Emphysema, or pulmonary emphysema, is a
lower respiratory tract disease,
characterised by air-filled spaces (
pneumatoses) in the
lungs
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side ...
, that can vary in size and may be very large. The spaces are caused by the breakdown of the
walls
Walls may refer to:
*The plural of wall, a structure
*Walls (surname), a list of notable people with the surname
Places
* Walls, Louisiana, United States
* Walls, Mississippi, United States
* Walls, Ontario, neighborhood in Perry, Ontario, C ...
of the
alveoli and they replace the spongy
lung parenchyma
Parenchyma () is the bulk of functional substance in an animal organ or structure such as a tumour. In zoology it is the name for the tissue that fills the interior of flatworms.
Etymology
The term ''parenchyma'' is New Latin from the word π ...
. This reduces the total alveolar surface available for
gas exchange
Gas exchange is the physical process by which gases move passively by diffusion across a surface. For example, this surface might be the air/water interface of a water body, the surface of a gas bubble in a liquid, a gas-permeable membrane, or a ...
leading to a reduction in oxygen supply for the blood.
Emphysema usually affects the
middle aged or
older
Older is the comparative form of "old".
It may also refer to:
Music:
* ''Older'' (album), the third studio album from George Michael (released in 1996)
** "Older" (George Michael song)
* "Older", a song on the 1999 album '' Long Tall Weekend'' ...
population because it takes time to develop with the effects of
tobacco smoking
Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believed ...
,
and other risk factors.
Alpha-1 antitrypsin deficiency
Alpha-1 antitrypsin deficiency (A1AD or AATD) is a genetic disorder that may result in lung disease or liver disease. Onset of lung problems is typically between 20 and 50 years of age. This may result in shortness of breath, wheezing, or an inc ...
is a genetic risk factor that may lead to the condition presenting earlier.
When associated with significant airflow limitation, emphysema is a
major subtype of chronic obstructive pulmonary disease (
COPD
Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce ...
), a progressive lung disease characterized by long-term breathing problems and poor airflow.
Without COPD, the finding of emphysema on
a CT lung scan still confers a higher mortality risk in
tobacco smokers. In 2016 in the United States there were 6,977 deaths from emphysema – 2.2 per 100,000 of the population.
Globally it accounts for 5% of all deaths.
A 2018 review of work on the effects of tobacco and cannabis smoking found that a possibly cumulative toxic effect could be a risk factor for developing emphysema, and
spontaneous pneumothorax
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve i ...
.
There are four types of emphysema, three of which are related to the anatomy of the
lobules of the lung – centrilobular or centriacinar, panlobular or panacinar, and paraseptal or distal acinar emphysema, and are not associated with
fibrosis
Fibrosis, also known as fibrotic scarring, is a pathological wound healing in which connective tissue replaces normal parenchymal tissue to the extent that it goes unchecked, leading to considerable tissue remodelling and the formation of perma ...
(scarring). The fourth type is known as paracicatricial emphysema or irregular emphysema that involves the
acinus irregularly and is associated with fibrosis. Though the different types can be seen on
imaging
Imaging is the representation or reproduction of an object's form; especially a visual representation (i.e., the formation of an image).
Imaging technology is the application of materials and methods to create, preserve, or duplicate images.
...
they are not well-defined clinically.
There are also a number of associated conditions including
bullous emphysema
Emphysema, or pulmonary emphysema, is a lower respiratory tract disease, characterised by air-filled spaces ( pneumatoses) in the lungs, that can vary in size and may be very large. The spaces are caused by the breakdown of the walls of the alve ...
,
focal emphysema, and
Ritalin lung. Only the first two types of emphysema – centrilobular and panlobular – are associated with significant airflow obstruction, with that of centrilobular emphysema around 20 times more common than panlobular. Centrilobular emphysema is the only type associated with
smoking.
Osteoporosis is often a
comorbidity
In medicine, comorbidity - from Latin morbus ("sickness"), co ("together"), -ity (as if - several sicknesses together) - is the presence of one or more additional conditions often co-occurring (that is, concomitant or concurrent) with a primary ...
of emphysema. The use of
systemic corticosteroids for treating exacerbations is a significant risk factor for osteoporosis, and their repeated use is recommended against.
