New pathological findings in emphysema of childhood. 3. Unilateral congenital emphysema with hypoplasia--and compensatory emphysema of contralateral lung.
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Angiography↗
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Reduction pneumoplasty for giant bullous emphysema. Implications for surgical treatment of nonbullous emphysema.
A review of the literature on reduction pneumoplasty for giant bullous emphysema was undertaken to identify current criteria for this surgical treatment and in the hope of obtaining insights into evaluating reduction pneumoplasty for nonbullous emphysema. Twenty-two retrospective case series, published since 1950, were retrieved by a computer search of the literature and a search of the Index Medicus prior to 1966. Reduction pneumoplasty is most effective when bullae are larger than one third of a hemithorax with evidence of compression of adjacent lung tissue and an FEV1 of less than 50% predicted; the presence of emphysema in nonbullous lung and the amount of compression are best judged by CT. The rationale for reduction pneumoplasty for nonbullous emphysema is supported by the similar early functional changes after reduction pneumoplasty for bullous and nonbullous-improvement of blood gas values and lung mechanics. A single study showing that decline of lung function after surgery for bullous emphysema was less in those who stopped smoking than in those who continued to smoke supports the need for preoperative and maintained smoking cessation in patients receiving reduction pneumoplasty. After 4 decades, the duration of improvement in lung function, whether worsening of emphysema occurs in remaining lung, and late morbidity and mortality after reduction pneumoplasty for bullous emphysema are not well defined. A registry with an unoperated-on comparison group could more rapidly accumulate such data after reduction pneumoplasty for nonbullous emphysema.
Humans↗
Quantitation of emphysema with three-dimensional CT densitometry: comparison with two-dimensional analysis, visual emphysema scores, and pulmonary function test results.
PURPOSE: To compare lung densitometric measurements that use a three-dimensional (3D) reconstruction of the lungs with those obtained from analysis of two-dimensional (2D) computed tomographic (CT) images, visual emphysema scores, and data from pulmonary function tests. MATERIALS AND METHODS: Thoracic helical CT scans were obtained in 60 adult patients (35 with no visual evidence of emphysema and 25 with emphysema). The lungs were reconstructed as a 3D model on a commercial workstation, with a threshold of -600 HU. By analysis of histograms, the proportions of lung volumes with attenuation values below -950, -910, and -900 HU were measured, in addition to mean lung attenuation. These values were compared with lung densitometric results obtained from 2D CT images, visual emphysema scores, and data from pulmonary function tests. RESULTS: Quantitation of emphysema with 3D reconstruction was efficient and accurate. Correlation was good among densitometric quantitation with 3D analysis, that obtained with 2D analysis (r = 0.98-0.99), and visual scoring (r = 0.74-0.82). Correlation was reasonable between 3D densitometric quantitation and the diffusing capacity of the lungs for carbon monoxide (DLCO) (r = -0.57 to -0.64), total lung capacity (r = 0.62-0.71), forced expiratory volume in 1 second (FEV1) (r = -0.57 to -0.60), and the ratio of FEV1 to forced vital capacity (FVC) (r = -0.75 to -0.82). The visual CT quantitation of emphysema correlated best with DLCO (r = -0.82) and FEV1/FVC (r = -0.89). CONCLUSION: Lung densitometry with 3D reconstruction of helical CT data is a fast and accurate method for quantifying emphysema.
Absorptiometry, Photon↗
Subcutaneous emphysema, pneumomediastinum, and pulmonary emphysema in a young schipperke.
A 4-month-old, intact female schipperke was presented for evaluation and treatment of subcutaneous (SC) emphysema. Radiographs revealed pneumomediastinum and SC emphysema. Sequential radiographs confirmed a worsening of the SC emphysema. Extensive, nonsurgical evaluation failed to reveal the source of the air within the mediastinum. Exploratory thoracotomy revealed an emphysematous right middle lung lobe. Lobectomy of the right middle lung lobe resolved both the pneumomediastinum and SC emphysema. Histopathological evaluation confirmed pulmonary emphysema. A variation of congenital pulmonary emphysema was considered in this case.
