How effective are the treatments for emphysema?

The Problem

In this coursework I will be answering the following question ‘How effective are the
treatments for emphysema?’ Emphysema is a progressive lung disease that results in shortness
of breath and reduces your capacity for physical activity. Emphysema is classified under the
diseases called chronic obstructive pulmonary disease or COPD {1} (pulmonary refers to the
lungs).

Unlike heart disease and other more common causes of death, the death rate for COPD
appears to be rising. According to NHS Choices, around 900,000 people in the UK have been
diagnosed with COPD, but it is thought that another 450,000 may have it without realising it.
COPD causes 30,000 deaths a year. COPD accounts for more time off work than any other
illness. A flare-up (exacerbation) of COPD is also one of the commonest reasons for being
admitted to hospital in the UK. {2} Emphysema changes the anatomy of the lung many ways.
Emphysema is called an ‘obstructive’ lung disease because the destruction of lung tissue around
smaller sacs, called alveoli, makes these air sacs unable to hold their functional shape
upon exhalation. In people with emphysema, lung inflammation
destroys these fragile walls of the air sacs which cause them to lose
their elasticity. This reduces the support of the airways, causing
them to narrow. It also means the lungs are not as efficient at
getting oxygen into the body, causing breathing to be difficult,
hence resulting in shortness of breath.

With advanced emphysema, the large air cysts

Figure 1 {5}: This image is
develop where normal lung tissue used to be. When
showing a microscopic view into
emphysema is advance, lungs must work so hard to expel air the lungs alveoli showing a normal
that breathing can consume up to 20% of resting energy. {3} alveoli and alveoli with
Air is trapped in the lungs due to a lack of supportive tissue, emphysema.
which in-turn decreases blood oxygenation; As a result, the
bronchioles collapse, which over interferes with your ability to exhale (hyperinflation). This
overstretching may cause several air sacs to rupture, forming one larger air space, Because the
larger, less-elastic sacs aren't able to force air completely out of your lungs when you exhale, you
have to breathe harder to take in enough oxygen and to eliminate carbon dioxide. In healthy
lungs, air and oxygen pass through the upper respiratory tract and into the bronchioles and
the alveoli in the lungs. The alveoli are tiny hollow sack-like structures where oxygen is
absorbed in to the bloodstream. {4} However, in a patient suffering with emphysema there is a
loss of elasticity in the bronchioles and alveoli and destruction of the walls between alveoli and
reduces the effectiveness of breathing and the intake of oxygen.
How is it caused?

There are many ways in which emphysema in a person develops. Smoking is by far the
single most clearly established environmental risk factor for emphysema and chronic bronchitis.
One in 5 persons who smoke develops COPD, and 80-90% of COPD patients have a smoking
history. {6} The damage begins when tobacco smoke temporarily paralyzes the microscopic
hairs (cilia) that line your bronchial tubes. Normally, these hairs sweep irritants and germs out of
your airways. But when smoke interferes with this sweeping movement, irritants remain in your
bronchial tubes and infiltrate the alveoli, inflaming the tissue and eventually breaking down
elastic fibers. Women smokers are nearly 13 times as likely to die from COPD as are women
who have never smoked. Men smokers are nearly 12 times as
likely to die from COPD as men who have never smoked. {7}
Cigarettes contain many hazardous substances that damage the
lung when inhaled, including tar nicotine, carbon monoxide, and
cyanide. Long-term exposure to secondhand tobacco smoke, air
pollution, and repeated respiratory infections also can increase a
person's risk for COPD. Industrial exposures, such as toxic fumes
or dust, can significantly increase a person's risk of COPD as well.

Also exposure to secondhand smoke, also known as passive or

environmental tobacco smoke, is smoke that you inadvertently
inhale from someone else's cigarette, pipe or cigar.
Figure 2 {8}: This graph is
Occupational exposure to chemical fumes also leads to risk of
showing the number of deaths
developing emphysema. If you breathe fumes from certain
due to COPD disease each year
chemicals or dust from grain, cotton, wood or mining
between the years 180- 2000.
products, you're more likely to develop emphysema. The risk This shows that the number of
is even greater if you smoke. Breathing indoor pollutants such woman that die each year has
as fumes from heating fuel as well as outdoor pollutants, car been increasing rapidly
exhaust, for instance — increases your risk of emphysema. {9} Smokers living with HIV are at
greater risk of emphysema and of developing the disease at a relatively young age than are
smokers who don't have HIV infection. Some conditions that affect connective tissue the fibers
which provide the framework and support for your body are associated with emphysema.

Protein deficiency sometimes plays a role in causing emphysema. In a small percentage

of people, emphysema results from low levels of a protein
called alpha-1-antitrypsin (AAt), which protects the elastic structures in your lungs from the
destructive effects of certain enzymes. {10} A lack of AAt can lead to progressive lung damage
that eventually results in emphysema. AAt deficiency is a hereditary condition that occurs when
you inherit two defective genes, one from each parent. Although severe AAt deficiency is rare,
millions of people carry a single defective AAt gene. Some of these people have mild to
moderate symptoms; others have no symptoms at all. One of the symptoms for emphysema is
loss of appetite and weight loss. Emphysema can make eating more difficult, as well as
breathing. The result is that you simply may not feel like eating much of the time. Also, when
you eat, your stomach expands and pushes up the diaphragm, which compresses the lungs and
makes it harder to breathe. Fatigue is another symptom of emphysema. You're likely to feel tired
both because it's more difficult to breathe and because your body is getting less oxygen. You also
become out of shape because exercise makes the person out of breath. {11} Carriers are at
increased risk of lung and liver problems and can pass the defect to their children. People with
two defective genes have a high likelihood of developing emphysema, usually between the ages
of 30 and 40.

