Diagnosis and etiology Emphysema means 'inflation' in the sense of abnormal distension with air. It is a condition in which there is permanent destructive enlargement of the airspace distal to the terminal bronchioles without obvious fibrosis. In the general population, emphysema usually develops in older individuals with a long smoking history. However, other causes include exposure to heavy metals such as cadmium, and 5% of early presenting cases are caused by the autosomal recessive disorder ai-antitrypsin deficiency. It affects almost 5% of older people, and it is more common in industrialised countries. The prognosis is variable. Progression is slow, provided it is treated.

Clinical features Patients may be very thin with a barrel chest and have little or no cough expectoration. Symptoms include intense dyspnea with purse-lip breathing and overinflation of the chest. Breathing may be assisted by pursed lips and use of accessory respiratory muscles. The chest may be hyperresonant, and wheezing may be heard. Heart sounds are very distant and overall appearance is more like classic COPD exacerbation.

Chemical Pathology There are three types of emphysema:

Panacinar emphysema: A generalized destruction of the alveolar walls. As a consequence, the elastic network of the normal lung is badly disorganized and the lung becomes floppy, leading to a severe degree of airways obstruction, particularly during expansion. It generally develops in patients with ^-antitrypsin deficiency. Centriacinar emphysema: Distension and damage affect the respiratory bronchioles; the more distal alveolar ducts and alveoli tend to be well preserved. This is very common and not necessarily associated with disability. Paraseptal emphysema: The least common form, involving distal airway structures and alveolar ducts and sacs.

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