What is the recommended management for emphysema?

Management of Emphysema

Primary Intervention: Smoking Cessation

Smoking cessation is the single most critical intervention in emphysema management and must be prioritized at every patient encounter. 1

• Reduction of occupational dust exposure, smoke, gases, and indoor/outdoor air pollutants is also essential 1
• This is the only intervention proven to modify disease progression and should be addressed before or concurrent with all other therapies 1

Pharmacological Management

Bronchodilator Therapy (First-Line)

All patients with emphysema should receive bronchodilator therapy regardless of whether measurable bronchodilation occurs, as these medications reduce symptoms and improve health status. 1

Initial Treatment Selection:

• Mild disease: Start with short-acting β2-agonist (SABA) or short-acting antimuscarinic agent (SAMA) 2
• More symptomatic patients: Use long-acting β2-agonist (LABA) or long-acting antimuscarinic agent (LAMA) as preferred treatment 2
• Highly symptomatic or frequent exacerbators: Consider LABA + LAMA combination 2

Specific Considerations:

• Patients with airway eosinophilia demonstrate better bronchodilator response to β2-agonists 1
• Bronchodilators improve exercise tolerance even without measurable spirometric improvement 2
• Use bronchodilators if airflow obstruction is present on testing 2, 1

Corticosteroid Therapy

• Oral corticosteroids are useful only in patients with a clear asthma component (asthma-COPD overlap) 1
• Use cautiously long-term due to bone loss effects, which contributes to lung volume loss and spinal pain-related disability 1
• Inhaled corticosteroid (ICS) + LABA combinations should be considered for frequent exacerbators 2

Antibiotic Therapy

• Use antibiotics only when there is evidence of bronchitis or upper respiratory tract infection 1
• Not recommended for routine prophylaxis 1

Oxygen Therapy

Long-term oxygen therapy (LTOT) >15 hours/day improves survival in patients with resting severe hypoxemia. 1

Indications for LTOT:

• PaO2 ≤55 mmHg or SaO2 ≤88% confirmed twice over 3 weeks 3
• Desaturation during exercise may warrant supplemental oxygen during activity 1

Important Caveat:

• LTOT does NOT prolong time to death or first hospitalization in stable COPD patients with only moderate arterial oxygen desaturation at rest or during exercise 1
• Short bursts of oxygen from cylinders for breathlessness relief lack supporting data 2

Pulmonary Rehabilitation

Pulmonary rehabilitation improves endurance, reduces dyspnea, and reduces hospitalization rates and should be offered to all symptomatic patients. 1

• Program components include cardiovascular fitness development, increased confidence, and stress control 1
• Benefits include improved exercise tolerance and quality of life even without lung function improvement 2
• Ensure bronchodilator therapy is optimized before initiating rehabilitation 2

Nutritional Management

Weight loss and malnutrition are common due to increased metabolic rate from increased work of breathing. 1

• Intensive nutritional support is largely unsuccessful in restoring ideal body weight 1
• Recommend small, frequent meals to reduce dyspnea by minimizing abdominal bloating 1
• Weight reduction in obese patients reduces energy requirements and improves exercise tolerance 2

Psychological Support

Early recognition and aggressive treatment of depression is essential, particularly monitoring for loss of appetite. 1

• Selective serotonin reuptake inhibitors (SSRIs) are effective for depression 1
• Tricyclic antidepressants may be poorly tolerated in patients with chronic sputum production 1

Vaccination

• Influenza vaccine is recommended and has shown 70% reduction in mortality from COPD in elderly patients 2
• Pneumococcal vaccine may be of value but lacks specific COPD efficacy data 2

Surgical Interventions

Lung Volume Reduction Surgery (LVRS)

LVRS improves survival in COPD patients with upper lobe emphysema and low post-rehabilitation exercise capacity compared to medical therapy alone. 1

Patient Selection Criteria:

• Best candidates: Upper lobe predominant emphysema with low exercise capacity after rehabilitation 1, 4
• Contraindications (higher mortality than medical management): FEV1 ≤20% predicted AND homogeneous emphysema on HRCT 1

Expected Outcomes:

• Improvement in FEV1, exercise performance, and quality of life 5, 4
• Reduction of lung volume by approximately 30% in both lungs 6
• Careful patient selection is paramount as LVRS increases mortality in certain subgroups 4

Bullectomy

• Indicated for large isolated bullae, particularly when occupying at least one-third of hemithorax and compressing adjacent lung tissue 3, 4
• Video-assisted thoracoscopic surgery (VATS) is a safe and effective approach 3
• Consider for recurrent pneumothorax 3

Lung Transplantation

• Reserved for patients with chronic respiratory failure who have not improved despite maximal surgical and medical therapy 4
• Requires absence of significant comorbid conditions 4

Bronchoscopic Interventions

Endobronchial valves improve FEV1 and 6-minute walk distance, but the magnitude of improvement is not clinically significant. 1

• Nitinol coils improve 6-minute walk distance compared to controls, with smaller improvements in FEV1 and quality of life 1
• These remain investigational with limited long-term data 7, 8

Alpha-1 Antitrypsin Deficiency

Augmentation therapy with human plasma-derived alpha-1 antitrypsin (60 mg/kg body weight once weekly) increases lung alpha-1 antitrypsin levels to 60-70% normal in patients with severe alpha-1 antitrypsin deficiency. 1

Palliative Care

Palliative care should focus on reducing dyspnea, pain, anxiety, depression, fatigue, and poor nutrition in patients with severe, unrelieved symptoms. 1

• Discussions about end-of-life care should involve patients and families early 1
• Advance care planning reduces anxiety and ensures care consistent with patient preferences 1

Common Pitfalls to Avoid

• Do not prescribe methylxanthines, aggressive hydration, chest physical therapy, or mucolytics as these lack evidence of benefit 2
• Avoid ambrisentan, which is contraindicated in emphysema due to increased mortality and hospitalizations 2
• Do not rely solely on FVC monitoring in combined pulmonary fibrosis and emphysema, as preserved volumes may mask disease severity 2
• Screen for obstructive sleep apnea syndrome with ventilatory polygraphy if clinically suspected, as prevalence is high (up to 88%) even without obesity 2