between a low vitamin A status and COPD, with suggestions that supplements of vitamin A might be beneficial. Aromatherapists have used essential oils like eucalyptus, lavender, pine, and rosemary, to help relieve nasal congestion and make breathing easier. The herb elecampane may act as an expectorant to help patients clear mucus from the lungs. The patient should discuss these remedies with their health care practitioner prior to trying them, as some may interact with the more traditional treatments already being given.

Prognosis

Emphysema is a serious and chronic disease that cannot be reversed. If detected early effects and progression can be slowed, particularly if the patient ceases smoking immediately. Complications of emphysema include higher risks for pneumonia and acute bronchitis. Overall, the prognosis for patients with emphysema is poor, with a medical survival rate for all COPD patients of four years, and even less for emphysema patients. However, individual cases vary, and many patients can live much longer with supplemental oxygen and other treatment measures.

Health care team roles

Many members of the health care team may treat the patient with emphysema. The patient usually seeks help from a physician first, who will make the diagnosis. In the course of the diagnostic workup, x-ray technicians and respiratory therapists may treat the patient. The nurse plays an important role in assessing the patient, administering medications, in teaching the patient how best to cope with and understand the disease, and—in some cases—provides home care. The physical therapist may assist the patient to find ways of increasing their strength and activity tolerance.

Prevention

The best way to prevent emphysema is to avoid smoking. Even patients with inherited emphysema should avoid smoking, as it hastens onset and worsens the severity of the disease. If patients quit smoking as soon as evidence of small airway obstruction begins, they can significantly improve their prognosis.

KEY TERMS

Alveoli— Small cells or cavities. In the lungs, these are air sacs in which oxygen enters the blood and carbon dioxide is filtered out.

Arterial blood gases— A test to analyze blood for oxygen, carbon dioxide, and bicarbonate content, as well as blood pH. Used to test the effectiveness of respiration.

Cor pulmonale— A disease characterized by an increase in bulk of the right ventricle of the heart that can lead to heart failure.

Hypoxemia— A condition characterized by deficient oxygen supply in the blood.

Peak flow measurement— Measurement of the maximum rate of airflow attained during a forced vital capacity determination.

Pulmonary— Related to or associated with the lungs.

Pulse oximetry— The noninvasive monitoring or determination of oxygen-hemoglobin saturation of the blood.

Resources

BOOKS

Beers, Mark H., and Robert Berkow. The Merck Manual of Diagnosis and Therapy, Whitehouse Station: Merck and Company, Inc., 2005.

PERIODICALS

"Data Mounting on Merits of Lung Volume Reduction Surgery." Family Practice News (February 15, 2001): 5.

Lewis, Laurie. "Optimal Treatment for COPD." Patient Care (May 30, 2000): 60.

ORGANIZATIONS

American Lung Association. 1740 Broadway, New York, NY 10019. (212) 315-8700. 〈http://www.lungusa.org〉.

The National Emphysema Foundation. 15 Stevens St. Norwalk, CT 06856. 〈http://www.emphysemafoundation.org〉.

National Heart, Lung and Blood Institute. 〈http://www.nhlbi.nih.gov〉.

Emphysema

Definition

Emphysema is a chronic respiratory disease where there is over-inflation of the air sacs (alveoli) in the lungs, causing a decrease in lung function, and often, breathlessness.

Description

Emphysema is the most common cause of death from respiratory disease in the United States, and is

the fourth most common cause of death overall. There are 1.8 million Americans with the disease, which ranks fifteenth among chronic conditions that cause limitations of activity. The disease is usually caused by smoking , but a small number of cases are caused by an inherited defect.

Normally functioning lungs are elastic, efficiently expanding and recoiling as air passes freely through the bronchus to the alveoli, where oxygen is moved into the blood and carbon dioxide is filtered out. When a person inhales cigarette smoke or certain other irritants, his or her immune system responds by releasing substances that are meant to defend the lungs against the smoke. These substances can also attack the cells of the lungs, but the body normally inhibits such action with the release of other substances. In smokers and those with the inherited defect, however, no such prevention occurs and the lung tissue is damaged in such a way that it loses its elasticity. The small passageways (bronchioles) leading to the alveoli collapse, trapping air within the alveoli. The alveoli, unable to recoil efficiently and move the air out, over expand and rupture. As the disease progresses, coughing and shortness of breath occur. In the later stages, the lungs cannot supply enough oxygen to the blood. Emphysema often occurs with other respiratory diseases, particularly chronic bronchitis . These two diseases are often referred to as one disorder called chronic obstructive pulmonary disease (COPD).

