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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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Early and long-term results of lung volume reduction in patients with emphysema
From CHEST, 10/1/05 by Koji Chihara

PURPOSE: We hypothesized that dyspnea in patients with emphysema was related with hyperinflation by highly destructed part with excessive trapped air and poor perfusion which could be expressed as "air-oma". Accordingly we selected patients for LVRS with functional imaging modalities (HRCT, perfusion scan, dynamic MRI etc.) as well as functional examinations. We report early and long-term results of LVRS for consecutive 31 patients.

METHODS: Between October 1995 and June 2003 we selected 31 patients who felt severe dyspnea during walk. Their characteristics and mean values in function testing were as follows; a mean age of 68 yr (range 52 - 80), BMI of 18 Kg/m2 (15-23), %FEV1 of 27% (11- 46), %RV of 263 % (178-385), and 6 MWD of 287m (75 - 450). We decided airoma in the upper lobes of 12 patients, in the lower lobes of 12 patients, in both lobes of 6 patients, and in the middle lobe of 1 patient, and resected these by bilateral procedure in 17 patients, and by unilateral procedure in others. All patients were followed ranging from 1.8 to 9.5 years (median 6.5 yrs).

RESULTS: There was no in-hospital mortality. Two patients underwent reexploration for air leak, and two patients needed mechanical ventilation for a few months one month after LVRS. All patients except one reported decrease in dyspnea, and were satisfied with surgery. Eleven patients out of 22 patients who underwent LVRS by Dec 1999 survived more than 5 years. The Kaplan-Meier survival after LVRS were 96.8%, 93.6%, 90.1%, 72.1%, 49.3% at 1,2,3,4, and 5 years, respectively. There were no difference between survival of patients with upper lobe airoma and those with lower lobe airoma.

CONCLUSION: Lung volume reduction surgery for patient with emphysema selected by functional imaging modalities produces symptomatic improvement in early-term, and better survival at least 3 years.

CLINICAL IMPLICATIONS: Lung volume reduction surgery is a good and promising palliative treatment for patients with advanced emphysema wherever the target area, or airoma, is located.

DISCLOSURE: Koji Chihara, None.

Koji Chihara MD * Daisuke Nakajima MD Akihiko Yamashina MD Masanao Nakai MD Hisashi Sahara MD Toru Tsuda MD Tomoya Kono MD Akihiro Osumi MD Akihiro Aoyama MD Fenshi Chen MD Noritaka Isowa MD Shotaro Iwakiri MD Shizuoka City Shizuoka Hospital, Shizuoka, Japan

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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