Emphysema – Causes, Symptoms, Treatments

What is Emphysema?

Emphysema is a type of chronic obstructive pulmonary disease (COPD) that causes shortness of breath. It is a progressive disease, which means it gets worse over time. Emphysema damages the air sacs in your lungs. These air sacs, called alveoli, are like tiny balloons that allow oxygen to enter your bloodstream and carbon dioxide to leave your bloodstream.

When you have emphysema, the walls of the alveoli break down. This makes it harder for your lungs to get rid of old air and take in new air. As a result, your blood oxygen levels can drop, and your carbon dioxide levels can rise. This can make you feel tired and short of breath.

Emphysema is typically characterized by the following features:

• Air sac damage: The walls of the air sacs become weakened and eventually break down, leading to the formation of larger air spaces. This reduces the elasticity of the lung tissue and impairs its ability to effectively push air out during exhalation.
• Air trapping: In emphysema, air can become trapped in the damaged air sacs, making it difficult for the affected individual to fully exhale. This leads to hyperinflation of the lungs and a characteristic “barrel chest” appearance.
• Decreased lung function: The destruction of lung tissue reduces the surface area available for gas exchange, resulting in decreased lung function. This leads to symptoms such as shortness of breath, particularly during physical activity, and reduced exercise tolerance.
• Chronic cough and sputum production: Many individuals with emphysema experience a chronic cough and produce excess mucus or sputum, which can be difficult to clear from the airways.
• Progressive nature: Emphysema is a progressive disease, meaning that it tends to worsen over time. The damage to the lungs is irreversible, and while treatments can help manage symptoms and slow the progression of the disease, there is currently no cure.

Emphysema is a significant public health concern, affecting a large number of people worldwide. The American Lung Association states that over three million people in the United States have been diagnosed with emphysema. This highlights the substantial number of individuals impacted by the disease within the US alone.

According to the World Health Organization, chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide, causing 3.23 million deaths in 2019. This emphasizes the widespread nature and severity of emphysema on a global scale.

Types of Emphysema

Emphysema can be classified into four main types based on the specific areas of the lung lobule that are damaged. The two most common types are centrilobular and panlobular emphysema. 

Centrilobular emphysema, primarily caused by smoking, affects the central regions of the acinus (air sac unit) and is more prevalent in the upper lobes. The damage starts in the center and progresses outwards, enlarging and destroying the alveoli. 

Panlobular emphysema, on the other hand, can have various causes including a genetic condition and air pollution. It affects the entire acinus uniformly and can involve all areas of the lung, though the lower lobes might be more affected.

There are two less common classifications: paraseptal and paracicatricial emphysema. Paraseptal emphysema primarily affects the walls of the acinus, especially along the borders separating lobules, and the cause is not fully understood. It often affects the upper lobes and lower edges of the lungs with damage progressing inwards from the walls.

Paracicatricial emphysema, the least common type, develops in areas of the lung with existing scarring and can occur anywhere significant scarring is present.

Causes of Emphysema

The primary causes of emphysema are related to long-term exposure to lung irritants, particularly cigarette smoke. Other factors, such as air pollution, chemical fumes, dust, and genetic factors, can also contribute to its development.

Cigarette smoke contains a complex mixture of chemicals and toxins that can cause inflammation and damage to the small airways and air sacs in the lungs. Chronic exposure to cigarette smoke leads to the breakdown of the elastic fibers in the lung tissue, impairing its ability to recoil during exhalation. This results in the characteristic air trapping and hyperinflation seen in emphysema.

Exposure to high levels of air pollution, including particulate matter, ozone, and other pollutants, can also contribute to the development of emphysema. Similar to cigarette smoke, these pollutants can cause inflammation and damage to the lungs over time.

Workers who are exposed to certain occupational hazards, such as chemical fumes, dust, and industrial pollutants, may be at increased risk of developing emphysema. Examples include workers in coal mining, construction, manufacturing, and agriculture.

In rare cases, emphysema can be caused by a genetic condition called alpha-1 antitrypsin deficiency. This condition leads to a deficiency or dysfunction of a protein called alpha-1 antitrypsin, which normally helps protect the lungs from damage by enzymes released by immune cells. Without enough alpha-1 antitrypsin, the lung tissue becomes more susceptible to damage, increasing the risk of emphysema, particularly in nonsmokers or individuals with minimal smoking history.

Other factors that can increase the risk of developing emphysema include aging (as lung function naturally declines with age), respiratory infections, and a family history of lung disease.

Common Symptoms of Emphysema

Common symptoms associated with emphysema include:

Shortness of breath is one of the most common symptoms of emphysema. It typically worsens over time, particularly with physical activity. In advanced stages, shortness of breath can occur even at rest. Individuals with emphysema often have a persistent cough, which may produce mucus or sputum. This cough may worsen in the morning or with exposure to irritants. Wheezing, a whistling sound produced when breathing, can also occur due to narrowed airways and obstruction of airflow in emphysema.

