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Emphysema

Brief Overview: Per UpToDate, “Emphysema describes enlargement of the airspaces distal to the terminal bronchioles that is accompanied by destruction of the airspace walls, a pathologic finding frequently seen in patients with COPD. This finding manifests clinically with decreased breath sounds and evidence of hyperinflation of the lungs on examination or imaging; it is frequently associated with dyspnea. Emphysema is classically not accompanied by macroscopic fibrosis. While emphysema can exist in individuals who do not have airflow limitation, it is more common among patients who have moderate or severe airflow obstruction.”

Per Cleveland Clinic: “The Global Initiative for Chronic Obstructive Lung Disease (GOLD) categorizes COPD in four stages. Emphysema is a cause of COPD, but not all patients with emphysema have COPD. Healthcare providers use the COPD stages to help describe emphysema. The stages are:

  • Stage 1. This is the mildest stage of emphysema. Your lungs operate at least 80% as well as the healthy lungs of someone who’s the same age, height and sex.
  • Stage 2. This is moderate emphysema. Your lungs operate between 50% and 79% as well as the healthy lungs of someone who’s the same age, height and sex.
  • Stage 3. This is severe emphysema. Your lungs operate between 30% and 49% as well as the healthy lungs of someone who’s the same age, height and sex.
  • Stage 4. This is very severe emphysema. Your lungs operate less than 30% as well as the healthy lungs of someone who’s the same age, height and sex.”

Prevalence: Per Pulmonology Advisor, “According to the Centers for Disease Control and Prevention (CDC), in 2021 COPD was the sixth leading cause of death in the United States (US).3 Approximately 14.2 million (6.5%) US adults were diagnosed with the disease in 2021.”

Etiology: According to Medline Plus, “The cause of emphysema is usually long-term exposure to irritants that damage your lungs and the airways. In the United States, cigarette smoke is the main cause. Pipe, cigar, and other types of tobacco smoke can also cause emphysema, especially if you inhale them. Exposure to other inhaled irritants can contribute to emphysema. These include secondhand smoke, air pollution, and chemical fumes or dusts from the environment or workplace. Rarely, a genetic condition called alpha-1 antitrypsin deficiency can play a role in causing emphysema.”

Risk Factors:

  • Cigarette smoking
  • Long-term exposure to irritants, smoke, fumes, chemicals, biomass fuel, etc.
  • Age > 40 years old
  • Genetics, family history

Commonly Associated Conditions:

  • Chronic bronchitis (COPD overlap)
  • Pulmonary hypertension
  • Right-sided heart failure (cor pulmonale)
  • Lung cancer
  • Anxiety and depression
  • Weight loss, muscle wasting
  • Osteoporosis

Common Medications:

Medication therapy focuses on bronchodilation, symptom relief, and exacerbation prevention.

  • Bronchodilators:
    • Short-acting beta-agonists (SABA): albuterol
    • Short-acting muscarinic antagonists (SAMA): ipratropium
    • Long-acting beta-agonists (LABA): salmeterol, formoterol
    • Long-acting muscarinic antagonists (LAMA): tiotropium, umeclidinium
  • Combination inhalers:
    • LABA/LAMA combinations
    • ICS/LABA or ICS/LABA/LAMA (selected patients with frequent exacerbations)
  • Other medications (selected patients):
    • Systemic corticosteroids during acute exacerbations
    • Antibiotics during infectious exacerbations

Common Labs, Imaging, and Tests:

  • Chest x-ray
  • Chest CT
  • Pulmonary function testing/spirometry
  • Arterial blood gas may be indicated for some
  • Blood tests, genetic tests (alpha-1 antitrypsin level)
  • ECG

Common Symptoms:

  • Shortness of breath
  • Fatigue
  • Cough
  • Wheezing
  • Chest tightness
  • Mucus production
  • Anxiety, depression
  • Reduced exercise tolerance
  • Weight loss

Common Treatments:

  • Medication (see above)
  • Smoking cessation (most effective intervention)
  • Stepwise inhaler therapy based on symptoms and exacerbation risk
  • Pulmonary rehabilitation
  • Supplemental oxygen therapy when indicated
  • Vaccinations (influenza, pneumococcal, COVID-19) as recommended by healthcare provider
  • Surgical options (selected cases): lung volume reduction surgery, endobronchial valves, lung transplant

Physical Findings:

  • Decreased breath sounds
  • Prolonged expiratory phase
  • Barrel-shaped chest (advanced disease)
  • Use of accessory muscles
  • Pursed-lip breathing
  • Signs of hypoxia or hypercapnia in severe disease

Potential Complications and Contraindications:

  • Potential complications:
    • Acute exacerbations
    • Respiratory failure
    • Pulmonary hypertension and cor pulmonale
    • Pneumothorax (due to bullae rupture)
    • Increased risk of lung cancer
  • Contraindications / cautions:
    • Overuse of systemic corticosteroids
    • Increased pneumonia risk with inhaled corticosteroids
    • Sedatives and opioids may suppress respiratory drive
    • Careful medication selection in patients with cardiac disease

General Health and Lifestyle Guidance:

  • Reinforce smoking cessation and avoidance of inhaled irritants
  • Encourage correct inhaler technique and adherence
  • Promote participation in pulmonary rehabilitation
  • Encourage regular, paced physical activity, as tolerated and approved by healthcare provider
  • Maintain adequate nutrition and monitor weight loss
  • Recognize early signs of exacerbations and seek prompt care
    • Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  

Suggested Questions to Ask Patients:

  1. How far can you walk before getting short of breath?
  2. How often do you use your rescue inhaler?
  3. Any recent flare-ups, ER visits, or hospitalizations?
  4. Have you noticed changes in sputum or cough?
  5. Are you using your inhalers correctly and daily as prescribed?
  6. Do you currently smoke or have exposure to smoke or fumes?
  7. Are symptoms limiting daily activities or sleep?

Suggested Talking Points:

  • Emphysema is a chronic lung condition that can be managed, even though it’s not reversible.
  • Stopping smoking is the most important step to slow disease progression.
  • Daily inhalers help keep airways open and reduce flare-ups.
  • Pulmonary rehab can significantly improve breathing and endurance.
  • Early treatment of flare-ups helps prevent hospital stays.
    • Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.