Emphysema as a Major Form of Chronic Obstructive Pulmonary Disease - Research Paper Example

Emphysema Emphysema is one of the manifestations of obstructive, chronic and usually progressive lung diseases, collectively referred to as chronic obstructive pulmonary disease, COPD. It is a major form of COPD. Borrowing from credible secondary sources, this paper seeks to evaluate the pathogenesis, etiology, clinical findings, prognosis, signs and symptoms, prognosis and treatment of emphysema from which appropriate recommendations would be made. Introduction Chronic obstructive pulmonary disease, COPD is among the most common lung diseases. People with this disease normally experience airflow obstruction because of the narrowing of their airways. According to National Institute of Health, NIH (2014), COPD encompasses varied lung diseases that include emphysema, chronic obstructive airways disease and chronic bronchitis. This paper focuses on emphysema, the main type of COPD as noted by Klaassen (2013). Emphysema is a type of chronic lung disease. It normally causes people to have breathing difficulties due to blowing out air being limited and majorly affects people between the ages of 45 and 60 (NIH, 2014). It is estimated that over 10 million people in America are likely to have emphysema with 2011 having had 4.7 million Americans diagnosed with the condition according to statistics from the American Lung Association (2013). Historically, men exhibit higher prevalence for emphysema than women, though the past five years has seen the prevalence in women increase by 63% while prevalence among men has decreased by 6%. Together with bronchitis, emphysema is ranked fourth among the leading causes of death in America, killing about 16,242 people every year. Pathogenesis of Emphysema The pathogenesis of emphysema largely remains unclear. However, it has been generally accepted that emphysema occurs when delicate linings of air sacs which occur in the lungs get irreversibly damaged. It involves the inflammatory changes that occur in small airways accompanied by loss of small vessels and alveolar septal structures. This, according to NIH (2014), occurs due to gradual destruction of air sacs in the lungs making the patient slowly deprived of breath. There is also the postulate by Nici and ZuWallack (2012) that emphysema results from protease-antiprotease imbalance. For proper maintenance of lungs, there needs to be a delicate balance in the activity of protease and antiprotease. Interference with this balance results to lungs being destroyed or inappropriately repaired, eventually leading to emphysema. Additionally, the destruction of elastin fragments resulting from proteinases, referred to as the matrix, has a chemotactic impact on monocytes causing an increase in protease and inflammatory burden on lungs. This causes a positive feedback loop that leads to lung parenchyma being continuously destroyed. With increase in severity, this disease causes the spherical air sacs to enlarge and become irregular with gaping holes in the inner walls. As a result, the surface area of the lungs reduces causing a reduction in the amount of oxygen reaching the lungs (NIH, 2014). Furthermore, emphysema gradually destroys the elastic fibers responsible for holding open the small airways that lead to the air sacs. This causes the airways to collapse during exhalation so that the air in the lungs does not escape. This phenomenon has been used to develop a popular emphysema staging system referred to as GOLD. According to Nici and ZuWallack (2012), GOLD emphysema staging measures the amount of air exhaled in a second, known as forced expiratory volume, FEV1. At stage I, the mild emphysema involves FEV1 not below 80% of normal. At stage II, the moderate emphysema involves FEV1 of between 80% and 50% of the normal. Severe emphysema at stage III has FEV1 between 50% and 30% of the normal. Finally, the very severe emphysema would have FEV1 going below 30% of normal or at below 50% accompanied by low levels of blood oxygen. Doctors use this staging system to describe the progression and severity of emphysema. Etiology Tobacco smoking has been widely cited as the major cause of emphysema. It is still unclear how tobacco smoke causes emphysema but smokers exhibit 6 times more risk of contracting emphysema that non-smokers (NIH, 2014). Interestingly, a majority of heavy smokers would not contract the disease but remain exposed to other forms of smoke-related diseases. Marijuana smoke, manufacturing fumes, air pollution and silica and coal dust also cause emphysema. Furthermore, it has been noted that secondhand smoke causes emphysema (Nici & ZuWallack, 2012). People exposed to environmental smoke eventually have their lungs damaged, thus the reason for studies concluding that exposure to high levels of secondhand smoke increases the risk of emphysema. This also applies to air pollution although it remains unclear the extent to which it causes emphysema. This is because of the difficulty in conducting such studies, bearing in mind that many people are exposed to pollution and the fact that emphysema gradually develops over many years. Rarely, emphysema would be hereditary. This occurs as a result of inheriting the deficiency of a natural protein circulating in the blood referred to as alpha-1 antitrypsin, ATT. ATT protects normal tissues from being damaged by white blood cells known to contain destructive substances for fighting infections. According to NIH (2014), about 100,000 people in America are genetically deficient of alpha-1 antitrypsin. It is generally estimated that between 2% and 3% of those people suffering from emphysema have ATT deficiency. Smoking for these people worsens the damage. Whereas the symptoms of emphysema caused by smoking and ATT deficiency resemble, people with emphysema as a result of ATT deficiency develop the condition at a younger age. Clinical Findings Clinical research studies indicate that a majority of patients suffering from emphysema