Emphysema: Overview and Practice Questions

Emphysema is a progressive lung disease characterized by increased lung expansion and damage to the alveoli. It’s a type of COPD that affects millions of people around the world each year.

In this article, we’ll provide a medical overview of emphysema, including its causes, symptoms, and treatment options. We included helpful practice questions on this topic as well.

What is Emphysema?

Emphysema is an obstructive disease that causes increased lung expansion due to air trapping. This results in irreversible damage to the alveoli, which are tiny air sacs in the lungs where gas exchange takes place.

The damage leads to a decrease in surface area and elasticity, which makes it difficult to expel air from the lungs. This can cause difficulty breathing, coughing, and wheezing, and can lead to respiratory failure.

Causes

Some examples of the most common causes of emphysema include:

• Smoking cigarettes
• Exposure to second-hand smoke
• Air pollution
• Genetics

Smoking is the leading preventable cause of emphysema in the United States.

Cigarette smoke contains harmful chemicals that, over time, cause damage to lung tissue and can result in this chronic condition.

Signs and Symptoms

Symptoms of emphysema typically don’t appear until the disease has progressed. However, some common signs and symptoms include:

• Hypoxemia
• Shortness of breath
• Wheezing
• Use of accessory muscles while breathing
• Diminished breath sounds
• Pursed-lip breathing

Each patient is different; therefore, each patient may experience different signs and symptoms. Additionally, the severity may also vary among each individual patient.

Diagnosis

The diagnosis of emphysema is based on a combination of tests, including:

• Medical history
• Physical examination
• Vital signs
• Pulse oximetry
• Arterial Blood Gas (ABG)
• Pulmonary Function Testing (PFT)
• Chest x-ray
• CT scan
• Electrocardiogram (ECG)

In addition, the physician may recommend testing for alpha-1 antitrypsin deficiency, which is a genetic condition that can lead to emphysema.

Treatment

The goal of treatment is to relieve symptoms and prevent further damage to the lungs. Some common treatment methods include:

• Inhaled bronchodilators
• Inhaled corticosteroids
• Smoking cessation
• Avoiding exposure to irritants
• Pulmonary rehabilitation
• Disease management education
• Low-flow oxygen therapy
• Noninvasive ventilation
• Mechanical ventilation (in severe cases)

Each patient is different, and the treatment plan will be tailored to their individual needs. Noninvasive ventilation (NIV) is preferred over conventional ventilation.

However, intubation and mechanical ventilation are indicated when a patient has severe problems with oxygenation or ventilation.

Emphysema Practice Questions:

1. What is the definition of emphysema?
It is defined pathologically as the presence of permanent enlargement of the alveoli where lung tissue is damaged and air-trapping occurs. It causes elastin destruction with an abnormal weakening and permanent enlargement of air spaces distal to the terminal bronchioles with destruction of the alveolar walls and pulmonary capillaries.

2. What are some of the causes?
Smoking, chronic irritation and inflammation, infections, pollutants, long-term exposure to airborne irritants and alpha one anti-trypsin deficiency.

3. What are the two types of emphysema?
Centrilobular or centroacinar, and panlobular or panacinar.

4. What type is more common?
Centrilobular.

5. What is the most common cause of emphysema?
Smoking.

6. What parts of the lungs does panlobular emphysema affect?
Respiratory bronchioles, alveolar ducts, and alveolar sacs which are destroyed by elastase.

7. What parts of the lungs does centrilobular emphysema affect?
Respiratory bronchioles and upper lobes.

8. What happens in the pathophysiology of emphysema?
The alveoli and the small distal airways are affected by this disease that is followed by the larger airways. The bronchioles lose their stability which leads to the collapse in the airways resulting in gas to be trapped distally. It develops when the production and activity of ant protease are not sufficient to counter the harmful effects of excess protease production. Destruction of the alveolar walls and the breakdown of elastic tissue and collagen is the result of this. In addition, destruction of alveolar sacs, loss of recoil, increased compliance (floppy airways), exhalation incomplete and requires energy, V/Q mismatch, chest and heart becomes long and narrow, and diaphragm flattens.

9. What happens when the lungs do not recoil properly?
Increased compliance (floppy airways), premature airway closure leading to air trapping, hyperinflation, and increased residual volume, functional residual capacity, and total lung capacity.

10. What are some signs and symptoms of emphysema?
Accessory muscle use- braced and leaned forward (tripod position), pursed-lip breathing, cachectic or malnourished, yellow fingers possible from smoking, digital clubbing, polycythemia, cor pulmonale, jugular venous distention, and edema (if cor pulmonale), increased respiratory rate, heart rate and dry nasopharyngeal carcinoma.