Signs and symptoms
![Blausen 0343 Emphysema](https://upload.wikimedia.org/wikipedia/commons/3/3c/Blausen_0343_Emphysema.png)
Emphysema is a respiratory disease of the
lower respiratory tract
The respiratory tract is the subdivision of the respiratory system involved with the process of Respiration (physiology), respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa.
Air is breathed ...
.
It is commonly caused by
tobacco smoking
Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believed ...
but a significant number of people are affected who either do not smoke, or have never smoked.
The presence of emphysema is a clear risk factor for the development of
lung cancer
Lung cancer, also known as lung carcinoma (since about 98–99% of all lung cancers are carcinomas), is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung. Lung carcinomas derive from transformed, malign ...
, made stronger in those who smoke.
Early symptoms of emphysema may vary from person to person. Symptoms can include a cough (with or without sputum), wheezing, a fast breathing rate, breathlessness on exertion, and a feeling of tightness in the chest. There may be frequent cold or flu infections.
Other symptoms may include anxiety, depression, fatigue, sleep problems and weight loss. Since these symptoms could also relate to other lung conditions or other health problems, emphysema is often under diagnosed.
The shortness of breath caused by emphysema can increase over time and develop into
chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce ...
.
A sign of emphysema in smokers is the finding of a higher number of
alveolar macrophage
An alveolar macrophage, pulmonary macrophage, (or dust cell) is a type of macrophage, a professional phagocyte, found in the airways and at the level of the alveoli in the lungs, but separated from their walls.
Activity of the alveolar macropha ...
s sampled from the
bronchoalveolar lavage (BAL) in the lungs. The number can be four to six times greater in those who smoke than in non-smokers.
Types
There are four main types of emphysema, three of which are related to the anatomy of the
lobules of the lung – centrilobular or centriacinar, panlobular or panacinar, and paraseptal or distal acinar and are not associated with
fibrosis
Fibrosis, also known as fibrotic scarring, is a pathological wound healing in which connective tissue replaces normal parenchymal tissue to the extent that it goes unchecked, leading to considerable tissue remodelling and the formation of perma ...
(scarring). Although fibrosis is not a normal feature of these subtypes, repair strategies in end-stage emphysema may lead to
pulmonary fibrosis
Pulmonary fibrosis is a condition in which the lungs become scarred over time. Symptoms include shortness of breath, a dry cough, feeling tired, weight loss, and nail clubbing. Complications may include pulmonary hypertension, respiratory failu ...
.
The fourth subtype is known as paracicatricial emphysema or irregular emphysema, involves the acinus irregularly and is associated with fibrosis.
Only the first two types of emphysema – centrilobular, and panlobular are associated with significant airflow obstruction, with that of centrilobular emphysema around 20 times more common than panlobular. The subtypes can be seen on
imaging
Imaging is the representation or reproduction of an object's form; especially a visual representation (i.e., the formation of an image).
Imaging technology is the application of materials and methods to create, preserve, or duplicate images.
...
but are not well-defined clinically.
There are also a number of associated conditions including bullous emphysema, focal emphysema, and Ritalin lung.
Centrilobular
Centrilobular emphysema, also called centriacinar emphysema, affects the centre of a
pulmonary lobule
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...
(centrilobular) in the lung, the area around the terminal bronchiole, and the first respiratory bronchiole, and can be seen on imaging as an area around the tip of the visible pulmonary artery. Centrilobular emphysema is the most common type usually associated with smoking, and with
chronic bronchitis
Bronchitis is inflammation of the bronchi (large and medium-sized airways) in the lungs that causes coughing. Bronchitis usually begins as an infection in the nose, ears, throat, or sinuses. The infection then makes its way down to the bronchi. ...
. The disease progresses from the centrilobular portion, leaving the lung parenchyma in the surrounding (perilobular) region preserved.
Usually the upper lobes of the lungs are affected.
Panlobular
Panlobular emphysema, also called panacinar emphysema affects all of the alveoli in a lobule and can involve the whole lung or mainly the lower lobes.
This type of emphysema is associated with
alpha-1 antitrypsin deficiency
Alpha-1 antitrypsin deficiency (A1AD or AATD) is a genetic disorder that may result in lung disease or liver disease. Onset of lung problems is typically between 20 and 50 years of age. This may result in shortness of breath, wheezing, or an inc ...
