Causes and Symptoms (Magill’s Medical Guide, Sixth Edition)
Emphysema is a lung disease in which damage to these organs causes shortness of breath and can lead to heart or respiratory failure. A discussion of the structure and function of the normal lung can illuminate the nature and effects of this damage.
Gases, smoke, germs, allergens, and environmental pollutants pass from the nose and mouth into a large duct called the trachea. The trachea branches into smaller ducts, the bronchi and bronchioles (small branches of the bronchi), which lead to tiny air sacs called alveoli. The respiratory system is like a tree: The trachea is the trunk, the bronchi and bronchioles are similar to the branches, and the alveoli are similar to the leaves. The blood vessels of the alveoli carry red blood cells, which pick up oxygen and transport it to the rest of the body. The cellular waste product, carbon dioxide, is released to the alveoli from the bloodstream and then exhaled. The alveoli are supported by a framework of delicate elastic fibers and give the lung a very distensible quality and the ability to “snap back,” or recoil.
The lungs and bronchial tubes are surrounded by the chest wall, composed of bone and muscle and functioning like a bellows. The lung is elastic and passively increases in size to fill the chest space during inspiration and decreases in size during expiration. As the lung (including the alveoli) enlarges, air from the environment flows in to fill this space....
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Treatment and Therapy (Magill’s Medical Guide, Sixth Edition)
The initial step in treating emphysema is to open the airways by eliminating the causes of irritation: smoke, dry air, infection, and allergies. The second treatment is to clean out the airways. There are several techniques and medicines for loosening airway mucus and expelling it. In most chronic obstructive lung diseases, including emphysema, the mucus becomes thick and purulent; coughing up mucus of this type is difficult. In addition, in emphysema the natural cleansing action of the cilia and lung elasticity are impaired. Thus, treatment is aimed at the patient consciously taking over the function of cleaning out the lungs. Coughing is nature’s way of bringing up mucus (phlegm), and the emphysemic patient is urged to cough. Since the mucus is thick, one needs to do whatever is necessary to thin it out and to lubricate the airways so that the mucus slips up easily with coughing. The cough must come from deep within the chest in order to be “productive” (to raise mucus).
Moisture is helpful in loosening up thick mucus; hence, drinking large amounts of fluid is encouraged. Adding a humidifier or a vaporizer to a home is often helpful to the emphysemic patient. There are also machines known as nebulizers and intermittent positive pressure breathing (IPPB) machines that can help to add moisture to the airway of the patient with emphysema. Nebulizers are more effective in getting moisture beyond the throat and major...
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Perspective and Prospects (Magill’s Medical Guide, Sixth Edition)
Chronic bronchitis and emphysema are responsible for at least fifty thousand deaths a year in the United States alone. An increase in air pollution and cigarette consumption are apparent causes for this rise. In males over forty, chronic obstructive pulmonary disease (COPD) is second to heart disease as a cause of disability. With more females and young people smoking, the incidence of lung disease is likely to increase. Aside from death, a disease such as emphysema can cause long years of disability, joblessness, loss of income, depression, hospitalization, and an inability to perform normal activities.
Smoking is, by far, the single most important risk factor for emphysema. In the United States especially, social acceptance of women smokers began after World War II and has increased the number of women being diagnosed with COPD. Socioeconomic status also influences smoking habits. In many countries in Europe, the mortality rate from lung disease for the lowest socioeconomic class has been six times higher than for the highest. In the United States, the COPD mortality rate among unskilled and semiskilled laborers is twice as high as among professionals. Families with lower incomes usually live in small, often overcrowded apartments; such overcrowding makes respiratory infections more frequent. Often, family members of the COPD patient also smoke, increasing the surrounding air pollution.
In the United...
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For Further Information: (Magill’s Medical Guide, Sixth Edition)
American Lung Association. http://www.lungusa.org. Includes in-depth information and recent research findings, a guide to local events and programs, and a section to share personal stories, among other features.
Bates, David V. Respiratory Function in Disease. 3d ed. Philadelphia: W. B. Saunders, 1989. Summarizes the effects of disease on pulmonary function. Also discussed are some of the more sophisticated pulmonary function tests. Exercise testing, obesity, and the effects of drugs are other topics reviewed in this work.
Decker, Caroline D. “Room to Breathe.” Saturday Evening Post 266, no. 6 (November/December, 1994): 48-49. This article on emphysema discusses lung surgery. Illustrated with photographs.
