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Emphysema

Emphysema

Definition

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.

Description

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 volumeair trapped inside the lungs. With the passage of time, this causes the chest to permanently expand and become barrel shaped. As the disease progresses, increasingly more effort is needed to breathe. Emphysema frequently occurs with one or more other respiratory diseases, such as bronchitis and asthma . It is one of the diseases that are collectively referred to as chronic obstructive pulmonary disease (COPD). As a cause of death, it ranks fourth after heart disease, cancer and stroke .

Causes & symptoms

People who smoke or live in polluted atmospheres are possible candidates for emphysema. People with a genetic defect (alpha 1-antitrypsin deficiency) are also at risk. The early stages of emphysema may go undiagnosed, but the main symptoms are breathlessness, blueness of the lips and fingernails, and exhaustion. Sufferers of chronic bronchitis and asthma are also at risk. People who develop emphysema as a result of their work often develop asthma prior to symptoms of their condition.

Emphysema is traditionally a disease suffered by miners, particularly coal miners, as the fine dust that results from mining attacks the alveoli over a period of time. Most miners suffer from emphysema to some degree after a lifetime "down in the pit." In fact, emphysema is sometimes referred to as miner's lung or black lung.

The situation has somewhat improved in recent years due to awareness of the causes of emphysema and improved work conditions for many workers. Others who may be at risk for emphysema include sand blasters, metal grinders, anyone whose job exposes him or her to silica (silicosis), asbestos (asbestososis), or iron filings (siderosis). In addition, dust from wood, cotton, talc, cereal grains coffee, pesticides, drug or enzyme powders, or fiberglass may cause emphysema. People who use their lungs in their work are also susceptible (such as trumpet players and glass blowers). Any worker who is exposed to abnormal levels of dust, fumes, smoke, gases, vapors, or mists over a long period of time may be at risk for emphysema.

Sufferers typically complain that they "can't get enough air" as stale air builds up inside the lungs and the patient becomes starved of oxygen. Coughing, wheezing, and chronic mucous production are other common symptoms.

Diagnosis

A diagnosis of emphysema will not be made on the basis of the above symptoms alone. A detailed medical history will be taken along with x rays and pathology examinations. Peak flow tests will also be conducted.

Treatment

Damage to the lungs as a result of emphysema cannot be reversed, so preventative measures to limit its progression

are essential. The following measures and treatments are regarded as beneficial for emphysema sufferers.

Herbalism

Herbs can be beneficial in relieving the symptoms of emphysema, helping the body to ward off infection, and easing the asthmatic symptoms that often accompany emphysema.

Some of them are:

  • Lobelia: This is a mild sedative, also having strong expectorant properties. It is widely used for chest complaints, including emphysema and bronchitis, and can help to cut an asthma attack short.
  • Thyme : A tea made with thyme is recommended for overcoming shortness of breath. It is also a powerful antiseptic.
  • Mullein: This is another traditional remedy for chest complaints. Boil two tablespoons of the dried leaves with a glass of milk and drink.
  • Echinacea : Echinacea is a powerful immune system stimulant and will strengthen the body in general, warding off colds and infections .
  • Lungwort: A member of the borage family, this herb is very healing for the lungs. It should be taken as an infusion.
  • Black cohosh: This herb is an expectorant and astringent. It relieves coughing.
  • Sage: This is one of the most useful of all herbs and is said to be good for whatever it is taken for. It is antiviral and bactericidal.
  • Garlic : A very powerful anti-viral, garlic can be of real help to those trying to avoid infections and lung congestion.

Chinese herbal medicine

Qing Qi Hua Tan Wan (Pinellia expectorant pills) are the Chinese herbalists' treatment for chronic lung complaints, particularly bronchitis and asthma.

Juices for emphysema

Herbalist Kitty Campion recommends the following juices for the treatment of emphysema: equal parts of carrot juice, parsnip juice, watercress juice and potato juice, or equal parts of orange juice and lemon juice, diluted half and half with a strong decoction of rosehip tea.

Aromatherapy

Aromatherapy involves massaging the patient with potent plant essential oils , which have been proven to enter the circulation through the skin. The constituents of the oils can have a powerful effect on a variety of illnesses, but since their beneficial qualities are also transported through the air, they are considered to be doubly beneficial to those who suffer from respiratory ailments.

Aromatherapy oils for respiratory disease:

  • Canada balsam may alleviate respiratory symptoms and is an expectorant. It is also a bactericide and recommended for those suffering from chronic chest ailments.
  • Tolu balsam is an excellent treatment for chest infections.
  • Frankincense is good for infection and catarrhal discharge.
  • Niaouli is a very strong antiseptic and beneficial for pulmonary trouble.
  • Rose damascena is recommended for bronchial complaints, and also uplifts the spirits.
  • Tea tree oil was recently discovered to be one of the most potent anti-viral, anti-bacterial and anti-fungal agents known to medicine. Therefore highly beneficial as a preventative measure against chest infection.