Emphysema is most common among people aged 50 and older. Those with inherited emphysema may experience the onset as early as their thirties or forties. Men are more likely than women to develop emphysema, but female cases are increasing as the number of female smokers rises.

Causes and symptoms

Heavy cigarette smoking causes about 80–90% of all emphysema cases. A few cases are the result of an inherited deficiency of a substance called alpha-1-antitrypsin (AAT). The number of Americans with this deficiency is relatively small, probably no greater than 70,000. Pipe, cigar, and marijuana smoking can also damage the lungs. While a person may be less likely to inhale cigar and pipe smoke, these types of smoke can also impair lung function. Marijuana smoke may be even more damaging because it is inhaled deeply and held in by the smoker.

The symptoms of emphysema develop gradually over many years. It is a common occurrence for many emphysema patients to have lost over half of their functioning lung tissue before they become aware that

something is wrong. Shortness of breath, a chronic mild cough (which may be productive of large amounts of dark, thick sputum, and often dismissed as “smoker's cough”), and sometimes weight loss are associated with emphysema. Initially, a patient may only notice shortness of breath when he or she is exercising. As the disease progresses, it will occur with less exertion or no exertion at all. Emphysema patients may also develop an enlarged, or “barrel,” chest. Other symptoms may be skipped breaths, difficulty sleeping, morning headaches , increased difficulty breathing while lying down, chronic fatigue, and swelling of the feet, ankles, or legs. Those with emphysema are at risk for a variety of other complications resulting from weakened lung function, including pneumonia .

Diagnosis

A variety of pulmonary function tests may be ordered. In the early stages of emphysema, the only result may be dysfunction of the small airways. Patients with emphysema may show an increase in the total amount of air that is in the lungs (total lung capacity), but a decrease in the amount of air that can be breathed out after taking a deep breath (vital capacity). With severe emphysema, vital capacity is substantially below normal. Spirometry, a procedure that measures air flow and lung volume, helps in the diagnosis of emphysema.

A chest x ray is often ordered to aid in the diagnosis of emphysema, though patients in the early stages of the disease may have normal findings. Abnormal findings on the chest x ray include over-inflation of the lungs and an abnormally increased chest diameter. The diaphragm may appear depressed or flattened. In addition, patients with advanced emphysema may show a smaller or vertical heart. The physician may observe blisters in the lungs and bulging of the accessory muscles of the respiratory system. Late in the disease, an EKG will show signs of right ventricular failure in the heart and increased hemoglobin due to lower levels of oxygen in the patient's blood.

Treatment

Treatment methods for emphysema do not cure or reverse the damage to the lungs. However, they may slow the progression of the disease, relieve symptoms, and help control possibly fatal complications. The first step in treatment for smokers is to quit, so as to prevent any further deterioration of breathing ability. Smoking cessation programs may be effective. Consistent encouragement along with the help of health care professionals as well as family and friends can help increase the success rate of someone attempting to quit.

If the patient and the health care team develop and maintain a complete program of respiratory care, disability can be decreased, acute episodes of illness may be prevented, and the number of hospitalizations reduced. However, only quitting smoking has been shown to slow down the progression of the disease, and among all other treatments, only oxygen therapy has shown an increase in the survival rate.

Home oxygen therapy may improve the survival times in those patients with advanced emphysema who also have low blood oxygen levels. It may improve the patient's tolerance of exercise , as well as improve their performance in certain aspects of brain function and muscle coordination. The functioning of the heart may also improve with an increased concentration of oxygen in the blood. Oxygen may also decrease insomnia and headaches. Some patients may only receive oxygen at night, but studies have illustrated that it is most effective when administered at least 18, but preferably 24 hours per day. Portable oxygen tanks prescribed to patients carry a limited supply and must be refilled on a regular basis by a home health provider. Medicare and most insurance companies cover a large proportion of the cost of home oxygen therapy. Patients should be instructed regarding special safety issues involving the transport and presence of oxygen in the home.

A variety of medications may be used in the treatment of emphysema. Usually the patient responds best to a combination of medicines, rather than one single drug.

Bronchodilators are sometimes used to help alleviate the patient's symptoms by relaxing and opening the airways. They can be inhaled, taken by mouth, or injected. Another category of medication often used is corticosteroids or steroids. These help to decrease the inflammation of the airway walls. They are occasionally used if bronchodilators are ineffective in preventing airway obstruction. Some patients' lung function improves with corticosteroids, and inhaled steroids may be beneficial to patients with few side effects. A variety of antibiotics are frequently given at the first sign of a respiratory infection, such as increased amounts of sputum, or if there has been a change in the color of the sputum. Expectorants can help to loosen respiratory secretions, enabling the patient to more easily expel them from the airways.