(A1AD or AATD), and
Ritalin lung,
and is not related to smoking.
Complications
Likely complications of centrilobular, and panlobular emphysema, some of which are life-threatening, include:
respiratory failure
Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise ...
,
pneumonia
Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severi ...
,
respiratory infections
Respiratory tract infections (RTIs) are infectious diseases involving the respiratory tract. An infection of this type usually is further classified as an upper respiratory tract infection (URI or URTI) or a lower respiratory tract infection (LRI ...
,
pneumothorax
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve i ...
,
interstitial emphysema,
pulmonary heart disease
Pulmonary heart disease, also known as cor pulmonale, is the enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance (such as from pulmonic stenosis) or high blood pressure in the lungs.
Chroni ...
, and
respiratory acidosis
Respiratory acidosis is a state in which decreased ventilation (hypoventilation) increases the concentration of carbon dioxide in the blood and decreases the blood's pH (a condition generally called acidosis).
Carbon dioxide is produced continu ...
.
Paraseptal
Paraseptal emphysema, also called distal acinar emphysema relates to emphysematous change next to a
pleura
The pulmonary pleurae (''sing.'' pleura) are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls.
The inner pleura, called the visceral pleura, covers the surface of each lung and dips b ...
l surface, or to a
fissure
A fissure is a long, narrow crack opening along the surface of Earth. The term is derived from the Latin word , which means 'cleft' or 'crack'. Fissures emerge in Earth's crust, on ice sheets and glaciers, and on volcanoes.
Ground fissure
...
.
The cystic spaces known as
blebs or bullae that form in paraseptal emphysema typically occur in just one layer beneath the pleura. This distinguishes it from the
honeycombing
Honeycombing or "honeycomb lung" is the radiological appearance seen with widespread fibrosis and is defined by the presence of small cystic spaces with irregularly thickened walls composed of fibrous tissue
Fiber or fibre (from la, fibr ...
of small cystic spaces seen in
fibrosis
Fibrosis, also known as fibrotic scarring, is a pathological wound healing in which connective tissue replaces normal parenchymal tissue to the extent that it goes unchecked, leading to considerable tissue remodelling and the formation of perma ...
that typically occurs in layers.
This type of emphysema is not associated with airflow obstruction.
Bullous
![Bullus emphasemaCT](https://upload.wikimedia.org/wikipedia/commons/f/fc/Bullus_emphasemaCT.png)
When the
subpleural bullae are significant, the emphysema is called bullous emphysema. Bullae can become extensive and combine to form giant bullae. These can be large enough to take up a third of a hemithorax, compress the lung parenchyma, and cause displacement. The emphysema is now termed giant bullous emphysema, more commonly called vanishing lung syndrome due to the compressed parenchyma.
A
bleb or bulla may sometimes rupture and cause a
pneumothorax
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve i ...
.
Paracicatricial
Paracicatricial emphysema, also known as irregular emphysema, is seen next to areas of
fibrosis
Fibrosis, also known as fibrotic scarring, is a pathological wound healing in which connective tissue replaces normal parenchymal tissue to the extent that it goes unchecked, leading to considerable tissue remodelling and the formation of perma ...
(scarring) as large spaces. The scarring is most often a result of
silicosis,
granulomatous infection,
tuberculosis
Tuberculosis (TB) is an infectious disease usually caused by '' Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can also affect other parts of the body. Most infections show no symptoms, i ...
, or
pulmonary infarction. It can be difficult to differentiate from the
honeycombing
Honeycombing or "honeycomb lung" is the radiological appearance seen with widespread fibrosis and is defined by the presence of small cystic spaces with irregularly thickened walls composed of fibrous tissue
Fiber or fibre (from la, fibr ...
of
pulmonary fibrosis
Pulmonary fibrosis is a condition in which the lungs become scarred over time. Symptoms include shortness of breath, a dry cough, feeling tired, weight loss, and nail clubbing. Complications may include pulmonary hypertension, respiratory failu ...
.
HIV associated
Classic lung diseases are a complication of
HIV/AIDS
Human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV), a retrovirus. Following initial infection an individual ...
with emphysema being a source of disease. HIV is cited as a risk factor for the development of emphysema, and COPD regardless of smoking status.