Acupuncture

This ancient Chinese system of holistic treatment works on the principal that illness is the result of blockage in the flow of life force. The practitioner aims to stimulate relevant meridians in the body, and so release trapped life force, returning bodily functions to normal. The treatment is virtually painless.

Treatment can be expected to improve blood circulation and the capacity of the body to restore itself. Research has indicated that acupuncture can produce changes in the electrical fields of body cells, promoting a return to the body's normal state. Consequently, few negative side effects are associated with acupuncture treatment.

Breathing techniques

Very few people actually breathe correctly, and if lung function is not up to par, the difference between breathing fully and taking shallow ineffective, breaths can make a remarkable difference in the way a person feels and the way his or her body functions. Oxygen shortage in the body promotes disease, and ensuring that oxygen levels are kept up can avert disaster, even with the existence of lung-impairment. Improved breathing techniques can rid the body of free radicals, neutralize environmental toxins, and destroy many harmful microbes that cannot exist in an oxygen-rich environment. Without sufficient oxygen, the body cannot fully utilize nutrients from food, and bodily functions generally become less efficient. Every effort must be made to promote proper breathing, in order to offset the effects of reduced lung function.

In cases of emphysema, it is particularly important to ensure that the out-breath expels all of the previous inbreath. When exhalation is incomplete, wastes produced by breathing are not expelled from the body in the normal way, and residual volume, which is a common occurrence with progressive emphysema, may cause chest enlargement.

Homeopathy

Homeopathy is the treatment of illness according to a system of "like cures like" that stimulates the body to heal itself. While it could definitely contribute to the successful treatment of emphysema, Homeopathy requires a qualified practitioner, as the patient's condition must be accurately assessed in order that the correct remedy be prescribed. Even for the same disorder, no two patients will receive the same treatment.

Lifestyle

For lung dysfunction of any kind, it is vital to take steps to ensure that a person's lifestyle is not contributing to the problem. Pollution must be avoided at all costs, and steps should be taken to ensure that the living environment is free of chemical irritants. This may involve avoiding fragrances, as they can overburden damaged lungs. Some unscented products use a masking fragrance which only increases toxicity. Common household products, such as fabric softeners, bleach, scented detergents, and furniture polish, can harm the body and the environment.

It must be noted that pesticides, fungicides, herbicides, and fertilizers are all neurotoxins, (poisonous to the nervous system). Natural alternatives are obtainable for most household cleaning products. Personal care products can also cause damage, so only natural sources should be used. Chlorinated pools should be avoided.

Every effort should be made to obtain food that is organically grown, in order to avoid pesticides and chemicals. Processed foods should be avoided because they often contain chemicals, dyes, and preservatives, and because the food is stripped of most of its nutritional value. Notably, artificial sweeteners, particularly aspartame, break down into deadly poisons in the body.

Clothing should be all natural fibers, as permanent press and wrinkle-resistant clothes have often been treated with formaldehyde which does not wash out. For the same reasons, synthetic fiber bed coverings should also be avoided. All plastic products should be avoided as far as possible as they all have toxic elements. Windows should be open as often as possible to increase oxygen in the atmosphere. Some houseplants should be acquired, as they give off oxygen.

It is also very important to undertake some form of gentle, regular exercise as this can do much to improve symptoms. Suitable forms of exercise may be swimming, walking and gentle rebounding. If an emphysema patient is very weak, he or she could sit on a mini-trampoline while a helper does the strenuous bit; very real benefits will still be obtained in this way. Strenuous activities are not suitable for anyone with lung impairment.

Naturopathy

According to the principles of naturopathy, the body has the power to heal itself. Treatment should focus on providing the system with optimum nutrition so it can carry out all repairs necessary. This involves ensuring that all food that is eaten is of the highest quality.

Naturopaths advocate dietary supplements to assist with this process, and certain dietary supplements can be very valuable in arresting the progress of Emphysema. Trials have been conducted involving treating emphysema patients with vitamin A , which is known to play an important role in healthy body tissue. Vitamin E can also be helpful, and vitamin C should always be taken, as it is a catalyst for other nutrients. For best results, it is advised to consult a practitioner.

Allopathic treatment

Prior to any other treatment, it is essential that emphysema sufferers who smoke take steps to give up the habit. Otherwise, damage to the lungs will continue to go unchecked and other measures will be very limited in their success. Apart from lifestyle changes, physicians generally recommend avoidance of infection, and antibiotics may be prescribed as a preventative measure.

A physician may also prescribe bronchodilator medicines, which are usually prescribed for asthma patients, if there is any obstruction of the airways. For the same reason, anti-inflammatories may also be prescribed.

