The Lungs
The lungs are two spongy organs surrounded by a thin, moist membrane called the pleura. They are the largest organs in our body. Each lung is composed of smooth, shiny lobes; the right lung has three lobes and the left has two. Approximately 90% of the lung is filled with air and only 10% is solid tissue. When a person inhales, the air is carried from the trachea (the windpipe) into the lungs through flexible airways called bronchi. Like the branches of a tree, bronchi divide successively into over a million smaller airways called bronchioles. The bronchioles lead to grape-like clusters of microscopic sacs called alveoli. In each lung of the adult there are about 300 million of these tiny sacs, which are composed of a thin membrane through which oxygen and carbon dioxide pass to and from capillaries.

Chronic obstructive lung disease (COLD), also known as chronic obstructive pulmonary disease (COPD), refers to a set of breathing-related symptoms: chronic cough, spitting or coughing mucus (expectoration), breathlessness upon exertion, and progressive reduction in the ability to exhale. The two major diseases in this category are emphysema and chronic bronchitis

Emphysema. In emphysema, the walls of the alveoli that join the very small airways (bronchioles) are damaged and lose elasticity. (In a rare, inherited form of emphysema known as alpha-1-antitrypsin deficiency, both the walls of the bronchioles and alveoli to which they connect, usually in the lower lungs, are diseased.) Pockets of dead air form in the injured areas, impeding the ability to exhale and so reduce normal Lung function. Inhalation, however, is not impaired, and until the late stages of the disease, oxygen and carbon dioxide levels are normal. The process leading to emphysema is primarily due to an imbalance in chemicals that, under ordinary circumstances, protect the lungs from infection and damage. Important chemicals in this process are enzymes called proteases, particularly those known as elastase and trypsin. These enzymes are produced by the immune system to fight infection and injury. However, if they are overproduced, they actually attack normal lung cell tissues and impair the structural integrity of elastin, the material that is essential for the "springy" quality of lung tissue. Ordinarily, these enzymes are neutralized by a protective protein called alpha 1-antitrypsin (AAT), another critical chemical. (This is sometimes referred to as alpha 1-antiprotease.) Any condition that causes an imbalance in any of these substances may trigger emphysema.

Chronic Bronchitis. Chronic bronchitis is characterized by structural changes in the airways of the lungs and enlargement of the mucous glands, which causes coughing and production of sputum. As chronic bronchitis often coincides with emphysema, it is frequently difficult for a physician to distinguish between the two.

Symptoms of Emphysema Emphysema patients have typically lost between 50% and 70% of their lung tissue by the time symptoms begin to appear. Shortness of breath is the predominant early symptom. Coughing is usually minor and there is little sputum. Typically, a heavy smoker in his or her mid-50s who develops emphysema has shortness of breath with light exertion, and by age 60 may be breathless during rest or after minimal exertion. Late, severe symptoms include rapid, labored breathing and persistent air hunger even without physical exercise. Physicians sometimes refer to patients with severe emphysema as "pink puffers" because they tend to have pinkish skin and barrel-shaped chests due to over-inflated lungs.

Symptoms of Chronic Bronchitis

Chronic bronchitis also causes shortness of breath and is often accompanied by infection, mucus production, and coughing. A diagnosis of chronic bronchitis is suggested when a patient experiences coughing with excessive sputum on most days for at least three months of a year over a period of at least two years. Lying down at night worsens the condition, so patients with advanced disease must sleep sitting up. In late, severe stages, some patients, who often have emphysema as well, are called "blue bloaters" because lack of oxygen causes the skin to have a blue cast (cyanosis)

Quitting Smoking and Avoiding Other Irritants

Quitting smoking is the first and most essential step in treating chronic obstructive lung disease. Once a patient stops smoking, lung function may stabilize and even improve slightly, eventually declining at only about the same rate as nonsmokers in the same age group.

Smoking
Cigarette smoke is the cause of over 80% of all cases of chronic obstructive lung disease. It contains irritants that inflame the air passages, setting off a cascade of biochemical events that damage cells in the lung, increasing the risk both for COLD and lung cancer. Emphysema most often develops when the damage caused by smoke incites the body's immune system to overproduce the damaging enzymes known as proteases, particularly elastase and tripsin. The protective alpha 1-antitrypsin (AAT) protein ordinarily neutralizes these enzymes, but smoke generates oxygen-free radical particles that deactivate AAT and make it ineffective, even in smokers who have sufficient and even high amounts of AAT. Cigarette smoke also causes chronic bronchitis through inflammation and damage to the airways. It also damages the cilia, hair-like waving projections that move bacteria and foreign particles out of the lungs, increasing the risk for infections that can lead to chronic bronchitis.

