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Emphysemic changes: Emphysema – Symptoms and causes

What is emphysema? Symptoms & treatment

When you’re healthy, you don’t really give breathing a second thought, let alone a first. Sure, it’s one of life’s essential functions, but breathing in and out is so automatic (and hardwired into our brains) that it doesn’t really give you a reason to think about it. That is, until something goes wrong, and it gets harder to take air in and out.

One condition that can make breathing a challenge is emphysema, where damage in your lungs makes it more difficult to bring oxygen into your body. It’s a serious disease that affects over 3 million people in the U.S. – it’s also one of the most preventable.

We’ll go over what emphysema is and how it relates to chronic obstructive pulmonary disease (COPD). We’ll also tell you the main causes, symptoms and stages of emphysema, and give you a rundown on available treatments.

What is emphysema?

Pulmonary emphysema is a long-term lung health condition that causes shortness of breath. Over time, the air sacs in the lungs, also called alveoli, become damaged. The inner walls of these air sacs weaken and rupture, which creates larger air spaces in the lungs. When this happens, the surface area of the lungs is reduced, and so is the amount of oxygen that makes it to the bloodstream.

Emphysema is a chronic illness, and it can develop slowly over time. There isn’t a way to repair or regrow the damaged lung tissue, but there are ways to treat it to live more comfortably with the disease. These treatments can also help control symptoms and slow the progression of the disease.

Types of emphysema

There are several different types of emphysema that can affect different areas of the lungs, as well as the body:

  • Centrilobular emphysema (CLE) – CLE is the most common type of emphysema, and it occurs in the upper sections, or lobes, of the lungs.
  • Panlobular emphysema (PLE) – PLE affects the lungs as a whole but can affect the lower section of the lungs more severely.
  • Paraseptal emphysema (PSE) – PSE damages the air sacs in the outermost part of the lungs, but with more severe forms of PSE, damage can occur in other parts of the lungs too.
  • Bullous emphysema – This form of emphysema occurs when giant, bubble-like cavities filled with fluid or air develop in the lungs.
  • Subcutaneous emphysema – This is a rarer form of emphysema, where air or gas gets under skin tissue. It commonly occurs in the chest, neck or face, but it can also develop in other areas of the body. This form of emphysema isn’t typically caused by smoking or other lung irritants but brought on by certain medical procedures or injuries to the body, among others.

What is the difference between emphysema and COPD?

First, what exactly is COPD? Chronic obstructive pulmonary disease, or COPD, is a group of lung diseases that make breathing difficult, and gradually worsens over time. COPD typically occurs in people who have a history of smoking, but it can also occur with long-term exposure to lung irritants like secondhand smoke or air pollution.

Emphysema and chronic bronchitis, where the lining of airways is constantly irritated and inflamed, are the two most common conditions that contribute to COPD. Both conditions make breathing harder, leading to shortness of breath, coughing or wheezing. People diagnosed with COPD are frequently diagnosed with both emphysema and chronic bronchitis, but they can occur separately.

What causes emphysema?

Emphysema can be caused by several things, but the four most common are:


This is the number one cause of emphysema. Smoking destroys lung tissue and irritates airways, causing inflammation and damage that results in swollen airways, difficulty clearing airways and increased mucus production.

Long-term exposure to lung irritants

Some examples of lung irritants include air pollution, secondhand smoke and occupational lung irritants, such as coal or exhaust fumes.


Emphysema is most commonly seen in people 40 years of age or older, especially in those who smoked early on in life, still smoke or had long-term exposure to lung irritants. Emphysema can occur in young adults, but as emphysema generally develops slowly, older adults are more at risk.


It’s rare, but an inherited genetic condition called alpha-1 antitrypsin deficiency that weakens the lungs, can cause emphysema. Also, people with a history of smoking are more likely to develop emphysema if they have a family history of COPD.

Symptoms of emphysema

Because emphysema usually progresses slowly, symptoms can take a while to appear – a person can actually have emphysema for years and not know it. Early symptoms are generally mild and become more severe as the disease progresses. Symptoms or signs of emphysema can include:

  • A frequent and persistent cough
  • A cough that produces a lot of mucus
  • Frequent respiratory infections, like colds or the flu
  • Shortness of breath during daily activities and physical activity
  • Wheezing while breathing
  • Chest tightness or pain
  • Loss of appetite
  • Sleep problems
  • Depression
  • Unexplained weight loss

What does emphysema feel like?