Chest physiotherapy, breathing exercises, and a program of physical exercise (collectively referred to as pulmonary rehabilitation) are considered beneficial to all emphysema patients, regardless of the degree of impairment. Supplementary oxygen may be required at some stage.

In extreme cases, lung volume reduction surgery may be recommended. If successful, this can eliminate the need for supplemental oxygen and improves breathing function. In this procedure, the damaged parts of the lung are removed in order to allow healthy lung tissue to expand. Careful evaluation of patients is carried out prior to this procedure. A final resort is lung transplant surgery. Because of the relatively large risk involved, this is carried out in only a small minority of patients.

Expected results

It is generally accepted that emphysema is incurable. Physicians and alternative medicine practitioners assert that they can relieve sufferers greatly from symptoms and halt the progress of the disease with appropriate management and preventative measures.

Prevention

Any person who feels that his/her work conditions are likely to be a possible cause of emphysema should take steps to protect him/herself. A respirator should be worn, at least until work conditions can be improved. Several steps may be taken to improve conditions, primary of which should be to improve ventilation.

Early diagnosis is vital to the successful management of emphysema. If preventative and therapeutic measures are taken at the early onset of symptoms, damage can be restricted and the outlook can be positive. At all times, care should be taken to eliminate sources of pollution or chemical irritants from the environment, both in the home and elsewhere. The first step in overcoming emphysema for any patient should be to remove the cause, whether working conditions, polluted atmosphere or smoking.

Resources

BOOKS

Ryman, Daniele. Aromatherapy London: Piatkus Books, 1999.

Treacher, Sylvia. Practical Homeopathy UK: Parragon Books, 2000.

ORGANIZATIONS

The National Emphysema Foundation <http://emphysemafoundation.org/>

OTHER

"Progress in Emphysema Research. <"http://www.lrri.org/gobmasso.html> (January 17, 2001).

Patricia Skinner

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Emphysema

Emphysema

Definition

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.

Description

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 are 1.8 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 collapse, trapping air within the alveoli. The alveoli, unable to recoil efficiently and move the air out, over expand and rupture. As the disease progresses, coughing and shortness of breath occur. In the later stages, the lungs cannot supply enough oxygen to the blood. Emphysema often occurs with other respiratory diseases, particularly chronic bronchitis. These two diseases are often referred to as one disorder called chronic obstructive pulmonary disease (COPD).

Emphysema is most common among people aged 50 and older. Those with inherited emphysema may experience the onset as early as their thirties or forties. 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 80-90% of all emphysema cases. However a few cases are the result of an inherited deficiency of a substance called 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 may be even more damaging because it is inhaled deeply and held in by the smoker.

The symptoms of emphysema develop gradually over many years. It is a common occurrence for many emphysema patients to have lost over half of their functioning lung tissue before they become aware that something is wrong. Shortness of breath, 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 only notice shortness of breath when he or she is exercising. However, as the disease progresses, it will occur with less exertion or no exertion at all. Emphysema patients may also develop an enlarged, or "barrel,", chest. Other symptoms may be skipped breaths, difficulty sleeping, morning headaches, increased difficulty breathing while lying down, chronic fatigue, and swelling of the feet, ankles, or legs. Those with emphysema are at risk for a variety of other complications resulting from weakened lung function, including pneumonia.

Diagnosis

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 the amount of air that can be breathed out after taking a deep breath (vital capacity). With severe emphysema, vital capacity is substantially below normal. Spirometry, a procedure that measures air flow and lung volume, helps 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 over-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 a smaller or vertical 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 levels of oxygen in the patient's blood.

Treatment

Treatment methods for emphysema do not cure or reverse the damage to the lungs. However, they may slow the progression of the disease, relieve symptoms, and help control possibly fatal complications. The first step in treatment for smokers is to quit, so as 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 success rate of someone attempting to quit.

If the patient and the health care 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 quitting smoking has been shown to slow down the progression of the disease, and among all other treatments, only oxygen therapy has shown an increase in the survival rate.

Home oxygen therapy may improve the survival times in those patients with advanced emphysema who also have 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 only receive oxygen at night, but studies have illustrated that it is most effective when administered at least 18, but preferably 24 hours per day. Portable oxygen tanks prescribed to patients carry a limited supply and must be refilled on a regular basis by a home health 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. They can be inhaled, taken by mouth, or injected. Another category of medication often used is corticosteroids or steroids. 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 if there has been a change in the color of the sputum. Expectorants can help to 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 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 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 an aerosol medication. The basic position involves the patient lying on the bed with his chest and head over the side and the forearms resting on the floor.
  • Chest percussion. This technique involves lightly clapping the back and chest, and 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 10 to 15 minutes, and is given three or four times a day.

