Emphysema – Causes, Symptoms, Treatment, Prognosis, Ayurvedic Understanding

By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S

Emphysema is a form of chronic lung disease. Chronic bronchitis and emphysema are two main types of COPD i.e. chronic obstructive pulmonary disease. Both these conditions are called as obstructive because patient feels as if something is blocking the smooth flow of air into and out of lungs.

It is a condition in which the air sacs in lungs get enlarged, damaged and also stretched. This happens due to loss of elasticity in the air sacs. This eventually results in chronic cough and difficulty in breathing. It is a type of COPD – chronic obstructive pulmonary disease. Most of the cases of emphysema are caused due to cigarette smoking.
Read – Smoker’s Cough: Symptoms, Ayurvedic Treatment, Medicines

Mechanism, Pathogenesis

The alveoli become enlarged due to the breakdown of their walls. This may also happen due to destruction, narrowing, collapse, excessive stretching or over-inflation of air sacs in the lungs. This creates a reduced surface area for exchange of oxygen and carbon dioxide. This damage is of permanent nature. Person afflicted with emphysema will not be able to breathe properly and there will not be total recovery. Treatment only eases the symptoms and prevents attacks.

In brief –

• Fragile tissues lining and in between the air sacs get damaged and destroyed.
• The destruction of this lining gets progressive and gets to a stage where it is beyond repair.
• As a result the air pockets are formed in lung.
• The air gets trapped in these pockets of damaged tissue.
• The lungs eventually get larger slowly.
• The patient feels harder to breathe.
• One may develop a state called as airflow limitation when they won’t be able to empty their lungs of air as quickly as they should do.
  Read – Dyspnoea – Difficulty in breathing: Causes, Pathophysiology, Diagnosis

Causes of Emphysema

Smoking cigarette – is the main causative factor for at least 85% of emphysema (and COPD) cases. But all the smokers might not develop these conditions. Those who are genetically susceptible are the usual victims. Those exposed to passive smoking are also susceptible but to a lesser extent. Studies show that smokers are about 6 times more likely to develop emphysema than non-smokers. Giving up cigarettes might slow down the damage it does to the lungs but there is no cure once emphysema has set up. Lung damage can also occur in passive smokers over a period of time.

Smoke from indoor cooking and heating and some toxins inhaled at work places are also causal.

Other risk factors –

• Air pollution
• Occupational dust – like mineral dust, cotton dust etc
• Inhaled chemicals – coal, grains, cadmium etc
• Childhood respiratory disorders – including asthma or a viral infection
• Low body weight

Other causes –

Deficiency of a genetic factor, alpha1-antitrypsin protein causes a rare form of emphysema. This protein protects the lungs against the destruction of alveolar tissue by neutrophil elastase. This is a congenital condition and people born with it develop emphysema without smoking and at a relatively early age. Even in these people smoking accelerates emphysema.
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Symptoms of Emphysema

Symptoms in the early stage of the disease – The main symptoms of emphysema are shortness of breath / dyspnea and chronic cough. Initially the shortness of breath may start only during physical exertion. As the disease progresses there is dyspnea even at rest. Both Emphysema and COPD develop over a number of years.

Symptoms in the later stage of the disease –

• Wheezing
• Plenty of mucus / expectoration
• Blue tinge on lips or fingernail beds / cyanosis – due to inadequate oxygen
• Headaches in the morning (as breathing at night is difficult due to lack of oxygen and there is sleep problems)
• Frequent lung infection
• Loss of weight
• Loss of appetite
• Fatigue
• Depression
• Anxiety
• Sleep disturbances
• Problems having sex
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Types of Emphysema

Depending on the part of lung affected, emphysema is classified into –

• Paraseptal
• Centrilobular – affecting mainly the upper lobes (most common in smokers)
• Panlobular – affects both the above said areas of the lungs

Stages of Emphysema

1. The GOLD Index (as per Global Initiative for Chronic Obstructive Lung Disease – GOLD)

The stages of emphysema are based on forced expiratory volume in 1 second (FEV1) i.e. how much air you can blow out of your lungs in 1 second –

