Chapter 12

Emphysema

Plate 3. Panlobular emphysema. Inset, Excessive bronchial secretions,

a common secondary anatomic alteration of the lungs.
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 Figure 12–2. Centrilobular emphysema. Abnormal weakening and enlargement
of the respiratory bronchioles in the proximal portion of the acinus.
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 Anatomic Alterations of the Lungs
 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
 Bronchospasm (with concomitant bronchitis)
 Hyperinflation of alveoli (air-trapping)

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 Etiology
 Cigarette smoking
 Genetic predisposition
 Alpha1 protease inhibitor
 Occupational exposure to chemical irritants
 Exposure to atmospheric pollutants

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 Overview of the Cardiopulmonary
Clinical Manifestations Associated
with EMPHYSEMA
The following result from the pathophysiologic
mechanisms caused by Distal Airway and
Alveolar Weakening ( Figure 9-12)—the major
anatomic alterations of the lungs associated
with emphysema (see Figures 12-1 and 12-2).

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 Figure 9-12. Distal airway and alveolar weakening clinical scenario.
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 Clinical Data Obtained at the
Patient’s Bedside
Vital signs
 Increased respiratory rate
 Increased heart rate, cardiac output,
blood pressure

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 Clinical Data Obtained at the
Patient’s Bedside
 Use of accessory muscles of inspiration
 Use of accessory muscles of expiration
 Pursed-lip breathing
 Increased anteroposterior chest diameter
(barrel chest)
 Cyanosis
 Digital clubbing

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 Clinical Data Obtained at the
Patient’s Bedside
Peripheral edema and venous distention
 Distended neck veins
 Pitting edema
 Enlarged and tender liver

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 Distended
Neck Veins

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

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 Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2,
London, 1992, Mosby-Wolfe.
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 Clinical Data Obtained at the
Patient’s Bedside
 Cough, sputum production, hemoptysis
 Chest assessment findings
 Hyperresonant percussion notes
 Wheezing
 Diminished breath sounds
 Diminished heart sounds
 Decreased tactile and vocal fremitus
 Crackles/rhonchi (when accompanied by bronchitis)

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 Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.
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 Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive
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lung diseases, breath sounds progressively diminish. Copyright © 2006 by Mosby, Inc.
 Clinical Data Obtained from
Laboratory Tests and Special
Procedures

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 Pulmonary Function Study
Expiratory Maneuver Findings

FVC FEVT FEF25%-75% FEF200-1200

   

PEFR MVV FEF50% FEV1%

   

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 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  

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 Decreased Diffusion Capacity
(DLCO)

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 Arterial Blood Gases
Mild to Moderate Emphysema
 Acute alveolar hyperventilation with
hypoxemia

pH PaCO2 HCO3- PaO2

   (Slightly) 

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 Time and Progression of Disease
Disease Onset Alveolar Hyperventilation
100

90 Point at which PaO2

declines enough to
80 stimulate peripheral
oxygen receptors
70
PaO2 or PaCO2

60
PaO2
50

40

30

20

10

Figure 4-2. PaO2 and PaC02 trends during acute alveolar hyperventilation.
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 Arterial Blood Gases
Severe Emphysema
 Chronic ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2

Normal  (Significantly) 

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 Time and Progression of Disease
Disease Onset Alveolar Hyperventilation Chronic Ventilatory Failure
100

90 Point at which disease

becomes severe and patient
Point at which PaO2
begins to become fatigued
80 declines enough to
stimulate peripheral
70 oxygen receptors
Pa02 or PaC02

60

50

40

30

20

10

0
Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.
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 Acute Ventilatory Changes Superimposed
on Chronic Ventilatory Failure
 Acute alveolar hyperventilation on chronic
ventilatory failure

 Acute ventilatory failure on chronic ventilatory

failure

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 Oxygenation Indices

QS/QT DO2 VO2 C(a-v)O2

  Normal Normal
O2ER SvO2
 

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 Hemodynamic Indices
(Severe Emphysema)

CVP RAP PA PCWP

   Normal

CO SV SVI CI
Normal Normal Normal Normal

RVSWI LVSWI PVR SVR

 Normal  Normal

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 Abnormal Laboratory Tests
and Procedures
Hematology
 Increased hematocrit and hemoglobin
Electrolytes
 Hypochloremia (chronic ventilatory failure)
Sputum examination
 Streptococcus pneumoniae
 Haemophilus influenzae

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 Radiologic Findings
Chest radiograph
 Translucent (dark) lung fields
 Depressed or flattened diaphragms
 Long and narrow heart
 Enlarged heart
 Increased retrosternal air space
(lateral radiograph)

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 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.
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 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:
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Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.) Copyright © 2006 by Mosby, Inc.
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 General Management of
Emphysema
 Patient and family education
 Behavioral management
 Avoidance of smoking and inhaled irritants
 Avoidance of infections
 Proper nutrition instruction

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 GOLD Standards

Global Initiative for Chronic

Obstructive
Lung
Disease

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 Figure 11-4. From GUIDELINES Pocketcard: Managing chronic obstructive pulmonary
disease, Baltimore, 2004, Version 4.0, International Guidelines Center. (From
GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease.
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Baltimore, 2004, Version 4.0, International Guidelines Center.)
 Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic
Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International
Guidelines Center.)
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 Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic
Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International
Guidelines Center.)
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 Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic
Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International
Guidelines Center.)
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 Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic
Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International
Guidelines Center.)
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 General Management of
Emphysema
Respiratory care treatment protocols
 Oxygen therapy protocol
 Bronchopulmonary hygiene therapy protocol
 Aerosolized medication protocol
 Mechanical ventilation protocol

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 Additional Treatment Considerations
for Emphysema
 Antibiotics
 Inoculations against influenza and pneumonia
 Alpha1 antitrypsin therapy
 Lung volume reduction surgery
 Lung transplantation

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 Classroom Discussion
Case Study: Emphysema

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