Around 20 percent of those with HIV have increased emphysematous changes. This has suggested that an underlying mechanism related to HIV is a contributory factor in the development of emphysema. HIV associated emphysema occurs over a much shorter time than that associated with smoking; an earlier presentation is also seen in emphysema caused by
alpha-1 antitrypsin deficiency
Alpha-1 antitrypsin deficiency (A1AD or AATD) is a genetic disorder that may result in lung disease or liver disease. Onset of lung problems is typically between 20 and 50 years of age. This may result in shortness of breath, wheezing, or an inc ...
. Both of these conditions predominantly show damage in the lower lungs which suggests a similarity between the two mechanisms.
Alpha-1 related
Emphysema may develop in some people with
alpha-1 antitrypsin deficiency
Alpha-1 antitrypsin deficiency (A1AD or AATD) is a genetic disorder that may result in lung disease or liver disease. Onset of lung problems is typically between 20 and 50 years of age. This may result in shortness of breath, wheezing, or an inc ...
, the only
genotype of chronic obstructive pulmonary disease. This usually occurs a lot earlier, as does HIV associated emphysema than other types.
Ritalin lung
The intravenous use of
methylphenidate
Methylphenidate, sold under the brand names Ritalin and Concerta among others, is the most widely prescribed central nervous system (CNS) stimulant medication used to treat attention deficit hyperactivity disorder (ADHD) and, to a lesser exten ...
, commonly marketed as ''Ritalin'' and widely used as a
stimulant drug
Stimulants (also often referred to as psychostimulants or colloquially as uppers) is an overarching term that covers many drugs including those that increase activity of the central nervous system and the body, drugs that are pleasurable and in ...
in the treatment of
attention deficit hyperactivity disorder
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by excessive amounts of inattention, hyperactivity, and impulsivity that are pervasive, impairing in multiple contexts, and otherwise age-inap ...
, can lead to emphysematous changes known as Ritalin lung. The mechanism underlying this link is not clearly understood. Ritalin tablets contain
talc
Talc, or talcum, is a clay mineral, composed of hydrated magnesium silicate with the chemical formula Mg3Si4O10(OH)2. Talc in powdered form, often combined with corn starch, is used as baby powder. This mineral is used as a thickening agent a ...
as a filler, and these need to be crushed and dissolved for injecting. It has been suggested that the talc exposure causes
granulomatosis leading to alveolar destruction. However, other intravenous drugs also contain talc and there is no associated emphysematous change.
High resolution CT scanning shows the emphysema to be panlobular.
CPFE
Combined pulmonary fibrosis and emphysema
Combined pulmonary fibrosis and emphysema (CPFE), describes a medical syndrome involving both pulmonary fibrosis and emphysema. The combination is most commonly found in male smokers. Pulmonary function tests typically show preserved lung volume w ...
(CPFE) is a rare syndrome that shows upper-lobe emphysema, together with lower-lobe interstitial fibrosis. This is diagnosed by
CT scan.
This syndrome presents a marked susceptibility for the development of
pulmonary hypertension.
Congenital lobar
Congenital lobar emphysema (CLE), also known as congenital lobar overinflation and infantile lobar emphysema, is a
neonatal condition associated with enlarged air spaces in the lungs of
newborn infants. It is diagnosed around the time of birth or in the first 6 months of life, occurring more often in boys than girls. CLE affects the upper
lung lobes
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...
more than the lower lobes, and the left lung more often than the right lung.
CLE is defined as the hyperinflation of one or more lobes of the lung due to the partial obstruction of the bronchus. This causes symptoms of pressure on the nearby organs. It is associated with several cardiac abnormalities such as
patent ductus arteriosus
''Patent ductus arteriosus'' (PDA) is a medical condition in which the ''ductus arteriosus'' fails to close after birth: this allows a portion of oxygenated blood from the left heart to flow back to the lungs by flowing from the aorta, which has ...
,
atrial septal defect
Atrial septal defect (ASD) is a congenital heart defect in which blood flows between the atria (upper chambers) of the heart. Some flow is a normal condition both pre-birth and immediately post-birth via the foramen ovale; however, when this d ...