Haas, François, and Sheila Sperber Haas. The Chronic Bronchitis and Emphysema Handbook. Rev. ed. New York: John Wiley & Sons, 2000. Helps patients with COPD learn to lead full and productive lives. Provides information pertinent to their disease and describes the treatments and medications available to them in order to improve their quality of life.
Hedrick, Hannah L., and Austin K. Kutscher, eds. The Quiet Killer: Emphysema, Chronic Obstructive Pulmonary Disease. Lanham, Md.: Scarecrow Press, 2002. Clinicians, researchers, and health educators combine their expertise in twenty-five chapters that discuss such topics as managing dyspnea, traveling with...
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Emphysema (Encyclopedia of Medicine)
Emphysema is a chronic respiratory disease where there is over-inflation of the air sacs (alveoli) in the lungs, causing a decrease in lung function, and often, breathlessness.
Emphysema is the most common cause of death from respiratory disease in the United States, and is the fourth most common cause of death overall. There are1.8 million Americans with the disease, which ranks fifteenth among chronic conditions that cause limitations of activity. The disease is usually caused by smoking, but a small number of cases are caused by an inherited defect.
Normally functioning lungs are elastic, efficiently expanding and recoiling as air passes freely through the bronchus to the alveoli, where oxygen is moved into the blood and carbon dioxide is filtered out. When a person inhales cigarette smoke or certain other irritants, his or her immune system responds by releasing substances that are meant to defend the lungs against the smoke. These substances can also attack the cells of the lungs, but the body normally inhibits such action with the release of other substances. In smokers and those with the inherited defect, however, no such prevention occurs and the lung tissue is damaged in such a way that it loses its elasticity. The small passageways (bronchioles) leading to the alveoli...
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Emphysema (Encyclopedia of Alternative Medicine)
Emphysema is a progressive, incurable chronic lung condition. The air sacs (alveoli) are destroyed and oxygen uptake is restricted due to the loss of elasticity of lung tissue.
As of 1998 there were an estimated two million people suffering from emphysema in America. Between three and five percent were attributed to genetic factors, the remainder being a result of environmental pollution, with smoking ranking far and away as the main cause.
Normally functioning lungs are elastic, and efficiently expand and recoil as air passes freely through their passageways (bronchus) to the alveoli, where oxygen is moved into the blood and carbon dioxide is filtered out. When a person inhales cigarette smoke or airborne pollutants, his or her immune system responds by releasing substances that are meant to defend the lungs against the smoke. These substances can also attack the cells of the lungs, but the body normally inhibits such action with the release of other substances.
When individuals are exposed to pollution over a long period of time the lung tissue is damaged in such a way that it loses its elasticity. When damage has occurred to the alveoli, sufferers have difficulty making a complete exhalation, which causes residual volumeir trapped inside the lungs. With the...
(The entire section is 2329 words.)
Emphysema (Encyclopedia of Nursing & Allied Health)
Emphysema is a chronic respiratory disease in which overinflation of the alveoli or air sacs causes a decrease in respiratory function and often dyspnea.
Emphysema is the most common cause of death from respiratory disease in the United States, and is the fourth most common cause of death overall. There are1.8 million Americans with the disease, which ranks fifteenth among chronic conditions that cause limitations of activity. Around 44% of those with emphysema state that their activities of daily living have been affected by the disease.
Normally functioning lungs are elastic, efficiently expanding and recoiling as air passes freely through the bronchus to the alveoli, where oxygen is moved into the blood and carbon dioxide is filtered out. When a person inhales cigarette smoke, his or her immune system responds by releasing substances that are meant to defend the lungs against the smoke. These substances can also attack the cells of the lungs. Normally, the body inhibits such action by releasing other substances. In smokers and those with the inherited emphysema defect, however, no such prevention occurs, and the lung tissue is damaged in such a way that it loses its elasticity. The small passageways leading to the alveoli collapse, trapping air within the alveoli. The alveoli, unable to recoil efficiently and move the air out, overexpand and rupture. The smaller areas of alveoli destruction are known as blebs and the larger ones are called bullae. As the disease progresses coughing and dyspnea occur. In the later stages the lungs cannot supply sufficient oxygen to the blood. Emphysema often occurs with other respiratory diseases, particularly chronic bronchitis. These two diseases are often referred to as onehronic obstructive pulmonary disease (COPD).
Emphysema is most common among people aged 50 years and older. Those with inherited emphysema may experience the onset as early as their 30s or 40s. Men are more likely than women to develop emphysema, but female cases are increasing as the number of female smokers rises.