Patients with COPD can learn to perform a variety of self-help measures that may help improve their symptoms and their ability to participate in everyday activities. These measures include:

  • Avoiding any exposure to dusts and fumes.
  • Avoiding air pollution, including the cigarette smoke of others.
  • Avoiding other people who have infections like the cold or flu. Get a pneumonia vaccination and a yearly flu shot.
  • Drinking plenty of fluids. This helps to loosen respiratory secretions so they can be brought up more easily through coughing.
  • Avoiding extreme temperatures of heat or cold. Also avoiding 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.

Alternative treatment

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 levels 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 that are already being used.

Prognosis

Emphysema is a serious and chronic disease that cannot be reversed. If detected early, the effects and progression can be slowed, particularly if the patient stops smoking immediately. Complications of emphysema include higher risks for pneumonia and acute bronchitis. Overall, the prognosis for patients with emphysema is poor, with a survival rate for all those with COPD of four years, and even less for emphysema. However, individual cases vary and many patients can live much longer with supplemental oxygen and other treatment measures.

Prevention

The best way to prevent emphysema is to avoid smoking. Even patients with inherited emphysema should avoid smoking, as it especially worsens the onset and severity. If patients quit smoking as soon as evidence of small airway obstruction begins, they can significantly improve their prognosis.

KEY TERMS

Alveoli Small cells or cavities. In the lungs, these are air sacs where oxygen enters the blood and carbon dioxide is filtered out.

Pulmonary Related to or associated with the lungs.

Resources

BOOKS

Beers, Mark H., and Robert Berkow, editors. The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck and Company, Inc., 2004.

PERIODICALS

"Data Mounting on Merits of Lung Volume ReductionSurgery." Family Practice News February 15, 2001: 5.

Lewis, Laurie. "Optimal Treatment for COPD." PatientCare May 30, 2000: 60.

ORGANIZATIONS

American Lung Association. 1740 Broadway New York, NY 10019. (212) 315-8700. http://www.lungusa.org.

National Emphysema Foundation. 15 Stevens St. Norwalk, CT 06856. http://www.emphysemafoundation.org.

National Heart, Lung and Blood Institute. http://www.nhlbi.nih.gov.

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Emphysema

EMPHYSEMA

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 )

Bibliography

American Thoracic Society (1995). "Standards for the Diagnosis and Care of Patients with Chronic Obstructive Pulmonary Disease." American Journal Respiratory Critical Care Medicine 152:S77S120.

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): 14971505.

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 132:182185.

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emphysema

emphysema (ĕmfĬsē´mə), pathological or physiological enlargement or overdistention of the air sacs of the lungs. A major cause of pulmonary insufficiency in chronic cigarette smokers, emphysema is a progressive disease that commonly occurs in conjunction with chronic bronchitis. It is found predominantly in people over age 45, but a genetically based early-onset form also exists. Symptoms are difficulty in breathing, cough with thick sticky sputum, and a bluish tinge of the skin. Progressive disease can result in disability, and in severe cases heart or respiratory failure and death.

Causes

Cigarette smoking is the cause of most cases of emphysema. Tobacco smoke damages the lungs' alveoli, the tiny air sacs through which inhaled oxygen is transferred to the bloodstream and carbon dioxide is passed back to the lungs to be exhaled. The lungs become less elastic and breathing becomes increasingly difficult. The genetic form of emphysema occurs earlier in life (worsened by, but not dependent upon cigarette smoking). It is caused by a rare genetic deficiency of the protein alpha1-antitrypsin. In the absence of antitrypsin, which normally functions to protect the lungs from damage, the walls of the alveoli are attacked by chemicals released in alveoli in response to tobacco smoke and air pollutants.

Treatment

Emphysematous lung damage is irreversible. Its progression can be slowed by giving up smoking. Treatment is aimed at increasing the functional capacity of the lungs and may include bronchodilators, administration of supplemental oxygen, or lung transplantation. Surgical removal of affected lung tissue (lung volume reduction surgery), aimed at allowing healthy areas of the lung room to function, is being studied for its effectiveness and safety. The genetic form is treated with supplemental antitrypsin administered by infusion or by a gene therapy technique that uses T cells (special immune cells that identify diseased or deformed cells) to deliver it to the desired cell sites.

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Emphysema

EMPHYSEMA

DEFINITION


Emphysema is a respiratory disorder characterized by problems in breathing. The disorder is caused by the enlargement of air sacs in the lungs.

DESCRIPTION


Emphysema is the most common cause of death from respiratory disease in the United States. It is generally caused by heavy cigarette smoking. In a small number of cases, it is caused by an inherited defect.

Emphysema is most common among people over the age of fifty. In the late 1990s, males are considered more likely to develop the disorder than females. However, that pattern is changing. The number of women who smoke is increasing rapidly. As this number continues to increase, the number of women who die of emphysema will also increase. In 1999, there were around two million people in the United States with emphysema.

