Pulmonary emphysema is a chronic lung disease. In most cases, smoking is the cause of this irreversible, i.e. irreversible, reduction in the lung surface area

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The lungs provide the body with vital oxygen. If pulmonary emphysema occurs, the organ can no longer perform its task properly

© mauritius images / Science Source / Monica Schroeder

Pulmonary emphysema - in short

Pulmonary emphysema occurs when the wall structures of the vesicles are increasingly destroyed. Several small alveoli merge into large bubbles. This reduces the inner surface, which is necessary for the gas exchange between air and blood - the result is an increasing lack of oxygen in the blood and thus also in the organs. The most common causes of emphysema are chronic inflammation of the lungs (chronic bronchitis and COPD) and cigarette smoke. Pulmonary emphysema manifests itself as shortness of breath, initially only with strong exertion, later with light exertion. Persistent cough and sputum are other common symptoms of accompanying inflammation (bronchitis). The susceptibility to respiratory infections is increased. An existing emphysema cannot be reversed, but the course of the disease can be influenced favorably. The most important step is to quit smoking and eliminate other possible triggers. Individually adapted physical exertion - for example in lung sports groups - is beneficial. In pronounced cases, the controlled administration of oxygen, especially during exercise, makes sense. Sometimes surgical or endoscopic procedures on the lungs are an option.

What is emphysema?

Pulmonary emphysema is a chronic disease in which the alveoli are permanently enlarged or destroyed, which leads to a reduction in the elastic restoring force and overinflation of the lungs. On the one hand, these over-inflated sections of the lungs retain more "old" air in the vesicles, so that less "fresh" air can be taken in, and on the other hand, the surface area covered by blood vessels is reduced and the blood is less loaded with oxygen. Overinflation increases during physical exertion and is then the main cause of shortness of breath and increasing difficulty in breathing.

Representation of the lower airways

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Background information - Structure of the airways

All parts of the body through which air flows when breathing are counted as respiratory tract. The airways are divided into upper and lower airways. The upper airways are exposed to each other

  • nose
  • Sinuses
  • Pharynx

The lower airways are formed from

  • Larynx
  • Windpipe (trachea)
  • Bronchi
  • Bronchioli
  • Alveoli

Below the windpipe, the airways divide into ever smaller bronchi (bronchial tree), at the end of which are the individual alveoli. These vesicles are affected in emphysema.

This is how the gas exchange between air and blood works

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Background information - gas exchange in the lungs

The alveoli are covered with blood vessels (capillaries). This is where the gas exchange between the blood and the air takes place. On the one hand, vital oxygen reaches these points from the air we breathe into the blood vessels of the lungs and with the bloodstream to the organs and tissues. On the other hand, the blood in the pulmonary vessels releases the metabolic product carbon dioxide back into the alveoli so that it can be exhaled.

Causes of the development of pulmonary emphysema:

First, we should look at the mechanism by which pulmonary emphysema develops - so that the causes become clearer.

The development mechanism of pulmonary emphysema:

  • In lung tissue there is normally a balance between certain proteins that break down lung tissue (proteases) and proteins that protect it (antiproteases, protease inhibitors).
  • Pollutants such as the smoke inhaled when smoking cigarettes and persistent inflammation can disturb this delicate balance, so that ultimately the degrading proteins predominate.
  • The walls of the alveoli are attacked and destroyed. More and more sack-like, blistered cavities are created. Larger bubbles are called Bullae designated.

How proteases and protease inhibitors interact (please click on the magnifying glass to enlarge)

© W & B / Dr. Ulrike Möhle

The cause for the development of pulmonary emphysema is a disproportion between the degrading enzymes (proteases) and the enzymes that regulate this process (anti-proteases, protease inhibitors).

The predominance of proteases occurs either because more proteases are produced (due to chronic inflammation) or because fewer anti-proteases are present (inactivation due to cigarette smoke, congenital deficiency).

In summary, the following risk factors can be found:

  • Smoke
  • COPD
  • hereditary predisposition
  • recurring respiratory infections (such as chronic bronchitis and pneumonia)
  • Pollutants, for example car exhaust fumes or dusts and gases in the workplace
  • Alpha-1 antitrypsin deficiency (congenital)

Smokers are at an increased risk of developing emphysema

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Forms of emphysema

Pulmonary emphysema as part of COPD (COPD = chronic obstructive pulmonary disease): It is the most common form of emphysema. It is mainly caused by smoking. Around ten percent of the population have COPD, around a third of whom have pronounced emphysema. In this form, the upper sections of the lungs are often affected first. The substances in the smoke damage the lungs directly, but also disturb the balance of degrading and protective proteins (see above) because they inactivate protective proteins.