Causes and symptoms
Heavy cigarette smoking causes about 800% of all emphysema cases. However, a few cases are the result of an inherited deficiency of alpha-1-antitrypsin (AAT). The number of Americans with this deficiency is relatively small, probably no greater than 70,000. Pipe, cigar, and marijuana smoking can also damage the lungs. While a person may be less likely to inhale cigar and pipe smoke, these types of smoke can also impair lung function. Marijuana smoke is even more damaging because it is inhaled deeply and held in the lungs longer by the smoker.
The symptoms of emphysema develop gradually over many years. It is a common occurrence for many emphysema patients to have lost 500% of their functional lung tissue before they become aware that something is wrong. Dyspnea, a chronic mild cough (which may be productive of large amounts of dark, thick sputum, and often dismissed as "smoker's cough"), and sometimes weight loss are associated with emphysema. Initially, a patient may notice shortness of breath only when he or she is exercising. However, as the disease progresses, it will occur during less exertion, and ultimately with no exertion at all. Emphysema patients may also develop an enlarged, or "barrel," chest. Other symptoms may include skipped breaths, insomnia, morning headaches, nasal flaring, increased difficulties breathing while lying down, chronic fatigue, and swelling of the feet, ankles, or legs. Those with chronic emphysema are at risk for other complications resulting from weakened lung function. These include pneumonia, pulmonary hypertension, cor pulmonale, and chronic respiratory failure.
A history of heavy smoking alone is not enough for a physician to differentiate emphysema from other respiratory diseases. A physician will combine information on symptoms, medical history, physical examination, lung function tests, and chest x ray results to make a diagnosis of emphysema. One of the first clues may be a hollow sound heard through a stethoscope as the patient's chest is being tapped. The hollow sound is the result of the enlargement or rupture of the lungs' alveoli.
A variety of pulmonary function tests may be ordered. In the early stages of emphysema, the only result may be dysfunction of the small airways. Patients with emphysema may show an increase in the total amount of air that is in the lungs (total lung capacity), but a decrease in vital capacity. With severe emphysema, vital capacity is substantially below normal. Spirometry, a procedure that measures respiratory gases and resulting pulmonary function, aids in the diagnosis of emphysema.
A chest x ray is often ordered to aid in the diagnosis of emphysema, though patients in the early stages of the disease may have normal findings. Abnormal findings on the chest x ray include excessive inflation of the lungs and an abnormally increased chest diameter. The diaphragm may appear depressed or flattened. In addition, patients with advanced emphysema may show an enlargement of the heart. The physician may observe blisters in the lungs and bulging of the accessory muscles of the respiratory system. Late in the disease an EKG will show signs of right ventricular failure in the heart and increased hemoglobin due to lower oxygen in the patient's blood.
Other tests that may be performed include peak flow measurements, arterial blood gases, and pulse oximetry.
Treatment methods for emphysema do not cure or reverse the damage to the lungs. However, they can slow the progression of the disease, relieve symptoms, and help control possibly fatal complications. The first step in treatment for smokers is to quit smoking to prevent any further deterioration of breathing ability. Smoking cessation programs may be effective. Consistent encouragement, along with the help of health care professionals as well as family and friends, can help increase the quit rate.
If the patient and the health team develop and maintain a complete program of respiratory care, disability can be decreased, acute episodes of illness may be prevented, and the number of hospitalizations reduced. However, only smoking cessation has been shown to slow down the progression of the disease; and among all other treatments, only oxygen therapy has exhibited an increase in survival rate.
Home oxygen therapy may improve the survival times in those patients with advanced emphysema who also have hypoxemia, or low blood oxygen levels. It may improve the patient's tolerance of exercise, as well as improve their performance in certain aspects of brain function and muscle coordination. The functioning of the heart may also improve with an increased concentration of oxygen in the blood. Oxygen may also decrease insomnia and headaches. Some patients may receive oxygen only at night, but studies have illustrated that it is most effective when administered for at least 18, but preferably, 24 hours per day. Those patients just beginning the therapy may wish to postpone continuous oxygen administration until it becomes absolutely necessary because of inconvenience and decreased mobility. Portable oxygen tanks prescribed to patients carry a limited supply and must be refilled on a regular basis by a home health care provider. Medicare and most insurance companies cover a large proportion of the cost of home oxygen therapy. Patients should be instructed regarding special safety issues involving the transport and presence of oxygen in the home.
