Emphysema is a chronic nonspecific lung disease, which is based on persistent, irreversible expansion of the air spaces and increased swelling of the lung tissue distal to the terminal bronchioles. Disease is manifested by expiratory dyspnea, cough with a small amount of mucosal sputum, signs of respiratory failure, recurrent spontaneous pneumothorax. Diagnosis of this pathology is carried out taking into account the data of auscultation, radiography and CT of the lungs, spirography, analysis of the gas composition of blood. Conservative treatment includes taking bronchodilators, glucocorticoids, oxygen therapy; in some cases, resection surgery is indicated.
ICD 10
J43 Emphysema
Meaning
Emphysema is a pathological change in the lung tissue, characterized by its increased airiness, due to the expansion of the alveoli and destruction of the alveolar walls. Pathology is detected in 4% of patients, and in men it occurs 2 times more often than in women. The risk of developing emphysema is higher in patients with chronic obstructive pulmonary diseases, especially after the age of 60. The clinical and social significance of pulmonary emphysema in practical pulmonology is determined by the high percentage of cardiopulmonary complications, disability, disability of patients and increasing mortality.
Causes of emphysema
Any causes leading to chronic inflammation of the alveoli stimulate the development of emphysematous changes. The probability of developing emphysema increases in the presence of the following factors:
- congenital deficiency of α-1 antitrypsin, leading to the destruction of alveolar lung tissue by proteolytic enzymes;
- inhalation of tobacco smoke, toxic substances and pollutants;
- microcirculation disorders in lung tissues;
- bronchial asthma and chronic obstructive pulmonary diseases;
- inflammatory processes in respiratory bronchi and alveoli;
- features of professional activity associated with a constant increase in air pressure in the bronchi and alveolar tissue.
Pathogenesis
Under the influence of these factors, damage to the elastic tissue of the lungs occurs, a decrease and loss of its ability to air filling and subsidence. Overflowing lungs lead to the adhesion of small bronchi during exhalation and obstructive pulmonary ventilation disorders. The formation of the valve mechanism in emphysema causes swelling and overgrowth of lung tissues and the formation of air cysts – bulls. Bull ruptures can cause episodes of recurrent spontaneous pneumothorax.
Emphysema is accompanied by a significant increase in lung size, which macroscopically become similar to a large-pore sponge. When examining emphysematous lung tissue under a microscope, destruction of the alveolar septa is observed.
Classification
Emphysema is divided into primary or congenital, developing as an independent pathology, and secondary, arising against the background of other lung diseases (more often bronchitis with obstructive syndrome). According to the degree of prevalence in the lung tissue, localized and diffuse forms of emphysema are distinguished.
According to the degree of involvement in the pathological process of the acinus (a structural and functional unit of the lungs that provides gas exchange, and consisting of a branching of the terminal bronchiole with alveolar passages, alveolar sacs and alveoli), the following types of emphysema are distinguished:
- panlobular (panacinar) – with the defeat of the whole acinus;
- centrilobular (centriacinar) – with a lesion of the respiratory alveoli in the central part of the acinus;
- perilobular (periacinar) – with damage to the distal part of the acinus;
- okolorubtsovaya (irregular or uneven);
- bullous (bullous lung disease in the presence of air cysts – bull).
Congenital lobar emphysema and McLeod syndrome are particularly distinguished – emphysema with an unclear etiology affecting one lung.
Symptoms of emphysema
The leading symptom of emphysema is expiratory shortness of breath with difficulty exhaling air. Shortness of breath is progressive, occurring first during exercise, and then in a calm state, and depends on the degree of respiratory failure. Patients exhale through closed lips, simultaneously inflating their cheeks (as if “puffing”). Shortness of breath is accompanied by a cough with the release of scanty mucosal sputum. Cyanosis, puffiness of the face, swelling of the neck veins indicate a pronounced degree of respiratory failure.
Patients lose weight significantly, have a cachectic appearance. The loss of body weight in emphysema is explained by the large energy consumption spent on intensive work of the respiratory muscles. With the bullous form of emphysema, repeated episodes of spontaneous pneumothorax occur.
Complications
The progressive course of emphysema leads to the development of irreversible pathophysiological changes in the cardiopulmonary system. The decline of small bronchioles on exhalation leads to obstructive pulmonary ventilation disorders. The destruction of the alveoli causes a decrease in the functional pulmonary surface and the phenomenon of severe respiratory failure.
Reduction of the capillary network in the lungs entails the development of pulmonary hypertension and an increase in the load on the right parts of the heart. With increasing right ventricular insufficiency, edema of the lower extremities, ascites, hepatomegaly occur. An urgent condition in emphysema is the development of spontaneous pneumothorax, requiring drainage of the pleural cavity and air aspiration.
