RiteFlo™ Can Be Combined With Rescue and Controller Inhalers Prescribed For Asthma, Bronchitis, Emphysema, and COPD.
- Emphysema is a progressive respiratory disease. It is characterized by shortness of breath due to the enlargement or over-inflation of the small, but vital air sacs, called alveoli, in the lungs.
What is Emphysema?
Emphysema is the most common cause of death from respiratory illness in the United States. Doctors often refer to areas where alveoli are destroyed as blebs and larger destroyed segments as bullae.
Emphysema, secondary to smoking, involves the progressive destruction of the bronchioles that connect to the alveoli (small air sacs in the lung) of the lung. These bronchioles lose their elasticity, which is crucial in supporting alveoli. Alveoli are crucial in the exchange of oxygen and carbon dioxide.
Emphysema commonly occurs in people age 50 or greater. Emphysema often coexists with chronic bronchitis and doctors usually refer to these two conditions as COPD or Chronic Obstructive Pulmonary Disease.
Less than 1% of patients with emphysema have the inherited disease called Alpha-1 Antitrypsin Deficiency. These patients begin to have symptoms of shortness of breath by the age of 30-40. The current therapy for this disease is plasma based replacement therapy with alpha-1 antitrypsin (Prolastin®, Aralast® Zemaira™). It is estimated that 50,000 to 100,000 people may have this condition, but many of these patients have yet to be identified. Most of these patients may present with symptoms of chronic bronchitis or even asthma.
The symptoms of emphysema are initially insidious. Patients may present with mild shortness of breath only with exertion or a mild cough or even weight loss. The cough may only be productive of clear mucus at the onset of disease. However, as the disease progresses patients develop: profound symptoms of shortness of breath without exertion, copious amounts of sputum production and patients may even develop a barrel-shaped chest. These patients are at risk for developing pneumonia, pulmonary hypertension, cor pulmonale and chronic respiratory failure.
Although emphysema is an irreversible lung process, it can be medically managed by both the patient and doctor. The first step is to stop smoking and the second step is to see a physician who will prescribe medications that will help you breathe better. Additionally, better nutrition and an active lifestyle with exercise can only help your condition.
The current thinking is that emphysema is caused by an imbalance of proteins, called proteases and antiproteases, in the lung. It is the antiproteases that help to protect the lung. Smoking inhibits the ability of antiproteases and other helpful proteins from protecting the lung and keeping the lung elastic.
A significant portion of the lung (greater than 50%) is damaged by the time a patient notices that he or she has difficulty breathing. Only in the later stages of the disease is it difficult to inhale.
Many patients develop acute exacerbations or flares of the disease resulting in significant infections that need the immediate attention of a physician.
Emphysema is manageable if you stop smoking, improve your nutrition, become more active and take your medications as prescribed.
How is a Diagnosis of Emphysema Made?
A careful medical history (looking for a history of smoking, quality of cough) and physical exam is the first step in the process of making a diagnosis. One of the first clues that may be elicited from a physical exam is the hollow sound a physician makes when tapping a patient’s chest. This hollow sound is the result of enlargement of the lung or rupture of the lung’s alveoli.
Laboratory tests are the next step in the diagnostic workup. A chest x-ray is often ordered. In the early phases of emphysema, the x-ray may be normal. However, as the disease progresses, the x-ray may reveal “over inflation of the lung” which looks like increased chest diameter and a flattening of the diaphragm. The heart may appear smaller or have a more vertical appearance on the x-ray. On careful review, the x-ray may reveal blebs or bullae.
The next phase and probably the most important laboratory test is to perform a pulmonary function test with a spirometer. This computer will measure the air flow in your lungs over a period of a few seconds. This is a non-invasive safe test. Based on the percentage of flow, your health professional will be able to assess the severity of your lung disease. If your predicted lung test value is below 80% of normal, you most likely have an obstructive lung disease. Your doctor or health professional will be able to stage your disease and give you appropriate therapy based on the published guidelines for treatment of emphysema.
Later in the disease process, an EKG will show signs of cor pulmonale or right ventricular heart failure. Many patients will have increased levels of hemoglobin due to the lower concentration of oxygen in the patients blood stream.
How to Treat Emphysema?
- Unfortunately, therapy can neither cure nor reverse the disease process. The goal of therapy is to slow the progression of the disease, relieve symptoms and attempt to control for potential fatal complications.
- The first and most important first step is to stop smoking at all cost. Studies have shown that stopping smoking has the greatest long term benefit to the patient. Patients are taught controlled coughing techniques to help remove excess mucus from the lungs, helping to prevent infections.