A variety of medications may be used in the treatment of emphysema. Usually the patient responds best to a combination of medicines rather than one single drug. Bronchodilators are sometimes used to help alleviate the patient's symptoms by relaxing and opening the airways. There are three primary categories of bronchodilators:
sympathomimetics (isoproterenol, metaproterenol, terbutaline, albuterol), which can be inhaled, taken by mouth, or injected; parasympathomimetics (atropine); and methylxanthines (theophylline), which may be administered intravenously, orally, or rectally.
Another category of medication often used is corticosteroids or steroids (beclomethasone, dexamethasone, triamcinolone, flunisolide). These help to decrease the inflammation of the airway walls. They are occasionally used if bronchodilators are ineffective in preventing airway obstruction. Some patients' lung function improves with corticosteroids, and inhaled steroids may be beneficial to patients with few side effects.
A variety of antibiotics are frequently given at the first sign of a respiratory infection, such as increased amounts of sputum or a change in the color of the sputum. Expectorants can help loosen respiratory secretions, enabling the patient to more easily expel them from the airways.
Many of the medications prescribed involve the use of a metered dose inhaler (MDI) that may require special instruction to be used correctly. MDIs are a convenient and safe method of delivering medication to the lungs. However, if they are used incorrectly the medication will not get to the right place. Proper technique is essential for the medication to be effective.
For some patients, surgical treatment may be the best option. Lung volume reduction surgery is a surgical procedure
Alveolimall cells or cavities. In the lungs, these are air sacs in which oxygen enters the blood and carbon dioxide is filtered out.
Arterial blood gases test to analyze blood for oxygen, carbon dioxide, and bicarbonate content, as well as blood pH. Used to test the effectiveness of respiration.
Cor pulmonale disease characterized by an increase in bulk of the right ventricle of the heart that can lead to heart failure.
Hypoxemia condition characterized by deficient oxygen supply in the blood.
Peak flow measurementeasurement of the maximum rate of airflow attained during a forced vital capacity determination.
Pulmonaryelated to or associated with the lungs.
Pulse oximetryhe noninvasive monitoring or determination of oxygen-hemoglobin saturation of the blood.
in which the most diseased parts of the lung are removed to enable the remaining lung and breathing muscles to work more efficiently. Preliminary studies suggest improved survival rates and better functioning with the surgery. Another surgical procedure used for emphysema patients is lung transplantation. Transplantation may involve one or both lungs. However, it is a risky and expensive procedure and donor organs may not be available.
For those patients with advanced emphysema, keeping the air passages reasonably clear of secretions can prove difficult. Some common methods for mobilizing and removing secretions include:
- Postural drainage. This technique helps to remove secretions from the airways. The patient lies in a position that allows gravity to aid in draining different parts of the lung. This is often done after the patient inhales and aerosol medication. The basic position involves the patient lying on the bed with chest and head over the side and forearms resting on the floor.
- Chest percussion. This technique involves a caregiver lightly clapping the back and chest of the patient. It may help to loosen thick secretions.
- Coughing and deep breathing. These techniques may aid the patient in bringing up secretions.
- Aerosol treatments. These treatments may involve solutions of saline, often mixed with a bronchodilator, which are then inhaled as an aerosol. The aerosols thin and loosen secretions. A treatment normally takes 105 minutes and is given three or four times a day.
Patients with COPD can be instructed to perform a variety of self-help measures that can help improve their symptoms and ability to participate in activities of daily living. These measures include:
- Avoiding any exposure to dust and fumes.
- Avoiding air pollution, including secondhand cigarette smoke.
- Avoiding other people who have infections like the cold or flu, and getting a pneumonia vaccination and a yearly flu shot.
- Drinking plenty of fluids to help loosen respiratory secretions so they can be coughed up more easily.
- Avoiding extreme heat or cold and high altitudes (special precautions can be taken that may enable the emphysema patient to fly on a plane).
- Maintaining adequate nutritional intake; normally, a high-protein diet taken in many small feedings, is recommended.
Many patients are interested in whether any alternative treatments for emphysema are available. Some practitioners recommend supplements of antioxidant nutrients. There have also been some studies indicating a correlation between a low vitamin A status and COPD, with suggestions that supplements of vitamin A might be beneficial. Aromatherapists have used essential oils like eucalyptus, lavender, pine, and rosemary, to help relieve nasal congestion and make breathing easier. The herb elecampane may act as an expectorant to help patients clear mucus from the lungs. The patient should discuss these remedies with their health care practitioner prior to trying them, as some may interact with the more traditional treatments already being given.