Animals↗
The scanning electron microscopy of elastase-induced emphysema. A comparison with emphysema in man.
Emphysema was produced in hamsters by a single intratracheal injection of 25 units of porcine pancreatic elastase. The lungs were examined by scanning electron microscopy at intervals from 24 hours to 1 year after the injection, and the appearance was compared to examples of human emphysema. Within 24 hours of injection, the alveolar ducts were dilated and air spaces were of more variable size than normal. Fibrin strands, erythrocytes and phagocytic cells were present in air spaces. By a week the hemorrhage and exudate had resolved, but adnormal air spaces continued to enlarge over the period of study. The abnormal airspaces formed by progressive dilation of alveolar ducts with shortening and occasionally effacement of interalveolar septa. Interalveolar pores were occasionally enlarged but only focally increased in number. The appearance of single examples of human congenital lobar emphysema and panlobular emphysema resembled the animal model. Abnormal air spaces were formed by dilated alveolar ducts with retraction of interalveolar septa. In contrast, in some cases of centrolobular emphysema marked fenestration of alveolar septa occurred and large air spaces were often traversed by threadlike strands of tissue remnants of some preexisting alveolar walls. The results suggest that there are at least two morphogenetic processes leading to emphysema. One is the coalescence of fenestrations leading to destruction of alveolar walls, and the other is a gradual remodeling of lung structure by mechanisms still to be defined.
Adult↗
[Relationships between emphysema, bronchiolar lesions, and pulmonary function tests in mild centrilobular emphysema of the human lungs].
The relationships between emphysema, bronchiolar lesions, and pulmonary function tests were studied in very mild centrilobular emphysematous lungs. The severity of emphysema was significantly related to VC, FEV1, FEV1/FVC, the slope of phase III, CC/TLC and static elastic lung recoil. Emphysema was not correlated with DLco. Bronchiolar lesions were poorly correlated with pulmonary function tests. Emphysema was related to bronchiolar lesions, such as smooth muscle hypertrophy and goblet cell metaplasia. These findings suggest that alterations of the mechanical property of the lung occur in very mild centrilobular emphysema. Measurements of these abnormalities may be useful to detect early emphysema.
Bronchi↗
Pulmonary hemodynamics, gas exchange, and the severity of emphysema as assessed by quantitative CT scan in chronic bronchitis and emphysema.
We have used the CT transthoracic scan to measure regional lung density in vivo, as our previous studies have shown that this correlates with the increase in size of distal air spaces, which is a defining characteristic of emphysema. We have studied 32 patients with chronic airflow limitation (FEV1, 15 to 68% predicted) caused by chronic bronchitis and emphysema (synonym, COPD), with a wide range of arterial PO2 (38 to 90 mm Hg) and PCO2 (32 to 63 mm Hg) while breathing air at rest. We could find no significant relationships between the extent of emphysema (as assessed in vivo by the EMI number defining the lowest fifth percentile of the CT density histogram of the lung fields) and either arterial blood gas tensions, mean pulmonary arterial pressure, cardiac output, or calculated total pulmonary vascular resistance while at rest (n = 32) or during supine leg exercise (n = 29). We conclude that the extent of emphysema does not correlate with the clinical or pathologic features of the "pink and puffing" (i.e., mild hypoxemia, no CO2 retention, no pulmonary hypertension, etc.) or "blue and bloated" (i.e., hypoxemia, CO2 retention, pulmonary hypertension) pattern of patients with COPD nor to the spectrum of hemodynamic and gas exchange abnormalities that commonly occur in patients between these two extreme examples. Thus, "pink puffers" should not be equated with "the emphysematous" pattern of this disease. Although these clinicophysiologic patterns remain valid as descriptions, they do not relate to the extent of underlying emphysema in COPD.
