Management of Paraseptal Emphysema
Paraseptal emphysema requires surgical intervention when it leads to pneumothorax or large bullae, while milder forms are managed with standard COPD treatments including smoking cessation, bronchodilators, and prevention of exacerbations.
Understanding Paraseptal Emphysema
Paraseptal emphysema is a distinct form of emphysema characterized by:
- Destruction of alveolar tissue adjacent to connective tissue septa and subpleural regions 1
- Often clinically silent until complications develop 2
- Frequently leads to blebs on the lung surface that predispose to pneumothorax or giant bullae 1
- May coexist with other forms of emphysema (centriacinar or panacinar)
Diagnosis
Paraseptal emphysema is often diagnosed incidentally or following complications:
- Chest radiography has poor sensitivity and specificity 2
- CT scanning is the diagnostic method of choice, showing characteristic subpleural distribution along interlobular septa 2
- Pulmonary function tests may be normal or show simple bronchial obstruction 2
Management Algorithm
1. Risk Factor Modification
- Smoking cessation is essential as the primary intervention for all patients with paraseptal emphysema 1
- Reduce exposure to occupational dusts, fumes, gases, and indoor/outdoor air pollutants 1
2. Pharmacologic Management
Follow standard COPD treatment principles based on symptom severity and exacerbation risk:
- Bronchodilators (short or long-acting) to reduce breathlessness 1
- Consider combination therapy with long-acting bronchodilators if symptoms persist
- Anti-inflammatory agents may be added based on exacerbation history
3. Surgical Management for Complications
Surgical intervention is indicated in specific scenarios:
Bullectomy
- Indicated for patients with relatively preserved underlying lung function who have large bullae 1
- Associated with decreased dyspnea and improved lung function and exercise tolerance 1
Management of Pneumothorax
- Paraseptal emphysema is a common cause of spontaneous pneumothorax 1, 2
- Treatment follows standard pneumothorax management protocols
Lung Volume Reduction Surgery (LVRS)
- Consider for selected patients with heterogeneous emphysema distribution
- Contraindicated in patients with FEV1 ≤20% predicted and either homogeneous emphysema or DLCO ≤20% predicted 1
Bronchoscopic Interventions
- Newer, less-invasive approaches for lung reduction may be considered in selected patients 1
- Options include endobronchial valves or nitinol coils, which have shown improvements in exercise capacity and lung function 1
4. Supportive Care
- Pulmonary rehabilitation to improve exercise capacity and quality of life
- Vaccination against influenza and pneumococcal disease
- Oxygen therapy if hypoxemic
- Education on disease management and early recognition of exacerbations
Special Considerations
- Paraseptal emphysema adjacent to the trachea (paratracheal paraseptal emphysema) is associated with expiratory central airway collapse 3
- Young patients with paraseptal emphysema should be monitored for pneumothorax risk
- Paraseptal emphysema can occasionally be seen in non-smokers, including those with COVID-19 4
Monitoring
- Regular follow-up with spirometry to assess disease progression
- CT imaging if new symptoms develop or complications are suspected
- Assessment for development of bullae or pneumothorax in patients with extensive paraseptal changes
The management approach should be tailored based on the extent of paraseptal emphysema, presence of other forms of emphysema, overall lung function, and development of complications such as bullae or pneumothorax.