11. What are the tiny air sacs in lungs called?
Alveoli.

12. What will be seen on a chest x-ray and CT scan of patients with emphysema?
Hyperlucent with black lung due to gas trapping and increase functional residual capacity bulla and/or blebs, prominent pulmonary arteries, flatten diaphragm, blunted costophrenic angle, and bullous lesions. 

13. What can immunizations do?
They can help to prevent the disease.

14. What is a bulla?
Bulla is air pockets greater than one centimeter in the lung parenchyma.

15. What is a bleb?
Bleb is the accumulations of air within the layers of the visceral pleura. This is usually smaller than bulla.

16. What can be observed in pulmonary function test on patients with emphysema?
Decreased forced expiratory flow, increased total lung capacity, residual volume, and functional residual capacity, increased residual capacity over total lung volume and low diffusion.

17. What are some treatments for emphysema?
Bronchial hygiene, lung reduction, breathing techniques, oxygen, mechanical ventilation and lung transplant.

18. What medication or treatment is available for alpha one antitrypsin patient?
Administration of prolastin.

19. What is panlobular emphysema?
Panlobular (pancinar) is the most severe but less common type. It is the abnormal weakening and enlargement of all alveoli distal to the terminal bronchioles, respiratory bronchioles, alveolar duct and alveolar sacs.

20. What is Centrilobular emphysema?
Centrilobular is the most common type. Its form begins at the respiratory bronchioles and spread peripherally and involves the upper half of the lungs.

21. What are the major pathological changes associated with emphysema?
Changes include permanent enlargement and destruction of the air spaces distal to the terminal bronchioles, destruction of pulmonary capillaries, weakening of the distal airways primarily the respiratory bronchioles and air trapping and hyperinflation

22. What is Bullous Emphysema?
It is also known as BLS, occurs in one or both lungs and is characterized by the presence of one or several abnormally large air spaces surrounded by relatively normal lung primarily on distal airways involving alveolar ducts and sacs. Some causes: shows inspiratory flow rates as normal but cannot get air out (gas trapping).

23. How is emphysema similar to chronic bronchitis?
It is very similar, except the airways have obstruction due to the reduced elastic recoil of the lungs. The inspiratory flow rates are normal if the patient has pure emphysema. The patient has dyspnea initially only on exertion with it intensifying at variable rates until shortness of breath at rest.

24. What are the symptoms of emphysema?
Increased A-P diameter (barrel chest appearance), accessory muscle usage, prolonged exhalation, shortness of breath, coughing, wheezing, hyper-resonant or decreased breath sounds, pursed-lip breathing, cyanosis and chronic cough.

25. What is the classification of patients with emphysema?
Patients with this disease are classified as a pink puffer. The show pursed-lip breathing. Patient has both a red complexion and rapid respiratory rate and has a barrel chest. They use accessory muscles of inspiration.

26. What are pink puffers?
Pink puffers are characterized as severe emphysema with relatively little information of the airway, increase dyspnea often appear anxious, marked weight loss often appearing malnourished, hyperlucent lungs, small heart with normal ABG. The term is derived from the reddish complexion in the patient.

27. What happens to alveolar walls in emphysema?
It enlarges and then degenerates.

28. How many smokers will develop damage of the alveoli and when will it start to show up?
All smokers will develop damage of the alveoli. Symptoms will show between ages 35-40 years old.

29. What kind of damage of the alveoli does emphysema cause?
Permanent and irreversible.

30. How would ventilation be affected by emphysema?
Easy compliance and low recoil manifesting as hard to breathe out and patients will often pant when they breathe.

31. How would emphysema affect gas exchange?
Less surface area in alveolar walls which will cause the patient to need oxygen therapy.

32. How will chronic obstructive pulmonary disease affect gas exchange?
It is harder to breathe out, there is a build-up of carbon dioxide in lungs resulting in acidosis.

33. What is centrilobular/centriacinar emphysema?
Centrilobar/Centriacinar is the abnormal weakening and enlargement of the respiratory bronchioles and alveoli in the proximal portion of the acinus. It is related to inflammation.

34. What is panlobular/pancinar emphysema?
Panlobular/Panacinar is an abnormal weakening and enlargement of all air spaces distal to the terminal bronchioles. It is related to alpha1-antitrypsin deficiency.

35. What are the risk factors of emphysema?
Alpha1-antitrypsin deficiency; genetic disorder affecting the lungs, liver, and rarely the skin; smoking; age; second-hand smoke; occupational exposure and pollution.

36. What is the risk factor for panlobular emphysema?
Severe deficiency of Alpha1-antitrypsin poses a strong risk factor.

