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PubMed1995

[Pulmonary emphysema--lung transplantation].

The most frequent form of lung emphysema leading to respiratory failure is the tobacco bronchitis-induced type of emphysema the so called chronic obstructive pulmonary (lung) disease (COPD). Histologically the centrilobular or centriacinar emphysema is believed to develop due to elastase and oxidant overload with concomitant antiprotease deficiency. The alpha1-antitrypsin deficiency is a rare genetic defect leading also in non-smoking patients to early death due to panlobular or panacinar emphysema. The functional pattern of both emphysema types shows irreversible lung overinflation with severe mainly expiratory bronchial obstruction with various degrees of pulmonary hypertension alpha1-proteinaseNinhibitor deficiency emphysema is prophylactically treated with prolastine and if hypoxia (PaO2 > 55 mm/Hg) is present with long term oxygen therapy. If hypercapnia develops O2 Therapy is combined with non invasive pressure supported ventilation. Volume reducing surgery may precede. In nonsmoking emphysema patients long term oxygen therapy and later unilateral lung transplantation improves quality of life as well as life expectancy.

Adult↗
PubMed1996

Elastin and collagen remodeling in emphysema. A scanning electron microscopy study.

The relationship between elastin degradation and emphysema is well known. Recent evidence suggests that a complex process of pulmonary remodeling occurs within the emphysematous lung. The aim of this study was to assess the extent of extracellular matrix remodeling in emphysema by ultrastructural examination of elastin and collagen templates in an animal model of emphysema and in human emphysematous lungs. Emphysema was induced in rats by the intratracheal administration of porcine pancreatic elastase. Human lung samples were obtained at surgical resection for lung carcinoma. Emphysema was confirmed morphometrically and quantitated using the mean linear intercept. Matching sections were treated with sodium hydroxide and formic acid to expose collagen and elastin templates, respectively. Scanning electron microscopy with stereo-pair imaging allowed three-dimensional visualization of the exposed templates. In emphysematous lungs from both sources, sheets of elastin were disrupted and perforated with multiple fenestrations. In elastase-induced emphysema, this disintegration was accompanied by a marked increase in thickness of collagen fibrils, which contrasted with the fine fibrillar network of control lungs. Similarly, a pattern of thickened fibrils and disorganized deposition of collagen was observed in human lungs. In conclusion, these findings support the novel concept of increased collagen deposition and aberrant collagen remodeling in the pathogenesis of emphysema.

Animals↗
PubMed1997

Reperfusion injury in single-lung transplant recipients with pulmonary hypertension and emphysema.

BACKGROUND: The early postoperative course of single-lung transplant recipients depends on the recipient's underlying lung pathophysiology and the degree of ischemic-reperfusion injury. We examined the effect of pulmonary hemodynamics and preoperative diagnosis on early allograft function and the effects of pulmonary hemodynamics, allograft blood flow, and chest radiographs on length of mechanical ventilation and intensive care unit length of stay. METHODS: We retrospectively collected data on 30 single-lung transplant recipients, 15 each with pretransplantation pulmonary hypertension and emphysema. Blood flow to the allografts was quantitated by perfusion scans obtained on the first postoperative day. Chest radiographs were graded for reperfusion injury. Pulmonary and hemodynamic data, gas exchange parameters, duration of mechanical ventilation, and intensive care unit stay were recorded. RESULTS: Patients with pulmonary hypertension had a prolonged intensive care unit stay compared with emphysema patients, but pulmonary artery pressures were not quantitatively related to duration of ventilation during the intensive care unit stay. There was no difference in the severity of allograft infiltrate between the emphysema and pulmonary hypertensive patients. The day 1 chest radiograph score was highly predictive of an intensive care unit stay of > or = 7 days, although the threshold score of those with pulmonary hypertension was significantly lower than in emphysema patients. Allograft blood flow and pulmonary hypertension were not contributors to early graft dysfunction. Allograft perfusion decreased with increasing radiographically demonstrated infiltrate in those with emphysema but not in those with pulmonary hypertension. CONCLUSIONS: Elevated allograft blood flow and pressures do not exacerbate radiographically confirmed reperfusion injury. Reperfusion injury is the major cause of early respiratory morbidity after single-lung transplantation. Allograft perfusion in emphysema patients decreases in response to reperfusion injury, but pulmonary hypertension patients remain almost entirely dependent on allograft function, even with severe chest radiograph scores. This may be an important mechanism by which single-lung transplant recipients with emphysema, unlike those with pulmonary hypertension, are able to mitigate the degree of respiratory impairment associated with reperfusion injury.

