Emphysema

Emphysema is a factor in the progression of chronic obstructive pulmonary disease (COPD), a condition that limits the flow of air when you breathe out. Emphysema occurs when the air sacs at the ends of your smallest air passages (bronchioles) are gradually destroyed. Smoking is the leading cause of emphysema.

As it worsens, emphysema turns the spherical air sacs — clustered like bunches of grapes — into large, irregular pockets with gaping holes in their inner walls. This reduces the number of air sacs and keeps some of the oxygen entering your lungs from reaching your bloodstream. In addition, the elastic fibers that hold open the small airways leading to the air sacs are slowly destroyed, so that they collapse when you breathe out, not letting the air in your lungs escape.

Airway obstruction, another feature of COPD, contributes to emphysema. The combination of emphysema and obstructed airways makes breathing increasingly difficult. Treatment often slows, but doesn't reverse, the process.

Symptoms

Emphysema symptoms are mild to begin with but steadily get worse as the disease progresses. The main emphysema symptoms are:

• Shortness of breath
• Wheezing
• Chest tightness
• Reduced capacity for physical activity
• Chronic coughing, which could also indicate chronic bronchitis
• Loss of appetite and weight
• Fatigue

When to see a doctor

• You tire quickly, or you can't easily do the things you used to do
• You can't breathe well enough to tolerate even moderate exercise
• Your breathing difficulty worsens when you have a cold
• Your lips or fingernails are blue or gray, indicating low oxygen in your blood
• You frequently cough up yellow or greenish sputum
• You note that bending over to tie your shoes makes you short of breath
• You are losing weight

These signs and symptoms don't necessarily mean you have emphysema, but they do indicate that your lungs aren't working properly and should be evaluated by your doctor as soon as possible.

Causes

The causes of emphysema include:

• Smoking. Cigarette smoke is by far the most common cause of emphysema. There are more than 4,000 chemicals in tobacco smoke, including secondhand smoke. These chemical irritants slowly destroy the small peripheral airways, the elastic air sacs and their supporting elastic fibers.
• Protein deficiency. Approximately 1 to 2 percent of people with emphysema have an inherited deficiency of a protein called AAt, which protects the elastic structures in the lungs. Without this protein, enzymes can cause progressive lung damage, eventually resulting in emphysema. If you're a smoker with a lack of AAt, emphysema can begin in your 30s and 40s. The progression and severity of the disease are greatly.

Risk factors

Risk factors for emphysema include:

• Smoking. Emphysema is most likely to develop in cigarette smokers, but cigar and pipe smokers also are susceptible, and the risk for all types of smokers increases with the number of years and amount of tobacco smoked.
• Age. Although the lung damage that occurs in emphysema develops gradually, most people with tobacco-related emphysema begin to experience symptoms of the disease between the ages of 40 and 60.
• Exposure to secondhand smoke. Secondhand smoke, also known as passive or environmental tobacco smoke, is smoke that you inadvertently inhale from someone else's cigarette, pipe or cigar. Being around secondhand smoke increases your risk of emphysema.
• Occupational exposure to fumes or dust. If you breathe fumes from certain chemicals or dust from grain, cotton, wood or mining products, you're more likely to develop emphysema. This risk is even greater if you smoke.
• Exposure to indoor and outdoor pollution. Breathing indoor pollutants, such as fumes from heating fuel, as well as outdoor pollutants — car exhaust, for instance — increases your risk of emphysema.
• HIV infection. Smokers living with HIV are at greater risk of emphysema than are smokers who don't have HIV infection.
• Connective tissue disorders. Some conditions that affect connective tissue — the fibers that provide the framework and support for your body — are associated with emphysema. These conditions include cutis laxa, a rare disease that causes premature aging, and Marfan syndrome, a disorder that affects many different organs, especially the heart, eyes, skeleton and lungs.

Complications

Emphysema can increase the severity of other chronic conditions, such as diabetes and heart failure. If you have emphysema, air pollution or a respiratory infection can lead to an acute COPD exacerbation, with extreme shortness of breath and dangerously low oxygen levels. You may need admission to an intensive care unit and temporary support from an artificial breathing machine (ventilator) until the infection

Preparing for your appointment

Your first appointment to check for emphysema may be with your primary doctor or with a specialist in lung diseases called a pulmonologist. Be prepared to answer questions regarding:

• Whether you smoke and if so, how many packs a day
• Your contact with other irritants, such as chemical fumes, industrial dust or secondhand smoke
• Whether you have a chronic cough, and how long you've had it
• Whether you've been wheezing or having trouble breathing in cold air
• Your family history of COPD

After the examination, your doctor will explain which tests are recommended in order to make an accurate diagnosis.