CAUSES


When a person inhales, air travels into the nose and mouth. The air then moves downward into the windpipe (trachea, pronounced TRAY-kee-uh). The windpipe branches off into two large tubes called the bronchi (pronounced BRON-ki). Each bronchus, in turn, divides into many smaller tubes called bronchioles (pronounced BRON-kee-olz). Finally, the bronchioles end in many small air sacs called alveoli (pronounced al-VEE-o-lie). It is in the alveoli that oxygen from the air passes into the blood. The blood then carries the oxygen to cells.

A healthy person's lungs contain many tiny alveoli. The total surface area of these alveoli is very large. Oxygen can get through the alveoli into the blood very easily.

Emphysema: Words to Know

Alveoli:
Small air sacs at the ends of bronchioles through which oxygen passes from the lungs into blood.
Bronchi:
Two large tubes that branches off the trachea and leads to the lungs; each tube is called a bronchus when referred to singularly.
Bronchioles:
Smaller extensions of the bronchi.
Bronchodilators:
Substances that help tissue relax and open up airways to make breathing easier.
Electrocardiogram:
A test that measures the electrical activity of the heart to determine whether it is functioning normally.
Pulmonary function test:
A test that measures the amount of air a patient can breath in and out.
Pulmonary hypertension:
High blood pressure in the arteries and veins associated with the lungs.
Trachea:
The windpipe, extending from the larynx (the voice box) to the lungs.
Volume reduction surgery:
A surgical procedure in which damaged portions of a patient's lung are removed to make it easier for the patient to use healthy parts of the lung to get the oxygen needed for ordinary functioning.

In people who smoke, the lungs undergo a change. The walls that separate the alveoli from each other break down. Air spaces combine with each other to make larger and larger air sacs. Although the air sacs get bigger, there are far fewer of them. Overall, the total surface area of these air sacs is much smaller than the surface area of the original alveoli. Less and less oxygen can pass through the air sacs into the blood. When this happens, the symptoms of emphysema begin to appear.

SYMPTOMS


A person with emphysema has to breathe harder to take in more oxygen. He or she is often short of breath and may have to gasp for air. Patients often develop a chronic (long-lasting) mild cough and may begin to lose weight.

These conditions gradually become worse over time. At first, a person may notice shortness of breath only when exercising. Later, even a mild exertion may cause breathing problems. Eventually, the person has trouble breathing even when sitting quietly.

Emphysema often leads to other problems of the pulmonary (lung) system. These problems include pneumonia (see pneumonia entry), pulmonary

hypertension (high blood pressure in the lungs), and chronic respiratory failure.

DIAGNOSIS


The symptoms of emphysema are obvious. However, they are similar to the symptoms of other respiratory disorders. A major goal of diagnosis is to eliminate other possible causes of the patient's symptoms.

A first step in diagnosis is a medical history. A doctor will determine if there are factors in the patient's background that might suggest emphysema. Smoking is the most obvious of these factors.

A physical examination can provide further information. A doctor may listen through a stethoscope as he or she taps on the patient's chest. A clue to the presence of emphysema is a hollow sound produced by the tapping.

The hollow sound is caused by the large air sacs that develop as a result of emphysema.

A pulmonary function test may also be conducted. A pulmonary function test involves measuring the amount of air a patient can breathe in and out. That amount is measured against the amount that a healthy person can breathe. The test tells whether the person has emphysema and, if so, to what extent it has developed.

As the disease develops, an X ray can be helpful in making a diagnosis. The X ray may show expansion or stretching of the lungs. The position of the heart may change, or blisters may show up on the lungs. Muscles around the lungs may also appear larger.

Late in the disease, an electrocardiogram (pronounced ih-LEK-tro-KAR-dee-uh-gram) may show progress of the condition. An electrocardiogram measures electrical activity of the heart. As the heart is stressed by the patient's efforts to breathe, changes in electrical activity may begin to show up.

TREATMENT


Once emphysema has developed, there is no way to cure the disease or reverse the damage it has done. However, there are many steps that can be taken to slow the progress of the disease, make the patient more comfortable, and prevent the worst complications of the condition.

The first step is for the patient to stop smoking. Unless the patient makes this decision, his or her condition will only continue to get worse. Further treatment can do relatively little to relieve the symptoms of the disorder.

Special exercises may be prescribed for the patient. One objective of these exercises is to keep the lungs healthy and free of infection. Another goal is to develop the muscles used in breathing.

Bronchodilators (pronounced brong-ko-die-LATE-urs) are sometimes used to help relieve the symptoms of emphysema. Bronchodilators are substances that help tissue relax. They assist airways in opening up to allow air to travel more easily through the lungs. Antibiotics may also be used to reduce the risk of lung infections.

