Lung emphysema (smoker's lung)

The lung emphysema is an irreversible hyperinflation of the lungs or pulmonary alveoli respectively. This often arises due to a chronic obstructive pulmonary disease COPD or asthma. Inflammatory processes and in particular the constant pressure due to continuous increased breathing resistance lead to over-extension of the pulmonary alveoli, which then rupture and merge with neighboring alveoli to larger air sacs. The oxygen exchange decreases constantly. The effects are shortness of breathing and respiratory distress, what can also lead to a cardiac insufficiency on the long run. The life quality is significantly restricted and in an advanced stage the life expectancy is also shortened.

Causes
Cigarette smoke is the greatest risk factor and most patients with advanced lung emphysema are active or former smokers. The consumption of marijuana also heavily increases the risk of a chronically obstructive lung disease. Additional risk factors are air pollution, an occupational exposure to chemicals or dust, passive smoking or often respiratory infections. Also a genetically lack of the blood protein alpha-1-antitrypsin (AAT) can result in an emphysema.

Diagnosis
The diagnosis of a COPD is made in patients with respiratory distress, chronic cough, with our without sputum and respiratory obstruction in the pulmonary function test. In most cases a lung emphysema is resulting, that shows typical signs in overview X-ray and computer tomography.

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The overview X-ray imaging of the thorax belongs to basic diagnostics. In advanced diseases signals of lung hyperinflation (e.g. low diaphragmatic cupolas, wide rib spaces, increased space behind the sternum) show.

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The computer tomography of the lungs shows the destroyed bubble-like lung areas. Additionally a color-coded depiction can show the most damaged lung parts (= red areas).

 
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Extraction of the most destroyed lung parts.

 

 

 

(re) Lateral image before (upper) and after (lower)  LVRS.

 

Therapy
Immediately quitting to smoke is the most important measure to take!
Medicative therapy with so-called bronchodilators, i.e. with medication to expand the bronchial tubes and anti-inflammatory medication (steroids) as well as the pulmonary rehabilitation (a training program with the target of improving the performance) can help to reduce the symptoms and to stabilize the course of the disease. In the advanced stage oxygen helps to reduce the respiratory distress and to extend the life expectancy. In this situation two surgical procedures have established as treatment opportunities; the lung volume reduction surgery (LVRS) and/or the lung transplantation (TPL: thoracoplasty).

In lung volume reduction surgeries (LVRS) the most destroyed lung parts are resected in order to reduce the oversized lung to a normal size. In advanced emphysemas the lung is too large for the thorax and is putting downwards pressure on the most important breathing muscle, the diaphragm, so that it is not working anymore. The lung reduced to a normal sizes allows the diaphragm to work again and to normalize the breathing mechanism. The extraction of the most overinflated and destroyed, inoperable lung parts allows the expansion of the pressed, still functional lung areas. .

Most important inclusion criteria for a surgical lung volume reduction are strong respiratory distress due to the emphysema and significant hyperinflation of the lungs, recognizable by the breathing mechanism of the patient as well as the pulmonary function test. The most important additional examination is the computer tomography of the lung which allows to localize the lung destruction. At many centers only patients with a heterogeneous lung emphysema infestation are operated. Or research team showed however years ago as first group worldwide at a huge collective that also selected patients with homogeneous emphysema infestation can profit from surgical procedures (W. Weder). The maximum effect is measurable after six months (K. Bloch).

The results of volume reduction are very good in selected patients and the patients benefit from a huge increase of life quality. Also their life expectancy increases by improved breathing. The maximum functional improvement is achieved three to six months after the surgery. Positive effects can be proved postoperatively in many patients even after four to five years. At LVRS usually about a third of the heavily overinflated lungs is resected by means of a video-assisted thoracoscopy (camera technique through three entries. The surgery is performed under general anesthetic with one-lung respiration and can be perform uni- or ambilaterally. Initially the surgery was assessed as very risky. In the last years we had the opportunity show that this is not the case in experienced centers at right patient choice.

 

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Basing on the imaging or intraoperative presentation of the lungs the resection limits are defined. With the lung forceps the lung is held at an edge and the resection line is defined with a second lung forceps. Then approx. 20 to 30 percent of the lung volume are resected with a stapler and cutting device in several steps.

 

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Access methods for the thoracoscopic volume reduction (left) and postoperative situs (right).

Prolonged air leakages, so-called air fistulas, are the most frequent surgery complications. Most leakages heal spontaneously within a few days after the surgery. At persistent leakage of more than 7 to 10 days another surgery with closing of the leakage needs to be considered. The perioperative mortality (2 to 7 percent) is low in centers with experience in emphysema surgery and patient selection.

Lung transplantation (TPL)   

The lung emphysema is the most frequent indication for a uni- or omnilateral lung transplantation and is used for young patients under 60 years with depleted treatment options It is very complex, demands for life-long medication intake and consequent regular follow-up examinations.

Bronchoscopic volume reduction (BVR)

Besides the two surgical treatment options since about 10 years also bronchoscopic lung volume reduction is used to improve the breathing technique. The implantation of one-way valves is the best-known form. Thereby air can escape but not intrude, the overinflated lung part is ventilated and finally shrinking. The effect of the valve implantation is heavily depending on the collateral ventilation, the short circuit connection between the individual pulmonary valves. In patients without collateral ventilation an improvement of the lung function and life quality can be achieved. The effect is however very low in patients with existing collateral ventilation. (See also interventional bronchology)