Aged↗
[Pulmonary emphysema. Changes in the pulmonary function of experimentally induced emphysema].
By intratracheal injection of the protease papain to experimental animals parenchymal changes in the lung can be induced, that resemble human emphysema. Papain (dosage 26 to 112 mg, 1 to 4 injections) was given intratracheally to 8 bastard dogs (weighing from 12.5 to 20 kg) during light general anesthesia. Pulmonary function was assessed in weekly intervals and related to morphologic changes in the lung. Static compliance of the lung and FRC measured during respiratory arrest were increased after papain, bronchial resistance, measured while artifically ventilated at constant pressure was also increased. Changes of static lung compliance and FRC were seen after the first administration of papain, but further increased with time of observation and after multiple doses of papain. Increase of resistance was not found before 5 weeks. At quiet breathing resistance was not increased at all. No significant changes were found of arterial pO2 and pCO2, pH, standard and actual bicarbonate, diffusion capacity for O2, tidal volume, minute ventilation and ventilatory rate. Morphological findings confirmed the changes described by others. Pulmonary function appears to be pathological at a time when morphology still seems to be normal. The question is discussed to what extent the model of experimental emphysema induced by proteolytic enzymes can contribute to the understanding of human pulmonary emphysema. Lung function in the course of experimental emphysema is compared with function in different clinical types of emphysema.
Acid-Base Equilibrium↗
[Pneumothorax, subcutaneous emphysema and mediastinal emphysema in transnasally intubated patients].
A 41-year-old woman was admitted to our clinic because of an acute subdural hematoma. After an emergency operation her neurological status improved with an increase in the Glasgow Coma Scale score from 6 to 11. On the second postoperative day she developed frequent episodes of clonic convulsive seizures localized in the face and the left upper extremity, and her level of consciousness deteriorated. Next day she was transnasally intubated for respiratory management, but no mechanical ventilation was required. While she was undergoing the CT scanning 5 days after intubation, respiratory arrest and cyanosis developed all of a sudden, and her face and neck became swollen. The chest x-ray revealed a marked subcutaneous emphysema, mediastinal emphysema and bilateral pneumothorax. CT at that time showed a diffuse low density area in the right hemisphere, and a marked midline shift returned. She did not regain consciousness and died 12 days after the incident. At autopsy an ulcer was observed in the wall of the trachea, where the tip or the cuff of the transnasal tracheal tube was supposed to be present. No perforation, however, was there. Case 2: A 75-year-old woman was admitted to our hospital because of SAH. In hospital course she was also transnasally intubated and required no mechanical ventilation. When she was undergoing the CT scanning 3 days after intubation, she developed subcutaneous and mediastinal emphysema similarly to case 1. Although it is reported to be not a rare complication in patients on a mechanical ventilator, subcutaneous emphysema or pneumothorax is extremely rare in those intubated patients with spontaneous respiration. The mechanism of these complications in these cases is briefly discussed.
Adult↗
CT scores of emphysema and oxygen desaturation during low-grade exercise in patients with emphysema.
PURPOSE: We evaluated the usefulness of CT for assessing oxygen desaturation during walking in patients with emphysema. MATERIAL AND METHODS: The study comprised 32 patients with emphysema (mean age 67+/-6 years). Serial CT images of 5 mm were obtained from the apex to the basal regions of the lung during deep inspiration. The severity of emphysema was scored by four physicians according to a visual method. A six-minute walking test and oxygen desaturation (pSO2) measurements were performed. RESULTS AND CONCLUSION: The mean CT score of the four observers was significantly correlated with the nadir pSO2 and deltapSO2, but did not correlate with the total distance walked. These results suggest that CT may be used for the assessment of oxygen desaturation during low-grade exercise in patients with emphysema.
Aged↗
Emphysema associated with intravascular leukocyte sequestration. Comparison with papain-induced emphysema.