Some of the first symptoms that can appear are shortness of breath and ongoing fatigue. These symptoms alone can be dismissed as minor or related to other illnesses, so when should you see your doctor? If breathing becomes more difficult even while not being physically active, or lung sounds change – from typical breathing to wheezing, clicking or crackling – it may be time to schedule a visit.

Diagnosing emphysema

A visit to the doctor will help diagnose emphysema with a few steps. Your doctor may recommend a chest X-ray, but an X-ray doesn’t always confirm a diagnosis. It can, however, rule out other causes of shortness of breath, such as pneumonia or asthma, and help diagnose advanced stages of emphysema.

Since an X-ray doesn’t always confirm diagnosis, your doctor may also recommend a computerized tomography (CT) scan. A CT scan takes X-ray images from multiple directions to create many different views of internal organs, helping to detect and diagnose emphysema.

Another step your doctor may take is to order a lab blood test, where blood is tested to determine how well lungs are transferring oxygen to your bloodstream, and how well they’re removing carbon dioxide.

Finally, your doctor may order lung function tests, called pulmonary function tests (PFTs). PFTs, such as spirometry, nitric oxide tests and arterial blood gas tests, are noninvasive tests that measure lung capacity, how well air flows in and out of the lungs, and how well lungs deliver oxygen to the bloodstream.

Why early detection of emphysema is important

Since emphysema can’t be reversed like other lung conditions, early detection is important. Emphysema symptoms worsen over time, and early detection can slow progression of symptoms and the disease, leading to improved quality of life. It can also help identify causes of the disease so you can limit exposure to them.

The four stages of emphysema

Emphysema is classified into four stages: early, moderate, severe and very severe. Doctors use these stages to describe the progression of the disease and provide the appropriate treatment for each stage.

Early emphysema

If someone is at risk for emphysema, like those with a history of smoking, it’s important to keep an eye out for symptoms such as a nagging cough or shortness of breath, even if it’s mild. Although it’s easy to dismiss the early warning signs. But catching emphysema in this stage may help slow progression, allowing you to maintain your health for longer.

Moderate emphysema

This stage occurs when symptoms such as frequent coughing, feeling tired, shortness of breath, trouble sleeping and wheezing affect daily life. Flare-ups of symptoms, where they intensify for a few days, may occur.

Severe emphysema

In this stage, symptoms become more severe: intensified shortness of breath, tiredness and coughing, and more frequent flare-ups. Also, there may be new signs of emphysema progression, such as more frequent respiratory infections, like a cold or the flu, tightness of the chest, trouble catching your breath and others.

Very severe emphysema

Emphysema likely will be affecting every activity in day-to-day life, and it may be difficult to breath even when not being physically active. Chronic respiratory failure may occur – which means not enough oxygen is moving from the lungs to blood, and when the lungs aren’t taking enough carbon dioxide out of the blood.

Treatments for emphysema

While there isn’t a cure for emphysema, there are treatments that may help slow the progression of the disease and help people with the disease to live more comfortably.

Pulmonary rehabilitation

The goal of pulmonary rehabilitation is to promote healthy lifestyle changes –using exercise, lifestyle education and diet to help improve quality of life and ability to exercise.

Oxygen therapy

If emphysema causes low levels of oxygen in the blood, oxygen therapy may help. With oxygen therapy, supplemental oxygen can help deliver more oxygen to the lungs and bloodstream.

Emphysema medications

These may include bronchodilators to relax airways and help breathing problems, inhaled steroids, aerosol sprays that reduce inflammation and help shortness of breath, and antibiotics to treat bacterial infections.


If the disease has progressed to the later stages, doctors may recommend lung volume reduction surgery, where damaged lung tissue is removed. If the damage is severe and other treatments haven’t worked, a lung transplant may be an option.

Lifestyle changes

Making changes to your lifestyle is easier said than done, but it’s the most important way to manage emphysema and keep living your life. Don’t be afraid to reach out for help – it’s a sign of strength, not weakness.

Stop smoking the right way for you

The number one priority is to figure out the best way to stop. Talk to your doctor about smoking cessation strategies – they may be able to prescribe gum, inhalers, patches or prescription medicines to help.

