Emphysema 

- a long-term, progressive disease of the lungs that primarily causes shortness of breath. In people with emphysema,
the tissues necessary to support the physical shape and function of the lungs are destroyed. It is included in a group of
diseases called chronic obstructive pulmonary disease or COPD (pulmonary refers to the lungs). Emphysema is called
an obstructive lung disease because the destruction of lung tissue around smaller sacs, called alveoli, makes these air
sacs unable to hold their functional shape upon exhalation. It is often caused by smoking or long-term exposure to air
pollution.

The term means swelling and comes from the Greek ἐμφυσᾶν emhysan meaning inflate, itself composed of

ἐν en meaning in and φυσᾶν physan meaning breath, blast

- a condition in which chronic inflammation of the lungs leads to destruction of alveoli and decreased elasticity of
the lungs. As a result, air is trapped and lungs hyperinflate.

INSPECTION: SOB, especially on exertion, barrel chest, pursed lip breathing, use of accessory muscles, cyanosis,
clubbing of fingers, tripod posture.

PALPATION: decreased chest expansion, decreased tactile fremitus (palpable vibration on the chest wall when the
client speaks)

PERCUSSION: hyperresonance : abnormally loud auscultatory tone that is low & long duration (ex. Lungs filled with air)

AUSCULTATION: decreased vesicular sounds and possible wheeze (whistling/high pitched)

Classification
Emphysema can be classified into primary and secondary. However, it is more commonly classified by location into
panacinary and centroacinary (or panacinar and centriacinar,  or centrilobular and panlobular).

 Panacinar (or panlobular) emphysema: The entire respiratory acinus, from respiratory bronchiole to

alveoli, is expanded. Occurs more commonly in the lower lobes, especially basal segments, and anterior margins of the
lungs.
 Centriacinar (or centrilobular) emphysema: The respiratory bronchiole (proximal and central part of the
acinus) is expanded. The distal acinus or alveoli are unchanged. Occurs more commonly in the upper lobes.
Other types include distal acinar and irregular.  A special type is congenital lobar emphysema (CLE).

Congenital lobar emphysema - CLE results in overexpansion of a pulmonary lobe and resultant compression of the
remaining lobes of the ipsilateral lung, and possibly also the contralateral lung. There is bronchial narrowing because of
weakened or absent bronchial cartilage.  There may be congenital extrinsic compression, commonly by an abnormally
large pulmonary artery. This causes malformation of bronchial cartilage, making them soft and collapsible.  CLE is
potentially reversible, yet possibly life-threatening, causing respiratory distress in the neonate.

Paraseptal emphysema - Paraseptal emphysema is a type of emphysema which involves the alveolar ducts and sacs
at the lung periphery. The emphysematous areas are subpleural in location and often surrounded by interlobular septa
(hence the name). It may be an incidental finding in young adults, and may be associated with
spontaneous pneumothorax. It may also be seen in older patients with centrilobular emphysema. Both centrilobular and
paraseptal emphysema may progress to bullous emphysema. A bulla is defined as being at least 1cm in diameter, and
with a wall less than 1mm thick. Bullae are thought to arise by air trapping in emphysematous spaces, causing local
expansion.

Signs and symptoms

Smoking is one major cause of this destruction, which causes the small airways in the lungs to collapse during forced
exhalation. As a result, airflow is impeded and air becomes trapped, just as in other obstructive lung diseases.
Symptoms include shortness of breath on exertion, and an expanded chest.

People with this disease do not get enough oxygen and cannot remove carbon dioxide from their blood; they therefore
exhibit dyspnea (shortness of breath). At first this occurs only during physical activity. Eventually it will occur after any
physical exertion. Later the patient may be dyspneic all the time, even when relaxing. Because breathing is difficult, the
patient must use accessory muscles to help them breathe; tachypnea (rapid breathing) may occur they try to extend
their exertion. They may have trouble coughing and lowered amounts of sputum. They may also lose weight.
The anteroposterior diameter of their chest may increase; this symptom is sometimes referred as "barrel chest." The
patient may lean forward with arms extended or resting on something to help them breathe.
When lung auscultation and chest percussion is performed a hyperresonant sound is heard (Mc Cance). The patient
may exhibit symptoms of cyanosis, lowered oxygen levels and increased carbon dioxide levels.

Diagnosis
The diagnosis is usually confirmed by pulmonary function testing (e.g. spirometry); however, X-ray radiography may aid
in the diagnosis. A DLCO test may be used to differentiate Emphysema from other types of Obstructive disorders such
as Chronic Bronchitis and Asthma. DLCO is a test that measures the ability of gases to diffuse across the alveolar-
capillary membrane. A DLCO will be decreased in Emphysema whereas it will be normal or increased in Asthma and
Chronic Bronchitis.

Management
Emphysema is also treated by supporting the breathing with anticholinergics, bronchodilators, steroid medication
(inhaled or oral), effective body positioning (High Fowlers), and supplemental oxygen as required. Treating the patient's
other conditions including gastric reflux and allergies may improve lung function. Supplemental oxygen used as
prescribed (usually more than 20 hours per day) is the only non-surgical treatment which has been shown to prolong life
in emphysema patients. There are lightweight portable oxygen systems which allow patients increased mobility.
Patients can fly, cruise, and work while using supplemental oxygen. Other medications are being researched.
Lung volume reduction surgery (LVRS) can improve the quality of life for certain carefully selected patients. It can be
done by different methods, some of which are minimally invasive. In July 2006 a new treatment, placing tiny valves in
passages leading to diseased lung areas, was announced to have good results, but 7% of patients suffered partial lung
collapse. The only known "cure" for emphysema is lung transplant, but few patients are strong enough physically to
survive the surgery. The combination of a patient's age, oxygen deprivation and the side-effects of the medications used
to treat emphysema cause damage to the kidneys, heart and other organs. Surgical transplantation also requires the
patient to take an anti-rejection drug regimen which suppresses the immune system, and can lead to
microbial infection of the patient. Patients who think they may have contracted the disease are recommended to seek
medical attention as soon as possible.
Emphysema is an irreversible degenerative condition. The most important measure to slow its progression is for the
patient to stop smoking and avoid all exposure to cigarette smoke and lung irritants.Pulmonary rehabilitation can be
very helpful to optimize the patient's quality of life and teach the patient how to actively manage his or her care.

Nursing Interventions
- If ordered, perform chest physiotherapy, including postural drainage and chest persussion and vibration
several times daily.
- Make sure the patient receives adequate fluids at least 3 liters per day to loosen secretions
- Monitor the patient’s RBC count for increases (warning signs of increasing lung and vascular congestion).
- Watch for complications, such as respiratory tract infections, cor pulmonale, spontaneous pneumothorax,
respiratory failure, and peptic ulcer disease.