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Emphysema

Emphysema is a chronic lung disease. It is often caused by exposure to toxic chemicals or long-term exposure to tobacco smoke. more...

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Signs and symptoms

Emphysema is characterised by loss of elasticity of the lung tissue; destruction of structures supporting the alveoli; and destruction of capillaries feeding the alveoli. The result is that the small airways collapse during expiration, leading to an obstructive form of lung disease (air is trapped in the lungs in obstructive lung diseases). Features are: shortness of breath on exertion--particularly when climbing stairs or inclines (and later at rest), hyperventilation and an expanded chest. As emphysema progresses, clubbing of the fingers may be observed, a feature of longstanding hypoxia.

Emphysema patients are sometimes referred to as "pink puffers". This is because emphysema sufferers may hyperventilate to maintain adequate blood oxygen levels. Hyperventilation explains why emphysema patients do not appear cyanotic as chronic bronchitis (another COPD disorder) sufferers often do; hence they are "pink" puffers (adequate oxygen levels in the blood) and not "blue" bloaters (cyanosis; inadequate oxygen in the blood).

Diagnosis

Diagnosis is by spirometry (lung function testing), including diffusion testing. Other investigations might include X-rays, high resolution spiral chest CT-scan, bronchoscopy (when other lung disease is suspected, including malignancy), blood tests, pulse oximetry and arterial blood gas sampling.

Pathophysiology

The scientific definition of emphysema is:

"Permanent destructive enlargement of the airspaces distal to the terminal bronchioles without obvious fibrosis".

Hence, the definite diagnosis is made by a pathologist. However, we can easily ascertain clinical diagnosis by history, clinical examination, chest radiography and lung function tests.

In normal breathing, air is drawn in through the bronchial passages and down into the increasingly fine network of tubing in the lungs called the alveoli, which are many thousands of tiny sacs surrounded by capillaries. These absorb the oxygen and transfer it into the blood. When toxins such as smoke are breathed into the lungs, the particles are trapped by the hairs and cannot be exhaled, leading to a localised inflammatory response. Chemicals released during the inflammatory response (trypsin, elastase, etc.) are released and begin breaking down the walls of alveoli. This leads to fewer but larger alveoli, with a decreased surface area and a decreased ability to take up oxygen and lose carbon dioxide. The activity of another molecule called alpha 1-antitrypsin normally neutralizes the destructive action of one of these damaging molecules.

After a prolonged period, hyperventilation becomes inadequate to maintain high enough oxygen levels in the blood, and the body compensates by vasoconstricting appropriate vessels. This leads to pulmonary hypertension. This leads to enlargement and increased strain on the right side of the heart, which in turn leads to peripheral edema (swelling of the peripherals) as blood gets backed up in the systemic circulation, causing fluid to leave the circulatory system and accumulate in the tissues.

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CT-scan determination of advanced, heterogeneous upper lobe emphysema at sites participating in a multicenter trial of the intrabronchial valve do not
From CHEST, 10/1/05 by David Ost

PURPOSE: Results of the National Emphysema Treatment Trial (NETT) demonstrated that patients with advanced, predominant upper lobe emphysema benefit the most from lung volume reduction surgery. Subjective upper lobe predominance and classification of emphysema as heterogeneous or homogeneous was based on scoring done by the designated radiologist at each NETT site. A central core lab was used by NETT for quality control. The purpose of this study was to evaluate if centers participating in a multicenter trial to evaluate the Spiration intrabronchial valve (IBV[TM]) system could correctly select patients with advanced heterogeneous, predominant upper lobe emphysema without the need of a central core lab. NETT radiological criteria and grading was recommended to the sites.

METHODS: CT-scans corresponding to patients enrolled in the study were evaluated by an independent, Board Certified Radiologist. The radiologist was blinded to patient and clinical site identification. The radiologist provided an independent determination of emphysema severity, predominance and heterogeneity based on a grading scale 0 (no emphysema)to 4 (severe emphysema) using NETT guidelines.

RESULTS: CT-scans corresponding to 27 patients enrolled and treated with IBV valves between January and July 2004 at 5 clinical sites were reviewed and evaluated. Average grading values of 3.11 [+ or -] 0.75 and 3.07 [+ or -] 0.78 were assigned to the right and left upper zones by the independent radiologist. Values of 1.33 [+ or -] 0.55 and 1.33 [+ or -] 0.48 were assigned the right and left lower zones.

CONCLUSION: Radiologist and/or investigators at each clinical site participating in the IBV multicenter trial, correctly selected and enrolled patients with advanced, heterogeneous and upper lobe emphysema. Guidelines established by the NETT study allowed for adequate selection without the need of using a central core lab.

CLINICAL IMPLICATIONS: CT-scan based selection of patients with advanced heterogeneous emphysema can be effectively done using appropriate radiological training and guidelines at new clinical sites participating in the IBV trial.

DISCLOSURE: David Ost, Grant monies (from industry related sources) Spiration Inc. is sponsoring clinical trial at my institution; Product/procedure/technique that is considered research and is NOT yet approved for any purpose. Intrabronchial Valve IBV being evaluated for the treatment of advanced emphysema.

David Ost MD * Justin P. Smith MD Xavier Gonzalez MD Steven C. Springmeyer MD Robert McKenna MD Northshore, Long Island Jewish, Manhasset, NY

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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