Avoid inhaled irritants

Avoiding air pollution, smoke from wood-burning fireplaces and dust may help you breathe a little easier.

Defend against infections

Washing your hands frequently when out in public, using hand sanitizer, avoiding people with respiratory illnesses, such as a cold or the flu, and getting an annual flu vaccination may help.

Stay active

Talk to your doctor, if necessary, to figure out a fitness regimen that works for you. Regular exercise can help decrease emphysema symptoms, improve circulation and help your body better use oxygen, strengthen your heart, improve mental health and so much more.

Eat well

This is an easy way to keep your immune system strong. Cutting back on red meat, processed foods and sugar, and eating a diet with more fruits, vegetables, nuts, whole grains, fish and olive oil may help reduce inflammation. Nutritional supplements may also be helpful – talk to your doctor about your options and what fits for your lifestyle.

When should you talk to your doctor?

Early detection is the best way to control your symptoms and the progression of emphysema. If you have shortness of breath or a history of smoking, reach out to your doctor sooner rather than later. They care about your respiratory health and will help you come up with a plan so you can live your best life.

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How Serious Is It, Treatment Options and More

Written by Paul Frysh

Medically Reviewed by Paul Boyce, MD on November 17, 2021

  • Stage 1 Emphysema
  • How Serious Is Your Emphysema?
  • Lifestyle Treatment
  • Medical Treatment

Emphysema happens gradually as tobacco smoke or other pollutants damage the tiny air sacs in your lungs called alveoli. Normally, some 300 million alveoli help bring oxygen into your body and get rid of carbon dioxide. As the alveoli break down, your bronchial tubes can start to collapse, too.

Emphysema can’t be cured. It’s progressive, so over time it will get harder and harder for you to catch your breath. But you might not know you have the disease for the first few years unless your doctor tests your breathing.

Emphysema stages are a measure of how well you can breathe. One widely used guideline is called the Global Initiative for Chronic Obstructive Lung Disease (GOLD). It’s a formula that ranks emphysema in four stages, with 4 being the most serious. Doctors use it as one of many ways to measure your emphysema.

A machine called a spirometer tests your breathing for the GOLD stages. It takes two key measurements:

Forced vital capacity (FVC). This is how much air you can breathe out after taking the biggest breath you can.

Forced expiratory volume-one second (FEV1). This is how much air you can breathe out in the first second after that big breath.

Your doctor uses those numbers to calculate how well you compare to your healthy peers.

You have emphysema if the ratio of FEV1 to FVC is less than 70%. That means that after you exhaled for 1 second, 30% or more of the air in your lungs hasn’t emptied out.

Stage 1 emphysema is when the amount of air you can breathe out in 1 second (your FEV1) is 80% or more of the average for someone of your age, sex, and height.

Stage 1 is also called mild emphysema. But that doesn’t mean your disease is mild.

You could have significant lung damage before you even notice the breathing problems of stage 1, especially if you’re relatively young and otherwise healthy. On the other hand, if you’re older, especially over age 65, even minor breathing problems can start to interfere with basic daily tasks like dressing, cooking, or climbing stairs, and they’re more likely to cause symptoms or send you to the hospital.

Once your doctor diagnoses your emphysema and determines your GOLD stage, they’ll look at a number of other signs and symptoms to fully evaluate your condition. They’ll want to know if you:

  • Have problems sleeping
  • Make high-pitched wheezing sounds when you breathe
  • Cough often, or cough up colored mucus
  • Have low blood-oxygen levels
  • Have flare-ups when your breathing worsens
  • Have gone to the hospital for your emphysema symptoms
  • Get lung infections
  • Show signs of scarring, holes, or enlargement in your lungs on X-rays and other imaging scans

You can’t reverse your emphysema. But you can ease your symptoms and slow the progress of the disease. And the earlier you act, the better.

Quit smoking. It’s the No. 1 cause of emphysema. If you smoke, quitting is the single best step you can take.

Breathe smarter. You can learn to breathe with pulmonary rehabilitation therapy. You follow a set of breathing techniques and physical exercises to lessen breathlessness and boost your stamina. Your doctor or a specialized breathing therapist can help design a program for you.