37. What are the distinguishing factors of emphysema?
Thin build, barrel chest, pursed-lip breathing, reddish skin, use of accessory muscles, hyper-resonance percussion, decreased breath sounds, prolonged expiration, decreased heart sounds, hyperinflation showing on chest x-ray, decreased carbon monoxide diffusing capacity and Hoover’s sign.

38. What is the definition of diffusing capacity of the lungs of carbon monoxide?
Diffusing capacity of the lungs of carbon monoxide is a medical test that determines how much oxygen travels from the alveoli of the lungs to the bloodstream.

39. What is the rarest cause of emphysema?
Asthma.

40. What is referred to as a Hoover’s sign?
Hoover’s sign is the inward movement of the lower lateral chest wall during each inspiration that indicates severe hyperinflation.

41. Will all smokers developing emphysema?
No, only if you’re genetically susceptible.

42. What is the rare inherited deficiency of the protein that protects the elastic function of lungs?
Alpha-1 antitrypsin deficiency; seen in emphysema.

43. How is the onset of this disease?
It is usually a slow onset.

44. What is one symptom you experience in the later stages of emphysema?
Frequent lung infections.

45. What is the pathogenesis of emphysema?
Slowly damages the alveoli (air sacs) in the lungs and makes it progressively harder to breathe. The inner walls of the air sacs weaken and rupture.

46. What is the problem with exhaling with emphysema patients?
The damaged alveoli do not work properly, the old air becomes trapped in lungs and it prevents oxygen-rich air from flowing in.

47. What happens when the inner walls of the air sacs weaken and rupture?
One large air space instead of many small reduces amount of surface area and reduces amount of oxygen to reach blood.

48. When should a patient with potential emphysema see a doctor?
It is advisable to see a doctor when experiencing unexplained increase in shortness of breath at rest or during activity that interfere with daily activities.

49. What are the four pathophysiologies behind emphysema?
It has these pathophysiologies: lungs respiratory defenses are broken down by foreign invaders from cigarette ingredients; inflammatory immune cells appear and transport antigens to the bronchial lymphatic tissue layer. Macrophages release enzymes that destroy the lungs epithelial barrier; loss of alveolar wall decrease in elastic recoil in lungs that reduces airflow; and, loss of alveolar supporting structures airway narrows which further limits airflow.

50. How is emphysema diagnosed?
Medical history questionnaire, physical examination of body, imaging tests like x-rays and computed tomography, laboratory tests and lung function tests.

51. What position is best for clients with emphysema under normal circumstances?
Semi-fowlers or higher.

52. What flow rates of oxygen are appropriate for a patient with emphysema?
Low flow — <2.5 L/min; never exceed 2.5L in chronic obstructive pulmonary disease. This is to prevent to loss of the hypoxic drive.

53. What position is best on patients with emphysema that has a severe dyspneic episode?
Sitting upright with arms folded on the overbed table.

54. What will you observe on the hands of the client with emphysema?
Clubbing of the fingernail beds.

55. What is the characteristic of the alveoli in this disease?
Over-enlarged and under-ventilated so that air is trapped in alveoli.

56. What is most associated with the development of emphysema is?
A history of smoking.

57. What are manifestations of emphysema?
The appetite decreases while the weight decreases and the anterior-post diameter of the chest increases.

58. What can be visibly seen on patients with emphysema?
They have grunting, pursed lips, and rapid breathing.

59. What is the increase in anterior-posterior diameter of emphysema typically called?
Barrel chest.

60. What dietary prescription is most appropriate for a patient with emphysema?
Frequent small meals to prevent tiring.

61. What fluid order should the emphysema patient have?
3 liters of fluid per day.

62. How will patients with emphysema appear?
Cyanotic (pink puffer).

63. What is the life expectancy after diagnosis?
5 years.

64. What age are you most likely to get emphysema?
40-60 years of age.

65. What is the first symptom seen with this disease?
Shortness of breath.

66. What is a physical therapy for lungs that improves symptoms of emphysema?
Pulmonary rehabilitation.

67. What can you do to treat a patient with low oxygen saturation levels?
Provide oxygen therapy.

68. What is the treatment for someone with severe emphysema?
Lung volume reduction surgery.

69. What is cyanosis?
A blueish appearance of the skin. This includes the fingernails and lips as well.

70. What is a lung infection that can lead to emphysema?
Pneumonia

Final Thoughts

Emphysema is a type of COPD that is characterized by increased lung expansion and damage to the alveoli. It’s a progressive disease that can ultimately lead to respiratory failure.

Respiratory therapists are involved in the care of patients with emphysema. They are essential workers who assess, treat, and provide education to patients with this condition.

If you found this helpful, be sure to check out some of our other guides on COPD, chronic bronchitis, and obstructive lung diseases. Thanks for reading!