,
ventricular septal defect
A ventricular septal defect (VSD) is a defect in the ventricular septum, the wall dividing the left and right ventricles of the heart. The extent of the opening may vary from pin size to complete absence of the ventricular septum, creating one ...
, and
tetralogy of Fallot
Tetralogy of Fallot (TOF), formerly known as Steno-Fallot tetralogy, is a congenital heart defect characterized by four specific cardiac defects. Classically, the four defects are:
*pulmonary stenosis, which is narrowing of the exit from the r ...
.
Although CLE may be caused by the abnormal development of
bronchi
A bronchus is a passage or airway in the lower respiratory tract that conducts air into the lungs. The first or primary bronchi pronounced (BRAN-KAI) to branch from the trachea at the carina are the right main bronchus and the left main bronchus. ...
, or compression of airways by nearby tissues, no cause is identified in half of cases.
CT scan of the lungs is useful in assessing the anatomy of the lung lobes and status of the neighbouring lobes on whether they are hypoplastic or not. Contrast-enhanced CT is useful in assessing vascular abnormalities and mediastinal masses.
Focal
![Pneumot rax bullae](https://upload.wikimedia.org/wikipedia/commons/9/9f/Pneumot_rax_bullae.JPG)
Focal emphysema, is a localized region of emphysema in the lung that is larger than alveoli, and often associated with
coalworker's pneumoconiosis
Coal workers' pneumoconiosis (CWP), also known as black lung disease or black lung, is an occupational type of pneumoconiosis caused by long-term exposure to coal dust. It is common in coal miners and others who work with coal. It is similar to ...
.
This is also known as ''localized pulmonary emphysema''.
Blebs and bullae may also be included as focal emphysema. These can be differentiated from the other type of enclosed air space known as a
lung cyst
A focal lung pneumatosis, is an enclosed pocket of air or gas in the lung and includes blebs, bullae, pulmonary cysts, and lung cavities. Blebs and bullae can be classified by their wall thickness.
* A bleb has a wall thickness of less than 1 m ...
by their size and wall thickness. A bleb or bulla has a wall thickness of less than 1 mm, and are smaller.
Occupational
A number of occupations are associated with the development of emphysema due to the inhalation of varied gases and particles. In the US
uranium mining
Uranium mining is the process of extraction of uranium ore from the ground. Over 50 thousand tons of uranium were produced in 2019. Kazakhstan, Canada, and Australia were the top three uranium producers, respectively, and together account f ...
that releases
radon gas
Radon is a chemical element with the symbol Rn and atomic number 86. It is a radioactive, colourless, odourless, tasteless noble gas. It occurs naturally in minute quantities as an intermediate step in the normal radioactive decay chains through ...
and particles has been shown to be a cause of emphysema deaths; the figures in the study included some miners who also smoked. Uranium mining and milling was found to create environmental pollution.
The inhalation of
coal mine dust that can result in
coalworker's pneumoconiosis
Coal workers' pneumoconiosis (CWP), also known as black lung disease or black lung, is an occupational type of pneumoconiosis caused by long-term exposure to coal dust. It is common in coal miners and others who work with coal. It is similar to ...
is an independent risk factor for the development of emphysema. Focal emphysema is associated with the
coal macule, and this extends into progressive centrilobular emphysema. Less commonly a variant of panlobular emphysema develops.
Silicosis results from the inhalation of
silica
Silicon dioxide, also known as silica, is an oxide of silicon with the chemical formula , most commonly found in nature as quartz and in various living organisms. In many parts of the world, silica is the major constituent of sand. Silica is ...
particles, and the formation of large silica nodules is associated with paracicatricial emphysema, with or without bullae.
Ozone-induced emphysema
Ozone
Ozone (), or trioxygen, is an inorganic molecule with the chemical formula . It is a pale blue gas with a distinctively pungent smell. It is an allotrope of oxygen that is much less stable than the diatomic allotrope , breaking down in the lo ...
is another
pollutant
A pollutant or novel entity is a substance or energy introduced into the environment that has undesired effects, or adversely affects the usefulness of a resource. These can be both naturally forming (i.e. minerals or extracted compounds like o ...
that can affect the respiratory system. Long-term exposure to ozone can result in emphysema.
