Transcript document

Emphysema
Michael Haines, MPH, RRT-NPS, AE-C
Loss of elastic recoil
 This loss of recoil
leads to an increased
compliance and
inability to expel gas
out of the alveoli
 Leading to trapped
air in the lung
 Alveoli cluster
together forming
“blebs”
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http://video.about.com/copd/Emp
hysema.htm
What is Emphysema?
Damage occurs to the tiny airways in the
lungs called bronchioles. Bronchioles are
joined to alveoli, tiny grape-like clusters
of sacs in the lungs where oxygen from
the air is exchanged for carbon dioxide
from the body. The elastic properties of
the lung reside in the tissue around the
alveoli
 Because the lungs lose elasticity they
become less able to contract.
 This prevents the alveoli from deflating
completely, and the person has difficulty
exhaling.

What is Emphysema Cont…
Hence, the next breath is started with
more air in the lungs.
 The trapped "old" air takes up space, so
the alveoli are unable to fill with enough
fresh air to supply the body with needed
oxygen.
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Emphysema Cont…
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A person with emphysema may feel short of
breath during exertion and, as the disease
progresses, even while at rest.
Emphysema is one of several irreversible
lung diseases that diminish the ability to
exhale. This group of diseases is called
chronic obstructive pulmonary disease
(COPD). The two major diseases in this
category are emphysema and chronic
bronchitis , which often develop together.
Emphysema Cont…
3rd Leading Cause of death in the US
 Cigarette smoking is the primary cause of
emphysema.
 Most people with emphysema are older men. As
with lung cancer and other smoking-related
diseases, however, the incidence of emphysema
is increasing among women.
 Emphysema doesn't develop suddenly. Instead, it
comes on gradually, usually after years of
exposure to cigarette smoke or some other
inhaled irritant.
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FACTS about Emphysema
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Typically, symptoms of emphysema appear
only after 30 to 50 percent of lung tissue is
lost.
Emphysema rates are highest for men age 65
and older.
More people in the Midwest have emphysema
than in any other region in the country.
Emphysema is an irreversible disease that
can be slowed but not reversed or stopped.
More FACTS…
Generally, lungs become damaged
because of reactions to irritants entering
the airways and alveoli. Researchers
continue to investigate the factors that
may make some people more susceptible
to emphysema than others. But there are
some clear causes for emphysema:
 Cigarette smoking
 Alpha-1 antitrypsin deficiency
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http://www.youtube.com/watch?v=SqGoZRBrlvs&feature=related
Causes
Alpha-1 Antitrypsin Deficiency
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People who a deficiency of a protein called alpha1 antitrypsin (AAT) are at a higher risk of
developing severe emphysema. Alpha-1
antitrypsin deficiency (AAT deficiency) is an
inherited condition and occurs in varying degrees
Other Cause
AAT is thought to protect against some of
the damage caused by macrophages. In
AAT deficiency-related emphysema, the
walls of the bronchial tubes and the
alveoli are both damaged, often leading to
severe disease.
 About 2 out of every 1,000 people have
an alpha-1 antitrypsin deficiency. People
who smoke and have AAT deficiency are
almost certain to develop emphysema.
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Cigarette smoking is the major cause of
emphysema. When exposed to cigarette
smoke, the air sacs of the lungs produce
defensive cells, called macrophages, which
"eat" the inhaled particles. But macrophages
are stimulated to release materials which can
destroy the proteins that let the lungs
expand and contract, called elastin and
collagen .
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Cigarette smoke also damages the cilia, tiny
hair-like projections in the bronchi that
"sweep" foreign bodies and bacteria out of
the lungs
Causes
The first sign of emphysema is shortness of breath when you
are exerting yourself. Eventually, this shortness of breath
may occur even when you are at rest.
As the disease progresses, the following symptoms which are
related to one of the other major lung diseases also caused
by smoking - bronchitis - may occur:
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Difficulty breathing (dyspnea)
Coughing (with or without sputum)
Wheezing (this can also be caused by emphysema itself)
Excess mucus production
A bluish tint to the skin (cyanosis)
Hypoxemia
Tachycardia
Polytcythemia
Symptoms
Clubbed fingers (chronic hypoxia)
 Right Heart Failure
 Stained yellow fingers, teeth
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More Symptoms
Nice To Know:
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If wheezing occurs, it helps to know whether it is
found while breathing in or out (or both). Wheezing at
the end of a complete exhalation is usually due to
bronchitis. Wheezing that begins early in expiration is
usually due to emphysema or the combination of
bronchitis and emphysema - COPD.