The pulmonary effects of endotoxin-induced, repetitive, intravascular leukocyte sequestration were studied in dogs and were compared to the effects of intratracheal papain. Lung specimens from 7 animals receiving 20 to 23 weekly injections were histologically and physiologically similar to those from 10 control animals. Dogs receiving 50 injections of endotoxin during 17 wk developed histologic evidence of emphysema as seen on whole lung sections, a significant increase in mean linear intercept, and loss of elasticity at high lung volumes. The group of animals given intratracheal papain also developed histologic evidence of emphysema, with increased mean linear intercepts and loss of lung elasticity. However, the effects on lung elasticity were much greater in the papain group. Endotoxin-induced, repetitive leukocyte sequestration in the lungs results in mild emphysema; however, similar changes in alveolar size appear to cause less effect on the pressure-volume loop than does papain-induced emphysema.
Animals↗
Protease-induced experimental emphysema: the relationship between elastolytic activity and emphysema induction.
Induction of experimental emphysema by protease was performed with several proteases both in vivo and in vitro to compare the ability of inducing emphysematous change and their elastolytic activity. The following results were obtained. 1) Only elastase and papain have emphysema inducing capacity. Emphysematous changes induced by elastase in vitro were dose dependent. But papain has no genuine elastolytic activity. Nature of the emphysema-inducing capacity of papain remains obscure. 2) Advantages of using the isolated lung for experiment were discussed, especially for the small dose required for enzyme-instillation. Moreover, there is no interferencey by endogeneous enzyme or protease-inhibitors. 3) Guinea pig is useful for the experiemnt of emphysema-induction both in vivo and in vitro. Minimal requirement of elastase is 50 microgram in vitro and 250 microgram for in vivo experiment.
Animals↗
Massive subcutaneous emphysema, pneumomediastinum, and spinal epidural emphysema as complications of violent coughing: a case report.
A 28-year-old man who manifested subcutaneous emphysema extending from the skull base and face to the chest, mediastinum and spinal epidural space following severe coughing caused by acute bronchitis is reported. Subcutaneous emphysema is a manifestation of non-surgical intrathoracic pathophysiology. In this patient percutaneous diagnostic peritoneal lavage resulted in the release of a large quantity of air and was negative for bleeding or contamination. No treatment other than antibiotics was prescribed. In this report, computer tomography study successfully demonstrated the areas of massive subcutaneous emphysema and the disappearance of the entrapped air, that might be absorbed into the tissues in the occupied sites within 7 days, except the air of epidural space, of a patient who manifested as a consequence of severe coughing caused by acute bronchitis.
Adult↗
The proteinase-antiproteinase theory of emphysema: a speculative analysis of recent advances into the pathogenesis of emphysema.
This review concerns the reasons why only an estimated 10-15% of patients with alpha-1-antitrypsin (A1AT) deficiency develop the destructive lung disease known as emphysema. The arguments presented revolve around the proteinase-antiproteinase balance in the 'microenvironment' of the epithelial space of the lung. Attention is focused on the balance between destructive enzymes such as neutrophil elastase and protective proteins such as A1AT, secretory leucocyte proteinase inhibitor (SLPI), human elastase inhibitor (HEI) and elafin. When neutrophil elastase is already attached to the elastin fibres the smaller molecules SLPI and elafin appear to be better inhibitors of this enzyme than larger inhibitors such as A1AT and HEI. Furthermore, SLPI and elafin may provide the first line of defence against proteinase attack from neutrophil elastase. In trying to explain the variability in the clinical expression of A1AT-deficiency and the development of emphysema, the importance of changes to A1AT, SLPI and elafin molecules induced by smoking and/or oxygen free radicals has been considered. It is possible that emphysema only develops in patients who have SLPI/elafin deficiency as well as A1AT deficiency.
Emphysema↗
Rationale and design of The National Emphysema Treatment Trial: a prospective randomized trial of lung volume reduction surgery. The National Emphysema Treatment Trial Research Group.
