COPD Emphysema

Emphysema can best be characterized as the progressive destruction of the grape-like air sacs (alveoli) that perform the lung's basic function of exchanging oxygen in the air for carbon dioxide in the cardiovascular system. The small air sacs are unable to completely deflate (over inflation) and unable to fill with fresh air for adequate ventilation. Emphysema is not reversible, but the disease is manageable through medications, exercise and good nutrition. In emphysema caused by smoking, which constitutes the majority of cases, the very small airways (bronchioles) that join the alveoli are damaged and the walls lose elasticity. Pockets of dead air form in the damaged lung areas restricting the ability to exhale, reducing normal lung function. Inhalation is not usually impaired in the early stages, but in the late stages of the disease, oxygen and carbon dioxide levels are abnormal and breathing becomes labored. Emphysema patients have typically lost between 50% and 70% of their lung function by the time symptoms begin to appear. Experts believe the process leading to emphysema is mostly due to an imbalance in chemicals that protect the lungs from infection and damage. Any condition that causes an imbalance in these substances may trigger emphysema. Cigarette smoke contains irritants that inflame the air passages, setting off these biochemical events that damage cells in the lung, thus increasing the risk both for emphysema and lung cancer. Because smoking is overwhelmingly the cause of emphysema and chronic bronchitis, they often develop together and frequently require similar treatments. In a rare, inherited form of emphysema known as alpha-1-antitrypsin deficiency, both the walls of the bronchioles and alveoli to which they connect, usually in the lower lungs, are diseased.

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Illustration: AMA

Chronic Bronchitis
Chronic bronchitis is an inflammation of the main air passages (bronchi) to the lungs, which results in the production of excess mucous, a reduction in the amount of airflow in and out of the lungs and shortness of breath. In chronic bronchitis, there is excessive bronchial mucus with a productive cough for three months or more over two consecutive years without any other disease that could account for these symptoms. In the early stages of chronic bronchitis, a cough usually occurs in the morning. As the disease progresses, coughing persists throughout the day. This chronic cough is commonly referred to as "smoker's cough." Also In the early stages of chronic bronchitis, only the larger airways are affected, but eventually all airways are involved. Over time the patient experiences abnormal ventilation-perfusion: insufficient oxygenation of blood (hypoxemia), labored breathing (hypoventilation) and right-sided heart failure (cor pulmonale). Compared with acute bronchitis, which may respond quickly to medications, such as antibiotics, chronic bronchitis can be difficult to treat because many patients with chronic bronchitis are susceptible to recurring bacterial infections. Excessive mucous production in the lungs provides a good environment for infection, which also causes inflammation and swelling of the bronchial tubes and a reduction in the amount of airflow in and out of the lungs. Therefore, at the first signs of a lung infection, people with chronic bronchitis should seek immediate medical treatment. Waiting until an infection is well established, usually leads to hospitalization and long intensive care (ICU) stays.

In the later stages of chronic bronchitis, the patient cannot clear this thick, tenacious mucus, which then causes damage to the hair-like structures (cilia) that help sweep away fluids and/or particles in the lungs. This in turn impairs the lung's defense against air-borne irritants. Cigarette smoking is the most common cause of chronic bronchitis. People who have been exposed for a long time to irritants, like chemical fumes, dust and other noxious substances, can also get chronic bronchitis. As chronic bronchitis often coincides with emphysema, it is frequently difficult for a physician to distinguish between the two. Chronic bronchitis also can have an asthmatic component. Lying down at night can worsen the condition, so some people with advanced chronic bronchitis must sleep sitting up. In late, severe stages people who often have emphysema as well, are called "blue bloaters" because lack of oxygen causes the skin to have a blue cast (cyanosis) and because the body is swollen from fluid accumulation caused by congestive heart failure. There is no cure for chronic bronchitis. Treatment is aimed at relieving symptoms and preventing complications. Not all people with COPD have asthma, but many do have an asthmatic component to either emphysema or chronic bronchitis, or even a mix of all three, while most asthma patients do not have COPD. There remains the debate among medical professionals whether chronic asthma belongs under the umbrella term COPD because, unlike emphysema and chronic bronchitis, asthma can be reversed and responds well to various medications. The fact remains, however, that many with already impaired lung function are highly susceptible to asthma. The word asthma originates from an ancient Greek word meaning panting. It is a chronic inflammatory disease of the airways in the lungs. This inflammation causes the airways to narrow or constrict, which produces wheezing and breathlessness, sometimes to the point where the sufferer gasps for air. When a healthy person inhales, the air passes into the lungs through progressively smaller airways (bronchioles). The lungs contain millions of bronchioles, all leading to air sacs (alveoli), where oxygen and carbon dioxide are exchanged. The airways in the lungs respond by constricting when exposed to allergens or irritants, but here is the major difference between people with and without asthma. When a healthy person breathes in and out deeply, the airways relax and open in order to rid the lungs of the irritant. When asthmatics try to take deep breaths, their airways do not relax, but instead narrow and the person pants for breath. These smooth muscles in the airways of people with asthma may have a defect, perhaps a deficiency in a critical chemical that prevents the muscles from relaxing. This obstruction of the airflow either stops spontaneously or responds to a wide range of medical treatments. Continuous inflammation makes asthmatics hyper-responsive to such stimuli as cold air, exercise, dust, pollutants in the air, stress or anxiety Research shows asthma has two primary stages: hyper-reactive response and the inflammatory response. In the hyper-reactive condition, the smooth muscles in the airways constrict and narrow excessively in response to inhaled noxious irritants. The inflammatory stage of asthma is when the immune system responds to allergens or other environmental triggers by producing white blood cells and other immune factors in the airways. These inflammatory factors cause the airways to swell and to fill with fluid, producing thick sticky

mucus. In an asthma attack, the muscle tissue in the walls of the constricted bronchi go into spasms, making it much harder to breath. Occupationally-related asthma is now the most frequent occupational respiratory disease diagnosis among patients visiting occupational medical clinics. Recent evidence shows that as many as 26% of adult asthma cases may be attributable to the workplace.