seek medical attention when the disease is at an advanced stage. This is because a majority of these people ignore the symptoms as they gradually progress over time. Moreover, Arunachalam, Sundar, Hwang, Yao and Rahman (2010) observe that the disease is associated with high mortality especially among patients with highly advanced emphysema. Prognosis There are various risk factors with regards to emphysema. The most common is smoking. According to Nici and ZuWallack (2012), cigarettes smokers are more likely to develop emphysema, though pipe and cigar smokers are also at risk. The American Lung Association (2013) support this observation noting that cigarette smoke is the most important factor leading to development of emphysema. As such, people smoking 30 cigarettes a day exhibit 20 times more likelihood of contracting emphysema than non-smokers. This risk increases with period of smoking and amount of tobacco. In a similar manner, secondhand smoke, also referred to as environmental or passive tobacco smoke, increases the chances of being infected with emphysema. Occupational exposure to dust from wood, cotton, grains or mining products and fumes from chemicals presents an even greater risk. This also applies for exposure to outdoor pollution such as car exhaust and indoor pollution such as heating fuel fumes. Age is also a risk factor with a high prevalence at ages 40 to 60. Finally, the genetic deficiency of alpha-1 antitrypsin protein the blood poses a risk of 1 out of 5,000 people contracting the disease. However, it is not always that when one has the gene that such a person would suffer from emphysema. Signs and Symptoms Emphysema symptoms are progressive and chronic, thus worsen over time. They also vary considerably and include breathing difficulties upon exertion, coughing and shortness of breath, referred to as dyspnea. Because of this gradual nature, they get diagnosed late when irreversible damage has occurred. Arunachalam, et al. (2010) also observe that episodes of worsening symptoms, referred to as exacerbations, are common with emphysema and become more frequent with advancement of the disease. Other symptoms include swelling, especially of ankles and feet, referred to as edema; bluish tint to fingertips, lips and skin due to low blood oxygen levels referred to as cyanosis; headaches especially upon waking up due to retention of carbon dioxide during sleep; weight loss; and fatigue. Emphysema patients often have chronic bronchitis. The end stages of emphysema would usually be indicated by inability to tolerate activity and increased shortness of breath. Emphysema signs as documented by NIH (2014) include breathing muscles moving irregularly; prolonged exhalation periods and grunting during exhalation; chest vibration during speaking, known as tactile fremitus; wheezes and crackles during inhalation; and barrel chest, referring to enlargement of chest and lungs and ineffectively using breathing muscles which cause the chest to change in shape. With progression of emphysema, shortness of breath during the slightest of activities would be observed. Patients also tend to lean forward and would use their arms or knees to support themselves on the surface ahead. There are a myriad complications associated with emphysema that make its mortality high. According to Klaassen (2013), people with emphysema are likely to have depression, anxiety and sleep disturbances. They also tend to have right-sided heart failure and pulmonary hypertension, referred to as cor pulmonale. Furthermore, they have excess production of red blood cells in response to the low levels of oxygen in the blood, referred to as polycthemia. Polycthemia poses the risk of small blood vessels blocking. People with emphysema would have air collect within the membrane surrounding the lungs referred to as the pleural space. This condition is referred to as pneumothorax. Other complications include heart failure, respiratory failure and pneuomonia and lung infectons. Diagnosis Diagnosis of emphysema involves collating complete history of the patient and the family then conducting physical examinations and diagnostic tests. As noted by Klaassen (2013), the physician seeks to determine smoking habits and history of symptoms through medical history. Physical examination would involve using a stethoscope to listen to the lungs and look for signs of emphysema like decreased breath sounds and barrel chest. If physical examination and medical history suggest the existence of emphysema, diagnostic tests would be conducted. Patients with familial history of emphysema would have their blood tested for alpha-1 antitrypsin deficiency so as to rule out other conditions. Nici and ZuWallack (2012) observe that arterial blood gas, ABG, where blood is drawn from arteries as opposed to veins, measures carbon dioxide and oxygen level in the blood to determine the viability of oxygen therapy. Imaging helps in detecting lung inflammations so as to rule out other possible lung conditions like lung cancer and pneumonia. This includes chest x-rays and computed tomography (CT scan). A pulse oximeter, an electronic device used in oximetry, would be attached to the body to measure the levels of oxygen in the blood. It measures the difference in color, borrowing from the fact that blood deprived of oxygen, unlike the brighter red oxygenated blood, is bluish purple. The normal oxygen saturation should be greater than 90% with lower rates pointing towards decreased lung functioning. Finally, pulmonary function tests measure lung air flow and evaluate the functioning of the lungs so as to confirm emphysema diagnosis and determine severity. Spirometry is used to measure the air capacity of lungs with lung volume tests used to measure the capacity and functioning of lungs. Chest x-rays have also been used in some instances to show the hyper-expansion of lungs. The presence of emphysema would show lung fields looking enlarged and empty and could flatten out the diaphragm (Klaassen, 