The National Emphysema Treatment Trial is a multicenter, randomized clinical trial of medical therapy vs medical therapy plus lung volume reduction surgery (LVRS) for the treatment of patients with severe bilateral emphysema. LVRS will be accomplished by bilateral stapled excision via median sternotomy or video-assisted thoracoscopic surgery. Every patient will complete 6 to 10 weeks of pulmonary rehabilitation prior to randomization and will participate in a maintenance program of pulmonary rehabilitation after randomization. The primary outcome to be assessed by the trial is survival. Additional outcomes to be assessed are maximum exercise capacity, pulmonary function, oxygen requirement, distance walked in 6 min, quality of life, respiratory symptoms, and health-care utilization and costs. In addition, selected clinics will evaluate lung mechanics and respiratory muscle function, partial and maximal flow-volume curves, gas exchange during maximal exercise, and right heart function. The trial is targeted to enroll patients with severe emphysema who have no significant comorbid conditions; each patient will be randomized to one of the two treatment groups. The study duration is 4.5 years with a close-out period of 6 months.
Humans↗
Rationale and design of the national emphysema treatment trial. A prospective randomized trial of lung volume reduction surgery. The national emphysema treatment trial research group
The National Emphysema Treatment Trial is a multicenter, randomized clinical trial of medical therapy vs medical therapy plus lung volume reduction surgery (LVRS) for the treatment of patients with severe bilateral emphysema. LVRS will be accomplished by bilateral stapled excision via median sternotomy or video-assisted thoracoscopic surgery. Every patient will complete 6 to 10 weeks of pulmonary rehabilitation prior to randomization and will participate in a maintenance program of pulmonary rehabilitation after randomization. The primary outcome to be assessed by the trial is survival. Additional outcomes to be assessed are maximum exercise capacity, pulmonary function, oxygen requirement, distance walked in 6 min, quality of life, respiratory symptoms, and health-care utilization and costs. In addition, selected clinics will evaluate lung mechanics and respiratory muscle function, partial and maximal flow-volume curves, gas exchange during maximal exercise, and right heart function. The trial is targeted to enroll patients with severe emphysema who have no significant comorbid conditions; each patient will be randomized to one of the two treatment groups. The study duration is 4.5 years with a close-out period of 6 months.
Journal Article↗
Results of lung volume reduction surgery in patients with emphysema. The Washington University Emphysema Surgery Group.
Between January 1993 and April 1995, 84 patients with emphysema underwent bilateral lung volume reduction surgery at Barnes Hospital, Fifty-three patients had completed 3 months; 37 patients, 6 months; and 19 patients, 1 year of follow-up. Significant improvement was observed in spirometric parameters, oxygenation, 6-minute walking distance, dyspnea indices, and quality-of-life scores. The average increases in FEV1 were 52%, 51%, and 61%, at 3,6, and 12 months, respectively, after surgery. The most common postoperative complication, prolonged ( > 7 days) chest tube drainage, was present in 63% of the cases, and the mean duration of hospitalization in the survivors was 15 days (range 5 to 49 days). This has been reduced to 11 days (median 7.5 days) for the subsequent 40 patients. Five postoperative deaths occurred, 2 in the first, 2 in the third, and 1 in the fifth postoperative month, respectively. The overall mortality in the 84 patients was 6%, and the actuarial survival at 1 year was 93%. Volume reduction surgery is a promising therapeutic option for patients with an appropriate pattern of emphysema. Improvement has been sustained for more than 1 year, and long-term follow-up is planned to ascertain the duration of the benefits.
Activities of Daily Living↗
[Diagnostic image (155). A man with facial emphysema. Subcutaneous facial emphysema due to dental cleaning].
A 47-year-old man developed subcutaneous emphysema of the right side of his face during a dental cleaning procedure by the dentist.
Dental Prophylaxis↗