Get to a healthy weight. In early emphysema, you may need to lose some pounds. But as your disease gets worse, you might find yourself needing to put weight back on. Nutritional therapy from your doctor or a nutritionist can help you customize a diet based on your size, health, and activity level.

Bronchodilators. You inhale these medications to relax and to expand your airways. This allows more air into your lungs so your body gets more oxygen. Talk to your doctor about which type is right for you.

Oxygen. If your blood oxygen levels get low for too long, your doctor might suggest taking in extra oxygen from a machine through tubes that go into your nose. It helps the most if you have severely low blood oxygen levels, not just moderately low. You and your doctor will go over your oxygen needs every 2 to 3 months.

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Pulmonary emphysema

Pulmonary emphysema is characterized by the destruction of the inner walls of the lung vesicles. Although the mechanism of this process is not fully understood, it is generally assumed that it is the result of a reaction to inflammation caused by foreign particles (for example, toxic substances in tobacco smoke). These particles enter the lungs, after which the immune system releases so-called proteases. These molecules can damage the elastin on the aveolar walls. So-called antiproteases can protect the aveolar walls from destruction. One such antiprotease is alpha-1 antitrypsin. Some people are born with a genetic error that causes not enough alpha-1 antitrypsin to be produced. Such people are especially susceptible to the disease of emphysema.

The elasticity of the lung vesicles is limited and the ability of the lungs to transport air in and out is reduced. Sooner or later, this leads to air retention in the lungs and their swelling (hyperinflation of the lungs). Air lingers in the affected area of ​​the lung and pressure on healthy areas increases and significantly reduces its function.

Another consequence is pressure on the diaphragm, which pushes it down. This leads to a vicious circle, while the first symptoms are shortness of breath and reduced mobility. During the progressive degeneration of the walls of the vesicles of the lungs, the surface on which gas exchange occurs becomes smaller. The consequence of this is an imbalance in gas exchange between the lungs and the blood, which often leads to the symptom of fatigue. Daily activities like climbing stairs can suddenly feel like a lot of work.
Causes of pulmonary emphysema:
– smoking
– dust
– toxic fumes
– environmental factors
– passive smoking
– alpha-1 antitrypsin deficiency

The main cause of emphysema, as well as lung cancer , is considered smoking .
However, dust, fumes and air pollution can also be responsible for its appearance.

  1. Chronic cough and mucus
  2. Dyspnea on exertion
  3. Fatigue and reduced fitness
  4. Persistent dyspnea, reduced quality of life, exacerbations, comorbidities, weight loss
  5. Social isolation and depression

Chronic cough, large mucus discharge and shortness of breath on exertion are the first symptoms of chronic obstructive pulmonary disease. If the disease progresses, shortness of breath becomes worse and the patient notices increased fatigue. If gas exchange is severely impaired, comorbidities (such as cardiovascular disease) accumulate and exacerbations become more frequent (sudden shortness of breath or coughing spells), which affects overall health and can lead to social isolation and depression.

As a rule, chronic obstructive pulmonary diseases are detected late, since symptoms appear only in the later stages of the disease. The earlier the disease can be diagnosed, the more effective will be the treatment selected by the pulmonologist and the more opportunities to stop or slow down the development of the disease.
There are many methods for diagnosing emphysema. They are also often combined in order to determine the degree of development of the disease and its spread.
The risk group includes long-term smokers, people of middle age and older, suffering from chronic cough, copious mucous secretions, or with a hereditary predisposition. In these cases, an examination by a pulmonologist is mandatory.

Method What is being measured? Why? Severe emphysema Short description of procedure
Speedometer FEV1, VC, FEV1/VC Measurement of lung capacity, observation of the course of the disease, exclusion of other diseases FEV1 below 50% Spirometry is a method for measuring lung function. With it, the volume of the lungs and respiration is measured and depicted graphically on a spirogram.
Body whip
residual volume Determining the volume of air trapped in the lungs to determine the degree of hyperinflation VR greater than 150%
Total lung capacity > 150% indicates severe lung swelling
Body plethysmography can measure lung parameters such as airway resistance, residual lung volume and total lung capacity.
Ventilation scintigraphy gas diffusion and blood circulation To determine the area of ​​the lungs in which gas exchange is impaired low gas exchange and blood circulation Radioisotopes are injected or inhaled and a picture is taken with a gamma camera
6-minute walk test physical activity Determining exercise capacity for personal training and treatment evaluation 300 meters Test on a flat surface limited in time, documented by honey. staff
X-ray X-ray of chest, heart, lungs and diaphragm To obtain a general view of the chest including the heart, lungs and diaphragms Dropped diaphragm, chest expansion due to lung swelling With the help of X-ray diagnostics it is possible to recognize pathological changes
CT detailed lung slices Evaluation of the distribution of emphysemic changes in the lungs. Diagnosis of emphysema. Lung swelling and collapsed veolar sacs Computed tomography (CT) also uses X-rays, only at different angles, which allows you to create a 3-D image