Testing of emphysema

Pulmonary function tests (PFTs) is a test that 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 the amount of gases
exchanged across the membrane between your alveolar wall and
capillary membrane. During the test, 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. {13} Figure 3 {12}: Shows a
patient being tested for
emphysema using a
Chest X-ray to help rule out other lung problems rather than to spirometer.
diagnose emphysema because even in the advanced stages of the disease, chest X-rays are often
normal. Arterial blood gases analysis are blood tests that measure how well your lungs transfer
oxygen to your bloodstream and how effectively they remove carbon dioxide.

Pulse oximetry 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. {14} To help determine whether you need supplemental
oxygen, the test may be performed at rest, during exercise and overnight.

Computerized tomography (CT) scan allows your doctor to see your organs in two dimensional
images or "slices." Split-second computer processing creates these images as a series of very thin
X-ray beams are passed through your body. A CT scan can detect emphysema sooner than an
ordinary chest X-ray can, but it can't assess the severity of emphysema as accurately as can a
pulmonary function test. {15}
Treatments for Emphysema

There are many treatments to emphysema. Stopping smoking is one of the main ones
doctors recommend to the patients. Stopping smoking may cut short the progression of the
disease and should recover the function of the lungs to some degree. Doctors can prescribe drugs
to help break the addiction and can also recommend behavioral therapies, such as the NHS
support groups. Bronchodilator drugs cause the air passages in the respiratory system to open
more effusive and allow enhanced air exchange. The most common bronchodilator for mild
cases of emphysema is Salbutamol. It reacts fast and one dose usually provides relief for 4-6
hours. Salbutamol is most frequently available as a metered-dose inhaler or MDI, and this is the
way that it will be used most often for mild emphysema. The problem with Salbutamol drugs is
that it can interact with body chemicals altering the blood level without warning. For this reason,
doctors prescribe Salbutamol carefully; as it does have a dangerous side effect.

Emphysema is a heterogeneous disease that affects different patients in different ways.

Treatment involves different approaches, which includes education, exercise, breathing
retraining, smoking cessation, oral and inhaled medications, oxygen therapy, and lung
transplantation. {15}

Lung volume reduction surgery may be an alternative for patients who experience
breathlessness, and have pulmonary function tests that show brutal obstacle and inflamed lungs.
Lung volume reduction surgery (LVRS) is a calming treatment that aims to remove the least
functional part of the lungs in order to advance airflow, diaphragm and chest wall procedure and
alveolar gas exchange in the remaining segment of the lung. A CT and perfusion scan are used
to identify the diseased lung tissue. The diseased part of the lung can be accessed by various
techniques including median sternotomy. Median sternotomy involves cutting through the
sternum to open the chest. {16}The procedure involves making a number of small openings in
both sides of the chest to allow the placing of instruments into the chest between the ribs. The
aim of the surgery is to reduce the volume of each lung by between 20 and 30%. This is done by
using a surgical stapling device to cut and seal the tissue, laser ablation to shrink lung volume or
a combination of both. Buttressing materials may be used along the staple line to prevent air
leaks following resection. Once the tissue has been removed the lung is re-inflated and the chest
closed.

Evidence on efficiency indicates that in certain patients lung function, exercise

performance and quality of life are improved in the short term following lung volume reduction
surgery. {16} The National Emphysema Treatment Trial found that at 24 months exercise
capacity had improved in 15% (54/371) of patients in the surgery group, compared with 3%
(10/378) of patients in the medical group (p < 0.001).

In one study of 250 patients, 45.2% of patients (113/250) experienced prolonged air leaks
lasting more than 7 days, with 8 patients (3.2%) requiring a subsequent operation. Other
complications in this series included pneumonia (24/250), in-hospital mortality (12/250),
myocardial infarction (5/250), deep vein thrombosis (4/250), small bowel obstruction (6/250),
and phrenic nerve injury (2/250). {16}
 References

1) http://www.emedicinehealth.com/chronic_obstructive_pulmonary_disease_co
pd/article_em.htm

2) http://www.webmd.boots.com/a-to-z-guides/emphysema

3) http://emphysema.org/

4) http://www.wrongdiagnosis.com/e/emphysema/intro.htm

5) Figure 1: http://www.google.co.uk/imgres?
imgurl=http://cdn.nursingcrib.com/wp-
content/uploads/emphysema.jpg&imgrefurl=http://www.blupress.it/telefilmsh
ow/c.o.p.d.-disease

6) http://emedicine.medscape.com/article/298283-overview

7) http://www.umm.edu/careguides/000108.htm

8) Figure 2: http://knol.google.com/k/-/-/W7JzU7Dr/LKNTdA/FemaleDeaths.jpg

9) http://www.cancer.gov/cancertopics/factsheet/Tobacco/ETS

10) http://www.scribd.com/doc/11823200/Emphysema

11) http://knol.google.com/k/chronic-obstructive-pulmonary-disease-copd#

12) http://www.scribd.com/doc/11823200/Emphysema

13) http://www.scribd.com/doc/11823200/Emphysema.uk

14) http://www.businessweek.com/lifestyle/content/healthday/650728.html

15) http://www.mayoclinic.com/health/emphysema/DS00296/DSECTION=te
sts-and-diagnosis

16) http://www.nice.org.uk/nicemedia/live/11139/31247/31247.pdf

17) http://www.umm.edu/thoracic/lvrs_success.htm