Emphysema is a lung disease where the air sacs (alveoli) are progressively destroyed, resulting in fewer and larger air spaces. The main causes are smoking and genetic conditions. In emphysema, elastic fibers and alveolar walls are broken down due to an imbalance between proteases from inflammatory cells and their inhibitors like alpha-1 antitrypsin. Symptoms include shortness of breath, cough, and fatigue. Diagnosis involves pulmonary function tests, chest imaging, and blood tests. Treatment focuses on bronchodilators, supplemental oxygen, and reducing risk factors.

1. EMPHYSEMA

2. ANATOMY OF EMPHYSEMA
 Emphysema is a lung disease involving damage to the air sacs
(alveoli).There is progressive destruction of alveoli and the surrounding
tissue that supports the alveoli. With more advanced disease, large air cysts
develop where normal lung tissue used to be. Air is trapped in the lungs due
to lack of supportive tissue which decreases oxygenation.

3. DEFINITION
Emphysema is a long-term, progressive disease of the
lung(s) and occurs when the alveolar walls are
destroyed along with the capillary blood vessels that
run within them. This lessens the total area within the
lung where blood and air can come together, limiting the
potential for oxygen and carbon dioxide transfer.
In early emphysema, there is associated inflammation of
the small airways or bronchioles that limits the amount
of air that can flow to the alveoli. In more severe
emphysema, there is also loss of elasticity in the alveolar
walls that have not been destroyed. When the patient
breathes out, the alveoli and small airways collapse. This
makes it hard for air to get out of the lungs and makes it
even harder for new air to enter.

4. ETIOLOGY
The main cause of emphysema is smoking, which
activates inflammatory cells in the lung. This
inflammation causes; 1) swelling within the bronchioles,
and 2) activation of enzymes called proteases which
attack and destroy lung tissue (the alveolar wall
structures).
There is a genetic predisposition to emphysema. The
relatively rare condition known as alpha 1-antitrypsin
deficiency is the genetic deficiency of a chemical that
protects the lung from damage by proteases.
Emphysema is also a component of aging. As the lungs
get older, the elastic properties decrease, and the
tensions that develop can result in small areas of
emphysema.

5. PATHOPHYSIOLOGY
Emphysema is characterized by abnormal
permanent enlargement of the airspaces distal to the
terminal bronchioles, accompanied by destruction of
their walls without obvious fibrosis.
There are 4 types of emphysema:
- centriacinar
- panacinar
- distal acinar
- irregular

6. 1) Centriacinar emphysema
- The central parts of acini, formed by
respiratory bronchioles are affected while distal
alveoli are spared.
- In severe centracinar emphysema, distal acinus
also become involved.
- This emphysema is consequence of cigarette
smoking in people who do not have congenital
deficiency of alfa-one antitrypsin.

8. 2) Panacinar emphysema
- Acini are uniformly enlarged from the level of
respiratory bronchiole to the terminal blind alveoli
- More commonly occur in lower lung zone.
- Occurs in people with alpha-one antitrypsin
deficiency.

10. 3) Distal acinar emphysema
- Proximal portion of acinus is normal but the
distal part is primarily involved.
- The emphysema is more striking adjacent to the
pleura, along the lobular connective tissue septa,
and at margins of lobules.
- the characteristic findings are the presence of
multiple, continuous, enlarged airspace that range
in diameter from less than 0.5mm to more than
2.0cm, sometimes forming cystlike structure called
bullae.

12. IRREGULAR EMPHYSEMA
4) Irregular emphysema
- acinus is irregularly involved

13. PATHOGENESIS
Protease-antiprotease imbalance favors emphysema.
Patient with genetic deficiency of antiprotease alpha-
one antitrypsin have tendency to develop pulmonary
emphysema and is compounded by smoking.
Alpha-one antitrypsin is normally present in serum,
tissue fluids and macrophage which is major
inhibitor of protease ( elastase ) secreted by
neutrophils during inflammation.
Most people develop symptomatic emphysema
which occurs at an earlier age and with greater
severity if individuals smoke.

14. The following sequence is postulated:
1. Neutrophils which is source of elastase normally
sequestered in peripheral capillaries, including
those in lung, and few gain access to alveolar space.
2. Any stimulus that increase either the number of
leucocytes in the lung wil increase elastase and
increase proteolytic activity.
3. With low level of serum alpha-one antitrypsin,
elastic tissue destruction is unchecked and
emphysema results.