Blood Flow Velocity↗
PubMed1976

The internal surface area of the lung in emphysema.

Quantitative histological studies on the lung are time consuming and for the pathologist may not reveal much additional imformation in relation to the time spent. Sixty-eight cases of emphysema were studied. The percentages of the lung tissue destroyed by alveolar, bronchiolar and bullous emphysema were determined by macroscopic point counting. The internal surface area (I.S.A.) and internal surface area at a standard lung volume of 3,000 ml(I.S.A.3,000) were determined by the mean linear intercept (M.L.I.) method. There was a significant correlation between both the M.L.I. and I.S.A.3,000 and the percentage of lung tissue destroyed. The M.L.I. was the most accurate guide to the presence of emphysema. The I.S.A. was the least reliable indication of emphysema. Cases of alveolar duct emphysema were both over and underdiagnosed on macroscopic point counting. It is therefore suggested that in cases with alveolar duct emphysema, apparently normal lungs or where full pulmonary function tests are available, quantitative histological studies should be carried out. In other cases it is possible to derive the I.S.A. and I.S.A.3,000 from the percentage of emphysema as determined macroscopically, without recourse to histological methods.

Adult↗
PubMed2003

A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema.

BACKGROUND: Lung-volume-reduction surgery has been proposed as a palliative treatment for severe emphysema. Effects on mortality, the magnitude and durability of benefits, and criteria for the selection of patients have not been established. METHODS: A total of 1218 patients with severe emphysema underwent pulmonary rehabilitation and were randomly assigned to undergo lung-volume-reduction surgery or to receive continued medical treatment. RESULTS: Overall mortality was 0.11 death per person-year in both treatment groups (risk ratio for death in the surgery group, 1.01; P=0.90). After 24 months, exercise capacity had improved by more than 10 W in 15 percent of the patients in the surgery group, as compared with 3 percent of patients in the medical-therapy group (P<0.001). With the exclusion of a subgroup of 140 patients at high risk for death from surgery according to an interim analysis, overall mortality in the surgery group was 0.09 death per person-year, as compared with 0.10 death per person-year in the medical-therapy group (risk ratio, 0.89; P=0.31); exercise capacity after 24 months had improved by more than 10 W in 16 percent of patients in the surgery group, as compared with 3 percent of patients in the medical-therapy group (P<0.001). Among patients with predominantly upper-lobe emphysema and low exercise capacity, mortality was lower in the surgery group than in the medical-therapy group (risk ratio for death, 0.47; P=0.005). Among patients with non-upper-lobe emphysema and high exercise capacity, mortality was higher in the surgery group than in the medical-therapy group (risk ratio, 2.06; P=0.02). CONCLUSIONS: Overall, lung-volume-reduction surgery increases the chance of improved exercise capacity but does not confer a survival advantage over medical therapy. It does yield a survival advantage for patients with both predominantly upper-lobe emphysema and low base-line exercise capacity. Patients previously reported to be at high risk and those with non-upper-lobe emphysema and high base-line exercise capacity are poor candidates for lung-volume-reduction surgery, because of increased mortality and negligible functional gain.

Aged↗
PubMed1976

A comparison of subcutaneous and preperitoneal emphysema arising from gynecologic laparoscopic procedures.

Out of 1,300 cases of gynecologic laparoscopic procedures reviewed, three incidences of preperitoneal emphysema and several incidences of subcutaneous emphysema were noted. There were a few significant differences in the diagnosis and management of these two types of emphysema. In the medical literature reviewed by the author, preperitoneal emphysema has not been discussed while subcutaneous emphysema has received quite a lot of attention. Preperitoneal emphysema is defined as a collection of air or other gas which occurs in the tissue spaces between the abdominal fascia and the ventral peritoneum.