- Mild forms of exercise are often recommended to help improve breathing. Patients are instructed on proper exercise programs designed to strengthen muscles involved in breathing. Ask your physician or professional health care provider for these helpful exercise techniques.
- Treatment of emphysema is very similar to treatment of chronic bronchitis. There are specific guidelines for the treatment of emphysema based on the stage of disease. A careful medical history, physical exam and laboratory tests including pulmonary function tests are required for proper staging of this disease. Once the stage of the disease is established, appropriate therapy can be prescribed. The following groups of medications are only a brief review of the potential therapies available to you and your physician to choose from.
- Medications come in three main groupings: (1) Bronchodilators (2) Anti-inflammatories (3) Mucolytics
- Bronchodilators are drugs that relax the smooth muscles surrounding the bronchial tubes. When these muscles are relaxed, greater air flow may pass to the lungs. Bronchodilators are available in four forms: (1) Metered-Dose Inhaler (MDI) (2) Small Volumed Nebulizer (SVN) (3) Dry Powdered Inhaler (DPI) (4) Pill form.
- The most cost effective and quickest acting formulation is the metered-dose inhaler or MDI. MDI’s are the most prescribed medication for respiratory illnesses.
- Both U.S. and European Guidelines recommend the use of a spacer if a patient is using a MDI. Spacers decrease oral side effects from inhaled steroid use and allow for better coordination effort when using a MDI. Additionally, spacers allow more medication to get deeper into the lung.<
- MDI’s are now being reformulated with a new type of gas. The old formulation of CFC’s (Chloroflurocarbons) are being changed to HFA (Hydroflurocarbons) to be in compliance with the Montreal Protocol. The change from CFC’s to HFA is being done to protect the atmosphere from depletion of ozone. Another important aspect of the new HFA gas is that medicine emitted from the HFA-MDI is of a more uniform microscopic size. These smaller particles can now travel deeper into the lung, possibly providing for lower doses of inhaled medication.
- Spacers will continue to have an important role even with the new MDI’s that are being released.
- Steroids are the most commonly prescribed anti-inflammatory class of drug prescribed in the world. Studies have shown that the use of steroids help patients with acute attacks or exacerbations of their emphysema. Short bursts of steroids (usually two weeks) in oral form have been shown to be most effective in controlling the inflammatory response.
- Oral steroids have serious side effects and their use must be carefully monitored. The side effect profile for steroids is quite long, but just some of these are increased risk for: (1) Diabetes (2) Cataracts (3) Adrenal Insufficiency (4) Weight Gain (5) Aseptic Necrosis of the Hip (6) Thinning of the Skin (7) Psychosis and (8) Gastrointestinal Bleeding.
- Inhaled steroids have a much lower risk profile compared to oral steroids. Inhaled steroids have their greatest utility in the treatment of asthma.
What is the Role of Oxygen Therapy in Emphysema?
Once emphysema progresses to where oxygen levels in the blood are low, supplemental oxygen therapy is required. At this point, a patient is entering the final stages of emphysema.
Supplemental oxygen therapy aids in breathing, but its primary purpose is to support heart function. Many patients only want to take their oxygen at night and do not want to be seen taking their oxygen during the day. However, clinical trials have shown that supplemental oxygen is most effective when used for 24 hours a day.
Most patients prefer not using supplemental oxygen. Yet, survival rates with patients with COPD (Chronic Obstructive Pulmonary Disease) is significantly longer in proportion to the time a patient is on supplemental oxygen.
Medicare and most insurance companies cover the cost of home oxygen therapy once it is prescribed by your doctor or health professional.
What is Volume Reduction Surgery?
- Patients with end-stage emphysema may become candidates for volume reduction surgery. This is a procedure that is gaining more acceptance in the medical community. This procedure improves pulmonary function by removing part of the non-functioning area of the lungs, thus reducing the overall volume in the chest allowing for improved efficiency of the remaining functioning lung structure.
- Lung reduction surgery has been shown in carefully selected patients to improve lung fuction and quality of life in patients with severe emphysema.
Is Lung Transplantation an Option for Patients with Severe Emphysema?
- Lung transplantation has also become another option for patients with end-stage emphysema. Transplantation may involve one or both lungs.
- Statistics reveal that survival after lung transplantation has been as high as 77% at two years and 75% at three years after surgery.
- Transplantation therapy is a risky and cost-prohibitive operation. Patients often have long waits for available matched donor lungs.
- Hospitalization is required and months of pulmonary therapy and lifelong anti-rejection therapy is required.