Emphysema

1. Emphysema Michael Haines, MPH, RRT-NPS, AE-C

2. Loss of elastic recoil • This loss of recoil leads to an increased compliance and inability to expel gas out of the alveoli • Leading to trapped air in the lung • Alveoli cluster together forming “blebs” • http://video.about.com/copd/Emphysema.htm What is Emphysema?

3. Damage occurs to the tiny airways in the lungs called bronchioles. Bronchioles are joined to alveoli, tiny grape-like clusters of sacs in the lungs where oxygen from the air is exchanged for carbon dioxide from the body. The elastic properties of the lung reside in the tissue around the alveoli • Because the lungs lose elasticity they become less able to contract. • This prevents the alveoli from deflating completely, and the person has difficulty exhaling. What is Emphysema Cont…

4. Hence, the next breath is started with more air in the lungs. • The trapped "old" air takes up space, so the alveoli are unable to fill with enough fresh air to supply the body with needed oxygen. Emphysema Cont…

6. A person with emphysema may feel short of breath during exertion and, as the disease progresses, even while at rest. • Emphysema is one of several irreversible lung diseases that diminish the ability to exhale. This group of diseases is called chronic obstructive pulmonary disease (COPD). The two major diseases in this category are emphysema and chronic bronchitis , which often develop together. Emphysema Cont…

7. 3rd Leading Cause of death in the US • Cigarette smoking is the primary cause of emphysema. • Most people with emphysema are older men. As with lung cancer and other smoking-related diseases, however, the incidence of emphysema is increasing among women. • Emphysema doesn't develop suddenly. Instead, it comes on gradually, usually after years of exposure to cigarette smoke or some other inhaled irritant. FACTS about Emphysema

8. Typically, symptoms of emphysema appear only after 30 to 50 percent of lung tissue is lost. • Emphysema rates are highest for men age 65 and older. • More people in the Midwest have emphysema than in any other region in the country. • Emphysema is an irreversible disease that can be slowed but not reversed or stopped. More FACTS…

9. Generally, lungs become damaged because of reactions to irritants entering the airways and alveoli. Researchers continue to investigate the factors that may make some people more susceptible to emphysema than others. But there are some clear causes for emphysema: • Cigarette smoking • Alpha-1 antitrypsin deficiency • http://www.youtube.com/watch?v=SqGoZRBrlvs&feature=related Causes

10. Alpha-1 Antitrypsin Deficiency • People who a deficiency of a protein called alpha-1 antitrypsin (AAT) are at a higher risk of developing severe emphysema. Alpha-1 antitrypsin deficiency (AAT deficiency) is an inherited condition and occurs in varying degrees Other Cause

11. AAT is thought to protect against some of the damage caused by macrophages. In AAT deficiency-related emphysema, the walls of the bronchial tubes and the alveoli are both damaged, often leading to severe disease. • About 2 out of every 1,000 people have an alpha-1 antitrypsin deficiency. People who smoke and have AAT deficiency are almost certain to develop emphysema.

12. Cigarette smoking is the major cause of emphysema. When exposed to cigarette smoke, the air sacs of the lungs produce defensive cells, called macrophages, which "eat" the inhaled particles. But macrophages are stimulated to release materials which can destroy the proteins that let the lungs expand and contract, called elastin and collagen . • Cigarette smoke also damages the cilia, tiny hair-like projections in the bronchi that "sweep" foreign bodies and bacteria out of the lungs Causes

14. The first sign of emphysema is shortness of breath when you are exerting yourself. Eventually, this shortness of breath may occur even when you are at rest. As the disease progresses, the following symptoms which are related to one of the other major lung diseases also caused by smoking - bronchitis - may occur: • Difficulty breathing (dyspnea) • Coughing (with or without sputum) • Wheezing (this can also be caused by emphysema itself) • Excess mucus production • A bluish tint to the skin (cyanosis) • Hypoxemia • Tachycardia • Polytcythemia Symptoms

15. Clubbed fingers (chronic hypoxia) • Right Heart Failure • Stained yellow fingers, teeth More Symptoms

16. Nice To Know: • If wheezing occurs, it helps to know whether it is found while breathing in or out (or both). Wheezing at the end of a complete exhalation is usually due to bronchitis. Wheezing that begins early in expiration is usually due to emphysema or the combination of bronchitis and emphysema - COPD.