Osteoporosis
Osteoporosis is a major
comorbidity
In medicine, comorbidity - from Latin morbus ("sickness"), co ("together"), -ity (as if - several sicknesses together) - is the presence of one or more additional conditions often co-occurring (that is, concomitant or concurrent) with a primary ...
of emphysema. Both conditions are associated with a low
body mass index.
There is an association between treating emphysema, and
osteoporosis; the use of
systemic corticosteroids for treating
exacerbations is a significant risk factor for osteoporosis, and their repeated use is not recommended.
Other terms
Compensatory emphysema, is overinflation of part of a lung in response to either removal by surgery of another part of the lung or decreased size of another part of the lung.
Pulmonary interstitial emphysema
Pulmonary interstitial emphysema (PIE) is a collection of air outside of the normal air space of the pulmonary alveoli, found instead inside the connective tissue of the peribronchovascular sheaths, interlobular septa, and visceral pleura. (This ...
(PIE) is a collection of
air
The atmosphere of Earth is the layer of gases, known collectively as air, retained by Earth's gravity that surrounds the planet and forms its planetary atmosphere. The atmosphere of Earth protects life on Earth by creating pressure allowing f ...
outside of the normal air space of the
alveoli, found as
pneumatoses inside the
connective tissue of the peribronchovascular sheaths, interlobular septa, and
visceral pleura
The pulmonary pleurae (''sing.'' pleura) are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls.
The inner pleura, called the visceral pleura, covers the surface of each lung and dips b ...
.
Lung volume reduction
Lung volume reduction may be offered to those with advanced emphysema. When other treatments fail, and the emphysema is located in the upper lobes, a surgical option may be possible.
A number of minimally invasive
bronchoscopic
Bronchoscopy is an endoscopy, endoscopic medical procedure, technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument (bronchoscope) is inserted into the airways, usually through the nose or mouth, o ...
procedures are increasingly used to reduce lung volume.
Surgical
Where there is severe emphysema with significant hyperinflation that has proved unresponsive to other therapies,
lung volume reduction surgery
Cardiothoracic surgery is the field of medicine involved in surgical treatment of organs inside the thoracic cavity — generally treatment of conditions of the heart (heart disease), lungs (lung disease), and other pleural or mediastinal struc ...
(LVRS) may be an option.
LVRS involves the removal of tissue from the lobe most damaged by emphysema, which allows the other lobes to expand and give improved function. The procedure appears to be particularly effective if the emphysema primarily involves the upper lobes; however, the procedure increases the risk of adverse events and early death in people who have diffuse emphysema.
Bronchoscopic
Minimally invasive bronchoscopic procedures may be carried out to reduce lung volume. These include the use of valves, coils, or thermal ablation.
Endobronchial valve
An endobronchial valve (EBV), is a small, one-way valve, which may be implanted in an airway feeding the lung or part of lung. The valve allows air to be breathed out of the section of lung supplied, and prevents air from being breathed in. This ...
s are one-way valves that may be used in those with severe hyperinflation resulting from advanced emphysema; a suitable target lobe and no
collateral ventilation Collateral ventilation (CV) is a back-up system of alveolar ventilation that can bypass the normal route of airflow when airways are restricted or obstructed. The pathways involved include those between adjacent alveoli (pores of Kohn), between bro ...
are required for this procedure. The placement of one or more valves in the lobe induces a partial
collapse of the lobe that ensures a reduction in residual volume that improves lung function, the capacity for exercise, and quality of life.
The placement of
nitinol
Nickel titanium, also known as Nitinol, is a metal alloy of nickel and titanium, where the two elements are present in roughly equal atomic percentages. Different alloys are named according to the weight percentage of nickel; e.g., Nitinol 55 and ...
coils instead of valves is recommended where there is collateral ventilation that would prevent the use of valves.
Nitinol is a
biocompatible
Biocompatibility is related to the behavior of biomaterials in various contexts. The term refers to the ability of a material to perform with an appropriate host response in a specific situation. The ambiguity of the term reflects the ongoing de ...
shape-memory alloy
In metallurgy, a shape-memory alloy (SMA) is an alloy that can be deformed when cold but returns to its pre-deformed ("remembered") shape when heated. It may also be called memory metal, memory alloy, smart metal, smart alloy, or muscle wire.
P ...
.
