What are the treatment options for emphysema?

Treatment Options for Emphysema

The cornerstone of emphysema treatment is long-acting bronchodilator therapy, with LABA/LAMA combination as first-line for symptomatic patients with high exacerbation risk, alongside mandatory smoking cessation and pulmonary rehabilitation. 1, 2

Smoking Cessation (Most Critical Intervention)

• Smoking cessation is the single most important intervention that modifies disease progression and improves survival 2
• Combination pharmacotherapy with behavioral support achieves up to 25% long-term success rates 2
• Nicotine replacement therapy significantly increases abstinence rates compared to placebo 2

Pharmacologic Bronchodilator Therapy

Initial Treatment Selection Based on Symptom Burden

For patients with high symptom burden and frequent exacerbations (Group D):

• Initiate LABA/LAMA combination therapy as first-line treatment 1, 2
• LABA/LAMA is superior to LABA/ICS for preventing exacerbations and improving patient-reported outcomes 1
• LABA/LAMA reduces pneumonia risk compared to ICS-containing regimens 1

For patients with high symptoms but low exacerbation risk (Group B):

• Start with a single long-acting bronchodilator (LABA or LAMA) 1, 2
• Escalate to dual LABA/LAMA therapy if breathlessness persists on monotherapy 1, 2
• For severe breathlessness, consider initiating dual bronchodilators immediately 1

Specific Bronchodilator Options

• Long-acting muscarinic antagonists (LAMAs): Tiotropium bromide 18 mcg once daily via inhalation is FDA-approved for maintenance treatment of emphysema 3
• Long-acting beta-agonists (LABAs): Used in combination with LAMAs for dual bronchodilation 1
• Short-acting bronchodilators taken intermittently are inferior to long-acting agents 1

When to Add Inhaled Corticosteroids (ICS)

ICS should only be used in combination with long-acting bronchodilators, never as monotherapy 2

Consider LABA/ICS as initial therapy for patients with:

• History or findings suggestive of asthma-COPD overlap 1
• High blood eosinophil counts 1

Critical caveat: ICS increases pneumonia risk, making LABA/LAMA the preferred primary choice for most emphysema patients 1

Escalation for Persistent Exacerbations

If exacerbations continue on LABA/LAMA:

• Escalate to triple therapy (LABA/LAMA/ICS) 1
• Alternative: Switch to LABA/ICS, then add LAMA if inadequate response 1

If still experiencing exacerbations on triple therapy:

• Add roflumilast for patients with FEV₁ <50% predicted and chronic bronchitis, particularly with recent hospitalization 1
• Add macrolide antibiotic in former smokers (monitor for resistant organisms) 1
• Consider stopping ICS due to elevated adverse effect risk without significant harm from withdrawal 1

Vaccination

• Influenza vaccination reduces serious illness, death, and exacerbation frequency 2
• Pneumococcal vaccines recommended for all patients ≥65 years and younger patients with significant comorbidities 2

Pulmonary Rehabilitation

• Pulmonary rehabilitation improves endurance, reduces dyspnea, and reduces hospitalizations 1
• Should be implemented for all symptomatic patients (Groups B, C, and D) 1, 2
• Combines cardiovascular fitness development, self-confidence building, and stress control 1
• Training effect diminishes over time after program completion, requiring ongoing maintenance 1

Oxygen Therapy

• Long-term oxygen therapy indicated for PaO₂ ≤55 mmHg or SaO₂ ≤88% confirmed twice over 3 weeks 4, 2
• Supplemental oxygen during exercise increases exercise capacity in patients who desaturate 1

Alpha-1 Antitrypsin Augmentation Therapy

• Indicated specifically for patients with severe hereditary alpha-1 antitrypsin deficiency and established emphysema 1, 2
• Intravenous human plasma-derived AAT at 60 mg/kg body weight once weekly 1
• FDA-approved since 1988 for this specific population 1
• Not applicable to typical smoking-related emphysema 1

Symptomatic Management

For Severe Dyspnea

• Low-dose long-acting oral or parenteral opioids may be considered for treating dyspnea in severe disease 1, 2

For Depression and Anxiety

• Selective serotonin reuptake inhibitors (SSRIs) are effective for both depression and anxiety disorders common in emphysema patients 1
• Short-acting benzodiazepines or buspirone for panic disorder 1

For Infections

• Aggressive antibiotic treatment for bronchitis or upper respiratory infections 1
• Macrolides may reduce neutrophil inflammation 1

Nutritional Support

• Screen for malnutrition using BMI and weight change (underweight defined as BMI <21 kg/m² for age >50 years) 1
• Smaller, more frequent meals may reduce dyspnea by reducing abdominal bloating 1
• Intensive nutritional support alone has limited success; combine with exercise or anabolic stimuli 1

Surgical and Interventional Options

Lung Volume Reduction Surgery (LVRS)

• Benefits select patients with non-homogeneous upper lobe emphysema and limited post-rehabilitation exercise capacity 1
• Improves mortality, exercise capacity, and health status in this specific subgroup 1
• Contraindicated in patients with homogeneous emphysema and good exercise capacity (higher mortality risk) 1

Bullectomy

• Indicated for large isolated bullae 4
• Video-assisted thoracoscopic surgery (VATS) is safe and effective 4

Lung Transplantation

• Improves pulmonary function, exercise capacity, and quality of life 1
• Effects on survival remain controversial 1

Treatments NOT Recommended

• Antitussives cannot be recommended 1
• Drugs approved for primary pulmonary hypertension are not recommended for pulmonary hypertension secondary to emphysema 1
• Antioxidant mucolytics recommended only in selected patients 1
• Prophylactic antibiotics not recommended for exacerbation prevention 1