Genetic Factors
Genetic factors that cause lungs to be hyper-reactive to stimulants and allergens may also increase the risk for COLD.
Alpha 1-Antitrypsin Deficiency (A1AD). An inherited condition that causes a deficiency in the protective enzyme AAT can trigger early-onset emphysema, even in nonsmokers. Known as alpha 1-antitrypsin deficiency (A1AD)-related emphysema, it accounts for only about 3% of all emphysema cases. The AAT protein is produced in the liver and neutralizes the effects of the protease enzymes, most importantly neutrophil elastase, which attacks the cell linings in the lungs. Without adequate amounts of AAT, the enzyme's destructive action is even more pronounced, causing early progressive damage to the lungs. In such cases, both the walls of the alveoli and the airways leading to them are damaged. There is also some evidence that in such patients the immune system over-responds to toxins or microorganisms, such as bacteria, and produces excess amounts of damaging inflammatory substances. Because smoke is a major toxin and also deactivates any residual amounts of AAT that these patients are able to produce, patients with A1AD who smoke have no chance at all for escaping emphysema.
Other Genetic Disorders. Researchers recently identified a group of patients who might have an inherited form of COLD that is unrelated to A1AD. In such patients, a genetic susceptibility may increase the effects of smoking so that severe COLD develops at an earlier age than usual. Some evidence suggests that some genetic factors may involve microsomal epoxide hydrolase, an important enzyme, which is responsible for the breakdown of harmful oxidants found in cigarette smoke. Two variants of the gene regulating the enzyme cause it to act either rapidly or slowly. A 1997 study showed that, compared to healthy people, those with COLD are four to five times more likely to have the genetic variant that slows the action of this enzyme, possibly making such people more vulnerable to lung damage.

Bacteria and Viruses

Certain bacteria, particularly Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are common in the lower airways of nearly half of chronic bronchitis patients. However, their role or the role of viruses and other organisms in causing chronic symptoms and inflammation is unclear. Some experts believe that a low-level infection in the lungs may trigger an inflammatory reaction that continues to produce subsequent acute symptomatic attacks.

Physical Examination and Medical History
The physician will request a history that includes information on past and present smoking, exercise capacity (e.g. whether the patient has trouble climbing stairs, the distance he or she can walk), and exposure to any industrial pollutants. The physician will next perform a simple examination of the chest area. Using a stethoscope, the physician will listen to the patient's breathing for signs of emphysema, such as diminished or distant breath sounds. Tapping the chest will usually produce a hollow, drum-like sound. In patients with chronic bronchitis, the physician is likely to hear wheezing or gurgling sounds.
Pulmonary Function Tests
The best tests for determining the presence and severity of chronic obstructive lung disease are pulmonary function tests. Using a spirometer, an instrument that measures the air taken into and exhaled from the lungs, the physician will determine two important values. The forced vital capacity (FVC) is the maximum volume of air that can be exhaled with force and is an indicator of the lung size, elasticity, and how well the air passages open and close. The forced expiratory volume (FEV1) measures the maximum volume of air expired in one second. Calculating a ratio of FEV1 to FVC is the best method for determining the presence and severity of COLD, but simply observing a reduction in FEV1 is useful. For example, a FEV1 of less than 1 liter/second is an indicator of a poor outlook for people with advanced emphysema.
Chest X-Ray and Other Imaging Tests Chest x-rays are often performed, but they are not very useful for detecting early COLD. By the time an x-ray reveals the disease, the patient is well aware of the condition. Clear signs of emphysema include a flattened diaphragm, exaggerated lung inflation in upper areas, abnormally large amounts of air spaces in the lung, and a smaller heart. (If heart failure is present, however, the heart size becomes normal and signs of over-inflated lungs are not present.) A1AD-related emphysema patients show larger amounts of air in the lower lungs. X-rays are rarely useful for diagnosing chronic bronchitis, although they sometimes show a so-called dirty chest (mild scarring and thickened airway walls).
Computed tomography (CT) scans may be used to determine the size of the air pocked (bullae) in the lungs.
Laboratory Tests
Physicians will typically test for the protective enzyme, alpha 1-antiprotease (or anti-trypsin), which is often deficient in COLD patients (although asthma patients may also have low levels). The physician may request an arterial blood gas test to determine the amount of oxygen and carbon dioxide in the blood (its saturation). This procedure draws blood from an artery, which can be quite painful. A less painful test is called a pulse ox, which involves placing a probe on the finger or ear lobe; this only measures oxygen in the blood. When blood is fully saturated with oxygen, it forms a compound called oxyhemoglobin, which gives blood its bright red color. When blood has insufficient oxygen, it turns a bluish color (called cyanosis). Low oxygen (hypoxia) and high carbon dioxide (hypercapnia) levels are often indicative of chronic bronchitis, but not always of emphysema. A blood gas analysis that shows very low oxygen levels (measured as PO2) is useful for determining which patients would benefit from oxygen therapy. Additional tests may be required if the physician suspects other medical problems. If pneumonia is present, for instance, blood and sputum tests and cultures may be performed to determine the cause of infection.