Emphysema is a serious and chronic disease that cannot be reversed. If detected early effects and progression can be slowed, particularly if the patient ceases smoking immediately. Complications of emphysema include higher risks for pneumonia and acute bronchitis. Overall, the prognosis for patients with emphysema is poor, with a medical survival rate for all COPD patients of four years, and even less for emphysema patients. However, individual cases vary, and many patients can live much longer with supplemental oxygen and other treatment measures.
Health care team roles
Many members of the health care team may treat the patient with emphysema. The patient usually seeks help from a physician first, who will make the diagnosis. In the course of the diagnostic workup, x-ray technicians and respiratory therapists may treat the patient. The nurse plays an important role in assessing the patient, administering medications, in teaching the patient how best to cope with and understand the disease, andn some casesrovides home care. The physical therapist may assist the patient to find ways of increasing their strength and activity tolerance.
The best way to prevent emphysema is to avoid smoking. Even patients with inherited emphysema should avoid smoking, as it hastens onset and worsens severity of the disease. If patients quit smoking as soon as evidence of small airway obstruction begins, they can significantly improve their prognosis.
Beers, Mark H., and Robert Berkow. The Merck Manual of Diagnosis and Therapy, 17th ed. Whitehouse Station, NJ: Merck and Company, Inc., 1999.
"Data Mounting on Merits of Lung Volume Reduction Surgery." Family Practice News (February 15, 2001): 5.
Lewis, Laurie. "Optimal Treatment for COPD." Patient Care (May 30, 2000): 60.
American Lung Association. 1740 Broadway, New York, NY 10019. (212) 315-8700. <<a href="http://www.lungusa.org">http://www.lungusa.org>.
The National Emphysema Foundation. 15 Stevens St., Norwalk, CT 06856. <<a href="http://www.emphysemafoundation.org">http://www.emphysemafoundation.org>.
National Heart, Lung and Blood Institute. <<a href="http://www.nhlbi.nih.gov">http://www.nhlbi.nih.gov>.
Deanna M. Swartout-Corbeil, R.N.
Emphysema (Encyclopedia of Public Health)
Emphysema is a lung disease that, along with chronic bronchitis, represents a type of chronic obstructive pulmonary disease (COPD). Medical scientists have defined emphysema as "a condition of the lung characterized by abnormal, permanent enlargement of airspaces distal to the terminal bronchioles, accompanied by the destruction of their walls, and without obvious fibrosis" (Snider 1985).
COPD is the fourth leading cause of death in the United States, accounting for about 113,000 deaths annually. About 14 million Americans have symptoms of COPD. Among these, 1.65 million have emphysema. Millions more likely have undiagnosed or incipient COPD. The prevalence of COPD peaks in the sixty-five to seventy-four age range, and men are affected more than women.
Pathologists recognize three major types of emphysema: localized (distal acinar, paraseptal), centrilobular (centriacinar), and panlobular (panacinar). Centrilobular emphysema, the most common of the three, is usually caused by cigarette smoking. Cigarette smoke is thought to cause chronic inflammation in the walls of the air sacs (alveoli) of the lung, leading to an imbalance between destructive proteases and protective protease inhibitors. The proteases, such as elastase, gradually destroy the structural proteins (elastin, collagen) in the alveolar walls. Substantial variation in individual susceptibility to cigarette smoke exists, as only about one in seven cigarette smokers develops symptoms of COPD. Other than cigarette smoking, the only condition clearly linked to emphysema is a hereditary disorder called alpha1-antitrypsin deficiency (AAT). This rare condition, which is found in less than one percent of patients with COPD, occurs because the blood level of a glycoprotein (protease inhibitor) is not sufficient to counteract the activity of the proteases. Coal miners and workers chronically exposed to cadmium fumes are at risk to develop emphysema. The effects of other occupational agents, air pollution, and familial factors in the pathogenesis of emphysema are not clear.
Destruction of alveolar walls in emphysema reduces the lung's elasticity, which results in obstruction to airflow in small airways, trapping air in the lung. Other pathophysiologic findings in emphysema include increased lung compliance, elevation of the pressure in the pulmonary arteries (pulmonary hypertension), and abnormal matching of air flow and blood flow (ventilation/perfusion imbalance), which causes hypoxemia (low oxygen level in the blood).
