What are the guidelines for treating emphysema?

Guidelines for Treatment of Emphysema

The single most important intervention for treating emphysema is smoking cessation, which can slow disease progression and improve outcomes. 1

Diagnosis and Classification

• Emphysema is characterized by permanent destructive enlargement of air spaces distal to terminal bronchioles 1
• Different types include centriacinar (most common in smokers), panacinar, and paraseptal emphysema 2
• Diagnosis requires objective measurement of airflow obstruction, with the key feature being inability to fully reverse this limitation 1
• High-resolution CT scanning can effectively diagnose emphysema patterns 2

First-Line Interventions

Smoking Cessation

• Must be the highest priority intervention for all patients with emphysema 1, 3
• Smoking cessation can slow the accelerated decline in lung function 1
• Early identification and intervention can prevent or even reverse disease progression 4

Bronchodilator Therapy

• Add or increase bronchodilators for symptom management 1
• Beta-agonists and/or anticholinergic drugs should be used for airflow obstruction 1
• Inhaled route is preferable, ensuring patients can use devices effectively 1
• For patients with combined pulmonary fibrosis and emphysema, inhaled bronchodilators should be used if airflow obstruction is present 1

Additional Pharmacological Management

Corticosteroids

• Oral corticosteroids may be prescribed during acute exacerbations 1
• Should not be used for acute exacerbations in the community unless:
  • Patient is already on oral corticosteroids
  • There is a previously documented response
  • Airflow obstruction fails to respond to increased bronchodilator dose
  • First presentation of airflow obstruction 1
• Typical dosage is 30 mg per day for one week during exacerbations 1

Antibiotics

• Indicated during acute exacerbations if two or more of the following are present:
  • Increased breathlessness
  • Increased sputum volume
  • Development of purulent sputum 1

Management of Complications

Respiratory Failure and Oxygen Therapy

• Long-term oxygen therapy is the only treatment known to improve prognosis in patients with severe COPD and hypoxemia 1
• Assessment for oxygen therapy should be conducted in a specialist setting 1

Pulmonary Hypertension

• Pulmonary hypertension in COPD is slowly progressive and implies poor prognosis 1
• Particularly frequent in patients with combined pulmonary fibrosis and emphysema 1

Sleep Apnea

• Ventilatory polygraphy should be performed if clinical signs suggest obstructive sleep apnea syndrome 1

Gastroesophageal Reflux

• Gastroesophageal reflux is common in patients with pulmonary fibrosis and emphysema 1
• Should be investigated and managed according to applicable recommendations 1

Specialized Care Considerations

Indications for Specialist Referral

• Suspected severe COPD
• Onset of cor pulmonale
• Assessment for oxygen therapy
• Assessment for nebulizer use
• Bullous lung disease
• Less than 10 pack-years smoking history with symptoms
• Rapid decline in FEV1
• COPD in patients less than 40 years old (to identify alpha-1 antitrypsin deficiency)
• Uncertain diagnosis
• Symptoms disproportionate to lung function
• Frequent infections 1

Hospital Resources

• Districts should have a specified respiratory physician responsible for COPD
• Facilities for spirometric testing should be available
• Specialized respiratory nurses should liaise between hospital and primary care
• Resources for respiratory rehabilitation and oxygen therapy assessment
• Nebulizer services including patient assessment and equipment support 1

Emerging Treatments

• For non-alpha-1 antitrypsin deficiency emphysema, potential therapeutic targets include decelerating proteolysis and restoring damage 5
• Vitamin A/K, hyaluronan, copper, and roflumilast are promising candidates 5

Monitoring Disease Progression

• Presence of emphysema at baseline is strongly associated with emphysema progression 6
• In patients without emphysema, functional small airway disease is associated with development of emphysema 6
• Emphysema progression can occur independently of FEV1 decline in patients without spirometric COPD 6

Critical Care Considerations

• Challenges in critical care include dynamic hyperinflation, Auto-PEEP, malnutrition, and weaning from mechanical ventilation 7
• Sufficient high dependency and intensive care facilities should be available for managing patients with respiratory failure 1