Tests and diagnosis

To determine if you have emphysema, your doctor is likely to recommend certain tests, including:

• Spirometry and other pulmonary function tests (PFTs). These noninvasive tests can detect emphysema before you have symptoms. They measure how much air your lungs can hold and the flow of air in and out of your lungs. They can also measure how well your lungs deliver oxygen to your bloodstream.

  During a spirometry, you're usually asked to blow into a simple instrument called a spirometer. PFTs may be done before and after the use of inhaled medications to test your response to them. If you're a smoker or a former smoker, ask your doctor about taking these tests, even if you don't have symptoms of emphysema or COPD.

• Arterial blood gases analysis. These blood tests measure how well your lungs transfer oxygen into, and remove carbon dioxide from, your bloodstream.
• Pulse oximetry. This test involves the use of a small device that attaches to your fingertip. The oximeter measures the amount of oxygen in your blood differently from the way it's measured in a blood gas analysis. To help determine whether you need supplemental oxygen, the test may be performed at rest, during exercise and overnight.
• Chest X-ray. A chest X-ray can help confirm a diagnosis of emphysema and rule out other causes of shortness of breath, but an X-ray alone isn't enough to make an accurate diagnosis.
• Sputum examination. Analysis of cells in what you cough up (sputum) can help determine the cause of some lung problems.
• Computerized tomography (CT) scan. A CT scan can allow your doctor to view your internal organs, where they'll look for the characteristic "holes" or bullae that are caused by emphysema.

Treatments and drugs

The most important step in any treatment plan for smokers with emphysema is to stop smoking; it's the only way to stop the damage to your lungs from becoming worse. But quitting is never easy, and people often need the help of a comprehensive smoking cessation plan, which may include:

• A target date to quit
• Relapse prevention
• Advice for healthy lifestyle changes
• Social support systems
• Medications, such as nicotine gum or patches and the prescription medications bupropion hydrochloride (Zyban) and varenicline (Chantix)

Other emphysema treatments focus on helping you feel better, stay more active and slow the progression of emphysema. They include:

• Bronchodilators. These drugs can help relieve coughing, shortness of breath and trouble breathing by relaxing constricted airways, but they're not as effective in treating emphysema as they are in treating asthma or chronic bronchitis.
• Inhaled steroids. Corticosteroid drugs inhaled as aerosol sprays may relieve symptoms of emphysema associated with asthma and bronchitis. Although inhaled steroids have fewer side effects than oral steroids do, prolonged use can weaken your bones and increase your risk of high blood pressure, cataracts and diabetes.
• GERD treatment. Symptomatic gastroesophageal reflux disease (GERD) aggravates airway disease in many people, so your doctor may recommend medications as well as life style changes to treat it.
• Supplemental oxygen. If you have severe emphysema with low blood oxygen levels, using oxygen regularly at home and when you exercise may provide some relief. Many people use oxygen 24 hours a day. Various forms of oxygen are available, as are different devices to deliver supplemental oxygen to your lungs.

• Pulmonary rehabilitation program. A key part of treatment involves a pulmonary rehabilitation program, which combines education, exercise training and behavioral intervention to help you stay active and improve your health and quality of life.

  You'll receive help with smoking cessation and your nutritional needs, and you may learn special breathing techniques and ways to conserve energy. Because exercise can help to slow the decline of your lung function, you'll also be given an exercise program.

• Antibiotics. If you develop a bacterial infection like bronchitis or pneumonia, antibiotics are appropriate.
• Inoculations against influenza and pneumonia. If you have emphysema or other forms of COPD, experts recommend an influenza (flu) shot annually and a pneumonia shot every five years.

• Surgery. In an experimental procedure called lung volume reduction surgery (LVRS), surgeons remove small wedges of damaged lung tissue. Removing the diseased tissue helps the lungs work more efficiently and helps improve breathing.

  In another surgery, called a bullectomy, doctors remove one or more of the large air spaces (called bullae) that form when the small air sacs are destroyed. This procedure can improve breathing.

• Transplant. Lung transplantation is an option if you have severe emphysema and other options have failed.

Lifestyle and home remedies

Some simple exercises can improve your breathing if you have emphysema or another chronic lung disorder. They help you control the emptying of your lungs by using your abdominal muscles. Do them two to four times daily.

