What is the treatment for chronic emphysema?

Treatment of Chronic Emphysema

Smoking cessation is the single most critical intervention that modifies disease progression and should be aggressively pursued with combination pharmacotherapy (varenicline or bupropion) plus behavioral counseling, as this is the only measure proven to slow the accelerated decline in lung function. 1

Risk Factor Reduction and Prevention

• Smoking cessation must be continuously encouraged with a structured five-step intervention program combining pharmacotherapy and behavioral support, achieving long-term quit rates up to 25% 1
• Varenicline, bupropion, and nortriptyline increase long-term quit rates and should be used as part of an intervention program rather than alone 1
• Nicotine replacement therapy increases abstinence rates, though e-cigarette efficacy remains controversial 1
• Reduce exposure to occupational dusts, fumes, gases, and indoor/outdoor air pollutants 1

Vaccination

• Influenza vaccination annually reduces serious illness, death, and exacerbations 1
• Pneumococcal vaccinations (PCV13 and PPSV23) are recommended for all patients ≥65 years and younger patients with significant comorbidities 1

Pharmacologic Therapy

Bronchodilators are the cornerstone of pharmacologic management and reduce symptoms, exacerbation frequency, and improve health status and exercise tolerance. 1

• Treatment selection depends on symptom severity, exacerbation risk, side effects, comorbidities, drug availability, and patient response 1
• Long-acting bronchodilators (LABAs and LAMAs) are preferred over short-acting agents 1
• Inhaler technique must be assessed regularly, as poor technique correlates with worse symptom control; older age, multiple devices, and lack of education predict poor technique 1
• The "teach-back" approach improves inhalation technique 1

Specific Pharmacologic Considerations

• Inhaled corticosteroids (ICS) can be combined with bronchodilators for greater efficacy in patients with frequent exacerbations 1
• Alpha-1 antitrypsin augmentation therapy should be considered in deficiency patients, with observational data suggesting reduced spirometric decline and CT evidence of preserved lung tissue 1
• Immunoregulators may decrease exacerbation severity and frequency, though long-term effects are unknown 1
• Simvastatin does not prevent exacerbations in patients without cardiovascular/metabolic indications 1
• Vitamin D supplementation does not reduce exacerbations in unselected patients 1

Pulmonary Rehabilitation

Pulmonary rehabilitation is a comprehensive intervention that significantly improves symptoms, quality of life, physical and emotional participation in daily activities, and reduces readmissions and mortality in patients after recent exacerbation (<4 weeks from hospitalization). 1

• Includes exercise training, education, and self-management interventions aimed at behavior changes 1
• Do not initiate pulmonary rehabilitation before hospital discharge, as this may compromise survival 1
• Exercise training should combine constant load or interval training, strength training, and upper extremity exercises 2

Oxygen Therapy

Long-term oxygen therapy (>15 hours/day) increases survival in patients with severe resting hypoxemia (PaO2 ≤55 mmHg or SaO2 ≤88%, confirmed twice over 3 weeks). 1, 3, 2

• Also indicated if PaO2 55-60 mmHg or SaO2 88% with evidence of pulmonary hypertension, peripheral edema suggesting heart failure, or polycythemia (hematocrit >55%) 3
• Long-term oxygen does NOT prolong survival or provide sustained benefit in patients with stable COPD and only moderate desaturation 1
• Supplemental oxygen increases exercise capacity in those who desaturate during exercise 1

Ventilatory Support

• Noninvasive positive pressure ventilation (NIPPV) may decrease mortality and prevent rehospitalization in patients with severe chronic hypercapnia and history of hospitalization for acute respiratory failure 1, 3
• In patients with both COPD and obstructive sleep apnea, continuous positive airway pressure (CPAP) improves survival and avoids hospitalization 1, 3, 2
• Home NIPPV data remain conflicting for chronic hypercapnic COPD 1

Surgical and Bronchoscopic Interventions

Lung Volume Reduction Surgery (LVRS)

LVRS improves survival in carefully selected patients: those with upper-lobe emphysema and low post-rehabilitation exercise capacity. 1

• In patients with high post-rehabilitation exercise capacity, LVRS improves health status and exercise capacity but not survival 1
• LVRS is contraindicated (higher mortality than medical management) in patients with FEV1 ≤20% predicted AND either homogeneous emphysema on HRCT OR DLCO ≤20% predicted 1

Other Surgical Options

• Bullectomy decreases dyspnea and improves lung function and exercise tolerance in selected patients with relatively preserved underlying lung 1
• Lung transplantation improves health status and functional capacity but does not prolong survival; bilateral transplantation has longer survival than single lung transplantation in patients <60 years 1

Bronchoscopic Interventions

• Endobronchial valve placement shows mixed outcomes depending on emphysema pattern (heterogeneous vs. homogeneous) 1
• Nitinol coils increase 6-minute-walk distance with smaller improvements in FEV1 and quality of life 1
• Bronchial stents are not effective 1
• Lung sealant caused significant morbidity and mortality 1
• Additional data needed to define optimal patient populations and compare long-term durability to LVRS 1

Education and Self-Management

• Education topics include smoking cessation, correct inhaler use, early exacerbation recognition, when to seek help, and advance directives 1
• Self-management interventions with written action plans may reduce respiratory-related and all-cause hospitalizations and improve health status 1
• Caution: some self-management programs may be associated with increased mortality, so generalization to real-life practice remains difficult 1

Palliative Care

• Palliative approaches are effective in controlling symptoms in advanced COPD 1
• Focus on relief of dyspnea, pain, anxiety, depression, fatigue, and poor nutrition 1, 3
• Low-dose long-acting oral and parenteral opioids may be considered for treating dyspnea in severe disease 2

Nutritional Support

• Weight loss and malnutrition are common due to increased work of breathing 1
• Nutritional supplementation is recommended for malnourished patients, though intensive support has been largely unsuccessful in restoring ideal body weight 1, 3, 2
• Smaller, more frequent meals may reduce dyspnea by reducing abdominal bloating 1

Common Pitfalls to Avoid

• Do not prescribe long-term oxygen routinely for patients with only moderate desaturation without severe resting hypoxemia 1
• Do not perform LVRS in high-risk patients (FEV1 ≤20% with homogeneous emphysema or very low DLCO) 1
• Do not start pulmonary rehabilitation before hospital discharge in recently hospitalized patients 1
• Ensure proper inhaler technique education using teach-back method, as poor technique is extremely common 1