2013). This x-ray scan could also show dilated airspaces, referred to as bullae, outside the lungs in the case of severe emphysema. Furthermore, echocardiogram, ECG could be used to test for signs failure of the right heart. Treatment Even though emphysema is irreversible, treatment could help in reducing the symptoms and slowing down progression. The most basic step to start with is quitting smoking. This could considerably slow down the decline in lung functioning (NIH, 2014). Furthermore, emphysema patients would be encouraged to undertake pursed-lip breathing so as to improve air flow into the lungs. Slow breathing through pursed lips allows these patients to effectively exhale more. Those considered to be healthy would be encouraged to engage in more exercises. Of importance is to seek advice from a physician before undertaking an exercise program. Treatment also includes medications, surgery, respiratory therapy and oxygen therapy. As noted by Klaassen (2013), medications range from a wide array of inhalers to varied oral drugs. Inhalers and nebulizers directly deliver medication into the affected lungs. Bronchodilators treat acute exacerbations or prevent worsening of symptoms. Anti-inflammatory drugs reduce lung inflammation while antibiotics treat infections responsible for acute exacerbations. Familial emphysema could be treated with alpha-1 protease inhibitor after prior introduction to medications aimed at reducing the risk of allergic reactions. Medications have varied side effects including pain, headache, dizziness, tremor, nervousness and thrush among many others. For advanced emphysema, oxygen therapy would be used. Physicians usually measure the level of blood oxygen to determine whether the patient would benefit from this therapy. The oxygen would mostly be delivered from an oxygen tank through small tubes, referred to as nasal cannula, to the nose of the patient. Arunachalam, et al. (2010) document studies that show prolongation of life among emphysema patients with low blood oxygen levels. Respiratory therapists monitor the condition of emphysema patients and regulate the treatment medical equipment. These therapists ensure that such equipment function well and make adjustments as guided by physicians. Furthermore, they perform physical therapy with the aim of improving or preserving lung function. Surgery could be used selectively and include lung transplant for end-stage disease patients and lung reduction surgery where damaged sites of the lung tissue would be removed to allow effective functioning of healthy tissues. Vaccinations have also proved to be beneficial. Yearly influenza vaccination together with pneumococcal vaccination reduces effective exacerbations. Right heart failure could perhaps call for treatment with tablets, known as diuretics, so as to remove excess fluid (Nici & ZuWallack, 2012). As noted by the American Lung Association (2013), antidepressant medication and counseling would help a patient overcome the depression associated with the disease that could cause disabilities. Thus, it would be important to consider the severity and nature of one’s condition before making a choice on medication for emphysema. Recommendation Therefore, emphysema is a critical condition that progressively impacts negatively on humans. As such, it would be critical for appropriate preventive measures to be adopted. Maintaining a healthy lifestyle, including proper eating and regular exercises would be beneficial as suggested by NIH (2014). Furthermore, people should avoid exposure to secondhand smoke and air pollution. Anyone with emphysema symptoms or with a history of smoking should promptly see a physician. Prompt medical treatment would play a critical role in preventing emphysema. Since different people exhibit different symptoms and severity of the disease as noted by the American Lung Association (2013), it would be appropriate to seek for advice from a physician before embarking on any medication. Furthermore, physicians should be aware of the side effects of the various forms of medication and advise their patients appropriately. Conclusion Emphysema is one of the chronic diseases collectively referred to as chronic obstructive pulmonary disease, COPD. It progresses from mild to severe over time, a characteristic which makes diagnosis difficult. In fact, clinical findings indicate that a majority would be diagnosed at advanced stages. This diagnosis involves reviewing the patient’s family history and smoking habits with confirmations from blood tests, oximetry, imaging tests and pulmonary function tests. It mostly affects tobacco smokers, including secondhand smokers, though air pollutants and hereditary factors also present the risk of contracting the disease. Signs and symptoms include respiratory complications and treatment only seeks to slow down progression as damage to lungs is irreversible. Thus, it would be appropriate to adopt preventive strategies including maintenance of healthy lifestyle and avoiding exposure to air pollutants. Importantly, physician’s advice should be sought promptly to better manage the condition. References American Lung Association. (2013). Trends in COPD (chronic bronchitis and emphysema): Morbidity and mortality. Retrieved 30 March 2014 from http://www.lung.org/ Arunachalam, G., Sundar, I. K., Hwang, J., Yao, H. & Rahman, I. (2010). Emphysema is associated with increased inflammation in lungs of atherosclerosis-prone mice by cigarette smoke: Implications in cormobidities of COPD. Journal of Inflammation, 7 (34). doi:10.1186/1476-9255-7-34 Klaassen, C. (2013). Casarett & Doull’s toxicology: The basic science of poisons (8th ed.). New York, NY: McGraw Hill Professional. National Institute of Health. (2014, January 7). Emphysema. US Department of Health and Human Services. Retrieved 29 March 2014 from http://www.nlm.nih.gov/ Nici, L. & ZuWallack, R. (2012). Chronic obstructive pulmonary disease: Co-morbidities and systemic consequences. New York, NY: Springer. Read More