Bronchiectasis is a lung disease, which is characterized by the permanent damage and widening of one or more of the large connecting bronchi (airways). Infections cause a change in the muscular and elastic components of the bronchial wall, which then become distorted and enlarged. This enlargement can be uniform or irregular. It begins a cycle in which the airways slowly lose their ability to clear mucus. As the mucus builds up, serious lung infections can then occur, which can cause more damage to the bronchi. This results in the vicious cycle of bronchial damage, bronchial dilation, inability to clear secretions, reoccurring infection and more bronchial damage. Over time, the airways become chronically inflamed, more stretched out, scarred and easily collapsed, resulting in airflow obstruction. In advanced cases, this can affect how much oxygen reaches the body's organs, leading to other serious illnesses involving damage to those critical organs.

There are two basic types of bronchiectasis:

Congenital bronchiectasis is present at birth, usually only affects infants and children, and is the result of developmental arrest of the bronchial tree in the fetus. Acquired bronchiectasis occurs in adults and older children and is the more common form. Some of the more common causes are: Chronic long diseases such as: Cystic Fibrosis Note: CF is considered the major lung disease contributing up to 50% of bronchiectasis cases Tuberculosis Allergic Aspergillosis Young Syndrome, a disease very similar to CF and may be a genetic variant Kartagener's Syndrome, a rare inherited disease that combines the loss of ability to clear mucus and chronic sinusitis Alpha1-antitrypsin deficiency Severe lung infections such as repeated episodes of pneumonia, fungal infections, whooping cough, and other disorders that affect the cilia (the small hair like structures that line the airways and help clear out mucus Immunodeficiency disorders such as HIV Blockages of the airways Growths and tumors Inhaled substances (a peanut, a small toy, etc.) Mucus plugs Impaired ability to swallow, causing food or saliva to enter the lungs Severe heartburn (gastroesophageal reflux disease) (GERD) allowing stomach contents to

enter the lungs Drug abuse (especially heroin) In a small number of case, inhaling toxic substances that injure the bronchi, such as noxious fumes, gases, smoke (including tobacco smoke), and injurious dust (silica, coal dust, glass dust) can lead to bronchiectasis. Chlorine gas, sulfur dioxide and ammonia are among the more suspected noxious fume agents. NOTE: There have been some reports that some service personnel who have seen duty in Iraq were exposed to large concentrations of ammonia and have developed bronchiectasis.

The symptoms for bronchiectasis fall into two broad categories.

The most common symptoms in early stages of bronchiectasis are: Daily cough, over months or years Daily production of large amounts of mucus, or phlegm (flem) Repeated lung infections Shortness of breath Wheezing Chest pain Breath odor The more serious longer term symptoms and conditions occurring in more advanced stages of bronchiectasis in addition to the above may include: Coughing up blood or bloody mucus Coughing that worsened by lying on one side Clubbing of fingers Change in skin color Bluish indicating oxygen deficiency Paleness Weight loss Fatigue Sinus drainage Collapsed lung Heart failure Brain abscesses Diagnosing bronchiectasis: This involves a series of tests designed to identify underlying causes of any symptoms and to determine the amount of damage to the lungs. Since the symptoms for bronchiectasis are very similar to other conditions such as chronic asthma and chronic bronchitis, a major part of the diagnosis involves eliminating the possible other conditions. The most common tests are: Chest X-ray, which can show infections and scarring CT Scan, considered a defining test for bronchiectasis, can show how much damage is done to the airways as well as the exact location of the damage Pulmonary Function Tests (PFT), including: Spirometry Lung volume measurements Diffusion capacity (DLCO) which measure how well the lungs take in and exhale air, and

how efficiently they transfer oxygen Blood Tests Complete blood count (CBC) Arterial Blood Gas (ABG) Sputum cultures can show if you have bacteria, fungi, or tuberculosis Sweat tests (A patch test for Cystic Fibrosis) Bronchoscopy A bronchoscope is a long narrow, flexible tube with a light on the end which is inserted through your nose or mouth into your airways, and provides a video image of the airways. It also allows your doctor to see possible blockages as well as collecting samples of mucus.

There are three classifications of bronchiectasis which describe the severity of the condition:
Cylindrical - most common and refers to the slight widening of the respiratory passages. This type can be reversed and may be seen after acute bronchitis Varicose - bronchial walls have both extended and collapsed portions Cystic - most severe and involves irreversible ballooning of the bronchi

Treating and managing bronchiectasis.

Early diagnosis and treatment plans are designed primarily to slow the progression of the disease, and to prevent additional damage to the lungs. Treatment plans encompass several categories Treatment of underlying conditions Treatment of respiratory infections early and aggressively Medications Antibiotics Bronchodilators Corticosteroids Mucus thinners Expectorants Nasal washes Mucus removal Prevention of future complications Pulmonary rehab In advanced instances Oxygen therapy Surgery to remove portions of the lungs. Single and double lung transplant

The prognosis for people with bronchiectasis is quite varied and dependent on a
number of factors, including: How early a comprehensive treatment plan was implemented How well subsequent infections are controlled The prevention of relapses is critical to a patients longevity. Relapses of bronchiectasis can be controlled with antibiotics, chest physiotherapy, inhaled bronchodilators, proper hydration, and good nutrition. The effects of other systemic diseases which impact the effectiveness of treatments Among

the more common diseases are: Chronic bronchitis Emphysema Pulmonary hypertension Cor pulmonale