15. This imbalance also help explains the effect of
cigarette smoking in development of emphysema,
particularly centriacinar form in subjects with
normal amount of alpha-one antitrypsin.
This is because in smokers, neutrophils and
macrophages accumulate in alveoli nicotine
stimulate reactive oxygen species to attract and
activate more neutrophils elastase
increasealveoli destruction emphysema

17. SIGNS AND SYMPTOMS
A person with emphysema will have shortness of
breath -- during physical activity and when the
condition is more advanced, also during rest.
Patients may eventually need supplemental oxygen
and may have to rely on mechanical respiratory
devices.
Other symptoms of emphysema include chronic
cough, frequent respiratory infections, reduced
appetite, weight loss and fatigue.


18. RISK FACTOR
Smoking
Genetic deficiency of alpha-one antitrypsin
Age

19. INVESTIGATION
 Oximetry
 Oxygenated blood is a brighter red and becomes purpler in
color when oxygen is removed. The oximeter is a device
usually placed on a finger and detects the pulse of blood. A
light is transmitted through the tissue, and the amount of
the brighter red color is determined, enabling a measure of
oxygen saturation, a measure of hemoglobin oxygen
content. This value is usually greater than 90%.

21. Radiology
A plain chest x-ray may show lungs that have
become too inflated and too lucent, signs that lung
tissue destruction has occurred.
Pulmonary Function Tests
A variety of lung functions can be measured and
may include how much air the lungs can hold and
empty with each breath, the degree of airflow
obstruction, the available surface for exchange of
carbon dioxide and oxygen, the amount of trapped
gases, and how elastic the lungs are with
inspiration and expiration.

23. Blood Tests
A complete blood cell count (CBC) may be
performed to check for an increase in the number
of red blood cells. In response to lower blood
oxygen concentrations, the body manufactures
more red blood cells to try to deliver as much
oxygen as possible to cells.
An arterial blood gas ( ABGs ) test will measure the
amount of oxygen and carbon dioxide in the blood

24. TREATMENT
Bronchodilators
Bronchodilators are used to relax the smooth
muscles that surround the bronchioles and allow the
breathing tubes to dilate and allow more air flow.
These medications can be inhaled using nebulizer
machine These medications can either be short or
long acting.
The bronchodilators include the albuterol agents
(Ventolin HFA, Proventil HFA, and Pro Air) and the
anticholinergic agent, ipratropium bromide
(Atrovent).

26. - Tablets and Extended-Release Tablet : Relief of
bronchospasm in adults and children 6 years and
older with reversible obstructive airway disease.

27. ADMINISTRATION
Aerosol and inhalation powder are indicated for children
4 years and older, solution for inhalation for children 2
years and older.
Nebulization ( facemask or mouth piece ). Use
compressed air or oxygen with gas flow of 6-10 L/min ,
single treatment last for 5 to 15 minutes.
Children maintained on the tablets or syrup may be
switched to extended-release tablet. ( eg. One 4mg
extended-release tablet q 12 hrs is comparable to one
2mg tablet q 6 hrs. )
Take extended-released tablet whole with aid of liquids:
do not chew or crush. The outer coating of extended-
release tablet will be excreted out in feces.

28. ACTION KINECTIC
Stimulates beta-2 receptors of bronchi, leading to
bronchodilation. Causes less tachycardia and is
longer-acting.

29. DOSAGE
Inhalation aerosol
Bronchodilation
Adults and children over 4 years of age :
180 ( 2 inhalation ) q 4-6 hrs.
Maintainence : 180 mcg ( 2 inhalation ) 4 times
per day.
Prophylaxis of exercise-induced
bronchospasm
Adults and children over 4 years of age:
180 mcg ( 2 inhalation ) 15 min before exercise

30. Inhalation solution
Bronchodilation
Adult and children over 12 years of age:
2.5 mg 3-4 times per day by nebulization ( dilute
0.5 mL of the 0.5% solution with 2.5mL sterile
NNS and deliver over 5-15 min )
Children 2-12 years of age :
2.5mg 3-4 times per day by nebulization.

31. Syrup
Bronchodilation
Adults and children over 14 years of age,
usual
Initial:
- 2-4 mg ( 5-10 mL ) 3-4 times per day, up to
maximum of 8mg 4 times per day.
Children over 6-12 years initial:
- 0.1 mg/kg 3 times per day, not to exceed 2mg
3 times per day

32. Tablets
Bronchodilation
Adults and children over 12 years of age,
initial:
- 2 or 4 mg 3-4 times per day, then increase dose
needed up to maximum of 8 mg 4 times per day, as
tolerated.
Children 6-12 years of age, usual, initial :
- 2 mg 3-4 times per day, then if necessary increase
the dose in the stepwise fashion to a maximum if
24 mg/day in divided dose.