Stage of Emphysema	FEV1	Other Symptoms
Stage 1 / Group A / GOLD 1 or 2 – Very Mild Stage	About 80% of normal	Symptoms are mild; you might not have had flare ups over the past 1 year or perhaps only one flare-up. You weren’t hospitalized.
Stage 2 / Group B / GOLD 1 or 2 – Moderate	Between 50 and 80% of normal	More symptoms than people of group A, people often visit doctor for coughing, wheezing and shortness of breath. There might have been one major flare-up but you have not been admitted in the hospital for your symptoms within the past 1 year.
Stage 3 / Group C / GOLD 3 or 4 – Severe	Between 30 and 50% of normal	Air flow into and out of your lungs is severely limited. You have had more than 2 flare-ups in the past year, or you have been hospitalized at least once.
Stage 4 / Group D / GOLD 3 or 4 – Very severe	Lower than in stage 3 or same as stage 3 but with low levels of blood oxygen	Extremely hard for you to breathe in or out. You have had at least 2 flare ups in the past year or you have been hospitalized at least once. This is also called as ‘end stage’ of COPD. You would have very little lung function. Any new flare-ups could prove life threatening.

These stages do not predict how long a person is likely to survive. The nature of severity can be assessed by many tests.

2. The BODE Index

This system measures how much the disease impacts your daily life. It focuses on four main areas.

B (Body Mass Index) – measures how much body fat you have compared to your height and weight.

O (Obstruction) – measures airflow limitation. This will allow the doctor to know how damaged your lungs are by how well you do on pulmonary function tests.

D (Dyspnea / breathlessness) – the doctor will assess how often you feel like you are out of breath and when.

E (Exercise capacity) – measures how far you can walk in 6 minutes.

According to studies BODE Index gives a better idea about the prognosis of emphysema than FEV1. These findings can be used to see how well you would respond to medications, lung rehab therapy and other treatments. Best treatment plans also can be made using this information. (Read more)

Diagnosis of Emphysema

A doctor would diagnose emphysema after carrying out a thorough examination of the patient and making a note of detailed case history including the symptoms. Some diagnostic tests also might be conducted to rule out other conditions. If there is no history of smoking test to diagnose alpha1 antitrypsin will be carried out.

Lung Function Tests – These tests are used to confirm diagnosis of emphysema, to monitor disease progression and also to assess the response to the treatment. Spirometry which assesses airflow obstruction is mainly included in this. Forced expiratory volume in one second is abbreviated to FEV. This helps in determining the various stages of the disease.

Other tests –

• Imaging – chest X-ray or CT scan of lungs
• Arterial blood gas analysis – to assess oxygen exchange

Prevention, Lifestyle changes

Important lifestyle changes include –

• Drinking lot of water – this enables loosening of mucus and their expulsion, thus keeping the airways clean
• Avoiding cold air in winter – prevents muscular spasm
• Wearing a scarf around the mouth or a cold-air-mask
• Doing exercises that can help in improving breathing like – diaphragmatic breathing, deep breathing etc

The above said ‘lifestyle changes’ may not alter the course of the illness but will help people live better. They will also improve the quality of life and exercise capacity of the patients.

Preventive measures

Quit smoking

Vaccination – may prevent COPD and emphysema from worsening

Nutrition – Patients of emphysema may develop weight loss and nutritional deficiency since reduced lung capacity demands higher energy for daily activities. Some people are overweight or obese. These people are encouraged to lose weight. Healthy diet with lot of fruits, vegetables and whole grains and low intake of fat and sugar is important.
(Read more)

Treatment

The treatment of emphysema (and COPD) includes use of medications and supportive therapy towards stabilizing the condition and also to prevent the complications of the disease. Oxygen therapy and help to come over smoking addiction are categorized into the supportive therapy.

Drugs – The bronchodilators are administered in the treatment of emphysema. They relax and open the air passages in the lungs. They include beta-agonists, anticholinergics or antimuscarinics. Corticosteroids may also help. Steroids are inhaled as an aerosol spray. Along with bronchodilators they can reduce the frequency of attacks.

Oxygen therapy – This improves oxygen delivery to the lungs and improves the quality of life. It is administered through various devices including electric oxygen concentrators, liquid oxygen systems or cylinders of compressed gas.

Surgery – Surgery is done in cases of severe emphysema. It helps to reduce lung volume. Sometimes lung transplantation is preferred.