Both of these techniques are associated with adverse effects, including persistent air leaks and cardiovascular complications. Bronchoscopic thermal vapor ablation has an improved profile. Heated water vapor is used to target affected lobe regions, which leads to permanent fibrosis and volume reduction. The procedure is able to target individual lobe segments, can be carried out regardless of collateral ventilation, and can be repeated with the natural advance of emphysema.
Other surgeries
Lung transplantation – the replacement of either a single lung or both (bilateral) – may be considered in
end-stage disease. A bilateral transplant is the preferred choice as complications can arise in a remaining single native lung; complications can include hyperinflation, pneumonia, and the development of lung cancer.
Careful selection as recommended by the ''National Emphysema Treatment Trial'' (NETT) for transplant surgeries is needed as in some cases there will be an increased risk of mortality.
Several factors including age, and poor exercise tolerance, using the
BODE index The BODE index, for Body-mass index, airflow Obstruction, Dyspnea, and Exercise, is a multidimensional scoring system and capacity index used to test patients who have been diagnosed with chronic obstructive pulmonary disease
Chronic obstr ...
need to be taken into account.
A transplant is only considered where there are no serious comorbidites.
A
CT scan or a
ventilation/perfusion scan
A ventilation/perfusion lung scan, also called a V/Q lung scan, or ventilation/perfusion scintigraphy, is a type of medical imaging using scintigraphy and medical isotopes to evaluate the circulation of air and blood within a patient's lungs, in ...
may be useful in surgery considerations to evaluate cases for surgical interventions, and also to evaluate post-surgery responses.
A
bullectomy may be carried out when a giant bulla occupies more than a third of a hemithorax.
History
![Giambattista morgagni](https://upload.wikimedia.org/wikipedia/commons/1/13/Giambattista_morgagni.gif)
The terms ''emphysema'' and ''chronic bronchitis'' were formally defined in 1959 at the
CIBA guest symposium, and in 1962 at the
American Thoracic Society The American Thoracic Society (ATS) is a nonprofit organization focused on improving care for pulmonary diseases, critical illnesses and sleep-related breathing disorders. It was established in 1905 as the
American Sanatorium Association, and ...
Committee meeting on Diagnostic Standards.
The word ''emphysema'' is derived from
Ancient Greek
Ancient Greek includes the forms of the Greek language used in ancient Greece and the ancient world from around 1500 BC to 300 BC. It is often roughly divided into the following periods: Mycenaean Greek (), Dark Ages (), the Archaic p ...
ἐμφύσημα 'inflation, swelling' (referring to a lung inflated by air-filled spaces), itself from ''emphysao'' 'to blow in, to inflate', composed of ἐν ''en'', meaning "''in''", and φυσᾶ ''physa'', meaning "''wind, blast''.
René Laennec
René-Théophile-Hyacinthe Laennec (; 17 February 1781 – 13 August 1826) was a French physician and musician. His skill at carving his own wooden flutes led him to invent the stethoscope in 1816, while working at the Hôpital Necker ...
, the physician who invented the
stethoscope, used the term ''emphysema'' in his book ''A Treatise on the Diseases of the Chest and of Mediate Auscultation'' (1837) to describe lungs that did not collapse when he opened the chest during an autopsy.
He noted that they did not collapse as usual because they were full of air and the airways were filled with mucus.
Early descriptions of probable emphysema include: in 1679 by T. Bonet of a condition of "voluminous lungs" and in 1769 by
Giovanni Morgagni
Giovanni Battista Morgagni (25 February 1682 – 6 December 1771) was an Italian anatomist, generally regarded as the father of modern anatomical pathology, who taught thousands of medical students from many countries during his 56 years as Prof ...
of lungs which were "turgid particularly from air".
In 1721 the first drawings of emphysema were made by Ruysh. These were followed the illustrations of
Matthew Baillie
Matthew Baillie FRS (27 October 1761 – 23 September 1823) was a British physician and pathologist, credited with first identifying transposition of the great vessels (TGV) and situs inversus.
Early life and education
He was born in the mans ...
in 1789 and descriptions of the destructive nature of the condition.
References
Bibliography
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External links
{{Medical resources
, ICD10 = {{ICD10, J43, {{ICD10, P25.0
Chronic lower respiratory diseases
Health effects of tobacco
Occupational diseases