Diagnostics of emphysema
In the anamnesis of patients with this disease, a long smoking experience, occupational hazards, chronic or hereditary lung diseases are noted. When examining patients with pulmonary emphysema, attention is drawn to an enlarged, barrel-shaped (cylindrical) chest, enlarged intercostal spaces and epigastric angle (obtuse), protrusion of supraclavicular pits, shallow breathing with the participation of auxiliary respiratory muscles.
Percussion determines the displacement of the lower borders of the lungs by 1-2 ribs downwards, a box sound over the entire surface of the chest. Auscultatively, with emphysema, weakened vesicular (“cotton”) breathing, deaf heart tones are heard. In the blood with severe respiratory insufficiency, erythrocytosis and an increase in hemoglobin are detected.
- X-ray diagnostics. Lung x-ray determines an increase in the transparency of the pulmonary fields, a depleted vascular pattern, limited mobility of the diaphragm dome and its low location (in front below the level of the VI rib), an almost horizontal position of the ribs, narrowing of the cardiac shadow, expansion of the chest space. With the help of CT of the lungs, the presence and location of bullae in bullous emphysema is clarified.
- FER research. Highly informative in emphysema is the study of the function of external respiration: spirometry, peak flowmetry, etc. In the early stages of the development of emphysema, obstruction of the distal segments of the respiratory tract is detected. Conducting a test with bronchodilator inhalers shows the irreversibility of obstruction, characteristic of disease. Also, with FER, a decrease in the VCL and the Tiffno sample is determined.
- Laboratory tests. Analysis of the gas composition of blood reveals hypoxemia and hypercapnia, clinical analysis – polycythemia (increase in Hb, erythrocytes, blood viscosity). The examination plan should include an analysis for an α-1-trypsin inhibitor.
Treatment for emphysema
Conservative therapy
There is no specific treatment. The elimination of the factor predisposing to emphysema (smoking, inhalation of gases, toxic substances, treatment of chronic respiratory diseases) is paramount.
Drug therapy for pulmonary emphysema is symptomatic. The lifelong use of inhaled and tableted bronchodilators (salbutamol, phenoterol, theophylline, etc.) and glucocorticoids (budesonide, prednisolone) has been shown. In case of cardiac and respiratory insufficiency, oxygen therapy is performed, diuretics are prescribed. The complex of treatment of emphysema includes breathing exercises.
Surgical treatment
Surgical treatment of emphysema consists in carrying out an operation to reduce the volume of the lungs (thoracoscopic bullectomy). The essence of the method is reduced to resection of peripheral areas of lung tissue, which causes “decompression” of the rest of the lung. Observations of patients after bullectomy show an improvement in the functional parameters of the lungs. Lung transplantation is indicated for patients with emphysema.
Prognosis and prevention
The lack of adequate therapy for emphysema leads to the progression of the disease, disability and early disability due to the development of respiratory and heart failure. Despite the fact that irreversible processes occur with emphysema, the quality of life of patients can be improved by constantly using inhaled medications. Surgical treatment of bullous emphysema somewhat stabilizes the process and relieves patients from recurrent spontaneous pneumothorax.
An essential aspect of the prevention of emphysema is anti-smoking propaganda aimed at preventing and combating smoking. Early detection and treatment of patients with chronic obstructive bronchitis is also necessary. Patients suffering from COPD are subject to the supervision of a pulmonologist.
Literature
- Rustagi N, Singh S, Dutt N, Kuwal A, Chaudhry K, Shekhar S, Kirubakaran R. Efficacy and Safety of Stent, Valves, Vapour ablation, Coils and Sealant Therapies in Advanced Emphysema: A Meta-Analysis. Turk Thorac J. 2019 Jan 01;20(1):43-60. link
- Fernandez-Bussy S, Labarca G, Herth FJF. Bronchoscopic Lung Volume Reduction in Patients with Severe Emphysema. Semin Respir Crit Care Med. 2018 Dec;39(6):685-692. – link
- Dunlap DG, Semaan R, Riley CM, Sciurba FC. Bronchoscopic device intervention in chronic obstructive pulmonary disease. Curr Opin Pulm Med. 2019 Mar;25(2):201-210. – PubMed
- Asri H, Zegmout A. [The two major complications of tobacco in a single image!]. Pan Afr Med J. 2018;30:252. – link
- Thomson NC. Challenges in the management of asthma associated with smoking-induced airway diseases. Expert Opin Pharmacother. 2018 Oct;19(14):1565-1579. – link