Diaphragmatic breathing
To perform this type of breathing exercise, take these steps:

• Lie on your back with your head and knees supported by pillows. Begin by breathing in and out slowly and smoothly in a rhythmic pattern. Relax.
• Place your fingertips on your abdomen, just below the base of your rib cage. As you inhale slowly, you should feel your diaphragm lifting your hand.
• Practice pushing your abdomen against your hand as your chest becomes filled with air. Make sure your chest remains motionless. Try this while inhaling through your mouth and counting slowly to three. Then purse your lips and exhale through your mouth while counting slowly to six.

Practice diaphragmatic breathing on your back until you can take 10 to 15 consecutive breaths in one session without tiring. Then practice it while lying on one side and then on the other. Progress to doing the exercise while sitting erect in a chair, standing up, walking and, finally, climbing stairs.

Pursed-lip breathing
Try the diaphragmatic breathing exercises with your lips pursed as you exhale, that is, with your lips puckered - the flow of air should make a soft "sssss" sound. Inhale deeply through your open mouth and exhale. Repeat 10 times at each session. Breathing out against pursed lips increases the air pressure inside the airways, including your very small airways, which minimizes how much they collapse.

Deep-breathing exercise
While sitting or standing, pull your elbows firmly backward as you inhale deeply. Hold your breath in, with your chest arched, for a count to five, and then force the air out by contracting your abdominal muscles and letting your elbows return to their starting position. Repeat the exercise 10 times.

Other steps you can take
If you have emphysema, you can take a number of steps to halt its progression and to protect yourself from complications:

• Stop smoking. This is the most important measure you can take for your overall health and the only one that might halt the progression of emphysema. Join a smoking cessation program if you need help giving up smoking. As much as possible, avoid secondhand smoke.
• Avoid other respiratory irritants. These include fumes from paint and automobile exhaust, some cooking odors, certain perfumes, even burning candles and incense. Change furnace and air conditioner filters regularly to limit pollutants.
• Exercise regularly. Try not to let your breathing problems keep you from getting regular exercise, which can significantly increase your lung capacity.
• Clear your airways. If you also have chronic bronchitis, mucus tends to collect in your air passages and can be difficult to clear. To keep secretions thin and easy to bring up, drink plenty of nonalcoholic fluids every day.
• Protect yourself from cold air. Cold air can cause spasms of the bronchial passages, making it even more difficult to breathe. During cold weather, wear a soft scarf or a cold-air mask — available from a pharmacy — over your mouth and nose before going outside, to warm the air entering your lungs.
• Avoid respiratory infections. Get pneumonia vaccinations as advised by your doctor. Also get an annual influenza immunization. Do your best to avoid direct contact with people who have a cold or the flu. If you have to mingle with large groups of people during cold and flu season, wear a face mask, wash your hands frequently and carry a small bottle of hand sanitizer in your pocket or purse. Try to avoid touching the inside of your nose or rubbing your eyes, which is the way you acquire most viral infections.

• Maintain good nutrition. A balanced diet gives your body the nutrients it needs for energy, for building and maintaining cells, and for regulating body processes. Work toward and maintain a desirable body weight. Being overweight causes your body to require more oxygen and can interfere with breathing. If you're underweight, achieving a healthy weight may increase your strength.

  When the effort to eat is taxing, you may need to eat smaller meals more frequently. Try eating your largest meal earlier in the day, and avoid lying down after meals. Soft, easy-to-digest foods, such as yogurt, rice, baked potatoes, and poached chicken or fish, may be more agreeable than red meat and heavy dishes.

Coping and support

These suggestions may help you cope with emphysema:

• Express your feelings. Your emphysema may limit some of your activities and affect your family's plans and routines in ways you can't always anticipate. If you and your family can talk openly about each other's needs, you'll be better able to meet the challenges of living with this disease. Be alert to changes in your mood and your relations with others, and don't be afraid to seek counseling.
• Consider a support group. You may also want to consider joining a support group for people with emphysema. Although support groups aren't for everyone, they can be a good source of information about new treatments and coping strategies. And it can be encouraging to spend time with other people in circumstances similar to yours. If you're interested in a support group, talk to your doctor. Or, contact your local chapter of the American Lung Association.

Prevention

Most cases of emphysema are preventable. To prevent emphysema:

• Don't smoke. If you do smoke, seek help to quit as soon as possible.
• Avoid exposure to secondhand smoke.
• Wear a mask to protect your lungs if you work with chemical fumes or dust.
• Increase your physical activity or exercise regularly if you've smoked in the past.