Many of the medications prescribed involve the use of a metered dose inhaler (MDI) that may require

special instruction to be used correctly. MDIs are a convenient and safe method of delivering medication to the lungs. However, if they are used incorrectly the medication will not get to the right place. Proper technique is essential for the medication to be effective.

KEY TERMS

Alveoli —Small cells or cavities. In the lungs, these are air sacs where oxygen enters the blood and carbon dioxide is filtered out.

Pulmonary —Related to or associated with the lungs.

For some patients, surgical treatment may be the best option. Lung volume reduction surgery is a surgical procedure in which the most diseased parts of the lung are removed to enable the remaining lung and breathing muscles to work more efficiently. Preliminary studies suggest improved survival rates and better functioning with the surgery. Another surgical procedure used for emphysema patients is lung transplantation. Transplantation may involve one or both lungs. However, it is a risky and expensive procedure, and donor organs may not be available.

For those patients with advanced emphysema, keeping the air passages reasonably clear of secretions can prove difficult. Some common methods for mobilizing and removing secretions include:

• Postural drainage. This helps to remove secretions from the airways. The patient lies in a position that allows gravity to aid in draining different parts of the lung. This is often done after the patient inhales an aerosol medication. The basic position involves the patient lying on the bed with his chest and head over the side and the forearms resting on the floor.
• Chest percussion. This technique involves lightly clapping the back and chest, and may help to loosen thick secretions.
• Coughing and deep breathing. These techniques may aid the patient in bringing up secretions.
• Aerosol treatments. These treatments may involve solutions of saline, often mixed with a bronchodilator, which are then inhaled as an aerosol. The aerosols thin and loosen secretions. A treatment normally takes 10 to 15 minutes, and is given three or four times a day.

Patients with COPD can learn to perform a variety of self-help measures that may help improve their symptoms and their ability to participate in everyday activities. These measures include:

• Avoiding any exposure to dusts and fumes.
• Avoiding air pollution, including the cigarette smoke of others.
• Avoiding other people who have infections like the cold or flu. Get a pneumonia vaccination and a yearly flu shot.
• Drinking plenty of fluids. This helps to loosen respiratory secretions so they can be brought up more easily through coughing.
• Avoiding extreme temperatures of heat or cold. Also avoiding high altitudes. (Special precautions can be taken that may enable the emphysema patient to fly on a plane.)
• Maintaining adequate nutritional intake. Normally a high protein diet taken in many small feedings is recommended.

Alternative treatment

Many patients are interested in whether any alternative treatments for emphysema are available. Some practitioners recommend supplements of antioxidant nutrients. There have also been some studies indicating a correlation between a low vitamin A levels and COPD, with suggestions that supplements of vitamin A might be beneficial. Aromatherapists have used essential oils like eucalyptus, lavender, pine, and rosemary to help relieve nasal congestion and make breathing easier. The herb elecampane may act as an expectorant to help patients clear mucus from the lungs. The patient should discuss these remedies with their health care practitioner prior to trying them, as some may interact with the more traditional treatments that are already being used.

Prognosis

Emphysema is a serious and chronic disease that cannot be reversed. If detected early, the effects and progression can be slowed, particularly if the patient stops smoking immediately. Complications of emphysema include higher risks for pneumonia and acute bronchitis. Overall, the prognosis for patients with emphysema is poor, with a survival rate for all those with COPD of four years, and even less for emphysema. However, individual cases vary and many patients can live much longer with supplemental oxygen and other treatment measures.

Prevention

The best way to prevent emphysema is to avoid smoking. Even patients with inherited emphysema should avoid smoking, as it especially worsens the onset and severity. If patients quit smoking as soon as evidence of small airway obstruction begins, they can significantly improve their prognosis.

Resources

BOOKS

Beers, Mark H., and Robert Berkow, editors. The Merck Manual ofDiagnosis and Therapy. Whitehouse Station, NJ: Merck and Company, Inc., 2004.

PERIODICALS

“Data Mounting on Merits of Lung Volume Reduction-Surgery.” Family Practice News February 15, 2001: 5.

Lewis, Laurie. “Optimal Treatment for COPD.” PatientCare May 30, 2000: 60.

ORGANIZATIONS

American Lung Association. 1740 Broadway New York, NY 10019. (212) 315-8700. http://www.lungusa.org.

National Emphysema Foundation. 15 Stevens St. Norwalk, CT 06856. http://www.emphysemafoundation.org.

National Heart, Lung and Blood Institute. http://www.nhlbi.nih.gov.

Deanna M. Swartout-Corbeil R.N.