In later stages of the disease, oxygen therapy may be necessary. Oxygen therapy consists of providing patients with an extra supply of oxygen, usually through a nose or face mask. The additional oxygen helps the heart to work more easily and reduces the stress that can lead to heart disorders.

Volume reduction surgery is increasingly used to treat emphysema. In volume reduction surgery, damaged portions of the patient's lung are removed. The procedure makes it easier for the patient to use healthy parts of the lung to get the oxygen needed for ordinary functioning.

A treatment of last resort is a lung transplant. In a lung transplant, a healthy lung is removed from a donor and used to replace the damaged lung of an emphysema patient. The procedure is very risky. In addition, there are seldom enough lungs available for transplant to meet the needs of all patients who want them.

Alternative Treatment

Alternative treatments are most valuable when they are used in conjunction with traditional medical care. Aromatherapists may use a variety of oils to make breathing easier. These oils include eucalyptus (pronounced YOOK-ahlip-tus), hyssop (pronounced HEYE-sop), aniseed, lavender, pine, and rosemary. The Chinese herb ephedra (pronounced EF-ed-ra; called ma huang in Chinese) is regarded as a bronchodilator, but it should not be used by patients with heart disorders or high blood pressure. Several herbs, such as elecampane (pronounced EL-i-cam-pane), may help patient's clear mucus from the lungs. Mullein (pronounced MULL-en) tea is recommended to soothe the linings of the lungs. Yoga may be helpful in improving a patient's breathing techniques.

PROGNOSIS


Emphysema is a serious and chronic disease. It cannot be cured or reversed. However, early treatment can slow the progress of the disease. It can also help to prevent its most serious complications. Overall, the survival rate of patients diagnosed with emphysema is about four years. However, that prognosis is dependent on a variety of factors. The ability of a patient to give up smoking is one of the most important factors. The availability and use of oxygen therapy is another factor.

PREVENTION


Emphysema is a condition that is relatively easy to prevent. The best way to prevent the disease is not to smoke cigarettes or, if a person already smokes, to quit. A relatively small number of cases are caused by genetic factors, over which a person has no control. But the vast majority of emphysema cases result from cigarette smoking.

Patients who have already developed emphysema can take a number of steps to slow its progress. For example, they should avoid breathing polluted air as much as possible. The pollutants in air have much the same effect on lungs as does cigarette smoke. Patients should also consider being vaccinated against diseases that affect the respiratory system, such as influenza (the flu; see influenza entry).

FOR MORE INFORMATION


Books

Adams, Francis V. The Breathing Disorders Sourcebook. Los Angeles: Lowell House, 1998.

Haas, Francois, and Sheila Sperber Haas. The Chronic Bronchitis and Emphysema Handbook. New York: John Wiley & Sons, 1990.

Ries, Andrew L., ed. Shortness of Breath: A Guide to Better Living and Breathing, 5th edition. St. Louis, MO: Mosby-Year Book, 1995.

Organizations

American Lung Association. (800) LUNGUSA (8005864872). http://www.lungusa.org.

National Heart, Lung, and Blood Institute. Building 31, Room 4A21, Bethesda, MD 20892. (301) 4964326. http://www.nhlbi.nih.gov.

The National Lung Health Education Program and the National Emphysema Foundation. http://www.emphysemafoundation.org.

Web sites

IVI Publishing Healthnet. "Emphysema." [Online] http://www.healthnet.ivi.com/bh/cond/ailments/htm/emphysema.htm (accessed on October 25, 1999).

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Emphysema

Emphysema

What Is Emphysema?

Who Gets Emphysema?

What Are the Symptoms of Emphysema?

How Is Emphysema Diagnosed and Treated?

How Can Emphysema Be Prevented?

Resources

Emphysema (em-fe-ZEE-ma) is a lung disease in which the alveoli (al-VEE-o-ly), tiny air sacs in the lungs, lose elasticity\ causing difficulty in breathing.

KEYWORDS

for searching the Internet and other reference sources

Alveoli

Chronic obstructive pulmonary disease

What Is Emphysema?

Air reaches the lungs through a series of ever-smaller tubes. First air passes through the trachea (TRAY-kee-a), which is the large windpipe from the throat down the neck. Then the trachea branches into smaller tubes called the bronchi (BRONG-ky), then into even smaller bronchi called bronchioles (BRONG-kee-olz) that branch still further deep into the lungs. The bronchioles end in tiny air sacs called alveoli. It is in the alveoli that the transfer of oxygen into the bloodstream and of carbon dioxide out of the bloodstream occurs.

In emphysema, the bronchi and bronchioles are inflamed and continually swollen and clogged. This causes the alveoli to swell. These fragile air sacs burst and merge together. This damage to the alveoli makes it more difficult for the transfer of oxygen and carbon dioxide to take place.