Some people with emphysema may experience a sensation of tightness or discomfort in the chest, which can be related to difficulty breathing. Chronic shortness of breath and reduced lung function can lead to fatigue and a decreased ability to engage in physical activities.

In advanced stages of emphysema, individuals may experience weight loss and muscle wasting due to the increased energy expenditure associated with breathing difficulties. In severe cases, the chest may become enlarged and rounded, a condition known as barrel chest, due to hyperinflation of the lungs.

Emphysema also  weakens the immune system in the lungs, making individuals more susceptible to respiratory infections such as pneumonia and bronchitis. Additionally, in advanced stages when oxygen levels in the blood are low (hypoxemia), the skin and lips may take on a bluish tint due to poor oxygenation.

Living with emphysema can be challenging due to the impact it has on daily activities and quality of life. Anxiety and depression are common among individuals with chronic respiratory diseases.

Complications of Emphysema

Emphysema is a condition that can trigger a cascade of complications that significantly impact a person’s health and well-being. Among those are: 

• Respiratory Insufficiency or Failure: As emphysema damages the alveoli, the lungs become less efficient at transferring oxygen into the bloodstream and removing carbon dioxide. This can lead to respiratory insufficiency, where the body struggles to get enough oxygen and eliminate excess carbon dioxide. In severe cases, it can progress to respiratory failure, a life-threatening condition where the lungs can no longer sustain life without mechanical ventilation.
• Pneumonia: People with emphysema are more susceptible to lung infections like pneumonia. The damaged airways and reduced ability to clear mucus make them more vulnerable to bacteria settling in the lungs and causing infection. Pneumonia can further worsen breathing difficulties and lead to hospitalization.
• Pneumothorax (Collapsed Lung): Emphysema can cause large air pockets (bullae) to form in the lungs. If one of these bullae ruptures, air can leak into the space between the lung and chest wall, causing a collapsed lung (pneumothorax). This can lead to sudden and severe shortness of breath and chest pain.
• Chronic Atelectasis: Inflammation and mucus buildup in the airways due to emphysema can sometimes cause a section of the lung to completely collapse (atelectasis). This further reduces the lung’s ability to function and can worsen symptoms like shortness of breath and fatigue.
• Cor Pulmonale (Right-sided Heart Failure):  The increased strain on the heart to pump blood through damaged lungs in emphysema can eventually lead to cor pulmonale. This is a condition where the right side of the heart weakens and enlarges due to high blood pressure in the arteries leading to the lungs. Symptoms can include fatigue, swelling in the legs and ankles, and shortness of breath.

Preventative Measures Against Emphysema

Since the leading cause of emphysema is smoking, the most effective preventive measure is to avoid smoking altogether or quit smoking if you already do. Smoking cessation is crucial for preventing emphysema and slowing its progression. Here are some additional steps you can take to reduce your risk:

Minimize exposure to secondhand smoke. Secondhand smoke can also irritate and damage the lungs, so avoiding secondhand smoke exposure is important.

Reduce exposure to air pollution. Air pollution can contribute to emphysema development. If you live in an area with high air pollution levels, try to limit your time outdoors on high pollution days. Consider using air purifiers indoors.

Use occupational protection. If your job exposes you to dust or chemicals, wear proper personal protective equipment (PPE) like masks and respirators to minimize inhalation.

Maintain a healthy lifestyle. Eating a balanced diet rich in fruits, vegetables, and whole grains can help strengthen your overall health and potentially reduce your risk of lung disease. Regular exercise can also improve lung function and overall health.

Get vaccinated. Talk to your doctor about getting vaccinated against pneumonia and influenza. These infections can worsen existing lung problems like emphysema.

How is Emphysema Diagnosed?

Emphysema diagnosis typically involves a combination of a doctor’s evaluation, your medical history, and specific tests to assess lung function and damage. Your doctor will discuss your symptoms in detail, such as shortness of breath, coughing, fatigue, and frequency of respiratory infections.

A physical examination will also be conducted. The doctor will listen to your lungs for abnormal sounds like wheezing and check your chest wall for signs of emphysema, such as a barrel chest (chest that appears inflated due to trapped air).

Your doctor will review your medical history. Among those your doctor will ask about your smoking history, exposure to irritants, and family history. Smoking is the leading cause of emphysema, and past or present exposure to air pollution, dust, or secondhand smoke can be relevant. A family history of COPD or alpha-1 antitrypsin deficiency (a genetic condition that can cause emphysema) can also be a risk factor.

Following the initial evaluation, specific tests might be recommended to confirm emphysema and assess its severity. Pulmonary function tests (PFTs) are the most crucial test. It measures how well your lungs work by assessing lung volume, airflow, and lung capacity. A specific type of PFT called spirometry is often used, where you forcefully exhale into a machine to measure airflow. 

