Signs and Symptoms of Severe Pulmonary

Emphysema

Saroglou MariaMD,MSc, PhDPulmonologist

Concultant G.N. Drama

EmphysemaDescription

Abnormal permanent enlargement of the

air space distal to the terminal bronchioles

Accompanied by destruction of bronchioles

Etiology

Cigarette smoking

Genetic predisposition

➢ Alpha1 protease inhibitor

Occupational exposure to chemical irritants

Exposure to atmospheric pollutants

Figure 9-12. Distal airway and alveolar weakening clinical scenario.

Anatomic Alterations of the Lungs (1)

Permanent enlargement and deterioration

of the air spaces distal to the terminal

bronchioles

Destruction of pulmonary capillaries

Weakening of the distal airways, primarily

the respiratory bronchioles

Anatomic Alterations of the Lungs(2)

Bronchospasm (with concomitant

bronchitis)

Hyperinflation of alveoli (air-trapping)

Emphysema Pathophysiology

➢ Two types:

Centrilobular (central part

of lobule)

▪ Most common

Panlobular (destruction of

whole lobule)

▪ Usually associated with AAT

deficiency

Emphysema Pathophysiology

Structural changes are:

➢ Hyperinflation of alveoli

➢ Destruction of alveolar capillary walls

➢ Narrowed, tortuous small airways

➢ Loss of lung elasticity

Emphysema Pathophysiology

➢ Small bronchioles become obstructed as a result of

Mucus

Smooth muscle spasm

Inflammatory process

Collapse of bronchiolar walls

Emphysema Pathophysiology

➢ Recurrent infections production/stimulation

of neutrophils and macrophages release

proteolytic enzymes alveolar destruction

inflammation, exudate, and edema

Emphysema Pathophysiology

➢ Elastin and collagen are destroyed

➢ Air goes into the lungs but is unable to come out on its own and remains in the lung

Causes bronchioles to collapse

Emphysema Pathophysiology

➢ Trapped air hyperinflation and overdistention

➢ As more alveoli coalesce, blebs and bullae may develop

➢ Destruction of alveolar walls and capillaries reduced surface area for O2 diffusion

Emphysema Pathophysiology

➢ Compensation is done by increasing respiratory rate to increase alveolar ventilation

➢ Hypoxemia usually develops late in disease

Clinical Data Obtained from

Laboratory Testsand Special Procedures

Pulmonary Function Study Expiratory Maneuver Findings

FVC FEV1 FEF25%-75% FEF200-1200

PEFR MVV FEF50% FEV1%

Pulmonary Function Study Lung Volume and Capacity Findings

VT RV FRC TLC

N or N or

VC IC ERV RV/TLC ratio

N or N or

Decreased Diffusion Capacity

(DLCO)

Arterial Blood Gases

Mild to Moderate Emphysema

Acute alveolar hyperventilation with

hypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)

Time and Progression of Disease

100

50

30

80

0

10

20

40

Alveolar Hyperventilation

60

70

90 Point at which PaO2

declines enough to

stimulate peripheral

oxygen receptors

PaO2

Disease OnsetP

aO

2o

r P

aC

O2

Figure 4-2. PaO2 and PaC02 trends during acute alveolar hyperventilation.

Arterial Blood Gases

Severe Emphysema

Chronic ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2

Normal (Significantly)

Time and Progression of Disease

100

50

30

80

0

10

20

40

Alveolar Hyperventilation

60

70

90

Point at which PaO2

declines enough to

stimulate peripheral

oxygen receptors

Chronic Ventilatory FailureDisease Onset

Point at which disease

becomes severe and patient

begins to become fatigued

Pa

02

or

Pa

C0

2

Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.

Clinical Data Obtained at the Patient’s Bedside

Peripheral edema and venous distention

Distended neck veins

Pitting edema

Enlarged and tender liver

DistendedNeck Veins

Figure 2-48. Distended neck veins (arrows).

Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2,

London, 1992, Mosby-Wolfe.

Clinical Data Obtained at the Patient’s Bedside

Cough, sputum production, hemoptysis

Chest assessment findings

➢ Hyperresonant percussion notes

➢ Wheezing

Clinical Data Obtained at the Patient’s Bedside

➢ Diminished breath sounds

➢ Diminished heart sounds

➢ Decreased tactile and vocal fremitus

➢ Crackles/rhonchi (when accompanied by bronchitis)

Clinical Data Obtained at the Patient’s Bedside

Use of accessory muscles of inspiration

Use of accessory muscles of expiration

Pursed-lip breathing

Clinical Data Obtained at the Patient’s Bedside

Increased anteroposterior chest diameter

(barrel chest)

Cyanosis

Digital clubbing

Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.

Abnormal Laboratory Testsand Procedures

Hematology

Increased hematocrit and hemoglobin

Electrolytes

Hypochloremia (chronic ventilatory failure)

Sputum examination

Streptococcus pneumoniae

Haemophilus influenzae

Radiologic Findings

Chest radiograph

Translucent (dark) lung fields

Depressed or flattened

diaphragms

Radiologic Findings

Long and narrow heart

Enlarged heart

Increased retrosternal air space

(lateral radiograph)

Figure 12-3. Chest X-ray of a patient with emphysema. The heart often appears long

and narrow as a result of being drawn downward by the descending diaphragm.

Figure 12–4. Emphysema. Lateral chest radiograph demonstrates a characteristically large

retrosternal radiolucency with increased separation of the aorta and sternum measuring 4.6 cm, 3 cm

below the angle of Louis and extending down to within 3 cm of the diaphragm anteriorly. Both

costophrenic angles are obtuse, and both hemidiaphragms are flat. (From Armstrong P et al, editors:

Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

Clinical Data Obtained at the Patient’s Bedside

Vital signs

Increased respiratory rate

Increased heart rate, cardiac

output, blood pressure

EmphysemaClinical Manifestations

➢ Dyspnea

Progresses in severity

Patient will first complain of dyspnea

on exertion and progress to rest

Emphysema Clinical Manifestations

➢ Minimal coughing with no to small

amounts of sputum

➢ Overdistention of alveoli causes

diaphragm to flatten and AP diameter to

increase

Emphysema Clinical Manifestations

➢ Patient becomes chest breather, relying

on accessory muscles

Ribs become fixed in inspiratory

position

EmphysemaClinical Manifestations

➢ Patient is underweight (despite adequate

calorie intake)