People with emphysema have difficulty breathing. It is usually caused by cigarette smoking, or a severe form of bronchitis called chronic obstructive bronchitis. Very often, a combination of these factors produces emphysema.

Because severe bronchitis, smoking, and emphysema are closely interrelated, physicians often refer to a combined disorder known as chronic obstructive lung disease (COLD), or chronic obstructive pulmonary (PULL-mo-nar-ee) disease (COPD).

Who Gets Emphysema?

Both emphysema and COPD are very rare in young people, but the incidence* steadily increases as people grow older, particularly during or

* incidence
means rate of occurrence.

300 Years Ago: No Smoking Please

Sir John Floyer (1649-1735), an English physician who had asthma, first described emphysema in the seventeenth century. Floyer was studying pulmonary (lung) disorders and described the characteristic prolonged expiration and progressive nature of emphysema.

Floyer warned his patients to avoid tobacco smoke, metallic fumes, and other potential irritants because he believed that they caused pulmonary disorders. He was right.

after middle age. This is believed to be due in large part to the cumulative effect of smoking on the lungs. One person cannot catch it from another. Emphysema is more common in men than it is in women, probably because more men smoke cigarettes than women. However, it is believed that this difference will become smaller because more teenage girls and young women are smoking cigarettes today than years ago. Heavier smoking among men over the past several decades is believed to account for the present imbalance in numbers.

In the United States, more than 2 million people have emphysema, making it a common disorder. More than 6 million people suffer from COPD. About 6 or 7 people per 100,000 die from emphysema each year, and COPD is the fourth most common cause of death in the United States. The incidence of emphysema is even higher in European countries.

Effects of Smoking and Other Causes

The great majority of emphysema cases are associated with cigarette smoking. It has been found that people who are heavy smokers of cigarettes are 10 to 15 times more likely to develop emphysema than are nonsmokers.

Additional factors may contribute to emphysema or be directly responsible for it. For example, if someone develops emphysema early in adult life, usually it is due to a rare genetic deficiency of a chemical that helps to maintain elasticity* in the lungs. Environmental air pollution also may make a person more likely to develop chronic bronchitis and emphysema. With on-the-job exposure to mineral dusts, such as coal dust in a mine, emphysema may occur as part of a disease known as pneumoconiosis (noo-mo-ko-nee-O-sis).

* elasticity
is the ability to be stretched and to return to original shape.

Emphysema also may accompany diseases such as asthma and tuberculosis that can obstruct the airways in the lungs. A less serious form of emphysema sometimes develops in elderly people whose lungs have lost elasticity only as a part of the aging process. Another usually mild form, called compensatory emphysema, results when a lung overexpands to occupy the space of another lung that has collapsed or has been removed surgically.

A Close-Up Look at the Alveoli

Understanding the alveoli, and the airways in the lungs that lead to them, is key to understanding emphysema. These tiny sacs or pockets are grouped in grapelike clusters and are so small that each lung contains 300 to 400 million of them. Because there are so many alveoli, their total surface area is about 50 times greater than the entire surface area of the skin on the body. This huge surface area is important because it allows oxygen from the air we inhale to be transferred to the bloodstream, and it allows carbon dioxide in the bloodstream to be transferred out.

Why Do We Breathe?

All living things need energy for their life processes, such as growth and reproduction. Plants get energy from the sun, whereas animals get it from food (plants and other animals). Because humans are animals, we might think we could get energy just by eating food, but this only gets the food to our stomachs; it does not get it to all the cells of our bodies, where it is needed. For this purpose, our digestive systems break down the food into sugar, fats, and proteins, and our circulatory systems carry it to our cells as food energy in this form.

This is still not enough to help our cells, however. The cells need to have oxygen from the blood to be able to carry out chemical reactions to release the energy from the food we eat. We breathe in so that our lungs can transfer oxygen to the bloodstream for delivery to our cells. We breathe out to carry away carbon dioxide, a waste product of the chemical reactions in our cells, that is returned in the bloodstream.

Inhaled air reaches the alveoli through bronchial tubes and repeatedly branching smaller bronchioles in the lungs that resemble an upside-down tree. The walls of the alveoli contain tiny blood vessels called capillaries, which lead to larger vessels that return blood to the heart to be pumped throughout the body. It is in the delicate capillaries of the alveoli that the transfer of oxygen and carbon dioxide takes place.

What Changes Occur in the Lungs from Emphysema?

In emphysema, tobacco smoke and other inhaled irritants damage the alveoli, causing them to lose elasticity. Moreover, smoking often causes chronic bronchitis, which tends to narrow and obstruct the bronchial airways with mucus, scarring, and muscle spasms in the walls of the bronchial tubes. As a result, air becomes trapped in the alveoli, stretching their walls and causing some to break down and form larger pockets by joining with other alveoli. As the lungs become less elastic, they tend to become distended, or overinflated.