Pulmonary rehabilitation and lifestyle management – Pulmonary rehabilitation is a program planned to take care of people suffering with emphysema. It helps the patients to quit smoking, follow healthy diet and practice regular exercise and also improve their lifestyle.
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Yoga and Emphysema

In a study on COPD patients – ‘Study of the effect of yoga training on diffusion capacity in chronic obstructive pulmonary disease patients – A controlled trial’ – Group 1 control group was compared with Group 2 Yoga group. Group 2, along with lifestyle changes was administered with –

1. Pranayama – breathing exercises – including Bhastrika, Anulom Vilom, Kapalbhati, Bhramari
2. Asanas – postures – including Surya Namaskara, Tadasana, Sukhasana, Pachimottasana and Shavasana.
   Read – How To Do Pranayama – A Simple Pranayama Technique

It was concluded that Yoga, especially the pranayamic breathing exercises when used adjunctively with standard pharmacological treatment can significantly improve TLCO in yoga with mild to moderate grades of COPD. (Read more)

Yoga postures meant for treating COPD are also effective in emphysema. Some important asanas are –

• Tadasana – Standing mountain pose
• Anuvittasana – Standing back bend
• Paschimottasana – Seated forwards bends
• Parsva urdhwa hastasana – Standing side bends

Though safe, Yoga postures shall be practiced only with consent of experts / doctors. Balasana i.e. Child’s pose or Halasana i.e. Plough pose shall be avoided as they restrict breathing by putting pressure on the diaphragm.

According to healthline.com, – a 2012 study published in the American Journal of Therapeutics, on the effects of yoga for people with COPD, people were taught yoga postures, breathing exercises and meditation for a duration of 6 weeks. People reported an overall improvement to their quality of life and tests showed that lung function improved on a short term basis. (Read more)

Yoga Breathing

According to Yoga science, correcting breathing will bring in more oxygen into the blood and helps to control vital energy. This in turn helps in calming the mind. Pursed lip breathing and diaphragm breathing are often taught to people with COPD as part of pulmonary rehabilitation program.

Abdominal breathing is highly useful for patients of COPD. The person should first breathe in letting the stomach to expand. As he breathes out he should contract his stomach muscles pressing his stomach inward. He should focus on contracting his lower abdomen and ribs as he breathes out. This helps in raising the diaphragm enabling his lungs to empty all the way and thus improvise the depth of his breathing. (Read more)

Ayurveda Concept of Emphysema

Looking at the pathogenesis and symptoms of emphysema, it falls under the topics of shwasa and kasa as explained in Ayurveda.

From point of view of pathogenesis and changes in lungs

The elasticity of the air sacs is maintained by balance between kapha and vata in the chest, in lungs to be precise. The main seat of kapha is chest. The seat of subtype of kapha i.e. avalambaka kapha is also chest. This kapha is said to provide support to the chest and chest organs. Due to the presence of kapha in a state of balance, the lung and air spaces inside it can easily expand and contract. When kapha in chest gets decreased, vata gets increased. When vata increases in lungs there is excessive dryness due to deterioration of moistness of kapha. Air spaces lose the support and elasticity. Vata is made up of air and ether components. When these components increase owing to increase of vata and decrease of kapha, the air sacs get enlarged, damaged and stretched as happens in emphysema.
Read – Symptoms Of Vata Dosha Increase And Imbalance – Vata Vruddhi Lakshana

From causes and risk factors perspective

Ayurveda has also mentioned dhuma i.e. smoke as one of the etiological factors for causation of cough and breathlessness. The term dhuma can also be extended to smoking and passive smoking. Raja has also been mentioned which means dust, can be extended to include air pollution, occupational dust etc causes.

Ayurveda has mentioned excessive exercise in the etiological factors of cough. This can be understood in terms of trigger factor too. Exercise is a trigger in the initial stages of emphysema and worsens the symptoms. Excessive exercise aggravates vata. This also shows the predominance of vata in emphysema.
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From point of view of symptoms

Emphysema is coexistence of kasa and shwasa – Since shortness of breath is the main symptom of emphysema it can be correlated with shwasa. Shwasa is a disease in which the person feels difficulty in breathing. There is also chronic cough associated with emphysema; therefore it also comes up in the discussion of kasa. Therefore Emphysema is a condition which is a mixture of shwasa and kasa.

Symptoms like Tamaka Shwasa – The symptoms like wheezing, accumulation of mucus in lungs and expectoration found in emphysema points towards explanation of symptoms of shwasa and kasa. All these symptoms can be seen in a subtype of shwasa, Tamaka Shwasa. This condition is often compared to asthma or asthmatic bronchitis. Chronic Bronchitis is also a part of COPD along with emphysema. The pathogenesis, symptoms and treatment principles of Tamaka Shwasa can be considered and applied to understand emphysema in Ayurvedic language.

Predominance of vata – Most symptoms and complications of emphysema point towards predominant involvement of vata in causation of disease.