33. SIDE EFFECTS
 Most common
- headache, palpitations/ tachycardia, tremor, bronchospasm.
 GIT
- diarrhea, dry mouth, appetite loss, epigastric pain
 CNS
- excitement, nervousness, tension, tremor, dizziness, weakness,
drowsiness, restlessness, headache, insomnia, ,malaise, fatique,
lightheadedness, aggressive behavior.
 Respiratory
- Cough, wheezing, dyspnea, bronchospasm, dry throat, throat
irritation, bronchitis
 CVS
- Palpitations, tachycardia, BP changes, hypertension, tight chest,
chest pain.

34. IPRATROPIUM BROMIDE
USES
- Treatment of COPD ( including bronchospasm ) in
those who are on regular aerosol bronchodilators
theraphy and who inquire a second bronchodilators
Action kinetics :
- Ipratropium is an antocholinergic drug that acts to
inhibit the effect of acetylcholine following vagal
berve stimulation. This result in bronchodilation
which is primarilly a local, site- specific effect.

35. DOSAGE
Aerosol
COPD
- 2 inhalations q 6 hours not to exceed 12
inhalations/24 hr
 Inhalation solution
COPD
- One 3-ml vial given 4 times per day via nebulization
with up to 2 additional 3mL doses daily, if needed.

36. SIDE EFFECT
Most common:
- Bronchitis, URTI, headache, pain, dyspnea,
coughing, nausea, pharyngitis, sinusitis.

37. Antibiotics
Since patients with emphysema are at risk for
infections like pneumonia, antibiotics may be
prescribed when the usually clear sputum changes
color, or when the patient presents with systemic
signs of an infection (fever, chills, weakness).

38. Oxygen
As the disease progresses, patients may require
supplemental oxygen to be able to function. Often it
begins with nighttime use, then with exercise, and as
the disease worsens, the need to use oxygen during
the day for routine activities increases.

39. COMPLICATION
 People with emphysema have a higher mortality than those
with normal lung function. Causes of death include
respiratory failure, lung infections such as pneumonia and
influenza, and other diseases related to smoking. These
include cancer, heart disease, and stroke. Eventually, severe
shortness of breath will limit the person's normal daily
activities.
 Emphysema patients are at increased risk of contracting
recurrent respiratory infections and lung cancer, and are at
high risk for respiratory and coronary failure. Enlargement
and strain on the right side of the heart. (Emphysema makes
the heart work harder to keep the lungs supplied with blood
because of damage to the lungs' circulatory system and other
tissue damage.)

40. NURSING INTERVENTIONS
1. Nursing diagnosis
- Difficulty in breathing in related to compressed lung.
Objective
- Ensure that patient can breath better during the time of
admission in ward.
Intervention
- Position patient in Semi-Fowler’s position so that patient’s lung
can expand better as abdominal pressure decrease and patient can
breath better and more comfortable.
- Assess patients appearance whether there is any blueish as this
indicate that patient is not receiving adequate oxygen into the
body.
- Assess the patients vital sign 4 hourly especially SPO2, breathing
pattern, respiratory rate to detect whether patient is receiving
enough oxygen into the body.

41. - Auscultate lungs and document significant
change in breath sound to indicate any
abnormality in lung such as presence of mucus so
that early intervention can be carry out.
- Monitor’s ABGs of patient so that PaCO2 and
PaO2 in body of patient so that any abnormality
is detected.
-Give oxygen supply to patient such as nasal
prong so that patient can receive more oxygen
and cells in body can get enough oxygen.
- Give patient bronchodilater so that airway is
open and can breath more easily.

42. 2) Nursing diagnosis
- Weight loss in related to loss of appetite
Objective
- Ensure that patient’s body weight is maintain during times in ward.
Nursing intervention
- Assess body weight of patient once a week to indicate any changes in
weight so that further interventions can be carry out.
- Give patient’s favourite food so that patient have appetite to eat.
- Encourage patient’s family member to bring food from house so that
patient has more appetite to eat.
- Encourage patient to eat more frequent and less amount at the same time.
- Make sure that environment is clean when feeding patient.
- Encourage family member to bring utensils from home so that patient can
eat comfortably.
- Encourage patient’s family member to encourage patient to eat more
because encourages from family members is most effective.
- Explain the purpose of eating food so that patient can recover faster as food
contains protein and vitamins that needed for better recovery.

43. HEALTH EDUCATION
Encourage patient to reduce smoking so that
nicotine will not further damage the alveoli and
reduce severity of emphysema.
Encourage patient to perform deep breathing so that
lung exercise is perform and lung can recover faster.
Encourage patient’s family member to buy SMI for
patient so that patient can perform lung exercise.