What Are the Symptoms of Emphysema?

The main symptom of emphysema is shortness of breath. The decrease in lung elasticity, the trapping of air in the lungs, and the loss of alveolar surface area means that the person must breathe harder to force carbon dioxide out of the lungs and draw in oxygen. A common outward sign of emphysema is a barrel-shaped chest caused by overinflation of the lungs.

Dr. E. Walker/ Science Photo Library, Photo Researchers, Inc.

As emphysema progresses, some people compensate by breathing faster. Others develop a condition known as cor pulmonale (KOR pul-mo-NAL-ee), in which the right side of the heart becomes enlarged because of the difficulty it has pumping blood through the damaged lungs.

How Is Emphysema Diagnosed and Treated?

A doctor can diagnose emphysema from a physical exam, symptoms, and a chest x-ray, which may show such signs as overinflation of the lungs and other changes. A lung function test can detect reduced ability to exhale fully. Blood tests can measure the concentrations of oxygen and carbon dioxide in the blood. Blood levels of carbon dioxide tend to rise in patients with emphysema, and blood levels of oxygen tend to fall.

Currently no form of treatment can reverse emphysema, but measures can be taken to control the disease and its symptoms. The person must stop smoking permanently. Antibiotics may be used to treat and prevent respiratory infections. Other medicines can be taken to widen the airways and relax spasms in their walls. Special breathing exercises often are helpful, and breathing equipment that delivers extra oxygen and medications may be provided for home use.

How Can Emphysema Be Prevented?

Because the damage that emphysema does to the lungs cannot be undone, it is especially important to try to prevent this disease from developing in the first place. Adopting healthy habits early in lifeespecially not smokingis very important. It can prevent health problems later on that include not only emphysema, but lung cancer, heart disease, and other disorders as well.

See also

Bronchitis

Pneumoconiosis

Asthma

Tuberculosis

Resources

Haas, Francois, and Sheila Sperber Haas. The Chronic Bronchitis and Emphysema Handbook. New York: John Wiley and Sons, 1990. This is a well-written and well-illustrated source.

Adams, Francis V. The Breathing Disorders Sourcebook. Los Angeles: Lowell House, 1998. This book has more information on lung conditions, including a chapter on emphysema, and lists many helpful local and regional organizations.

The American Lung Associations national office is located at 1740 Broadway, New York, NY 10019. Call them at 212-315-8700 or

locate a local office by calling 1-800-LUNG-USA (586-4872). The Associations website includes valuable information about lung diseases and tobacco control. Material is available in English and in Spanish. http://www.lungusa.org.

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emphysema

emphysema (em-fi-see-mă) n. air in the tissues. pulmonary e. emphysema in which the alveoli of the lungs are enlarged and damaged, which reduces the surface area for the exchange of oxygen and carbon dioxide. Severe emphysema causes breathlessness, which is made worse by infections. surgical e. emphysema in which air escapes into surrounding tissues through wounds or surgical incisions, usually into the tissues of the chest and neck from leaks in the lungs or oesophagus. Bacteria may form gas in soft tissues.

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emphysema

em·phy·se·ma / ˌemfəˈsēmə; -ˈzēmə/ • n. Med. 1. (also pulmonary emphysema) a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness. 2. a condition in which air is abnormally present within the body tissues. DERIVATIVES: em·phy·sem·a·tous / ˌemfəˈsemətəs/ adj. em·phy·se·mic adj.

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emphysema

emphysema Accumulation of air in tissues, most often occurring in the lungs (pulmonary emphysema). Pulmonary emphysema, characterized by marked breathlessness, is the result of damage to and enlargement of the alveolus. It is associated with chronic bronchitis and smoking.

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emphysema

emphysemabeamer, blasphemer, Colima, creamer, dreamer, emphysema, femur, Iwo Jima, Kagoshima, lemur, Lima, oedema (US edema), ottava rima, Pima, reamer, redeemer, schema, schemer, screamer, seamer, Selima, steamer, streamer, terza rima, Tsushima •daydreamer •dimmer, glimmer, limber, limner, shimmer, simmer, skimmer, slimmer, strimmer, swimmer, trimmer, zimmer •enigma, sigma, stigma •Wilma, Wilmer •charisma • Gordimer • polymer •ulema • anima • enema •cinema, minima •maxima • Bessemer • eczema •dulcimer • Hiroshima •Fatima, Latimer •optima • Mortimer • anathema •climber, Jemima, mimer, old-timer, part-timer, primer, rhymer, timer •Oppenheimer • two-timer •bomber, comma, momma, prommer •dogma • dolma

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