Adult↗
PubMed1965

THE SURGICAL TREATMENT OF PULMONARY EMPHYSEMA.

Emphysema may be focal or multifocal. In either type an area of disease may enlarge and reduce the function of adjacent lung.Thirty patients who required treatment for emphysema and its complications are described. Fifteen patients with focal emphysema that did not constitute a space-occupying lesion required operation because of recurrent pneumothorax or infection in the affected area. The results were excellent. Ten patients with focal emphysema and progressive "space occupation" complained of moderate but increasing dyspnea. Removal of the enlarging lesion resulted in marked improvement. Five patients with multifocal emphysema and progressive space occupation in one focal area suffered from severe dyspnea and poor general health. The space-occupying lesion was removed by lobectomy. The results, measured by pulmonary function tests and subjective improvement, were rewarding in most cases. No patient with multifocal emphysema but without a space-occupying lesion under-went operation.

Classification↗
PubMed2001

Genetic polymorphism in matrix metalloproteinase-9 and pulmonary emphysema.

Protease-antiprotease imbalance due to genetic variation may be responsible for the development of pulmonary emphysema induced by smoking. Since matrix metalloproteinases (MMPs) have recently been suggested to play important roles in the pathogenesis of pulmonary emphysema, the association between the functional polymorphism of MMP-9 (-1562C/T) and the development of pulmonary emphysema was examined in 110 smokers and 94 nonsmokers in Japan. The T allele frequency was higher in subjects with distinct emphysema on chest CT-scans (n = 45) than in those without it (n = 65) (0.244 vs 0.123, P = 0.02). Logistic regression analysis demonstrated that the T allele is a risk factor for smoking-induced emphysema (odds ratio = 2.69, P = 0.02). DL(CO)/VA was lower (P = 0.02) and emphysematous changes were more conspicuous (P = 0.03) in subjects with C/T or T/T (n = 35) than in those with C/C (n = 75). These results suggest that the polymorphism of MMP-9 acts as a genetic factor for the development of smoking-induced pulmonary emphysema.

Adult↗
PubMed2005

Lung transplantation for emphysema. Lung hyperinflation: incidence and outcome.

Lung transplantation, single or bilateral sequential, is the final option for patients with emphysema. This study analyzed the outcome of lung transplants for emphysema (single or double), and evaluates the incidence, predictive factors and prognosis of lung hyperinflation (LHI) in unilateral transplants. We prospectively studied patients undergoing lung transplantation for emphysema. On admission to the Intensive Care Unit (ICU) and at 12, 24, 48 and 72 h we tested the patients' respiratory function, oxygen arterial pressure (PaO2) and mean pulmonary arterial pressure (MPAP) before transplantation. LHI incidence, duration of mechanical ventilation and hypoxemia, ICU stay and mortality was also analyzed. We studied 34 consecutive patients undergoing lung transplantation for emphysema, 14 single and 20 bilateral. Single-lung transplantation had a higher mortality (50%) than double-lung transplantation (11%), with an odds ratio of 9.0 (1.3-48.7). Of the 14 patients who received a single graft, 9 patients (64%) developed LHI. No predictive factors for LHI could be established. Duration of mechanical ventilation (22 vs 3 days) and ICU stay (36 vs 6 days) was much longer in patients with LHI; however, only ICU stay reached statistical significance (P = 0.011). Mortality in patients with LHI was higher, 67% vs 20% (NS). We conclude that single-lung transplant in emphysema patients has a worse prognosis than bilateral transplant, with a 9-fold higher mortality rate. LHI is a common event in single-lung transplant for emphysema and is associated in our patients with a longer stay at the ICU.

APACHE↗
PubMed2000

The role of chlamydia in the pathogenesis of pulmonary emphysema. Electron microscopy and immunofluorescence reveal corresponding findings as in atherosclerosis.