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If you only wheeze when you breathe in, you
probably have asthma (or, very rarely, a
narrowing of your windpipe in your neck).
Asthma and emphysema sometimes are
confused with each other. One way to tell the
difference is to try asthma medications
prescribed by your doctor and see if they make a
difference. While people with asthma often
respond dramatically to medications, people with
emphysema usually do not respond to asthma
medications and those with COPD may respond
somewhat. In some people bronchitis may lead
to asthma which is difficult, even for physicians,
to distinguish from asthma due to allergy.
Emphysema may affect the brain, too.
Low oxygen levels in the blood may mean
that the brain is not getting enough
oxygen. The end result can be
grumpiness, irritability, impaired mental
ability. High carbon dioxide levels in the
blood can lead to headaches and
sleeplessness.
 As you age your lung naturally looses
elasticity, so you can have a degree of
emphysema naturally
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History And Physical Examination
 Smoking history (calculate pack years, #
packs smoked times # years smoked)
 Working environment- Breathing in any
harmful chemicals?
 A physical examination will include an
examination of your chest and breathing
patterns; prolonged expiratory times
 Nasal flaring, accessory muscle usage
(due to loss of diaphragm recoil from
airtrapping)
Diagnosis
X-Ray and/or CT of the Chest
 Chest x-rays are a very useful tool to evaluate
anatomy of the lung. In emphysema, there is
evidence of increased air in the chest and
destruction of some of the lung tissue. Bronchitis
can be suspected on a chest x-ray by presence of
thickening of the tissue around the large airways
(bronchi). Chest x-rays are also useful as
screening for lung cancer and heart disease.
 Computerized axial tomography or CAT scans
indicate lung anatomy in greater detail. In some
cases, this information is needed to fully
evaluate lung disease.
Diagnosis Continued
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Cat scan of chest
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Air Trapping,
flattened diaphragm
Lung Function Tests
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Routine lung function tests can help define the
kind and amount of damage to the lungs. The
following tests can identify various stages of
emphysema:
Spirometry measures breathing capacity. A
common measure of breathing capacity is the
forced expiratory volume in one second (FEV1),
or the amount of air that can be forced out of the
lungs in one second. This is a common way to
determine the amount of airway obstruction.
http://www.youtube.com/watch?v=ZZdSkvf9l6U
Frequently, your physician will ask that
spirometry and body plethysmography be
repeated after administration of an
inhaled bronchodilator
 This test will help your physician
determine if there is an asthmatic
component present
 Lung Volumes measures the amount of
air in the lungs. This increases markedly
in emphysema.
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Diffusing Capacity measures the ability of the
lung to transfer the gases from the air to the
blood and vice versa. Decrease in diffusing
capacity allow fairly accurate estimation of
amount of emphysema.
Body Plethysmography is a rapid way of
evaluating both degree and type of obstruction
and lung volumes. It is an useful adjunct to
understanding the mechanism of airway
obstruction - e.g., asthma vs emphysema.
Arterial blood gases (ABG) analyzes blood
from an artery for amounts of carbon dioxide and
oxygen. This test is often used in more advanced
stages of emphysema to help determine if a
person needs supplemental oxygen.
Patient’s with emphysema have chronic
CO2 retention due to the inability to expel
gas. Their blood reflects higher levels of
CO2 than normal people; CO2 is acidic in
nature
 Over time their body compensates for this
higher CO2 by creating more buffer in the
blood in the form of Bicarb from the
Kidney
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Arterial Blood Gas
The over all balance of the blood is
reflected by the blood’s pH.
 People with emphysema have normal pH’s
and high CO2 and high Bicarb
 They also have chronically low oxygen in
the blood
Example
 pH 7.36
 PaCo2 60
 PaO2 60
 HCO3 32
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Tests For Alpha-1 Antitrypsin Deficiency
 The symptoms of alpha-1 antitrypsin
deficiency-related emphysema tend to
appear between the ages of 30 and 40. The
symptoms and diagnostic tests are basically
the same in any kind of emphysema except
that, in this disease, emphysematous
changes are greatest in the lower lung.
However, if AAT deficiency is suspected, a
special blood test can confirm the diagnosis.