Studies have indicated that diets rich in antioxidants, including vitamins E and C, selenium, and beta carotene, improve lung function and may provide some protection against lung damage from chronic obstructive pulmonary disease among smokers. However, in one study, the protection appeared to be effective for smokers only if such foods were eaten throughout the smoking years. Another study found protection from diets rich in vitamin C, but other antioxidants, including vitamins E, A, and beta carotene, had no effect. Beta carotene supplements, in any case, are not recommended because of studies suggesting an increased risk of lung cancer in smokers. Foods rich in such antioxidants include dark colored fruits and vegetables (vitamin C and beta carotene), whole grains, nuts (selenium), and vegetable oils and wheat germ (vitamin E). The trace elements zinc and selenium may have some effect in reducing the severity of upper Women's Health tract infections.

Patients should not take tranquilizers, sedatives, or other drugs that suppress respiration. As much as possible, a patient should avoid exposure to airborne irritants, including hair sprays and any aerosol products, paint sprayers, and insecticides. To minimize the amount of contaminants in the home, the following may be helpful measures:

• Ventilate by keeping windows open (weather permitting), by using exhaust fans for stoves and vents for furnaces, and by keeping fireplace flues open.
• Make sure wood-burning stoves or fireplaces are well ventilated and meet the Environmental Protection Agency's safety standards and burn pressed wood products labeled "exterior grade" since they contain the least amount of pollutants from resins.
• Have furnaces and chimneys inspected and cleaned periodically.
• Eliminate molds and mildews stemming from household water damage.
• People who are sensitive to allergens, such as pollen, pet dander, house dust, and mold, should avoid exposure to them.

Vaccines
People with emphysema should be vaccinated against influenza each year at least six weeks before flu season. The other important vaccination is the pneumococcal vaccine, which protects against the major bacterium that causes pneumonia. The vaccine remains effective for years. Flu and pneumococcal vaccines can be administered at the same time without increasing any adverse effects.

Breathing Exercises A technique called pursed-lip breathing can help improve lung function before starting activities. It takes about 10 minutes. When first learning the technique, the patient should lie flat on a bed with the head on a pillow. Later, the technique can be performed while walking or enduring any activity requiring extra air. First, the patient inhales through the nose, moving the abdominal muscles outward so that the diaphragm lowers and the lungs fill with air. The patient then exhales through the mouth with the lips pursed, making a hissing sound. The exhalation should be twice as long as the inhalation, so that pressure is experienced in the windpipe, and chest and trapped air is forced out.
The use of an incentive spirometer for 15 minutes twice a day may also be helpful in strengthening breathing muscles and loosening sputum. This is a small hand-held device that contains a breathing gauge. The patient exhales and then inhales forcefully through the tube, using the pressure of the inhalation to raise the gauge to the highest level possible.
Controlling Secretions
Patients who experience congestion and heavy sputum can benefit from maintaining good fluid intake and keeping their homes humidified. If a nebulizer is used, the reservoirs, tubes, and mouthpieces may be kept clean to avoid bacterial contamination in the lungs. Although unproven, many patients report benefits from using expectorant drugs that thin mucus available in many over-the-counter brands. The use of incentive spirometry rhythmic inhalation and coughing, and chest tapping may also help in loosening and raising sputum. In rhythmic breathing and coughing, the patient should inhale deeply three or four times and then cough to produce sputum. The patients should also practice postural drainage. This involves leaning over the side of the bed, head down with elbows on a pillow placed on the floor. A family member or caregiver thumps gently on the back while the patient coughs. When coughing to produce mucous one effective method is to lean forward and "huff" repeatedly, take relaxed breaths, and huff again. If possible, forceful coughing should be avoided.
Exercise
Although exercise does not change lung function, it does help some patients with chronic lung disease by strengthening their limb muscles and thus improving their endurance and reducing breathlessness. In studies of pulmonary rehabilitation, regular exercise increases walking distance and improves breathing. Walking is the best exercise for people with emphysema. Patients should try to walk three to four times daily for five to 15 minutes each time. Yoga or martial arts exercises, such as tai chi, may be useful.

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These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, cure, mitigate, treat, or prevent any disease.