Definition
A.Emphysema is an abnormal dilation and destruction of alveolar ducts and airspaces distal to the terminal bronchioles. Lung function slowly deteriorates over many years before the illness develops. Emphysema is one of the chronic obstructive pulmonary diseases (COPDs)—a term that refers to conditions characterized by continued increased resistance to expiratory airflow. Chronic bronchitis, emphysema, and asthma comprise COPD. Chronic bronchitis and emphysema with airflow obstruction commonly occur together.
B.There are three morphological types of emphysema:
1.Centriacinar emphysema: Associated with long-term smoking; primarily involves the upper half of the lungs.
2.Panacinar emphysema, found predominantly in the lower half of the lungs; this is observed in patients with alpha 1-antitrypsin (AAT) deficiency.
3.Paraseptal emphysema involves the distal airway.
Incidence
A.Emphysema typically occurs in people older than age 50, with peak occurrence after the age of 65.
B.The prevalence of emphysema is 20.2 cases per 1,000.
C.The prevalence is greater in Caucasians than other ethnicities.
D.Emphysema is slightly greater in females (21.4/1,000) than males (19.0/1,000).
Pathogenesis
A.Decreased gas exchange occurs due to focal destruction limited to the airspaces distal to the respiratory bronchioles, causing airway obstruction, hyperinflation, loss of lung recoil, and destruction of alveolar–capillary interface.
Predisposing Factors
A.Long-term cigarette smoking.
B.Occupational and environmental exposure to toxic agents:
1.Dust.
2.Chemical fumes.
3.Secondhand smoke.
4.Air pollution.
5.Gases.
C.Alpha 1-protease inhibitor deficiency.
D.Intravenous (IV) drug use secondary to pulmonary vascular damage from the insoluble fillers (e.g., cornstarch, cotton fibers, cellulose, talc).
E.Connective tissue disorders (e.g., Marfan syndrome and Ehlers-Danlos).
F.HIV.
Common Complaints
A.Gradually progressing exertional dyspnea.
B.Chronic cough.
C.Wheezing.
D.Fatigue.
E.Weight loss.
Other Signs and Symptoms
A.Cough with mild to moderate sputum production and clear to mucoid sputum.
B.Early morning cough.
C.Shortness of breath (SOB).
D.Tachypnea.
E.Use of accessory muscles for breathing, pursed-lip breathing, prolonged expiration.
F.Barrel chest (increased anterior to posterior chest diameter).
G.Flushed skin.
H.Clubbed fingers.
I.Decreased libido.
J.Thin, wasted appearance.
K.Wheezing, particularly during exertion and exacerbations of emphysema.
L.Functional impairment related to dyspnea.
M.Depression.
Subjective Data
A.Elicit information about onset, duration, and course of symptoms.
B.Determine if the patient is a smoker. Determine cigar use and cigarette pack-year history (pack/day times the number of years smoked). If so, how much and for how long? Evaluate exposure to secondhand smoke. How much of the day? Are they interested in quitting?
C.Ask about current and previous work. Is the patient exposed to occupational and environmental irritants, such as dust, fumes, or gases? If so, what are the type, level, and duration of exposures?
D.Inquire about the cough’s characteristics. Is it productive, dry, bronchospastic, brassy, wheezy, strong, or weak?
E.Question the patient about episodes of tachypnea, frequency of respiratory infections, and incidence of angina during exertion.
F.Does the patient have a hereditary disease (e.g., cystic fibrosis (CF) or AAT deficiency), asthma, nasal abnormalities (e.g., deviated septum), or other respiratory problems?
G.Last tuberculin skin test and recent risk for tuberculosis (TB) exposure?
H.Find out the patient’s usual weight, and assess how much weight loss has occurred and over what time period.
I.Evaluate current vaccination status for pneumonia and influenza.
J.Review all medications, including over-the-counter (OTC) and herbal products.
K.Assess the patient’s ability to perform activities of daily living (ADL) and instrumental activities of daily living (IADL), including grooming and personal hygiene, performing chores around the home, shopping, cooking, and driving.
L.Ask about alcohol use.
M.Screen for depression.