VC – Vital lung capacity. It is estimated as the difference between the volumes of air in the lungs during full inhalation and full exhalation.
FEV1 – Forced expiratory volume in the first second of the forced expiratory maneuver.
The ratio FEV1/VC , expressed as a percentage – the Tiffno index – is a sensitive index of the presence or absence of deterioration in airway patency. normally 70-75%.

Pulmonary Rehabilitation

Pulmonary Rehabilitation is an individually tailored activity that includes both a physical training program and various educational programs. The patient learns at the same time the correct attitude towards his illness and life without smoking if he is a smoker.

The combination of training and sports for the lungs makes it possible to increase physical performance and promote social contact with other people suffering from this disease. It is very important to continue the exercise even after the end of the rehabilitation course, this can contribute, if not to an improvement in lung function, then at least slow down its deterioration.

The following exercises will help you learn to control your breathing and breathe effectively.

Home exercises:

Lip inhibition breathing:
This breathing can help with shortness of breath by emptying the lungs of residual air in them and slowing down the rate of breathing. To perform this exercise, you need to keep your mouth closed and inhale through your nose. When exhaling, keep your lips together slightly and exhale slowly. When the exhaled air is decelerated through the lips, pressure is created due to which the airways remain open, which allows the remaining air to exit the lungs.

Driver seat
This position helps with breathing difficulties by improving the efficiency of the diaphragm.

Respiratory muscle training
This type of training aims to strengthen the muscles of the neck and shoulders, which maintains a low diaphragm.

Strength exercises and walks
Exercise improves breathing.

Surgical treatment
A certain group of patients with emphysema is an indication for surgical reduction of lung volume or lung transplantation. Surgery may be an option for patients with severe or very severe emphysema who have not been helped by other treatments.

Lung volume reduction (LVL)
The goal of lung volume reduction (LVL) surgery is usually to remove diseased areas of the upper lobe of the lung. The affected areas of the lung are removed surgically to free up space and relieve pressure on healthy areas. With this procedure, the pressure on the diaphragm is also reduced, which also makes it easier to breathe. The selection of suitable patients and comprehensive preliminary examinations are the basis for good results.

Interventional treatment
Surgery is associated with high risks and the last decades have seen the development of less invasive methods. These methods can be summarized by the concept of bronchoscopic lung volume reduction. There are many methods of bronchoscopic lung volume reduction that can help patients with severe emphysema for whom medical treatment and rehabilitation have not been effective. With this treatment, the removal of a lobe of the lung is not required, the affected area is “turned off” in a controlled manner. This happens by blocking the passage of air into the affected area, compression or influence on the inflammatory process.
The essence of bronchoscopy is the use of a thin, flexible long tube, at the tip of which is a small camera, which allows you to reproduce the image on the screen in live time. A bronchoscope is inserted through the nose or mouth into the lungs.

Application of valves
In Germany, two types of valves are used – endobronchial and intrabronchial. These are so-called one-way valves and are placed in the lungs in order to block the path of air to damaged, swollen areas of the lungs. They are designed in such a way that they remain closed when inhaling, thus preventing the inhaled air from entering the affected area, and open when exhaling, which allows the accumulated fluid and air to be released outside. The valves are placed with a bronchoscope at the branches of the pulmonary lobes. They must be installed in such a way that the affected tissue is completely isolated. It usually takes two to five valves to close one lobe of the lung. The goal is to reduce as much of the affected area as possible.

Endobronchial valve – a valve about 8 mm wide and 12 mm long. The valve frame is made of nitinol metal and adapts to the size of the bronchus in which it is placed. It has a silicone shell.

The intrabronchial valve has an umbrella shape and a polymembrane.