Chlamydia pneumoniae has been detected in atherosclerotic plaques by various means. Chlamydiae are able to cause persistent infections. Serologically elevated antibody titers are found in severe chronic obstructive pulmonary disease. In atherosclerosis and pulmonary emphysema, inflammatory reactions can be seen by means of light microscopy. Specimens from patients with obliterative arteriosclerosis undergoing thrombendarteriectomy and with advanced emphysema undergoing lung volume reduction surgery were examined using scanning (SEM) and transmission (TEM) electron microscopy, and using immunofluorescence with monoclonal antibodies and antiserum against chlamydiae. SEM shows spherical bodies (SBs) with a diameter from 0.3 microm to 0.6 microm on the surface of the alveoli and bronchioles, as well as in atherosclerotic plaques. In atherosclerosis and emphysema, SBs reveal a double membrane, adherence to collagen fibers, tissue destruction, as well as intracellular and interstitial localization in TEM. They show in parts a densely packed central structure. SBs are seen both in alpha-1-antitrypsin deficiency emphysema and smoker's emphysema. Using immunofluorescence microscopy, spots are seen in corresponding distributions to the SBs. Morphological findings are typical for aberrant chlamydiae seen in persistent infections. Chronic infection and bacterial colonization associated with progressive disease seems to be relevant not only in atherosclerosis but also in pulmonary emphysema.

Arteriosclerosis↗
PubMed1988

Effects of pulmonary emphysema on QRS infarct size score.

Pulmonary emphysema can produce false-positive electrocardiographic (ECG) changes of anterior myocardial infarction (MI). This problem was not addressed in earlier studies of the Selvester 54 Criteria/32 Point QRS score for MI size. The purpose of this study was to examine an automated Hewlett Packard ECG Computer Language (HP-ECL) implementation of the QRS score in the following groups of subjects. Patients who had been studied for possible lung disease with pulmonary tests, including lung volumes, were divided into two groups: group 1 (n = 133), with abnormal tests (emphysema); and group 2 (n = 102), with normal tests (no emphysema). Two other groups were studied: group 3 (positive controls, n = 44), with greater than 3 QRS points for MI on ECG and documented coronary disease with wall motion abnormalities on angiography; and group 4 (negative controls, n = 146), 49 house staff and 97 clinically normal men. A frontal plane P axis greater than 65 separated 90% of patients with emphysema from those without. Of 133 patients with emphysema, 60 (45%) had greater than 3 QRS points for MI on ECG, mainly from Q criteria in aVL and V1-V3; decreased R criteria 1 in V2, V3, and V6; and abnormal R/S criteria in V4-V6. Using HP-ECL, the QRS score was readily modified so that when P axis was greater than 65 these MI size criteria were suppressed. This resulted in a more appropriate incidence of MI diagnoses: 2% (down from 45%) in emphysema patients, no change in specificity, and minor reduction in sensitivity to MI in infarct controls from 100% to 96%.(ABSTRACT TRUNCATED AT 250 WORDS)

Electrocardiography↗
PubMed1992

Longitudinal Gompertzian analysis of emphysema mortality in the US, 1962-1987: the differing basis for evolving mortality patterns in men and women.

Age-specific mortality rates for emphysema in the United States from 1962 through 1987 were subjected to longitudinal Gompertzian analysis, a method that can be used to identify and distinguish aggregate genetic, environmental, and competitive influences upon mortality. Annual crude emphysema mortality rates (per 100,000) among men increased from 11.77 in 1962 to 20.94 in 1968, and then fell to 7.74 in 1987. The basis for this rise and fall is shown to be the corresponding changes in environmental influences upon emphysema mortality in men. Between 1962 and 1987, the annual crude emphysema mortality rates among women increased from 1.71 to 4.25. The basis for the increase of emphysema mortality in women, on the other hand, is shown to be an enhancement of the competitiveness of emphysema as a cause of mortality in women, and not the result of worsening environmental influences. The capability to distinguish between environmental and competitive influences upon evolving human mortality patterns could have a significant impact upon public health policy.

Adult↗
PubMed2005

Results of unilateral lung volume reduction surgery in patients with distinct heterogeneity of emphysema between lungs.