17. If you only wheeze when you breathe in, you probably have asthma (or, very rarely, a narrowing of your windpipe in your neck). Asthma and emphysema sometimes are confused with each other. One way to tell the difference is to try asthma medications prescribed by your doctor and see if they make a difference. While people with asthma often respond dramatically to medications, people with emphysema usually do not respond to asthma medications and those with COPD may respond somewhat. In some people bronchitis may lead to asthma which is difficult, even for physicians, to distinguish from asthma due to allergy.

18. Emphysema may affect the brain, too. Low oxygen levels in the blood may mean that the brain is not getting enough oxygen. The end result can be grumpiness, irritability, impaired mental ability. High carbon dioxide levels in the blood can lead to headaches and sleeplessness. • As you age your lung naturally looses elasticity, so you can have a degree of emphysema naturally

19. History And Physical Examination • Smoking history (calculate pack years, # packs smoked times # years smoked) • Working environment- Breathing in any harmful chemicals? • A physical examination will include an examination of your chest and breathing patterns; prolonged expiratory times • Nasal flaring, accessory muscle usage (due to loss of diaphragm recoil from airtrapping) Diagnosis

20. X-Ray and/or CT of the Chest • Chest x-rays are a very useful tool to evaluate anatomy of the lung. In emphysema, there is evidence of increased air in the chest and destruction of some of the lung tissue. Bronchitis can be suspected on a chest x-ray by presence of thickening of the tissue around the large airways (bronchi). Chest x-rays are also useful as screening for lung cancer and heart disease. • Computerized axial tomography or CAT scans indicate lung anatomy in greater detail. In some cases, this information is needed to fully evaluate lung disease. Diagnosis Continued

21. Cat scan of chest • Air Trapping, flattened diaphragm

22. Lung Function Tests • Routine lung function tests can help define the kind and amount of damage to the lungs. The following tests can identify various stages of emphysema: • Spirometry measures breathing capacity. A common measure of breathing capacity is the forced expiratory volume in one second (FEV1), or the amount of air that can be forced out of the lungs in one second. This is a common way to determine the amount of airway obstruction. • http://www.youtube.com/watch?v=ZZdSkvf9l6U

23. Frequently, your physician will ask that spirometry and body plethysmography be repeated after administration of an inhaled bronchodilator • This test will help your physician determine if there is an asthmatic component present • Lung Volumes measures the amount of air in the lungs. This increases markedly in emphysema.

24. Diffusing Capacity measures the ability of the lung to transfer the gases from the air to the blood and vice versa. Decrease in diffusing capacity allow fairly accurate estimation of amount of emphysema. • Body Plethysmography is a rapid way of evaluating both degree and type of obstruction and lung volumes. It is an useful adjunct to understanding the mechanism of airway obstruction - e.g., asthma vs emphysema. • Arterial blood gases (ABG) analyzes blood from an artery for amounts of carbon dioxide and oxygen. This test is often used in more advanced stages of emphysema to help determine if a person needs supplemental oxygen.

26. Patient’s with emphysema have chronic CO2 retention due to the inability to expel gas. Their blood reflects higher levels of CO2 than normal people; CO2 is acidic in nature • Over time their body compensates for this higher CO2 by creating more buffer in the blood in the form of Bicarb from the Kidney Arterial Blood Gas

27. The over all balance of the blood is reflected by the blood’s pH. • People with emphysema have normal pH’s and high CO2 and high Bicarb • They also have chronically low oxygen in the blood Example • pH 7.36 • PaCo2 60 • PaO2 60 • HCO3 32

28. Tests For Alpha-1 Antitrypsin Deficiency • The symptoms of alpha-1 antitrypsin deficiency-related emphysema tend to appear between the ages of 30 and 40. The symptoms and diagnostic tests are basically the same in any kind of emphysema except that, in this disease, emphysematous changes are greatest in the lower lung. However, if AAT deficiency is suspected, a special blood test can confirm the diagnosis. Emphysema Diagnosis Cont…

