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Patients with emphysema are often unable to carry out daily activities. They frequently find themselves short of breath (called "dyspnea" in medical terms) during normal activities. There are several reasons for this shortness of breath.
The available therapies for emphysema have three goals:
Because there are multiple therapies for emphysema, it is important to understand the goal of these approaches. The most important contribution to the improvement in breathlessness and the prevention of lung deterioration, is to quit smoking. Smoking causes inflammation in the lungs. In some people, this inflammation leads to the development of emphysema. Smoking-related inflammation resolves once the cigarette smoking is stopped.
A small number of individuals have a familial type of emphysema due to a lack of a certain protein in the blood (alpha 1 anti-trypsin deficiency). These patients may benefit from regular intravenous infusions of the missing protein.
Patients with emphysema must try to avoid any lung infections that can lead to further lung damage. For this reason, most physicians recommend that patients with emphysema get Pneumovax. Pneumovax is a vaccine, given once every 7-10 years, that protects against certain types of bacterial pneumonia. Most physicians also recommend an annual influenza vaccine that is usually given in the fall. Early treatment of any respiratory infection is also an important contribution to the preservation of lung function.
In some patients, oxygen therapy can diminish the sensation of breathlessness and improve overall conditioning. If testing demonstrates low oxygen levels in the bloodstream, oxygen may be prescribed by the treating physician. It is important to realize that for patients with low oxygen levels, wearing oxygen as prescribed has been shown to prolong life. The more reliably these patients wear the oxygen, the greater the benefit of oxygen therapy. Other medications are directed at opening the breathing passages to facilitate the movement of air into and out of the lungs. These include bronchodilators and anti-inflammatory medications. Bronchodilators work to relax the muscles that are wrapped around the airways. Relaxation of the airway muscles can significantly improve air flow. Anti-inflammatory medications work to reduce inflammation and swelling of the airways. Both of these medications can be taken by inhalation or by mouth.
Some individuals with emphysema receive functional benefit by participating in Pulmonary Rehabilitation Programs. As mentioned above, many patients reach a level at which deconditioning limits their ability to participate in daily exercises. Pulmonary rehabiltiation programs teach breathing techniques and exercises to strengthen the breathing muscles. Rehabilitation programs also provide instruction in regular conditioning exercises to improve cardiovascular fitness. Although lung function does not change much during rehabilitation, the patient's ability to exercise and perform normal activities usually improves significantly. Studies of rehabilitation programs specifically designed for patients with emphysema have shown significant functional benefit.
Despite the use of medical therapy and pulmonary rehabilitation, many patients with emphysema remain limited in their activities because of poor lung function. While some of this limitation is due to the loss of the surface area of the lung, some of the disability may also be due to the loss of the lung's elasticity. The loss of elasticity in the lung may result in the lung becoming too large for the chest cavity. Recent reports in the press have described improvements in patients with emphysema and chronic obstructive lung disease as a result of surgery that removes a portion of the lung. This surgery has been attempted in the past. The surgery did not become widely accepted because it required specialized postoperative care. The specialization and expertise acquired in lung transplantation has recently been applied to emphysema surgery in several major centers. The goal of the surgery is to reduce the size of the lung. The smaller lung fits better within the chest cavity and allows the muscles of breathing to work more efficiently. The better fit of the lung also may help keep the airways open and improve the sensation of breathlessness.
An example of the problem is shown in the image above. The normal lung in "A" (shown in cross-section) fits in the chest (adapted from 1). The lung is normally distended. In contrast, the emphysematous lung in "B" is too large for the chest. Because the lung is oversized for the chest cavity, the lung is compressed, the airways are closed, and breathing is more difficult. Preliminary reports of surgical lung reduction have described significant functional improvement in patients symptoms and breathing tests. No long-term follow up is yet available and it is unclear how many patients will maintain their benefit after surgery. A major unanswered question is the relative benefit of surgery and respiratory rehabilitation.
Reference:
Brantigan OC, Mueller E, Kress MB. A surgical approach to pulmonary emphysema. Am Rev Respir Dis 1959; 80:194-206.
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