While not definitive for diagnosing early-stage emphysema, a chest X-ray can reveal signs of lung damage and rule out other lung conditions.

A high-resolution computed tomography (HRCT) scan is a detailed CT scan that provides a clearer picture of the lungs and can help identify characteristic features of emphysema, such as destruction of air sacs (alveoli). Arterial blood gas (ABG) tests measure the levels of oxygen and carbon dioxide in your blood. Low oxygen levels may indicate severe emphysema. In some cases, analyzing the mucus coughed up (sputum) can help identify underlying infections or other lung problems.

How is Emphysema Treated?

Emphysema, a chronic obstructive pulmonary disease (COPD), has no cure, but there are effective treatments that can help manage symptoms, slow disease progression, and improve quality of life.

Smoking Cessation 

Quitting smoking is essential to prevent further lung damage and allow existing damage to stabilize. Your doctor can recommend various resources and support programs to help you quit successfully.

Medications

Several medications can help manage emphysema symptoms and improve breathing:

• Bronchodilators: These relax the muscles around narrowed airways, making breathing easier. There are different types of bronchodilators, and your doctor will determine the most suitable one for your needs.
• Inhaled corticosteroids: These medications reduce inflammation in the airways, which can improve airflow and ease breathing. They are usually used in combination with bronchodilators.
• Other medications: Depending on your specific needs, antibiotics (for respiratory infections), mucolytics (to thin mucus), and medications to manage other coexisting conditions might be prescribed.

Pulmonary Rehabilitation

This comprehensive program helps individuals with COPD learn techniques to manage their symptoms and improve their overall well-being. It typically involves exercise training, breathing exercises, education about the disease, and nutritional counseling. Pulmonary rehabilitation can significantly improve exercise tolerance, reduce shortness of breath, and enhance daily activities.

Oxygen Therapy

In severe cases where emphysema has significantly reduced your blood oxygen levels, supplemental oxygen therapy may be necessary. This involves using a nasal cannula or mask to deliver oxygen, improving your oxygen intake and reducing breathlessness.

Surgery

In some cases, surgery might be an option for individuals with severe emphysema.

• Lung volume reduction surgery (LVRS): This surgery removes a small portion of damaged lung tissue, allowing the remaining healthy lung tissue to function more efficiently. It’s a complex procedure with potential risks and benefits, so careful evaluation by your doctor is crucial.
• Lung transplant: In rare cases, a lung transplant may be considered for individuals with very severe emphysema who no longer respond to other treatments. This is a major surgery with significant risks and requires lifelong immunosuppressive medications to prevent rejection of the transplanted organ.

Lifestyle Modifications

Certain lifestyle changes can significantly improve your quality of life with emphysema:

• Maintaining a healthy weight: Excess weight can put additional strain on your lungs.
• Eating a balanced diet: A healthy diet rich in fruits, vegetables, and whole grains can help ensure you get the essential nutrients to support your overall health and lung function.
• Getting regular vaccinations: Staying up-to-date on vaccinations against influenza and pneumonia can help prevent respiratory infections that can worsen emphysema symptoms.
• Managing stress: Chronic stress can exacerbate breathing difficulties. Relaxation techniques like yoga or meditation can be beneficial.

What Medications are Most Often Prescribed for Emphysema?

While there’s no cure for emphysema, several medication classes are commonly prescribed to manage symptoms, improve breathing, and slow disease progression.

Bronchodilators relax the muscles surrounding narrowed airways in the lungs, allowing for easier breathing. There are two main types:

• Short-acting beta2-agonists (SABAs): These provide quick relief from sudden shortness of breath and are often used as rescue inhalers. Examples include levalbuterol (Xopenex).
• Long-acting beta2-agonists (LABAs): These offer longer-lasting relief (usually 12-24 hours) and are used for maintenance control of symptoms. Examples include salmeterol (Serevent) and formoterol (Foradil).

Anti-inflammatory medications: These medications help reduce inflammation in the airways, which can improve airflow and ease breathing. They are often used in combination with bronchodilators for better symptom control. Here are two main types:

• Inhaled corticosteroids (ICS): These are typically used for people with moderate to severe emphysema and chronic inflammation. Examples include budesonide (Pulmicort) and fluticasone (Flovent).

Other medications might be prescribed depending on individual needs. 

• Mucolytics: These medications help thin and loosen mucus in the airways, making it easier to cough up. Examples include guaifenesin (Mucinex).
• Antibiotics: If you have a respiratory infection that worsens your emphysema symptoms, antibiotics might be prescribed to clear the infection.
• Medications for co-existing conditions: If you have other health conditions like heart disease or anxiety, your doctor might prescribe medications specific to those conditions to improve your overall health and well-being.