OBJECTIVE: This study was undertaken to analyze the comprehensive outcome of unilateral lung volume reduction in patients with distinct heterogeneity of emphysema between lungs assessed by a visual radiologic scoring system. METHODS: Ninety-seven patients who underwent intentional unilateral lung volume reduction because of distinct heterogeneity of emphysema between lungs (asymmetric ratio of emphysema >/=1.1) between 1995 and 2003 were evaluated. Baseline median measures were 0.83 L for forced expiratory volume in 1 second, 5.0 L for residual volume, 380 m for 6-minute walking test distance, 0.50 for maximal incremental treadmill test score, and 25 for physical functioning domain score assessed by the Short Form-36 Quality of Life questionnaire. RESULTS: Median follow-up was 34 months. Significant improvements occurred for as long as 36 months in forced expiratory volume in 1 second (+24%), residual volume (-12%), Short Form-36 Quality of Life questionnaire physical functioning domain score (+100%), 6-minute walking test distance (+18%), and maximal incremental treadmill test score (+200%). A direct correlation was found between asymmetric ratio of emphysema and change in forced expiratory volume in 1 second ( r = 0.65, P < .00001). At 60 months, residual volume (-6.2%), maximal incremental treadmill test score (+100%), and Short Form-36 Quality of Life questionnaire physical functioning domain score (+70%) were still significantly improved. Five-year survival was 82%; 5-year freedom from contralateral lung volume reduction was 70%. CONCLUSIONS: In this series, significant, long-lasting improvements and satisfactory survival were seen after intentional unilateral lung volume reduction. Heterogeneity of emphysema between lungs was directly correlated with improvement at 36 months in forced expiratory volume in 1 second. Our results suggest that unilateral lung volume reduction is a suitable option for patients with distinct heterogeneity of emphysema between lungs.

Adult↗
PubMed1993

Parenchymal emphysema measured by CT lung density correlates with lung function in patients with bullous disease.

In subjects with chronic obstructive pulmonary disease (COPD) computed tomographic (CT) lung density correlates with direct pathological measurements of the size of the distal airspaces, as well as with measurements of airflow limitation and impairment of the diffusing capacity. Thus, CT lung density can be used to quantify emphysema in life. We wanted to assess the use of CT scanning to detect and measure the extent of bullous lung, and to quantify the severity of emphysema in the non-bullous areas of the lungs. In patients with bullous emphysema (21 males and 2 females; aged 31-69 yrs; forced expiratory volume in one second (FEV1) 14-84% predicted; volume corrected diffusing capacity of the lungs for carbon monoxide (DLCO/VA) 17-114% predicted). CT lung density was measured in electromagnetic imaging (EMI) units. The extent of bullous emphysema correlated poorly with all respiratory function measurements. In contrast, the severity of emphysema in the non-bullous parts of the lungs, expressed as either the mean EMI number, or the EMI number of the lowest 5th percentile of the CT lung density histogram, correlated well with measurements of airflow limitation and diffusing capacity. Our findings, thus, suggest that in patients with bullae the major determinant of respiratory function is the severity of the emphysema in non-bullous lung, and that the extent of the bullae has less functional importance.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1998

Changes in pulmonary physiology after lung volume reduction surgery in a rabbit model of emphysema.

OBJECTIVE: The purpose of this study is to investigate the effects of lung volume reduction surgery on pulmonary compliance, airway flow, and helium lung volumes in an elastase-induced emphysema animal model. METHODS: A 15,000-unit bolus of elastase was aerosolized through an endotracheal tube in 14 New Zealand White rabbits to induce emphysema. Stapled lung volume reduction of bilateral upper and middle lobes was performed through a midline sternotomy at 4 weeks after induction of emphysema. Lung functions were measured at baseline before induction of emphysema, preoperatively at 4 weeks, and 1 week postoperatively. RESULTS: Compliance increased after induction of emphysema and decreased in response to lung volume reduction surgery. Functional residual capacity decreased after lung volume reduction surgery in proportion to the amount of excised lung tissue. Expired flows suggested improvement in response to lung volume reduction surgery. Histologic examination confirmed presence of diffuse heterogeneous emphysema in each animal at necropsy. CONCLUSIONS: The decreased compliance and increased airway flow after volume reduction surgery in this model parallels findings in human studies and suggests that similar mechanisms of increased elastic recoil and airway support contribute to improvement.