Emphysema Diagnosis Cont…
There is no cure for emphysema. The goal
of treatment is to slow the development of
disabling symptoms. The most important
step to take is to stop smoking.
 Treatments for emphysema caused by
smoking include medication, breathing
retraining, and surgery.
 People with inherited emphysema due to
alpha-1 antitrypsin deficiency can receive
alpha 1-proteinase inhibitor (A1PI), which
slows lung tissue destruction.
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Treatment
Breathing Techniques
Diaphragmatic Breathing
 The diaphragm is a major muscle used in breathing and is
located beneath the lowest two ribs. At rest, the diaphragm
muscle is bell shaped. During inspiration, it lowers and
flattens out.
 Optimizing the use of the diaphragm is beneficial because it
pulls air into the lower lobes of the lungs where more gas
exchange takes place. Not only is the diaphragm the most
efficient of all respiratory muscles, but using it tends to be
very relaxing and calming.
 Along with our diaphragm, we use intercostal and
abdominal muscles in the work of breathing. The
intercostals (muscles between the ribs) pull to lift the rib
cage up and out. This causes the lungs to open in all
directions and air can be pulled down the airways. To
exhale, the muscles that have been pulling relax and air is
forced out.
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The diaphragm tenses, pulling air in; and
relaxes, letting the spring of the ribs push
the air out again.
Pursed Lip Breathing
How:
Breathe in through your nose.
Purse lips slightly as if to whistle.
Breathe out slowly through pursed
lips.
Do not force the air out.
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http://www.youtube.com/watch?v=8zA8Q2EPmkc
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Medications To Treat Emphysema
 Emphysema cannot be cured and, except for
oxygen, does not reverse with any medication.
However, emphysema is frequently associated
with bronchitis and asthma and the symptoms
associated with these processes often can be
alleviated with medication (hence, you can see
the value of pulmonary function and other tests
designed to discover if there is asthmatic
component present:
 Bronchodilator medication
 Corticosteroids
 Supplemental oxygen
Medications Used
Bronchodilator Medication
 Bronchodilator medication may be prescribed for
airway tightness. Bronchodilators react similar to
norepinephrine through the sympathetic nervous
system
 The most commonly prescribed bronchodilators
are beta2 agonists , the anti-cholinergic drug
ipatropium bromide, and theophylline
 Anti-cholinergics block musacaric receptors which
normally respond to acetylcholine and cause
bronchoconstriction
Corticosteroids
 The potent anti-inflammatory medications
known as corticosteroids - commonly
called steroids - may be used to help
lessen the inflammation that often
accompanies emphysema. These may be
taken by mouth or inhaled.
Due to the chronic state of increased CO2
in the blood (hypercapnia), the patient
has adapted a breathing regulation in the
brain that responds to changes in O2 and
not CO2 like most people
 If you give a patient with COPD more than
30% oxygen they will stop breathing!!!
 Give low flow oxygen at 2 LPM by NC
 Or high flow with venturi mask at 22-30%
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Oxygen
Surgical Treatments
 Surgical treatments for emphysema remain
experimental and are not covered by insurance.
Most people with emphysema are not candidates
for surgery.
 Two types of surgery for people with emphysema
are:
 Lung reduction
 Lung transplantation
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http://www.youtube.com/watch?v=DNbflWcJbeA
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Lung Reduction
A surgical procedure called lung reduction may
improve symptoms for people with certain types of
emphysema. During the procedure, part of the lung is
cut out, giving healthy lung tissue more room to
expand.
 Lung reduction may eliminate the need for
supplemental oxygen and make it much easier for the
person to breathe. Early studies show that it reduces
the volume of the over-inflated lungs. This improves
the ability of the lung and chest wall to spring back
during exhalation. This more-elastic lung appears to
be the biggest reason that emphysema sufferers
experience relief.
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Emphysema is a chronic disease that takes years
to progress; usually as a result of heavy
cigarette smoking but also can be caused by
inherited Alpha-1 antitrypsin deficiency
It destroys the stability of the alveoli and
bronchioles leaving them over compliant
This leads to air trapping and an accumulation of
CO2 and decrease in O2
The air trapping leads to dyspnea
Diagnose with symptoms, ABG, CXR, PFT and
history
Treatment consists of stop smoking, medications
and lung reduction surgery or transplant
Conclusion