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Emphysema; stalking the susceptible.

Can we eliminate emphysema as a health problem? I believe we can if we simply apply modern knowledge about the cause of emphysema and how it progresses. Let's review the problem, hand in hand with our current knowledge, and see what can de done for millions of Americans who now have or will develop disabling emphysema.

Almost everyone has seen a friend, coworker or even a family member suffer from the problem of emphysema. Coughing, struggling to breathe and finally requiring oxygen therapy isn't a pleasant experience. It sure isn't pleasant for the patient, and it is also alarming for the family or coworkers who from time to time must witness the struggle to breathe and thus cope with emphysema.

Even physicians are quite frustrated over the plight of the advanced emphysema victim, because they know that the disease has already run a long course by the time most patients come to help. Much can be done for the emphysema victim today through techniques of pulmonary rehabilitation and with the use of oxygen therapy, including new devices that allow for patients to carry their oxygen with them. But it is a tradedy that emphysema is allowed to progress to advanced stages before it is identified and treated. Emphysema is a slowly progressive disorder that takes 20 to 30 years to develop into its full-blown stage--the stage of shortness of breath and disability. Therefore, it is critical to alert the public to the possibilities of emphysema, to identify it early and to intervene before irreversible damage to one of our most vital organs, the lungs, occurs.

What are the risk factors that lead to emphysema? Now well-known, these are primarily the smoking of tobacco, family history, sex and age. Let's elaborate.

1. Beyond question, the most profound risk factor is smoking. Smoking is known to release irritants and to damage protective materials within the lung that lead to inflammatory damage of the small air passages and the delicate gas-exchange membrane.

We need to think in terms of the lungs and lung health. The lungs, as illustrated on the opposite page, are made up of branching tubes, beginning with the windpipe (trachea) and sequences of branching where each air passage branches into two, two into four, four into eight, etc., until there are approximately 100,000 small air passages before the gas-exchange membrane is reached.

This concept of branching tubes ultimately arriving at the gas-exchange surface (alveoli) is illustrated in the diagram of the two lungs in the inset, showing the small air passages that finally reach the alveoli, where gas exchange takes place (the absorption of oxygen and the elimination of carbon dioxide, a by-product of metabolism).

The delicate membrane of the lung appears similar to a lacelike structure. In the photograph on the opposite page, one is looking at the cut surface of the gas-exchange membrane and the ducts, which still contain alveoli.

In emphysema, there is an inflammatory destruction of this alveolar membrane, as shown in the photograph (top, right). Now the architecture of the lung is totally disrupted and destroyed, and it is easy to understand how the elasticity of the lung, which allows it to fill and empty in a coordinated fashion, is gone. No wonder the lungs cannot empty and fill in a normal fashion!

2. For some reason, emphysema runs in families. This fact probably means there is a hereditary predisposition to the damaging effects of cigarette smoke and other irritants. Thus we think of emphysema as a disease of the susceptible smoker rather than the disease that all smokers get.

3. Men have a higher incidence of emphysema than women, but this is likely due to more smoking. In fact, women are catching up with men, because they are smoking in a pattern similar to men.

4. Finally, age is a (Illegible data) it appears that our lungs finally wear out. The elasticity of the lung does reduce with age as does the elasticity of other organs such as the skin. Age-related losses of the lung's elasticity, however, are small and rarely, if ever, lead to the development of emphysema without the additional factor of smoking or family predisposition. Those who live to be 100 or more still have ample lung power and breath for living.

There are a number of additional aggravating factors, such as air pollution and pollution in certain work environments. These factors are relatively minor modifiers and, compared to smoking, for example, are not of major importance unless the individual is particularly susceptible to dust of fumes, as when specific allergies are present.

Here is a personal checklist that will enable you to determine if you should consult your physician for the possibility of emphysema.

1. Do I smoke?

2. Does emphysema run in my family?

3. Am I short of breath more than others doing the same thing?

4. Do I cough?

5. (Illegible Data) I cough up yellow or green mucus?

If the answer to any of these questions is yes, you should consult your physician for a breathing test. A breathing test is very simple to do using a machine called a spirometer. Spirometry means "breath measurement." It is a pity so few physicians actually use spirometers in their offices, but the trend is changing. Below is shown a simple spirometer suitable for the physician's office. Basically, it records the amount of air that can be blown out of fully inflated lungs and how fast the air flow occurs. The inset shows a patient blowing into the machine after taking a very large breath. Nose clips, such as those used for swimming under water, are in place so that all air flow occurs through the mouth into the machine. By blowing into the machine, one can tell whether one's lung capacity is normal or abnormal. After a breathing test, these further questions can be answered:

1. Are my measurements normal or abnormal?

2. How abnormal are they?

3. Is the abnormality one that can be treated with drugs or by stopping smoking?

4. Is the abnormality becoming worse, and if so, how fast?

5. What exactly should I do for my problem, if I have one?

These are key questions. If your tests are normal, it means that little or no damage has occurred, even if you have smoked cigarettes or have a family history of chronic lung disease. This, in fact, is a perfect time to stop smoking, not only to protect your lungs but also to avoid the increased incidence of other smoking-related diseases, such as the three-or fourfold increase in heart attacks, more strokes and the greatly increased risk of cancer of various organs, including lung cancer (the commonest cancer of men and the second commonest cancer of women) and cancer of the bladder, uterus and esophagus.