N.Ask about frequency of use of short-acting beta-2 agonists (SABA) and effectiveness.
O.Inquire about use of ED or need for hospitalization. Previous ventilation?
Physical Examination
A.Temperature (if indicated), pulse, respirations, blood pressure (BP), and weight for changes. Consider pulse oximetry.
B.Inspect:
1.Observe general appearance; note flushed skin color, use of accessory muscles, pallor around lips, pursed-lip breathing, barrel chest (lung hyperinflation), and thinness.
2.Assess for peripheral edema.
3.Dermal examination: Note finger clubbing and cyanosis.
4.Observe mental status and psychiatric concerns including depression
C.Auscultate:
1.Auscultate heart.
2.Auscultate lungs for wheezes, crackles, decreased breath sounds (generally diffuse decreased breath sound).
3.Assess for vocal fremitus (vibration) and egophony (increased resonance and high-pitch bleating quality). Air trapping causes air pockets that do not transmit sound well.
D.Percuss:
1.Percuss chest for presence of hyperresonance and signs of consolidation.
2.Percuss abdomen for organomegaly.
E.Palpate:
1.Palpate the neck, superior and inferior clavicular spaces for lymphadenopathy.
2.Palpate abdomen for organomegaly.
3.Grade dependent edema.
F.Further physical examinations are dependent on comorbidities.
G.Mental status: Assess for decreased level of consciousness (LOC).
Diagnostic Tests
A.Pulse oximetry: Blood gases if indicated. Baseline should be considered as early in disease process as patient presents.
B.AAT to rule out hereditary deficiency.
C.Tuberculin skin test.
D.Pulmonary function tests (PFTs) reveal increased total lung capacity with poor respiratory expulsion and increased respiratory volume.
E.ECG reveals sinus or supraventricular tachycardia.
F.Chest radiograph (CXR) reveals hyperinflation, flat diaphragm, and enlarged heart.
G.Sputum evaluation and/or culture.
Differential Diagnoses
A.Emphysema.
B.Chronic bronchitis.
C.Chronic asthma.
D.Bronchiectasis.
E.CF.
F.Chronic asthmatic bronchitis.
G.TB.
H.AAT deficiency.
I.Congestive heart failure (CHF).
Plan
A.Medical management: Supplemental oxygen therapy is indicated if the patient has a resting PaO2 less than 55 mmHg or a PaO2 less than 60 mmHg along with right heart failure or secondary polycythemia. Goals are to achieve a PaO2 of greater than 55 mmHg (usually 1–3 L/min).
B. 
See Section III: Patient Teaching Guide Emphysema.
C.Develop a smoking cessation plan: Assess readiness to quit. Set a quit date, and encourage a group smoking cessation program. A smoking cessation plan is an essential part of a comprehensive treatment plan:
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines note a five-step program for smoking intervention:
1.ASK: Systematically identify all tobacco users at every visit, EVERY patient at EVERY clinic visit is queried about tobacco-use status.
2.ADVISE: Strongly urge all tobacco users to quit in a clear, strong, and personalized manner.
3.ASSESS: Determine willingness and rationale of the patient’s desire to make a quit attempt. Ask every tobacco user if he or she is willing to make a quit attempt at this time (e.g., within the next 30 days).
4.ASSIST: Aid in quitting, make a quit plan, provide practical counseling, provide educational materials, and help the patient to obtain social support. Pharmacotherapy if appropriate
5.ARRANGE: Schedule a follow-up contact either in person or by telephone.
D.Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain at this time. See Section III: Patient Teaching Guide Nicotine Dependence
:
1.Nicotine chewing gum produces better quit rates than counseling alone.
2.Transdermal nicotine patches have a long-term success rate of 22% to 42%.
3.The use of vapor nicotine products should be discussed, as their long-term adverse effects on lung function is unknown.
4.The use of an antidepressant such as bupropion sustained release (Zyban) has been shown to be effective for smoking cessation by reducing the enjoyment of smoking, reducing withdrawal symptoms, and limiting weight gain. Bupropion may be used in combination with nicotine replacement therapy (NRT). Begin dosing 1 week before quit date:
a.Day 1 to 3 of treatment: 150 mg every morning.