Animals↗
PubMed1998

Lobectomy combined with volume reduction for patients with lung cancer and advanced emphysema.

OBJECTIVE: Early-stage lung cancer is best treated by anatomic pulmonary resection. Patients with lung cancer and severe emphysema are often denied resection or are offered only limited, nonanatomic resections when established pulmonary function criteria for lobectomy are not met. Recently, with the introduction of the volume reduction operation, selected patients with disabling emphysema have undergone excision of approximately 30% of the most destroyed lung tissue and have subsequently demonstrated subjective and objective improvement in pulmonary function. Using these principles, we elected to combine anatomic lobectomy with volume reduction in a select group of patients with both emphysema and lung cancer who would not otherwise be candidates for pulmonary resection. METHODS: Five patients with severe emphysema and suspected or proven lung cancers, who were poor candidates for anatomic lobectomy by traditional criteria but were good candidates for volume reduction, underwent lobectomy combined with volume reduction of one or more additional lobes. RESULTS: All five patients having lung volume reduction and anatomic lobectomy for early-stage primary lung cancer did well postoperatively. Furthermore, each patient has demonstrated subjective and objective improvement in respiratory function on serial postoperative studies. CONCLUSIONS: Selected patients with disabling emphysema and suitable anatomy for volume reduction, who have a lung cancer situated in destroyed lung tissue, may benefit from combined lobectomy and volume reduction. The introduction of the volume reduction operation has added a new factor in the algorithm for the evaluation and treatment of lung cancer in selected patients with advanced emphysema.

Aged↗
PubMed1982

Post-mortem study of emphysema in coalworkers and non-coalworkers.

A post-mortem survey of emphysema in coalworkers and non-coalworkers was carried out in men aged 50-70 years dying of ischaemic heart disease (IHD). It was determined that in such men selection for necropsy was similar in coalworkers and non-coalworkers. All lungs were examined in a standard way and the amounts of centrilobular and panacinar emphysema were scored on numerical scales. Emphysema in men dying of IHD was significantly more frequent in coalworkers than in non-coalworkers even after age and smoking habits were accounted for by stratification. In the coalworkers, the severity of emphysema was related to the amount of dust in simple foci in the lungs. Because both groups were selected similarly from their parent populations the relative frequency of emphysema found in this study reflects that in the whole populations of coalworkers and non-coalworkers in the study area and confirms an excess of emphysema in coalworkers. This excess is likely to be due to occupational factors.

Aged↗
PubMed2003

[Asthmatic characteristics in smokers with advanced emphysema].

OBJECTIVES: Most pneumologists assume that chronic asthma and emphysema associated with smoking differ both in their etiology and type of inflammation. However, it is difficult to study subjects who have both diseases simultaneously. We designed a prospective study to determine whether or not some advanced emphysema patients who are smokers have an asthmatic profile suggesting the two diseases overlap. PATIENTS AND METHOD: Twenty-three smokers with moderate to severe obstruction and radiologic signs of advanced emphysema were studied. The following signs of asthma were analyzed for all patients: positive acute response to bronchodilators, eosinophilia in peripheral blood, significant eosinophilia in sputum, significant total serum immunoglobulin E (IgE) and specific IgE positive for common allergens and fungi. An asthmatic profile was defined as the presence of 3 or more of the aforementioned signs. Statistical analysis was by calculation of the confidence interval on the total number of positive cases to estimate the population percentage. RESULTS: Data on at least 4 characteristics were available for 21 of the 23 patients. Ten (48%) of the 21 had asthmatic profiles (3 or more of the aforementioned characteristics). This finding suggests that asthmatic characteristics are present in between 17.6 and 79.6% of the studied population with advanced emphysema, with a confidence interval of 99.9%. CONCLUSIONS: We conclude that emphysema initially associated with smoking may mean that at least 17.6% of patients have a clear asthmatic profile, which indicates a high degree of overlap between asthma and emphysema in smokers. Thus, our findings are consistent with the Dutch theory that chronic obstructive diseases have a common origin in underlying allergic sensitization and bronchial hyperresponsiveness alongside various other influential factors such as tobacco smoking over the course of disease.

Administration, Inhalation↗