29. There is no cure for emphysema. The goal of treatment is to slow the development of disabling symptoms. The most important step to take is to stop smoking. • Treatments for emphysema caused by smoking include medication, breathing retraining, and surgery. • People with inherited emphysema due to alpha-1 antitrypsin deficiency can receive alpha 1-proteinase inhibitor (A1PI), which slows lung tissue destruction. Treatment

30. Breathing Techniques Diaphragmatic Breathing • The diaphragm is a major muscle used in breathing and is located beneath the lowest two ribs. At rest, the diaphragm muscle is bell shaped. During inspiration, it lowers and flattens out. • Optimizing the use of the diaphragm is beneficial because it pulls air into the lower lobes of the lungs where more gas exchange takes place. Not only is the diaphragm the most efficient of all respiratory muscles, but using it tends to be very relaxing and calming. • Along with our diaphragm, we use intercostal and abdominal muscles in the work of breathing. The intercostals (muscles between the ribs) pull to lift the rib cage up and out. This causes the lungs to open in all directions and air can be pulled down the airways. To exhale, the muscles that have been pulling relax and air is forced out.

31. The diaphragm tenses, pulling air in; and relaxes, letting the spring of the ribs push the air out again. • Pursed Lip Breathing • How: • Breathe in through your nose. • Purse lips slightly as if to whistle. • Breathe out slowly through pursed lips. • Do not force the air out. • http://www.youtube.com/watch?v=8zA8Q2EPmkc

32. Medications To Treat Emphysema • Emphysema cannot be cured and, except for oxygen, does not reverse with any medication. However, emphysema is frequently associated with bronchitis and asthma and the symptoms associated with these processes often can be alleviated with medication (hence, you can see the value of pulmonary function and other tests designed to discover if there is asthmatic component present: • Bronchodilator medication • Corticosteroids • Supplemental oxygen Medications Used

33. Bronchodilator Medication • Bronchodilator medication may be prescribed for airway tightness. Bronchodilators react similar to norepinephrine through the sympathetic nervous system • The most commonly prescribed bronchodilators are beta2 agonists , the anti-cholinergic drug ipatropium bromide, and theophylline • Anti-cholinergics block musacaric receptors which normally respond to acetylcholine and cause bronchoconstriction

34. Corticosteroids • The potent anti-inflammatory medications known as corticosteroids - commonly called steroids - may be used to help lessen the inflammation that often accompanies emphysema. These may be taken by mouth or inhaled.

35. Due to the chronic state of increased CO2 in the blood (hypercapnia), the patient has adapted a breathing regulation in the brain that responds to changes in O2 and not CO2 like most people • If you give a patient with COPD more than 30% oxygen they will stop breathing!!! • Give low flow oxygen at 2 LPM by NC • Or high flow with venturi mask at 22-30% Oxygen

37. Surgical Treatments • Surgical treatments for emphysema remain experimental and are not covered by insurance. Most people with emphysema are not candidates for surgery. • Two types of surgery for people with emphysema are: • Lung reduction • Lung transplantation • http://www.youtube.com/watch?v=DNbflWcJbeA

38. Lung Reduction • A surgical procedure called lung reduction may improve symptoms for people with certain types of emphysema. During the procedure, part of the lung is cut out, giving healthy lung tissue more room to expand. • Lung reduction may eliminate the need for supplemental oxygen and make it much easier for the person to breathe. Early studies show that it reduces the volume of the over-inflated lungs. This improves the ability of the lung and chest wall to spring back during exhalation. This more-elastic lung appears to be the biggest reason that emphysema sufferers experience relief.

39. Emphysema is a chronic disease that takes years to progress; usually as a result of heavy cigarette smoking but also can be caused by inherited Alpha-1 antitrypsin deficiency • It destroys the stability of the alveoli and bronchioles leaving them over compliant • This leads to air trapping and an accumulation of CO2 and decrease in O2 • The air trapping leads to dyspnea • Diagnose with symptoms, ABG, CXR, PFT and history • Treatment consists of stop smoking, medications and lung reduction surgery or transplant Conclusion