Emphysema in the case of alpha-1 protease inhibitor deficiency: This form of emphysema is based on an innate deficiency in protective protein (protease inhibitor, PI, see above): The body produces too little alpha-1 antitrypsin (AAT), there is an AAT deficiency. This substance normally works against the breakdown of lung tissue. Emphysema develops more easily when alpha-1 antitrypsin is not present in sufficient quantities. This form of emphysema often affects the lower lungs in particular. Pure Alpha1-PI deficiency emphysema is rather rare (around one to two percent of all emphysema diseases). The liver is often affected at the same time. This emphysema can be treated with the administration of alpha-1 antitrypsin.

However, there are different variants of the Alpha-1-PI deficiency, depending on which information is present in the genetic make-up. In addition to a pronounced deficiency, there are also significantly milder forms that can remain symptom-free for many years - provided that those affected do not put additional strain on their lungs. However, anyone who has an Alpha1 PI deficiency and also smokes significantly increases their risk of emphysema. In pronounced cases, this can occur in younger to middle age.

Scar emphysema and overstretching emphysema: It usually causes fewer problems. This is not a "classic" emphysema, in which the wall of the alveoli is destroyed by chronic inflammation. In the case of scar emphysema, lung tissue is overstretched in the vicinity of scarred areas of the lung - for example as a result of a scarred lung disease such as pneumonia or tuberculosis. Overstretching emphysema occurs when the remaining lung expands after a partial surgical removal of the lungs, or when there are major changes in the shape of the chest (for example a curvature of the spine).

Old age emphysema is a special form of pulmonary emphysema that is not a disease. Since it is a normal symptom of aging, it is also known as "physiological emphysema". As a result of age, the lungs lose their elasticity and flexibility. Severe shortness of breath is not observed in old age emphysema.

Cough and shortness of breath can indicate emphysema

© Fotolia / Hartphotographie / 2011

Symptoms: what symptoms does pulmonary emphysema cause?

Shortness of breath is a typical symptom of emphysema. In the early stages, breathing problems are often only minor, and only occur from time to time or under greater stress. The condition worsens as the lungs become overinflated - those affected gasp for air even with small exertions. In addition to shortness of breath, the following symptoms are found, especially in chronic bronchitis (see COPD):

  • to cough
  • Expectoration

Since the alveoli are gradually destroyed and the normal gas exchange is no longer so successful, organs and tissues are no longer adequately supplied with oxygen. At the same time, the metabolic end product carbon dioxide can rise in the blood as a result of the tiredness of the respiratory muscles. This can trigger other symptoms:

  • Exhaustion
  • Reduction in performance
  • Quick fatigue
  • General health deterioration
  • a headache

Background - pulmonary emphysema: how do the symptoms come about?

Due to the action of proteases, there is an increasing loss of elasticity in the alveoli. Furthermore, the wall breakdown processes lead to the fact that the bubbles merge into larger, "bag-like" bubbles. This reduces the inner surface of the alveoli, which are important for gas exchange (oxygen and carbon dioxide). Usually, when you breathe in, the alveoli become filled with air and expand. When you exhale, the elastic alveoli contract again.In pulmonary emphysema, the damaged wall structure lacks this regulatory elasticity during exhalation, the alveoli and also small airways (bronchioli) collapse and the air cannot completely escape from the vesicles ("air-trapping"). There is now residual air in the lungs, which increases the overinflation with each breath and leads to shortness of breath (shortness of breath)

Listening to the lungs with a stethoscope provides clues for the diagnosis

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Diagnosis: how does the doctor make the diagnosis?

The doctor will first ask a few questions about your history and lifestyle, for example whether you already have a known lung disease such as chronic bronchitis, COPD or bronchial asthma. It is also of interest whether people smoke and, if so, how many cigarettes per day, whether medication is taken and whether there is professional or private contact with irritants. In addition, the doctor asks about the current symptoms such as shortness of breath, cough, sputum, fatigue and the frequency of respiratory infections.

Physical examination

There is no sure sign of the physical exam. The following signs indirectly indicate pulmonary emphysema:

  • Barrel-shaped chest (due to the overinflation of the lungs), the ribs are more horizontal than oblique
  • Difficulty breathing, especially when you breathe out
  • When tapping the chest (percussion), the knocking sound sounds louder and more hollow than usual (hypersonic sound), the diaphragm is low
  • Listening to the lungs with a stethoscope (auscultation) produces a quiet, weak breathing noise and possibly background noises that indicate an additional obstruction.

If emphysema is suspected on physical examination, pulmonary function tests and further examinations are required. They are also used to determine the exact extent of the disease.

Pulmonary function tests

Pulmonary function tests are important tests for assessing the severity of emphysema. Spirometry (here a sensor measures the airflow during inhalation and exhalation) and whole-body plethysmography (which can also be used to determine the amount of air in the lungs that cannot be exhaled) help to identify additional overinflation or obstruction.

The emphysema can only be determined with the so-called diffusion capacity measurement. This test requires holding your breath for ten seconds. During this time, test gases (usually a small amount of carbon monoxide) provide information about the size of the lung surface.