Patients with emphysema suffer from shortness of breath (dyspnea), which typically appears between the ages of fifty and sixty. Initially, the dyspnea is noted only with heavy exertion, but it progresses over time to a persistent, daily symptom that may eventually limit simple activities and even be present at rest. If the patient also has chronic bronchitis, daily cough and sputum production are present. Physical examination in emphysema reveals chest hyperinflation (overdistention) and reduced breath sounds on auscultation (listening to breathing noises with a stethoscope). In severe cases, there may be signs of respiratory failure and failure of the right side of the heart (cor pulmonale).
The clinical diagnosis of emphysema is suggested by the presence of a risk factor for emphysema (smoking and/or AAT), the clinical findings described above, the absence of alternative diagnoses to explain these findings (e.g., bronchial asthma, bronchiectasis, and central airways obstructive diseases), and evidence of airflow obstruction on spirometry (pulmonary function testing). Airflow obstruction in emphysema is usually irreversible, meaning there is no improvement in the obstruction after inhaling a bronchodilator drug. Specialized pulmonary tests may demonstrate air trapping and reduction in the gas-transfer ability of the lung. The chest radiograph in mild emphysema may be normal, but in severe cases there is hyperinflation. Sometimes large air sacs called bullae are seen. Computed tomographic imaging may confirm lung destruction, bullae, and hyperinflation. Arterial blood-gas analysis and transcutaneous measurement of oxyhemoglobin saturation (oximetry) reveal hypoxemia in advanced emphysema.
Emphysema is treated with a broad-based approach that includes elimination of cigarette smoking, immunization against influenza virus and Streptococcus pneumoniae infection, exercise, maintenance of a healthy lifestyle, and the use of bronchodilator medications (e.g., ipratropium bromide and albuterol). Supplemental oxygen is prescribed if hypoxemia is present. Continuous long-term oxygen therapy improves survival in COPD patients with hypoxemia. Anti-inflammatory drugs such as corticosteroids are helpful in a small percent of emphysema patients. COPD exacerbations, with increasing dyspnea, cough, and sputum production, are usually treated with intensification of the bronchodilator regimen, antibiotics, supplemental oxygen, and in some cases corticosteroids. Hospitalization may be necessary, and in severe cases insertion of a breathing tube into the airway (endotracheal intubation) and mechanical ventilation are necessary. Debilitated COPD patients may benefit from comprehensive outpatient rehabilitation. Rarely, patients with advanced emphysema are treated surgically (removal of large bullae, volume reduction surgery, or lung transplantation).
With the exception of AAT, emphysema is a preventable disease. Smoking abstinence remains the best hope for reducing the morbidity and mortality associated with emphysema. Early detection of airflow limitation in young cigarette smokers may provide a strong stimulus to quit smoking. This is important because smoking cessation is known to slow the rate of decline in lung function in middle-aged smokers with mild COPD.
Survival in patients with COPD is determined by multiple factors, including age, gender, lung function, and levels of oxygen and carbon dioxide in the blood. The prognosis is worse when the airflow obstruction is irreversible. COPD patients with severe obstruction, as defined by spirometry, have a median survival of about four to five years, but there is substantial variability. Death in emphysema patients is usually a result of pneumonia, lung cancer, heart disease, or respiratory failure.
JOHN L. STAUFFER
(SEE ALSO: Asthma; Chronic Respiratory Diseases; Pulmonary Function; Smoking Behavior; Smoking Cessation; Tobacco Control)
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Anthonisen, N. R.; Connett, J. E.; Kiley, J. P.; Altose, M. D.; Bailey, W.C.; Buist, A. S.; Conway, W. A. Jr.; Enright, P. L.; Kanner, R. E.; O'Hara, P.; Owens, G. R.; Scanlon, P. D.; Tashkin, D. P.; and Wise, R. A.(1994). "Effects of Smoking Intervention and the Use of an Inhaled Anticholinergic Bronchodilator on the Rate of Decline of FEV1. The Lung Health Study." Journal of the American Medical Association 272(19): 1497505.
Celli, B., Benditt, J.; and Albert, R. K. (1999) "Chronic Obstructive Pulmonary Disease." In Comprehensive Respiratory Medicine, eds. R. Albert, S. Spiro, and J. Jett, St. Louis, MO: Mosby.
Snider, G. L.; Kleinerman, J.; Thurlbeck, W. M.; and Bengali, Z. H. (1985). "The Definition of Emphysema. Report of a National Heart, Lung, and Blood Institute, Division of Lung Diseases Workshop." American Review of Respiratory Diseases 132:18285.