If there is a mild abnormality, it is critical to stop smoking now. What can you do if early emphysema is found? The answer is simple. Certainly this finding should be a sign to avoid all things that can cause and make emphysema worse by the immediate stopping of all cigarette smoking and possibly avoiding excessive air pollution. Smoking, of course, is the most important thing. It is the first order of business. Many patients who realize that they are beginning to become abnormal will take a careful look at their health and future and do something on their own behalf, that is, to protect their long-term happiness and survival.

Your physician will help you with new techniques to stop smoking. There are basically to approaches:

One is to deal with the habit patterns in smoking. Many people reach for a cigarette almost as a reflex--a cup of coffee, during a telephone conversation, following meals, etc. Once patients realize that certain habits lead them to reach for a cigarette, they can change their habits to the extent that they more or less forget to reach for that cigarette.

Second, patients also learn to deal with the nicotine-addiction problem and learn ways to distract themselves when they feel the need for a cigarette. We now have, for instance, a nicotine chewing gum available with a physician's (Illegible Data) Called Nicorette, it has been used for several years in Europe with good results. One study found that 48 percent of the users were successful in stopping smoking. The gum helps the smoker through nicotine withdrawals by supplying small amounts of the drug without inflicting the lungs with carbon monoxide or any of the 2,000 other chemicals found in tobacco smoke. Once the cigarettes are fully eliminated, it is usually relatively easy to stop chewing the gum.

Another stop-smoking aid is the EZ Quit cigarette, which is a plastic replica with both the feel and the draft of a cigarette. Instead of smoke, it offers the exhilarating flavor of mint, with which the filter is impregnated. Patients have reported favorable results with this aid, especially when used in conjunction with Nicorette.

Now let's talk about medication for early stages of the disease. Since our objective is to prevent the progress of disease, it will naturally be important to consult with a physician if a cough and yellow phlegm are present, indicating the presence of bronchitis, which commonly accompanies emphysema. Common bacterial organisms are easily treated with antibiotics that the patient can take at home. The physician will have to decide which antibiotic is useful, and most physicians will allow the patient to have a supply of antibiotics to take at home at the sign of a deep chest infection, which is characterized by an increased cough and colored phlegm. If there are mild to moderate abnormalities, the physician will likely want to prescribe a flu vaccination each fall to prevent this one form of a virus infection, which can be devastating to emphysema patients in any stage of disease.

In addition, more physicians are using bronchodilating drugs to help open up air passages that are irritable and are becoming constricted by the process called bronchospasm. Bronchospasm is a sudden, reflex narrowing of the small air passages. It interferes with air flow. Uncontrolled bronchospasm can lead to progressive losses of lung function faster than if the bronchospasm is treated. These theories are currently under study, but many would use a simple inhaled bronchodilator such as that illustrated on page 67 to open up air passages if tests of breathing capacity indicate reversibility, that is improvement in air flow from the use of such medications.

So, how about eliminating emphysema as a health problem in the United States in the next decade? This goal seems like a tremendous undertaking, considering that there are at least 10,000,000 emphysema sufferers, and probably 30,000,000, if we count all those with mild to moderate forms of disease. In fact, 500,000 patients receive Social Security disability payments on the basis of emphysema alone. Thus it seem preposterous to suggest that emphysema could be eliminated as a health problem in this country in the next decade.

My own belief is that the elimination of emphysema is well within our grasp. If patients simply realize that emphysema "clusters" in families and is a smoking-related disorder that gets worse with age, they will insist upon a simple breathing test that will indicate whether they have an abnormality. The presence of any abnormality can be a strong motivating force to stop all smoking of cigarettes, which is the most important thing by far. In addition, these patients can embrace additional health habits and preserve lung function by joining forces with their doctors to treat and prevent infections and perhaps use other medications, which will open up air passages and improve air flow.

Today, emphysema is a truly devastating disorder that costs our country about $10,000,000,000 in terms of medical care and loss of productivity. Since the disease is characterized by premature morbidity and mortality, covers 20 to 30 years and can be readily identified in physicians' offices, it is now time for patients and physicians to enter into a partnership in order to identify, treat and finally eliminate emphysema as a health problem, now and forevermore.
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Author:Petty, Thomas L.
Publication:Saturday Evening Post
Date:Sep 1, 1984
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