Imaging examination procedures

Computed tomography (high-resolution CT, HRCT) is well suited to depict emphysema. It is used in particular to prepare for an operation or an endoscopic lung volume reduction. In addition, X-ray examinations of the chest provide indications of the overinflation and possible differential diagnoses.

Blood tests

On the one hand, blood tests can be used to determine general blood values, such as signs of inflammation. On the other hand, a blood test can be used to determine an Alpha1-PI deficiency as a possible cause of emphysema (see chapter "Causes").

In a so-called arterial blood gas analysis, the doctor measures the oxygen and carbon dioxide pressure as well as the pH value in the blood as indicators (characteristics) for the extent of the respiratory disorder. The so-called pulse oximeter is used to determine the amount of oxygen in the red blood cells. This is known as oxygen saturation.

No more cigarettes: the diagnosis of "emphysema" should be the reason to give up smoking at the latest

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Therapy: How is emphysema treated?

If left untreated, emphysema can lead to death, particularly due to lung failure. It is therefore particularly important to do everything possible to slow the progression of the disease. In addition, the symptoms can be alleviated. Treatment includes the right way of life, individually dosed sport, possibly with breathing exercises, medication, oxygen and in some cases also surgical or endoscopic interventions.

Crucial: the smoke stop

If possible, all unfavorable factors should be eliminated immediately. For smokers this means: quit smoking immediately. Anyone who continues to smoke even though emphysema has already formed will significantly reduce their life expectancy.

Anyone who is professionally confronted with irritants that trigger or worsen pulmonary emphysema should ask the doctor about the recognition of their condition as an occupational disease.

Furthermore, all concomitant diseases that represent an additional burden or that can have a negative effect on the course of emphysema must be treated. These include infections, chronic bronchitis, high blood pressure, diabetes mellitus (diabetes), heart disease, obesity.

Get advice on vaccinations

Respiratory infections can be more severe in patients with emphysema than in healthy people. Apparent minor infections should therefore not be taken lightly. Vaccinations against influenza viruses (causing flu) and pneumococci (causing pneumonia) may be advisable. The doctor can provide information about which preventive measures are suitable.

Often with emphysema, chronic obstructive bronchitis is also present. This must be treated according to the usual therapy standard (see there) in order to reduce this proportion of the shortness of breath.

There are no drugs that directly improve emphysema. Alpha-1 antitrypsin may help people with alpha-1 protease inhibitor deficiency emphysema.

Breathing exercises

Breathing aerobics is another important treatment measure. Patients should learn the appropriate breathing technique under expert guidance. With the lip brake, for example, the person concerned exhales against the resistance of the half-closed lips. This increases the pressure in the bronchi and counteracts their collapse. The doctor may prescribe breathing exercises, during which the appropriate exercises are taught. Contacting the nearest lung sports group is important and helpful.

Oxygen administration

If there is a lack of oxygen, treatment with oxygen is often advisable, especially under stress. However, it must be started under medical supervision. If there is severe shortness of breath due to an infection, it may be necessary to be admitted to the clinic with artificial ventilation through a mask (non-invasive ventilation, NIV mask ventilation). No anesthesia is necessary for this. In rare cases or if there is insufficient improvement, artificial respiration must be provided by means of a tube in the trachea (intubation) under anesthesia. However, since patients with poor lung function are very difficult to get away from this form of ventilation, this option remains an emergency intervention.

Emphysema: Sometimes surgery helps

In certain cases, surgical procedures for emphysema can be considered. In the so-called lung volume reduction operation, some of the over-inflated lung sections are surgically removed. However, this procedure is not promising for every emphysema patient; In some emphysematics, however, this can improve lung function.

There are also procedures in which doctors use a lung specimen (bronchoscopy) to place valves or wire spirals (coils) in certain sections of the lungs. In this way, heavily affected areas can be specifically vented and less affected lung sections can be relieved. But sometimes they also make the situation worse. For this reason, a careful pre-selection of the patients who may benefit after an exchange of information between the surgeon and the endocopist (doctor performing the endoscopy) is important and necessary.

In very severe cases of emphysema, a lung transplant is the last option. This procedure is also not possible for every emphysema patient. In addition, the number of donor lungs is limited.

What is the prognosis for emphysema?

The life expectancy of smokers depends crucially on the fact that they stop smoking. Another important prognostic factor is the lung function test and the measurement of the lung surface area. The findings must be discussed with the attending physician on a case-by-case basis. The gradients can be very different. Pulmonary emphysema is a chronic disease that cannot be reversed (irreversible). In severe pulmonary emphysema, there is a significant reduction in quality of life due to the increasing shortness of breath.

Dr. Peter Haidl

© Source H. P. Kappes, Schmallenberg

Consulting expert:

Dr. Peter Haidl is the chief physician of the Department of Pneumonology II (general pulmonology and internal medicine) and medical director of the Kloster Grafschaft specialist hospital.


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Important NOTE:
This article contains general information only and should not be used for self-diagnosis or self-treatment. He can not substitute a visit at the doctor. Unfortunately, our experts cannot answer individual questions.