Involvement of vata and kapha in varying proportions, individually and relatively – Expectoration of mucus is due to excessive stimulation of respiratory passages by vata. Vata can be further aggravated when it is blocked by mucus in respiratory passages. Vata and Kapha are predominantly aggravated at different stages of the disease and also affect each other mutually as explained in pathogenesis of shwasa. Cough, headache, expectoration, shortness of breath, fatigue, severe dyspnea posing threat to life, unconsciousness and fainting (due to deficit oxygenation) are mentioned among the symptoms of tamaka shwasa.
Read – Shwasa Roga Chikitsa: Ayurvedic Treatment, Medicines

From the perspective of stages of disease

From GOLD Index perspective

Stage 1 – The disease seems to start up with a milder kasa or shwasa or both as in stage 1. Here the shortness of breath is mainly after exercise or exertion. This can be compared to kshudra swasa.

Stage 2 – Later the symptoms of kasa and shwasa seem to increase. The symptoms could resemble vataja kasa wherein the air sacs have started to expand towards a larger proportion or kaphaja kasa wherein the person produces more sputum and experience expectoration. If the disease starts with dry cough along with breathlessness it might be due to predominance of vata. If the disease starts with inflammation around air spaces as in bronchitis, the condition may mimic pittaja kasa at the onset. Later the air spaces may expand and vata dominate the picture. Simultaneously or in later time there may be involvement of kapha causing mucus and expectoration. Thus at different stages of the disease, different doshas may be predominant. At advanced stages all doshas may be involved making it a sannipata condition. Alternatively there may be more mucus and expectoration at the beginning and later leading to expansion of air spaces. This denotes vata predominance over kapha pathology. Since at all points the person has breathlessness the condition is also a swasa associated with vataja or kaphaja kasa depends on the cough being dry of with expectoration.
Read – Charaka Kasa Chikitsa – 18th Chapter

Stage 3 – The flow of air into and out of lungs is severely affected here. In stage 2 and 3 we can see that shwasakrichrata i.e. breathlessness / shortness of breath is getting worse. The kshudra swasa type of dyspnea in stage 1 has gradually transformed to difficult to cure conditions of shwasa like tamaka shwasa. Later the disease progresses to more severe conditions i.e. urdhwa shwasa and maha shwasa. The prana carrying channels are severely obstructed and are at trouble. Signs of severe affliction of these channels are found in this stage. Unlike stage 1, the patient feels it difficult to breathe not only after exercise but also at rest and any time of the day.

Stage 4 – The breathing patterns are extremely hard. Since this is called as end stage of COPD it falls under one or the other type of Maha, Urdhwa or Chinna Shwasa depending on the severity and proportion of affliction of prana carrying channels. Here the prognosis of the disease is bad and has reached an incurable stage.
Read – Pranavaha Srotas: Channels Carrying Vital Life Element – Oxygen

Ayurveda treatment

Emphysema should be treated on the lines of treating one or more of the below mentioned conditions –

• Vataja Kasa Chikitsa – treatment of vata predominant cough, when there is chest pain and discomfort, shortness of breath, dry cough with difficult and less expectoration of phlegm, with mild to moderate breathlessness and other vata conditions
• Kaphaja Kasa Chikitsa – treatment of kapha predominant cough, when there is heaviness in the chest, difficulty in breathing, wheezing, chest congestion, plenty of mucus, expectoration of large quantities of phlegm with mild to moderate breathlessness and other kapha symptoms
• Kshudra Shwasa Chikitsa – rest, restorative and strengthening medicines and foods, rejuvenators, with vata alleviating measures should be adopted when the dyspnea is related to exercise, is regular and frequent and not going away by itself. This type of shwasa should calm down all by itself. When it is not happening and when symptoms are regularly associated with mild to moderate exercise or exertion, it shall be addressed with proper measures.
• Sthoulya and Karshya Chikitsa – BMI of the patient should be maintained at normal numbers. Excessive weight will cause the symptoms of Emphysema to flare up. At the same time too less weight due to destruction of tissues will keep the person in bad state of health and compromised immunity. When the patient has more weight treatment of sthoulya or medo vriddhi should be adopted. When the patient is thin and emaciated, karshya chikitsa should be implemented.
• Tamaka Shwasa Chikitsa – treatment of tamaka shwasa should be considered when there is severe breathlessness along with congestion and expectoration of phlegm with difficulty and when other signs and symptoms of this shwasa type are found in emphysema. Tamaka Shwasa line of treatment is highly effective in cases of COPD.
• Rajayakshma Chikitsa – treatment lines of Rajayakshma too shall be considered in treating complicated cases of emphysema.

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