Emphysema And Chronic Bronchiti
EMPHYSEMA and CHRONIC BRONCHITIS
Together, the two diseases emphysema and chronic bronchitis are termed “chronic obstructive pulmonary disease” (COPD) and this term tells much about the nature of the disorders. The vast majority of occurrences are the direct and unequivocal result of cigarette smoking. A sad result of the increasing incidence of smoking among women is that COPD is rising rapidly in that segment of the population, quickly catching up to that of males, who still comprise the majority of patients. Unlike asthma, the respiratory damage of COPD is irreversible, yet ironically quite preventable.
Cigarette smoke contains hundreds of chemicals which can damage lung tissue. The net result after many years is that the lung loses its natural tendency to deflate or spring shut. The bronchial tubes become swollen and inflamed, and their diameter may decrease markedly. Excessive amounts of sputum are characteristic of bronchitis, and this may further impair air movement. In emphysema, the air sacs (alveoli) are destroyed and replaced by scar tissue. Finally, the lungs become like large floppy balloons, with a major effort necessary to squeeze out each breath. In some cases, eventhat air that is breathed in and out fails to transmit its life giving oxygen normally, since it comes into contact with scar tissue or sputum instead of healthy lung tissue. An additional result in severe cases is that the carbon dioxide produced in the body by everyday metabolism can no longer be exhaled adequately, and accumulates in the blood.
Some individuals are more sensitive to nicotine and to cigarette smoke than are others. In addition, an occasional nonsmoker may develop the syndrome, either through congenital chemical imbalances, occupational exposures, or unknown factors. In general, the patient must have accumulated a long and heavy smoking history before noting symptoms; the disease may have been present for years but the lungs’ reserve capacity will have compensated until over 50% of the airways are involved.
SYMPTOMS
The first symptom of emphysema is usually shortness of breath on exertion. Chronic bronchitis usually has a longstanding cough as its first warning. Most patients have a mixture of the two. As the disease progresses, shortness of breath increases such that in the end, even speaking more than a few words at a time is too much. Cough may become incapacitating; in chronic bronchitis cups of yellow or green sputum may be coughed up daily. Low blood oxygen is not always present, and in fact is unusual in emphysema, as compared to bronchitis. When low oxygen levels are present, the lips and digits may appear blue or dusky, and cardiac or cerebral symptoms may appear.
As the terminal stages are approached the patient begins to lose weight as eating becomes difficult, and energy is spent breathing through the damaged lungs. The slightest respiratory burden such as a mild cold, or the use of even mild sedatives is enough to cause respiratory failure, and periods on a mechanical ventilator become necessary if the patient survives. Eventually, the patient succumbs to the disease, as even intensive care cannot replace a totally damaged respiratory tree.
The heart is burdened in many cases by trying to maintain circulation through a scarred and narrowed pulmonary circulation; heart failure commonly results. Pneumonia finds a fertile home in the lung of COPD patients, who can ill afford additional lung problems. Still others get lung cancer from their smoking habits.
Discontinuation of smoking slows down but does not stop the progression, and continuation always speeds up the disease. Amazingly, many patients keep smoking even as they are recovering from a bout on the ventilator!
DIAGNOSIS
The complaints mentioned above in a heavy smoker are highly suggestive of the disease. Examination of the lungs reveals characteristic sounds. A peculiar rounding of the finger nails occurs in some patients. Chest x-rays sometimes but not always reveal hyperinflation or scarring of the lungs. The most sensitive and reliable test is pulmonary function breathing measurement (spirometry) where the rate of airflow is measured. Unlike asthma, the reduced flow is not reversed to near normal after bronchodilator drugs are given. Blood samples are measured for oxygen and carbon dioxide content from an arterial sample taken usually at the wrist.
Rarely is the diagnosis in question in the above evaluation, although occasionally congestive heart failure, sarcoidosis, tuberculosis and other lung diseases can be present. Care must be taken by the physician to rule these out.
TREATMENT
No treatment can arrest or reverse COPD, although a variety of aggravating factors can be treated. In some patients, overgrowth of bacteria in the bronchi cause flare-ups, and antibiotics such as tetracycline, amoxicillin, and TMP-sulfa can help. Still others have an asthma-like reaction as part of their disease, and treament as outlined for asthma provides benefit. A fraction of patients respond to cortisone or prednisone, and although long term use can have serious side effects, this drug can also be helpful.
Training of the patient in pulmonary exercises and other techniques can enhance adaptation to the handicap. A small minority of patients will benefit from chronic oxygen use, although most do not, and this is an expensive modality. Prompt treatment of any worsenings is important. The importance of pneumonia and influenza immunizations are clear. Emotional counseling is important for others. Obviously, avoidance of smoking is advised. It is very important for severely ill patients to avoid sedating drugs, as these may precipitate respiratory failure.
Experimental treatments such as x-ray therapy and surgery have found little acceptance, as their benefit has been disappointing. It seems that once the diagnosis is made, the best course is to stop smoking, find a skilled and caring physician, call her/him as soon as any flare-ups begin, and follow a comprehensive program of judicious medications, training, and careful lifestyle adjustment. Despite the fact that 50,000 people die yearly in the U.S. of COPD, and many thousands more become severely disabled, the incidence of smoking and illness continue to rise; this is a national health problem of major proportions.